▶ 0:15:04>> this committee will please come to order. Congress created the 340 b program to make health care more affordable for low income and uninsured patients. Hospitals and community health centers that qualify are able to purchase prescription drugs at a discounted rate. It is well-intentioned but people are judged by its actions, not intentions.
▶ 0:15:25Today we will hear testimony about how the program participation ballooned with limited oversight raising questions about how the revenue is used and whether it is actually benefiting low income patients. Anyone who says the 340 b is cost neutral to taxpayers is not paying attention as the 340 b program gross total health care costs.
▶ 0:15:52Cbo reported the dramatic growth at a higher cost for patients and taxpayers I will also note a study by the national pharmaceutical council found that 340b causes -- caused employer participation costs -- dollars.
▶ 0:16:17Our goal is to make health care more affordable but 340b is making employee sponsored which pays for health care less affordable. Looking at the program, the problems are clear. 340b incentivizes physicians to prescribe more expensive drugs and healthier systems to consolidate and require other health care systems.
▶ 0:16:43The financial incentives demonstrably drive up costs within medicare, medicaid and the commercial insurance market. It is clear that participating providers can benefit from 340 b. I conducted an investigation on how 340b is generated and used, following the money.
▶ 0:17:11A significant share of the revenue goes to for-profit middlemen and patients do not always realize direct benefits from the program. The growth of the program is causing patients to pay more now for prescription drugs than they have before.
▶ 0:17:32It appears the significant growth of 340b has become a means, for some, to pad bottom line but with little focus on affordability for families or for the employers hoping that family pay for their insurance. It was one said there is no silver bullet for reducing drug costs but that there is buckshot.
▶ 0:17:57I told him I would never attribute that to him but I wouldn't steal it for the record, this is angus. That is a great quote. Maybe reforming three 40 v is one of those silver buckshot that if you do something positive about this that on the margin you can get downward pressure on the high cost of pharmaceuticals.
▶ 0:18:21If this committee is serious about making drugs more affordable and improving commercial insurance and helping the patient, perhaps we need to reform 340b. Limited improvements to improve the integrity but only five of those recommendations have implemented. I appreciate gao being here to discuss recommendations and inform future efforts.
▶ 0:18:49Recently I released recommendations to increase 340b transparency, establishing clear guidelines to ensure patients benefit directly and requiring entities to report how 340b revenue is being used. We need to examine the role for for-profit middlemen to make sure the fees are not disadvantaging patients.
▶ 0:19:15340b should be about making drugs more affordable and not a line item on an investor call. There are many special interests who do not want 340b reform. A profit off of status quo and fear mongering that if we touch it would hurt providers. This is a false choice.
▶ 0:19:35We can support providers in underserved communities and reform misaligned symptoms that providers have used to raise costs and to put the patient's ability to pay. I want to share an anecdote.
▶ 0:19:54We found a small community health center, that we want to help to support with 340b that reported the cost of compliance and fees forced upon them by the middlemen made it almost unprofitable to participate in it and were thinking of dropping it.
▶ 0:20:19Middlemen making so much profit at the community health center that this program was designed to benefit can no longer afford to participate. This is a system that has lost its way. We have a responsibility to fix the broken status quo.
▶ 0:20:35340b are crucial to them of patient, pro family that lowers the cost of health care insurance and pharmaceuticals for all americans and american businesses which pay the bill for employee sponsored insurance. I look forward to discussing these and other ideas to reform the program. I recognize senator baldwin.
▶ 0:20:55Sen. Baldwin: Thank you. I'm pleased the committee is meeting to discuss the 340b program for our rural hospitals and other safety net providers. I want to start by recognizing the context in which we are having this hearing. We are in day 23 of a government shutdown, 22 million americans are about to see their health care premiums double or worse.
▶ 0:21:25Sen. Baldwin: The only way for us to get out of this mess and prevail -- prevent health care costs from skyrocketing this for democrats and republicans to sit down together and negotiate a solution. So far president trump and republicans have refused to come to the table. President trump's bill will devastate both patients and providers that serve them.
▶ 0:21:53Sen. Baldwin: Thanks to the nearly $1 trillion in health care cuts to medicaid and the affordable care act, along with along the enhanced premium tax credits to expire, an estimated 15 million americans are about to lose their health insurance.
▶ 0:22:11Sen. Baldwin: It is imperative that we act to extend the enhanced premium tax credits to prevent for millions of our neighbors from losing their health care coverage and 22 million americans from seeing premiums double, triple or even quadruple. Open enrollment begins november 1 and people will start seeing lisa devastating think very soon .
▶ 0:22:37Sen. Baldwin: I've said this before and I will say it again, I am at the table and I hope my colleagues will come and negotiate with us to avoid these disasters health care impacts. Through hospitals will be particularly hard hit these cuts. Over 300 nationwide are at risk of closing their doors. 500 providers at risk for having to close our stop writing certain types of specialty care.
▶ 0:23:06Sen. Baldwin: 340b is already a critical lifeline for providers. Savings from the program allows hospitals and clinics to expand their services, ensuring that patients have access to services like dental and behavioral health and maternal health. Here community health centers use 340b to lower out-of-pocket drug costs for patients, making the medication they need more assessable.
▶ 0:23:35Sen. Baldwin: For some providers, 340b can be the difference of staying open in closing their doors. That is white in the face of these devastating republican cuts to health care system, we must ensure that the 340b program is sustainable for years to come and can support the safety net health care providers. That doesn't mean that the program is without its issues.
▶ 0:24:03Sen. Baldwin: I am proud to serve on a bipartisan working group in the senate. You may know less as a gang of six to take steps to sustain the 340b program. My colleagues in this committee serve in this bipartisan effort along with senators capital and moran -- catapo and moran.
▶ 0:24:31Sen. Baldwin: Chad boseman happy for the support given to the program. We must focus on ways to improve the program and meet the intent of supporting providers who serve the most vulnerable in our communities. I have long said that we need more transparency in our health care system. And know that members of both 40 -- parties agree on that appearance it on that.
▶ 0:25:02Sen. Baldwin: Our need for more transparency applies to the 340 b program. We must take steps to better understand how program savings are used in the late benefit patients and communities without putting undue burden on providers. We must also ensure there is appropriate oversight of the program and that there are adequate resources to conduct this oversight.
▶ 0:25:27Sen. Baldwin: Our working group wants to increase transparency and ensure appropriate oversight as well as work together towards a strong patient definition and address contract premises, child sites and duplicate discounts.
▶ 0:25:44Sen. Baldwin: Best approach to reforming this program is to be comprehensive and bipartisan so that we can ensure 340b that -- ensure that 340b supports as it is intended to. It is more important than ever to supply those who rely on 340b .
▶ 0:26:11Sen. Baldwin: I would like to make witnesses for being here and I look forward to hearing your testimony in interest to our questions. I go back to you, Mr. care.
▶ 0:26:19Chair Cassidy: -- Mr. care.
▶ 0:26:24Chair Cassidy: -- Mr. chair.
▶ 0:26:30Chair Cassidy: Michelle rosenberg has led a variety of engagements on medicaid, the health care safety net including the gao portfolio on the discount program in indian health service and other policy issues. Throughout her tenure, she has been recognized with numerous gao wide and health care team awards, including two meritorious service awards and eight distinguished service award.
▶ 0:26:58Chair Cassidy: She wrote a masters of public health from michigan. Thank you for joining us and thank you for your meritorious service to the people of the united states. >> aye by proxy.
▶ 0:27:11Thank --Ms. Rosenberg: Thank you for having me. This requires drug manufacturers to provide discounts on outpatient drug to certain hospitals and federal grantees also known as covered entities to have drugs covered by medicaid.
▶ 0:27:36Thank --Ms. Rosenberg: Covered entities may disc -- this menses through pharmacies they own or outside pharmacies referred to as contract premises. Covered entities can realize substantial savings through price discounts and can generate revenue want reimbursement from patients and insurance exceeds the price paid. The statute does not specify how the revenue is to used.
▶ 0:28:03Thank --Ms. Rosenberg: Covered entities have reported using 340b revenues to serve more patients and services and sometimes provide discounted drugs to patients. As participants are not allowed subject manufacturers to duplicate discounts in which they are subject to the 340b and a medicaid drug rebate. They are not allowed to divert 340b drugs to individuals who are not part of the covered entity.
▶ 0:28:32Thank --Ms. Rosenberg: Health resources and services administration is responsible for oversight of 340 b including ensuring entities are eligible to participate and comply with requirements. Gao issued several reports looking at various aspects of the program and identify numerous oversight. Since 2011 when it was first looked at, they have implemented five recommendations.
▶ 0:29:02Thank --Ms. Rosenberg: Most notably, after we've found that prison had been relying on covered entities to self police the program, in 2012, they began conducting audits of entities and audits 200 per year.
▶ 0:29:17Thank --Ms. Rosenberg: Shortcomings in the administration of the program persist through for example, the processes do not provide reasonable assurance that participating hospitals meet eligibility requirements, specifically they have not ensured has reliable data to determine if participating hospitals are nonprofits, the key eligibility.
▶ 0:29:37Thank --Ms. Rosenberg: They cannot verify that nongovernmental hospitals which make up over two thirds of hospitals participating in 340 b have a contract with the state or local government to provide services to low income individuals not eligible for medicare or medicaid as required by law.
▶ 0:29:55Thank --Ms. Rosenberg: They do not possess it covered entities have procedures to prevent duplicate discounts and does not audit for duplicate discounts in medicaid managed care or require covered entities to address duplicates in managed care. This is concerning since the risk of duplicate discounts related to medicare managed care have existed since 2010 when the medicaid drug rebate program was expanded to managed care.
▶ 0:30:19Thank --Ms. Rosenberg: Data shows there are merit -- more medicaid enrollees and spending for drugs under managed care. Despite allowing covered entities to have an unlimited number of contract pharmacies, hrsa has not articulated how to oversee these pharmacies to prevent diversion and duplicate discounts.
▶ 0:30:41Thank --Ms. Rosenberg: Although 340b requires -- although hrsa requires -- doesn't require the b entity -- while hrsa concurred with recommendations, the agency has told us it does not believe that has appropriate enforcement capability and that it needs regulatory authority from congress to implement many of them.
▶ 0:31:10Thank --Ms. Rosenberg: As a result of legal challenges, hrsa not only issues audit findings for clear and direct statutory violations for this limits the issuance of findings including the diversion of drugs to an eligible individuals and oversight of contract pharmacies as the statute does not give criteria for determining patient eligibility end address pharmacy use.
▶ 0:31:35Thank --Ms. Rosenberg: The program has grown and become more complex for federal oversight needs to catch up with the growth and related changes to ensure the program is operated as congress intended. This concludes my prepared remarks. I'm happy to answer any questions you may have.
▶ 0:31:48Chair Cassidy: Thank you. Next we are joined by Dr. Dr. sen,, from the congressional budget office. He leads a team that oversees reports and policy analysis on topics such as prescription drugs, pharmaceutical innovation , hepatitis c and other public health issues.
▶ 0:32:11Chair Cassidy: Previously the director of research and policy at the health care cost institute and an assistant professor at the johns hopkins bloomberg school of public health and she also previously held positions at the department of health and human services and the white house council of economic advisors. She owns a bachelor's yale, phd in economics from the wharton school in pennsylvania. We look forward to hearing from you. Thank you.
▶ 0:32:35Dr. Sen: Chairman cassidy, senator baldwin and members of the committee, thank you for inviting me to testify today. My remarks can summarize the congressional budget office growth and 340b program which examines trends and purchases from 2010 through 2021, factors driving trends and implications for the federal budget.
▶ 0:32:59Dr. Sen: The 340b program requires to sell discounted drugs to eligible facilities. Hospitals that treat a large share of patients with low income, federally qualified health centers and specialized clinics. Participating facilities by drugs at discounted prices and typically receive larger reimbursements from public and private insurers.
▶ 0:33:22Dr. Sen: The resulting difference generates net revenues that may use to expand services although the statute does not specify how the revenues must be used or use two services for low income. Health services and resources and services administration administers the program and contracts with the prime vendor to manage distribution, negotiate discounts and support participating facilities.
▶ 0:33:49Dr. Sen: In 2021, 50,000 facilities participated in 340b and 90% joint hrsa -- joined hrsa phosphorus program. They spent $43.9 billion on drugs from 2021, up from 6.6 billion dollars in 2010, never general growth rate of 19%. By contrast, nationwide spending on brand-name drugs grew by 4% per year during the same period.
▶ 0:34:19Dr. Sen: In 2021, hospitals and affiliated outpatient clinics represented 87% of spending through the vendor program, a federal qualified clinics allowed for 13%. There were concentrated areas of cancer drugs, anti-infective and immunosuppressant's. Cbo estimates one third of the increase in 340b spending from 2010 to 2021 reflects overall growth in prescription drugs.
▶ 0:34:48Dr. Sen: Cbo examined three factors that contributed to the remaining two thirds at the increase. Vertical integration, the growing affiliation between hospitals and off-site clinics, expanded eligibility for 340b discounts, the affordable care act, further participation and changes in hrsa guidance in 2010 a lot hospitals contract with multiple off-site pharmacies, increasing the share of prescriptions for which facilities received discounts.
▶ 0:35:15Dr. Sen: Cbo does not have sufficient data to quantify the contribution of each factor but in the assessment, vertical integration contributed most to the increase in 340b purchases. In the assessment, the 340b program encourages behaviors that tend to increase federal spending, although the magnitude of those is uncertain.
▶ 0:35:36Dr. Sen: Cbo is not estimated how legislation affecting these behaviors would alter federal spending pretty behaviors include first prescribing more and higher priced drugs. Facilities that financial incentives to prescribe more drugs which raises more spending and shift restrictions to drugs for which the gap between reimbursement and the 340 b price is large. If those are more expensive, that shift would also increase federal spending. Second, reducing manufacturer rebates to insurers.
▶ 0:36:06Dr. Sen: For drugs purchased at 340b prices, many manufacturers may limit to part d medicare, medicare advantage or commercial plans. Smaller rebates increase costs for insurers and in turn federal subsidies for premiums and federal outlays for medicare and medicaid. Third, expanding services. Facilities may use 340 b revenues to open new clinics or provide more comments of care, some of which is reimbursable by federal programs.
▶ 0:36:40Dr. Sen: Integration of hospitals and off-site clinics raises prices paid by commercial insurers and medicare. The 340 b program is one of several factors encouraging such integration to the extent it amplifies those incentives, it contributes to federal spending. In some cases reassures me lower insurance rates for 340b drugs. They are likely small. That concludes my remarks. I look forward to your questions.
▶ 0:37:09Chair Cassidy: I now recognize senator baldwin to introduce Mr. feldman.
▶ 0:37:17Sen. Baldwin: I am pleased to introduce Dr. william feldman, a health policy research at the university of california los angeles. His research focuses on drug pricing, food and drug administration regulation and intellectual property, pharmaceutical policy and copd outcomes. Thank you for being here, we look forward to your testimony.
▶ 0:37:42Dr. Feldman: Chair cassidy, ranking member baldwin, members of the committee, I am honored to talk with you all today about the 340b program and were generally about improving health care in the united states. At the start of the new shared here today are my own and do not necessarily represent those of my employer.
▶ 0:38:04Dr. Feldman: As you have heard, the 340 b program allows qualified entities to purchase drugs at discounts which are set by statute and sell these drugs as markups, retaining the difference. There are two broad types of qualifying entities, community health centers and hospitals, both earn revenue by acquiring drugs at low prices and selling them at higher prices.
▶ 0:38:27Dr. Feldman: The program started small but has gotten considerably bigger over the last 30 years, more than 40% of acute care hospitals in the U.S. qualify in covered entities purchased $65 billion worth of drugs each year. 340 b participants rely on the program to expand offerings and fill budget gaps. Community health centers in particular play an outsized role in the health care safety net of our country.
▶ 0:38:53Dr. Feldman: These clinics see patients regardless of their ability to pay and provide comprehensive services from ob care in cancer screening to addiction and diabetes treatment. On the hospital side, seller -- some 340b are in rural locations. Some are in cities treating the sickest patients with the fewest resources.
▶ 0:39:18Dr. Feldman: Despite the many benefits provided by these entities, the 340b incentivizes health care increase costs and allocate resources away from those of the greatest needs. Covered entities earn more money when more expensive medications are prescribed. The program may promote acquisitions with clinics were high because therapies are administered.
▶ 0:39:42Dr. Feldman: It tends to reward hospitals that locate satellites -- satellite clinics in affluent communities. 340b tends to direct the larger sums to hospitals with the highest by at top grossing entities with the most injured patients. I applaud the bipartisan senate working group for laying the foundation of reform through the sustained 340b workbook.
▶ 0:40:13Dr. Feldman: There is increased transparency regarding how revenue is generated by the program and how it is spent. Two is more funding for hrsa to conduct more audits by user fees are direct appropriations. Three displays and some limits on child sites and contract pharmacies. For example, ensuring they are also located in areas that serve disadvantaged patient populations.
▶ 0:40:40Dr. Feldman: I would also encourage other reforms, including aggressive debt collection, standards for community benefit spending and more assistance to help patients with out-of-pocket costs. These reforms if carefully targeted and implement it could improve 340 b without compromising the ability of community health centers in safety net hospitals to provide care.
▶ 0:41:08Dr. Feldman: We should be very clear about this, bill crafted reforms could jeopardize facilities that depend on 340b for their function and even their survival. Performed on its own it will not lower pharmaceutical prices. Any serious discussion of 340b should be companied by how we can lower drug prices in the country.
▶ 0:41:37Dr. Feldman: As congress considers it for the year, I would encourage you to think about two key areas of reform. One is protecting and expanding price negotiation under the inflation reduction act and the second is addressing abuses by pharmaceutical companies that limit generic and similar competition.
▶ 0:42:01Dr. Feldman: I want to close by noting that the 340 b program was designed to support the health care safety net of our country, if the current administration is gutting that very safety net. Over 10 million medicaid beneficiaries will lose coverage in the coming years because of legislation passed this summer. Premiums could double for patients if congress allows the marketplace plans to expire.
▶ 0:42:29Dr. Feldman: Such cuts increase the burden on 340 b clinics and hospitals as they may be forced to devote more resources. I would urge you to continue reform but not in a vacuum. Coupling it with measures to lower pharmaceutical prices and enhance insurance coverage is vital if we are to improve the health care in the united states.
▶ 0:42:51Chair Cassidy: I will defer to senator turberville. For the first questions.
▶ 0:43:02Sen. Tuberville: Thank you for being here. The 340b is the only income and I repeat only source of income for americans hospitals that is a taxpayer-funded. Taxpayers are carrying the whole load other than this. We should be expanding it, not reforming it.
▶ 0:43:24Sen. Tuberville: Hit I have a hospital east of alabama in alabama that shared with me in 2025 they provided almost $100 million in uninsured care majority of that was illegals. During the same period, they received 70 million in 340b savings.
▶ 0:43:52Sen. Tuberville: In the past, it does not cover the loss from uncompensated care and there is pressure to expand health care services all over my state. We are dropping beds, sinking. Thank goodness we had the 50 billion dollars coming for a health care from the one big beautiful bill. East alabama along with many hospitals know that the 340b program is working as intended to offset uninsured losses.
▶ 0:44:22Sen. Tuberville: The program established a clear expectation of pharmaceutical manufacturing drugs covered by medicare and medicaid. Ms. rosenberg, would reforming 340b in a way that undermines the ability to provide for uninsured patients go against the original purpose?
▶ 0:44:45Ms. Rosenberg: I would not the statute doesn't specify what the purpose of the program is, what individuals have the light on is something in house report language for a bill that was similar to that that implemented the 340 b program which was to enable covered entities to stretch federal resources to reach more eligible patients and provide more comprehensive services.
▶ 0:45:10Ms. Rosenberg: It would seem that if that is the intent, than the -- then the 340b program is allowing that to be done.
▶ 0:45:21Sen. Tuberville: What other revenue due date received that is not taxpayer-funded?
▶ 0:45:27Ms. Rosenberg: I don't have full knowledge of those programs but none that I am aware.
▶ 0:45:34Sen. Tuberville: 80% of rural hospitals in my state operate at a loss. Think about that. 83%. If others want to highlight those flush with cash, then reform efforts should be directed toward those. That is my opinion. You can't vote for people who are losing money already, not like in states like mine that we absolutely survive off of.
▶ 0:45:57Sen. Tuberville: We support services such as mental health and substance abuse treatments and if this happens in weight reform and cut back, those will all disappear, forcing rural patients to seek care in hospitals that are already barely getting by. What would meaningful reform look for the estate that is poor and demonstrated it is not abusing this program?
▶ 0:46:17Ms. Rosenberg: Our recommendations really focus on hrsa oversight of the program and making sure the entities that participate are eligible to participate and making sure they follow program requirements don't divert drugs to individuals who aren't patients of the entity and don't create didn't get discounts in which manufacturers are required to pay both rebate under the medicaid rebate and the discounted price.
▶ 0:46:47Sen. Tuberville: , based on your research into how the 340 b program affects hospital spending, how can we ensure that community health centers in my state continue using the 340b savings directly to benefit patients rather than losing resources to the larger systems or middlemen?
▶ 0:47:10Dr. Sen: At the congressional budget office we would not recommend specific policy approaches but I will stay for our work in the data on how covered entities and how they could inform that policy discussion.
▶ 0:47:30Sen. Tuberville: What would you consider wasteful or fraudulent in-hospital using 340b?
▶ 0:47:38Dr. Sen: We do not have the data to track how they are using the revenues by the program. Those revenues enter the covered entities and we can't see how they are using them.
▶ 0:47:57Sen. Tuberville: Dr. feldman, have you seen any fraudulent uses of 340b?
▶ 0:48:04Dr. Feldman: No.
▶ 0:48:07Sen. Baldwin: Currently 340b discounts are provided at the point of purchase but pharmaceutical manufacturers have tried to implement rebate models in the program and the hrsa has proposed a pilot program that would go into effect on january 1.
▶ 0:48:31Sen. Baldwin: I've heard from hospitals and community health care clinics in wisconsin that it would be disruptive to the finances and threaten their ability to continue to provide their current level of care and services. One community health center in wisconsin has said that under the proposed pilot program the upfront cost would increase by 2360%. , threatening their financial stability and patient care.
▶ 0:49:05Sen. Baldwin: I've heard this from particularly rural hospitals. They wouldn't struggle with millions more with additional upfront costs under a pilot program as proposed Dr. feldman, how would a rebate model change the operation of the 340 b program and what with the impact of this shift be on providers and on patients?
▶ 0:49:29Ms. Rosenberg: The way the discounts currently work -- they would pay for the drug upfront. The way that a rebate model would work as a hospital would pay $1000 upfront and they get back $700 later. I worry about this model for a couple of reasons.
▶ 0:49:54Ms. Rosenberg: One, as you pointed out, is that some institutions may not have the cash to make that payment upfront in the second is it puts the pharmaceutical industry in control of determining which rebates to give. I would much prefer to see a solution like a third-party clearinghouse that is helping to resolve the discounts that are being given.
▶ 0:50:26Sen. Baldwin: Some have criticized the 340b program for lack of transparency including how the savings are used to benefit patients and communities. Many have also said that hrsa has insufficient resources to provide oversight above manufacturers and covered entities. I believe we need to increase transparency within the 340b program while ensuring there is not an undue administrative burden. Ms.
▶ 0:50:55Sen. Baldwin: Rosenberg, what concerns about transparency and ability to provide oversight has the gao identified?
▶ 0:51:03Ms. Rosenberg: So as you noted, there are requirements for entities to specify how they use the revenue from the 340b program. There are also been questions about whether they pass on discounts to patients and there's not information in terms of that.
▶ 0:51:27Ms. Rosenberg: Hrsa doesn't have good insight to themes of whether the entities with ewert -- the eligibility requirements. The nongovernmental hospitals are eligible if they need a certain dish metric. That is something that hrsa checks but they also have to have a contract with the state and local government to provide services to low income individuals who are not eligible for medicare or medicaid.
▶ 0:51:50Ms. Rosenberg: Hrsa has not reviewed all of the hospitals to see if they have such a contract and when we looked at a sample of them, we found that not all of the hospitals did. >> aye by proxy. -- Sen. baldwin: thank you. They are staring down the barrel of medicaid cuts and the undermining of the affordable care act including by ending the tax credits.
▶ 0:52:24Ms. Rosenberg: I think 340b will only become more essential to prevent hospital and clinic closures and ensuring patients have the access they need to health care. Dr. feldman, please briefly explain why 340 b is essential to those types of providers.
▶ 0:52:45Dr. Feldman: I agree with you that as we see more cuts to medicaid, we are only going to see more strain on committee health centers and other 340b covered entities because they will be providing more uncompensated care.
▶ 0:53:24Hustead: I would like to share this chart that shows the guess what we are all sharing. You see hospital services at the top of the list and other services are here.
▶ 0:53:40Chair Cassidy: Can you get that out so the audience can see as well? >> we have some rule hospitals that can hardly make ends meet.
▶ 0:53:56Chair Cassidy: We have some truly is serving low income patients but we have some people who are 340b hospitals running super bowl ads and have huge ceo salaries and expenses at those entities and so what I hope we will be able to accomplish with this conversation is targeting the savings that comes out of 340b that comes toward the places
▶ 0:54:26Chair Cassidy: Most in need of those resources to help drive down the costs for consumers. I do want to clarify a couple of things. Some claim the 340b doesn't cost the taxpayers one penny but the cbo program found it encourages haber in a variety of always that increases spending such as a clinician prescribing more drugs that are more costly. Could you please expound on that a bit?
▶ 0:54:56Dr. Sen: Thank you for the question. In our recent report, we talk about behaviors that we believe are incentivized by the 340b that increased federal spending.
▶ 0:55:13Dr. Sen: There are incentives to prescribe more and higher cost drugs, incentives for manufacturers to limit rebates to commercial lands, medicare part d and medicare advantage plans and to expand services, some of which -- which would be reimbursable by federal programs and incentives to increase vertical integration which generally raises prices.
▶ 0:55:39Dr. Sen: Would you agree you could reform the program so it serves low income and make the low income patients help make health care more affordable but can resolve those issues?
▶ 0:55:52Dr. Feldman: --Dr. sen: the report doesn't have a different policy options but if cbo were asked we would look at the specifics.
▶ 0:56:03Sen. Husted: Consider that we will be asking. Thank you. Ms. rosenberg, I want to talk to you about the fact that the 340b program requires hospitals to have a contrast -- contract for state and local governments to provide health services to low income patients. In report it recommended hr essay in the meta-process -- hrsa to have an active contract that complies with the statute.
▶ 0:56:32Sen. Husted: Can you explain hrsa's enforcement and how it can help patients?
▶ 0:56:45Ms. Rosenberg: Hrsa looks at a small sample of newly registering hospitals and they would also look at hospitals if they were selected for an audit and they audit 200 entities, hospitals and grantees each year . At the large majority of hospitals have been participating in the program for years and hrsa has not verified whether they have a contract or not.
▶ 0:57:12Sen. Husted: Why?
▶ 0:57:14Ms. Rosenberg: In response our recommendation that they do so, hrsa said it would be burdensome on the covered entities to submit the contracts and --
▶ 0:57:26Sen. Husted: Is it the law?
▶ 0:57:28Ms. Rosenberg: It is required to have a contract and also that hrsa was worried about the resources out of their pockets.
▶ 0:57:37Sen. Husted: Fqhc's make up a fraction of the spending and they help low income individuals afford health care. As congress looks at 340b, should we look at them differently than hospitals?
▶ 0:57:54Ms. Rosenberg: I think you could. One thing I would know about them as part of getting a grant from the health center program, they are required to have a discount for low income individuals. That is a requirement that doesn't necessarily exist on all of the other 340b programs.
▶ 0:58:13Sen. Husted: It helps create for ability?
▶ 0:58:15Ms. Rosenberg: Absolutely.
▶ 0:58:17Chair Cassidy: Senator murray.
▶ 0:58:21Sen. Murray: Thank you, chair cassidy. It is critical we look at the programs that support our safety net health care providers like the 340 b but we can't have the discussion without also talking about how so many of our hospitals and health centers that families rely on are facing an existential threat from the massive health care cuts that republicans cast early this year.
▶ 0:58:47Sen. Murray: We are already seeing the closures and they will face more pressure if republicans refuse. Just work with us to say the aca tax credits and stop the premiums from skyrocketing and prevent millions of families from getting priced out of insurance.
▶ 0:59:06Sen. Murray: As crucial as this 340b plan is, indeed for months now but we have not had a hearing and note talks and no real serious interest from republican leaders .
▶ 0:59:29Sen. Murray: Open enrollment starts next week and this committee has yet to hold a single hearing on the fact that premiums are going to spike for 22 million plus people who rely on the aca premium tax credits. We are talking about 5 million people in this country getting priced out of their insurance entirely and going uninsured. This is not some distant issue.
▶ 0:59:55Sen. Murray: Window shopping has already started including in my home state and I am hearing from a lot of people. Families are logging in and facing sticker shock and wondering how I am going to be able to afford this. I talked to small business owners. Our worry they are going to have to close their doors or give up their insurance entirely. I have talked to seniors not quite eligible for medicare who haven't told their premiums will jump by over $1000 a month.
▶ 1:00:27Sen. Murray: I know this is not just a crisis in my state but happening across the country and most of the people who rely on these tax cuts live in those states that will be impacted and premiums are on track to more than double . Many of them will simply not sign up and lose coverage and forgo care.
▶ 1:00:54Sen. Murray: We also know that will lead to job loss, an estimated 340,000 jobs in the country in the health care space. It is frustrating to me and baffling that with the health care millions on the line, the committee has not held a hearing on the issue. Ignoring this problem is not going to make it go away.
▶ 1:01:16Sen. Murray: We are going to keep pressing to work with our colleagues across the aisle and have been asking about this for months and been at the table for months and we have got to get this work going now before the height premiums are locked in and every date makes it much harder. Having said that, I have questions for those in front of us. Dr. feldman, I want to talk to you because you are a critical care physician and a pulmonologist.
▶ 1:01:44Sen. Murray: We are talking about 5 million americans becoming uninsured because of the failure to extend the aca premium tax credits. When people become uninsured, what do you see as a physician the patients skip out on and what does it mean for their health?
▶ 1:02:01Dr. Feldman: Patient's skip out on doctor visits, medications. I vividly remember seeing a patient in the icu last year who was there in diabetic ketoacidosis which can be a fatal convocation of diabetes because she couldn't before her insulin. I think people losing their insurance will have very real consequences for patients across this country.
▶ 1:02:29Sen. Murray: I talked to some providers in the rural part of my state and we were talking about with all the uninsured that they will see a real impact on providers, hospitals and doctors and we will see more of them not be able to provide the care because they get the care eventually but usually when it is more expensive and they provide it uncompensated.
▶ 1:02:59Sen. Murray: I wanted to ask you as a physician and researcher, what happens to our safety net providers and hospitals when americans go uninsured, from your perspective?
▶ 1:03:07Dr. Feldman: The safety net providers get stretched. When patients don't have insurance, hospitals, community health centers are providing more care without reimbursement and it makes their jobs much harder.
▶ 1:03:24Sen. Murray: Thank you very much.
▶ 1:03:25Chair Cassidy: To defend the work of the committee, I will point out we have a hearing in july on health care insurance portability and not a single democrat brought up expiring enhanced aca tax credits. We have attempted to address it but it has to be raised. With that I recognize senator marshall.
▶ 1:03:49Chair Cassidy: >> I just have to remind my friends across the aisle, the aca is broken. 24 million people average deductibility is $5,000. That is not an access to health care. If you are a family making $80,000 a year, $5,000 deductible is not access to health care. Regardless of what we do in the next month or three, your premiums are going to go up at least 18% for the aca plans.
▶ 1:04:23Chair Cassidy: I am waiting for you all to say we need to fix the fraud, the cost, we need to fix the deductibles as well here simply throwing money at a problem doesn't solve the problem. We need to go after the true issues, fraud, the premium increases and the deductibility. But first we need to get the government open.
▶ 1:04:49Chair Cassidy: Let's turn to 340b, something I am familiar with. It started off as a wonderful program, my community health centers are so dependent upon them. It is interesting to me they get less plenty only 2% going to rule hospitals.
▶ 1:05:21Chair Cassidy: And we need to continue to fund more community health centers meaningful affordable primary care and integrating health and nutrition. The program is vitally important.
▶ 1:05:43Chair Cassidy: We see big monopolistic hospital systems abuse the system and frankly they are taking 94% of the dollars. It is not to be and it should be and we are here to fix it.
▶ 1:06:00Chair Cassidy: I am frustrated and we form committees and prayed about it and before we leave for christmas.
▶ 1:06:25Chair Cassidy: There are big hospital clinics that stop a patient five years ago and the patient moved out of state and they are using 340b as a profit center. Ms. rosenberg, any thoughts about how you would identify how you would identify the programs?
▶ 1:06:48Ms. Rosenberg: We have not specified a specific definition but we do have an open recommendation to them to clarify guidance. >> what does the definition look like?
▶ 1:07:02Ms. Rosenberg: What I can say, things to consider may be the frequency with an individual have been served. And whether or not the drug that they are provided as a result of a visit at that facility or from eight referral or is it
▶ 1:07:34Ms. Rosenberg: Unrelated to those are things. Can you add anything?
▶ 1:07:42The Ceo Would Not --Dr. Sen: A ceo would not recommend that.
▶ 1:07:51Sen. Marshall: Would it make it impact?
▶ 1:07:52Dr. Sen: I think any narrowing outpatient definitions.
▶ 1:08:06Sen. Marshall: , chairman cassidy cited a report let's go back to Ms. rosenberg. Since the fee structures are the same for grantees like community hospitals and health centers and hospitals, would you say this place is a disproportionate burden on grantees who typically operate on a tighter margin and what transparency requirements could help us implement and prevent neat diversions of resources.
▶ 1:08:44If You Are --Ms. Rosenberg: If you are a smaller entity, it may be more challenging. I would note that hrsa does not have insight to contracts that entities may have with third-party administrators or others.
▶ 1:09:03Sen. Marshall: You would agree that the pbm's are taking the chunk of money?
▶ 1:09:07Ms. Rosenberg: We have looked at third-party administrators and they get paid for their services.
▶ 1:09:14Sen. Marshall: Is a significant amount of money?
▶ 1:09:15Ms. Rosenberg: We don't know.
▶ 1:09:18Sen. Marshall: That is the problem. If you don't know that I don't know. I will yield my time. But I begged the committee to mark up a bill and let's get this done.
▶ 1:09:27Chair Cassidy: I will as regards the bill, senator baldwin has worked on the committee of six. Now it is senator kaine.
▶ 1:09:41Sen. Kaine: I am happy we are having a hearing on this important topic. I would like to introduce into the record one of my letters from the piedmont access to health services and southside virginia. Without objection.
▶ 1:10:01Sen. Kaine: They talk about using 340b dollars to ob/gyn after hospitals stopped delivering babies. And 7000 ob/gyn visits where the rural hospitals have not been able to figure out making it work. We are talking about where we are.
▶ 1:10:30Sen. Kaine: I will just stay in virginia over the 20 four hours between tuesday night and last night, 400 thousand people received notice about what their health care premiums would be on the exchange. In their reaction is it is a very big bill and hope we can ameliorate the suffering these families the 340b is important
▶ 1:11:02Sen. Kaine: Am glad to enter into the working group looking at reforms and I think we are making some real progress in response to what senator marshall and I hope we can do some of the things you suggest.
▶ 1:11:20Sen. Kaine: I was at an event with bunkie camp county virginia not long ago and doing early detection of breast cancer they said was, they have 20 sites in virginia and their financial model was a the related school -- stool.
▶ 1:11:50Sen. Kaine: Reimbursement for services provided to patients, especially medicaid and marketplace coverage. And the third is the 340b savings. These are the three pillars they use to operate and serve this particular entity. They are worried that all three of the pillars are in significant danger.
▶ 1:12:15Sen. Kaine: So first, hrsa, while there haven't been hrsa grant cuts, there have been staffing cuts at hrsa. Ms. rosenberg talked about doing more documentation about the contracts and more audits and assessments and information to be more transparent. If you are shrinking a staff that already didn't have enough resources.
▶ 1:12:41Sen. Kaine: They are word about what budget cuts might be coming down the path. The second pillar is medicaid. And medicare services. Obviously the big bills promotion and attacking subsidies down the road causing them huge concern and the third
▶ 1:13:12Sen. Kaine: Stool is the 340b program. This is pretty bipartisan and the focus on the focus on that, on both sides of the aisle we have to work for the entities for the sq agency's, these -- fq
▶ 1:13:44Sen. Kaine: Hc's, it is the medicare and medicaid reimbursement and 340b work together. These are the three pillars and that is why I am happy to be a part of this bipartisan group but preserved the program for those who need it so desperately.
▶ 1:14:11Sen. Kaine: And I am mindful that you said we don't offer policy advice, for the audience, the cbo is not in a position to freelance positions. If we put proposals on the table, we asked them what effect this will have and they did a study and make a suggestion. I didn't think folks was saying that de. Sen was playing along but it is a role she has to respect and I respect that.
▶ 1:14:47Sen. Kaine: In a motion with the reform efforts would be.
▶ 1:14:51Sen. Husted: --Ms. rosenberg: I would encourage you to look at the recommendations to hrsa an earlier discussion draft that the working group put out did address and it appears that it would address and happy to work with your staff as you proceed. >> the hrsa report is still outdated.
▶ 1:15:21Sen. Husted: >> 15 of them are still open. We would certainly encourage you to address them. Some of them have been discussed already today clarifying the definition of a patient, ensuring that duplicate discounts are addressed, whether they aren't service or managed care, making sure that entities are actually eligible to participate.
▶ 1:15:43Sen. Kaine: I am sorry that I didn't leave time for Dr. sen and Dr. feldman. I feel some other colleagues might answer that.
▶ 1:15:52Chair Cassidy: Senator collins.
▶ 1:15:56Sen. Collins: According to the maine hospital collective, main hospitals receive 100 44 million dollars for the 340b program last year. That made the difference between a negative operating margin and a positive operating margin for many maine hospitals.
▶ 1:16:24Sen. Collins: If we were to limit or eliminate altogether the 340b benefit without other policy changes we would wipe out the ability for these hospitals to operate. And I have heard the saying from many of maine's federally qualified health centers. Dr.
▶ 1:16:49Sen. Collins: Senn, I know that the cbo doesn't make recommendations, as he made clear to us, but did you evaluate the impact of the 340b program on the financial viability for rural hospitals?
▶ 1:17:09Dr. Sen: Thank you for the questions. Cbo doesn't have the data that we would need to estimate how much net revenue hospitals get from the 340b program, and therefore it is difficult for us to say what the effect would be if those people or revenues were pulled from hospitals or general revenue pot.
▶ 1:17:33Sen. Collins: Dr. feldman, I was very glad to hear you bring up some of the patent reforms that are desperately needed. It is something I worked on for years. For example, that block the development of generic drugs and need for an expedited approval for bio similars.
▶ 1:18:02Sen. Collins: Those are issues of parked on a bipartisan way, particularly with senator jeanne shaheen. I wanted to ask you about something that I'm told by my rural hospitals about access to drugs that are essential to the treatment of their patients.
▶ 1:18:22Sen. Collins: Some of the rural hospitals tell me that without the 340b program they are concerned that they would not be able to provide access to drugs that are essential to the treatment of their patients.
▶ 1:18:38Sen. Collins: Could changes in the 340b program unintentionally limit access to critical drugs for low income americans in rural areas and thus negatively impacted their health outcomes?
▶ 1:18:56Dr. Feldman: Absolutely. We could certainly see unintended consequences if we don't have carefully targeted reforms. As you said, rural hospitals, community health centers are lot of 340b-covered entities that depend on the program, such that if it went away or if it was drastically reduced they would not be able to provide their patients with the medications they need.
▶ 1:19:20Sen. Collins: Thank you. Ms. rosenberg, you are gao report notes that the 340b program gives qualified providers savings that enabled them to "reach more eligible patients and provide comprehensive services." I don't think this should be overlooked. I want to get an example of how one of my state's community health centers is doing exactly that.
▶ 1:19:50Sen. Collins: The hometown health center in newport, maine has used 340b savings to ensure that patients facing financial difficulties are able to get medications with no co-pay.
▶ 1:20:09Sen. Collins: Hometown health has also used 340b savings to provide transportation services to homebound patients, to bring them to their appointments, and then to the pharmacy. To pick up prescriptions. Could you discuss the oversight and accountability measures that govern the way that community health centers can use their 340b savings?
▶ 1:20:37Ms. Rosenberg: There are no requirements in the 340b program itself. As to how savings should be used, there may be requirements as part of their other grants that made them eligible for 340b as to how they are to use savings that are generated. I believe there are some requirements for health centers that they are to use those funds to further their grant and the goal of their grant.
▶ 1:21:05Sen. Collins: Thank you. This is something I think we need to take a look at, and we certainly need audits and accountability, but we've got to be careful that we don't restrict the ability of the savings from this program to provide much-needed health care services. Thank you, Mr. chairman.
▶ 1:21:28Chair Cassidy: Senator hassan.
▶ 1:21:32Sen. Hassan: Thank you, chairman, ranking member, and our witnesses for being here today. I will add that this is important and so is reopening the government and addressing the spike in health care costs that people will see if we cannot resolve the extension of the premium tax credits. I hope we can continue to work in a bipartisan way to do that. Ms. rosenberg, I want to follow up on the question senator collins was just asking.
▶ 1:22:01Sen. Hassan: Community health centers are required to reinvest any savings from the 340b drug discount program directly into patient services. Health centers in new hampshire, as we heard as well in maine, use the savings to directly lower drug costs for patients at their in-house pharmacies but also to make other services available. What additional steps can we take to increase transparency and help ensure that the 340b discounts in all settings are used to lower patient costs?
▶ 1:22:28Ms. Rosenberg: I would reiterate that there are no requirements in the 340b program itself. Those are part of their section 330 health center grant funding. There are not necessarily similar requirements on all of the participating entities in the 340b program.
▶ 1:22:46Sen. Hassan: Are there steps to add transparency and make sure the savings are used to lower patient costs?
▶ 1:22:52Ms. Rosenberg: If congress wanted to they could put specifications on how revenue is to be used. You could, if you wanted to, ask for covered entities to report the amount of revenue that they receive. I believe hr essay has asked for that authority to report on the revenue and what they are used for.
▶ 1:23:19Sen. Hassan: Dr. feldman, today's discussion about 340b is important, but I want to be clear that big pharma is responsible for driving a patient's costs at the pharmacy counter. I recently launched an investigation into the pharmaceutical company gsk after the company discontinued the most common children's inhaler last year. The company hiked the price of the brand-name inhaler above the rate of inflation for years.
▶ 1:23:47Sen. Hassan: Last year, because it had done that, it was do to pay more than $300 million in rebates to the federal government to account for its price gouging. Instead, the company pulled the brand name inhaler from the market right before it was set to pay these rebates. By doing so, it dodged accountability for its years of raising the price of this inhaler.
▶ 1:24:08Sen. Hassan: As a result of this decision, some families were forced to pay hundreds of dollars more for an alternative inhaler, without which their children could suffer life-threatening asthma attacks. Dr. feldman, what are the health consequences for children if their families cannot afford these inhalers?
▶ 1:24:24Dr. Feldman: The health consequences can be severe, as you mentioned. Increased asthma attacks, emergency department visits, hospitalization. The inhaler contains a molecule that is an anti-inflammatory. Children depend on that to stay out of the hospital to keep their asthma under control.
▶ 1:24:45Sen. Hassan: Thank you for that answer. I also want to follow up on another topic that senator collins touched on. Big pharma also dries up drug costs for patients by exploiting a loophole involving the food and drug administration and to the U.S. patent office.
▶ 1:25:06Sen. Hassan: Companies can use information about a drug that they already provided to the fda but withheld from the patent office to secure additional patents years after their original patent has expired, giving them that exclusivity pricing advantage. By exploiting a lack of communication between the two agencies, companies unfairly extend the patent protection for their drug and block low-cost versions from the market, and thereby artificially extend high drug prices. Dr. feldman, what are the real impacts of these patent gains on patients?
▶ 1:25:36Dr. Feldman: The patent gains can delay generic and bio similar competition which keeps prices high. Generic competition in our country is the key way we lower drug prices. When drug prices remain high, patients cannot afford their medications and we see worse clinical outcomes.
▶ 1:25:59Sen. Hassan: Senator hawley and I have a bill that would close that patent loophole and lower drug costs for patients, so I wanted to let my colleagues know about it. I thank you for your testimony about it and I hope we can get it over the finish line.
▶ 1:26:08Chair Cassidy: Senator murkowski.
▶ 1:26:10Sen. Murkowski: Thank you, Mr. chairman. I appreciate we are having this hearing this morning. I want to follow on both of the comments from senator hassan and senator collins with regards to ensuring that as we are looking to certain reforms for 340b that passing the savings on to patients. I come from a very, very rural state, as you know.
▶ 1:26:39Sen. Murkowski: The costs that they experience in accessing services, we are trying to do everything that we possibly can to make sure any savings achieved out there are translated through to the individual. Ms. rosenberg come along that vein, I wanted to ask you about access in remote and underserved areas. Contract pharmacies and tele pharmacy services are critically important for us. Connecting the patients to essential medications.
▶ 1:27:10Sen. Murkowski: In my state we have over 80% of our communities not connected to a road system, so we have to figure out really innovative delivery models. As you have examined the 340b program, what have you observed about contract pharmacies and how they are being leveraged to promote access for rural and isolated populations and how can
▶ 1:27:44Sen. Murkowski: We make sure these arrangements are preserved and strengthened for communities who would otherwise like pharmacy services ? We just don't have them in so many different ways.
▶ 1:27:54Ms. Rosenberg: Back in 2018, when we looked at contract pharmacies, we found about one third of covered entities utilized contract pharmacies at the time. They had anywhere between 1 and 400 contract pharmacies. The average was 12. One thing I would note, we often look at the extent to which entities passed on the discounts on drugs at their contact pharmacies.
▶ 1:28:24Ms. Rosenberg: A small sample of entities we looked at. Some did pass on the discounts and others didn't. I would say grantees were more likely to pack on the discount through their contract pharmacies onto patients in hospitals were -- van hospitals were.
▶ 1:28:43Sen. Murkowski: I went to asked the same question a little bit to Dr. sen and Dr. feldman. In terms of some of these proposed restrictions on the use of contract pharmacies by 340b-covered entities, can you speak to the impact that individuals will see if we don't do this right?
▶ 1:29:15Sen. Murkowski: Dr. feldman, I think you are the one that said that it needed to be carefully targeted reforms? Can you speak to the threat we would face if we don't get this right?
▶ 1:29:28Dr. Feldman: I think what we don't want to do is tota don't want to do is tot take away access to care in communities that really depend on it, that need it. Some research that our team conducted found that 340b covered entities disproportionate a share of hospitals had been increasingly placing their satellite clinics, known as child sites, into more affluent areas.
▶ 1:29:58Dr. Feldman: One of the things that you should think about in reforming the program is how to get these clinics, these pharmacies that 340b entities contract with inta area serving more disadvantaged patient populations.
▶ 1:30:12Sen. Murkowski: And underserved areas as well?
▶ 1:30:16Dr. Feldman: Yes.
▶ 1:30:17Sen. Murkowski: Dr. sen, can you comment on that?
▶ 1:30:21Dr. Sen: We did document in our report the growth in contract pharmacies and the change to hrsa guidance allowing covered entities to contract with an unlimited number of pharmacies. We seen a growth in contract pharmacies. We have not looked ourselves out the placement of those pharmacies, but we have seen literature from Dr. feldman and others.
▶ 1:30:46Sen. Murkowski: I would suggest that we keep this in the forefront of our minds. Again, we are talking but limited access in the first place. Again, trying to figure out ways that we can, through our policies, allow for greater equity, greater access.
▶ 1:31:08Sen. Murkowski: Sometimes I think the smaller underserved areas, socioeconomically disadvantaged, they kind of get caught in the backwash or some of this. I'm very interested in making sure that we do right with our reforms, but to your point, Dr. feldman, that we are a little cautious as well. Thank you, Mr. chairman.
▶ 1:31:37Chair Cassidy: Senator kim.
▶ 1:31:41Sen. Kim: Thank you to the three of you for showing up here today. Dr. sen, I want to start with you. I heard Ms. rosenberg earlier say that the purpose of 340b programs is to enable covered entities to stretch scarce of federal resources that reach more eligible patients, provide more comprehensive services, and I think that the key phrase is about stretching scarce federal resources.
▶ 1:32:09Sen. Kim: I guess I wanted to get an update from you just what that landscape is. Do you recall what cbo's estimate was for how much the republican reconciliation bill passed early this year would reduce federal health care programs five? -- programs by?
▶ 1:32:30Dr. Sen: I don't have those numbers at my fingertips but I would be happy to follow up.
▶ 1:32:36Sen. Kim: I have it here. Approximately $1 trillion, does that sound right?
▶ 1:32:41Dr. Sen: I would have to verify.
▶ 1:32:43Sen. Kim: I already have and it is about $1 trillion. I raised that because I think we need to be looking at this in terms of the context. Stretching already scarce resources, understanding how much more scarce that is. Dr. feldman, I wanted to turn to you.
▶ 1:33:04Sen. Kim: How much are hospitals and community health centers, how much are they stretched already, and how much further stretched will they be given what we saw in terms of the cuts from the reconciliation bill passed earlier this year?
▶ 1:33:16Dr. Feldman: I think hospitals are already stretched. We heard reports from the american hospital association the hospitals provide around $100 billion a year in uncompensated care and community benefits.
▶ 1:33:33Dr. Feldman: What I worry about is the removed people from insurance programs, like medicaid, we will see more folks who can't afford care in hospitals and community health centers -- and hospitals and community health centers will bear the brunt of that.
▶ 1:33:52Sen. Kim: Being able to understand it in the context of where our country is headed, health services are going, I think it's important for this committee to keep in mind. Dr. feldman, one of the policy suggestions you've made is 340b hospital should have the -- have to meet certain standards for community benefits they provide. Can you talk about with those benefits would look like in practice and what factors we should consider in setting such standards?
▶ 1:34:20Dr. Feldman: I think the standards could be set in a variety of ways. The goal of 340b is to help underserved patient populations. I think setting clear standards for hospitals in terms of the amount of the uncompensated care they provide, the amount of debt they forgive, the number of community programs they start, the amount of financial resources they are committing to local communities.
▶ 1:34:49Dr. Feldman: All would be on the table in terms of defining these community benefits. There's a lot of good that 340b covered entities are doing already in their communities. I think setting some standards that all 340b covered entities, depending on the type, would have to meet would be a good idea. I have to emphasize that it depends on the type. You don't want the same requirements on a rural health center as you do on a big academic medical center.
▶ 1:35:18Sen. Kim: That makes sense. We were hearing about rural hospitals, the topography is different. I want to reiterate that as of now there are no requirements in terms of how the money is spent?
▶ 1:35:30Dr. Feldman: That is correct. Hospitals can spend the money however.
▶ 1:35:35Sen. Kim: That is something I want to highlight and underscore because it was surprising to a lot of my constituents that I've talked to about this that aren't necessarily in the health field. Recognizing how little there is in terms of specifications on how the revenues can be used. I want to raise one more issue. Ms. rosenberg, a number of recommendations have been made with respect to 340b.
▶ 1:36:01Sen. Kim: One recommendation was to ensure that their policies in place to prevent duplicative discounts, where a provider benefits from rebates under medicaid and 340b. I wanted to ask, because we've seen a number of states set up clearinghouses to reconcile medicaid 340b rebates. Do you think that a national clearinghouse could address some of these concerns?
▶ 1:36:24Ms. Rosenberg: I think that is something worth considering.
▶ 1:36:27Sen. Kim: Dr. feldman, do you have thoughts on this?
▶ 1:36:30Dr. Feldman: I like the idea of a national clearinghouse. I worry when you leave it up to the pharmaceutical companies in a rebate model you will disadvantage the hospitals. If you leave it up to the hospitals it disadvantages the pharmaceutical companies. I think having a third party adjudicate some of these claims is a great idea.
▶ 1:36:49Sen. Kim: Mr. chairman, I'm glad to hear from my colleagues that there is bipartisan work being done amongst them. Thank you, senator baldwin, for your participation and senator hickenlooper. I join you in trying to figure out how to come up with sensible, tangible ways to address this. I hope that is something the committee can get done this congress.
▶ 1:37:10Chair Cassidy: You addressed the yin and yang, the good and bad. Thank you for your question.
▶ 1:37:20Sep. Hawley: Dr. feldman, I want to talk a little about the cost of prescription drugs. You noted in your testimony, written testimony, that the united states pays the highest prices for prescription drugs anywhere in the world. I was looking at some of the numbers this morning. We pay about 250 percent more than 32 comparison countries in the last 2021 rand corporation analysis. Insulin, for example. The average U.S.
▶ 1:37:50Sep. Hawley: Price for a standard unit of insulin is $98.70. In australia it is six dollars $.94. I think that is really extraordinary. Why should we not required by law some index pricing where we say to the pharma companies that you can set the price how you want on the global market?
▶ 1:38:18Sep. Hawley: But taking the industrialized or western european countries, choose your set of countries, whatever would be appropriate economically, you can't charge in the U.S. more than the average price you're charging in the similar markets. Is there something wrong with that? What would you suggest as another alternative?
▶ 1:38:33Dr. Feldman: I don't think there's anything wrong with that if it's done well. We have to be careful about who we are referencing to and exactly which prices you might be referencing. But you're right. We pay more than every other country by far in the world for prescription drugs. 340b reform is important. I'm glad we're here to talk about 340b reform, but it's not going to solve the problem you mentioned. We need other solutions to solve the problem.
▶ 1:39:03Dr. Feldman: International reference pricing is one solution. Expanding the price negotiation is another solution, patent reform to get generics and bio similars on the market is another solution. There are a lot of ways to lower drug prices in our country that we have not been managing to do that for a long time.
▶ 1:39:18Sen. Hawley: I think that's obvious. Everybody who is out there paying these prices for prescription drugs, people just can't afford it. The cost of insurance is totally unaffordable as it is. You add on top of that prescription drugs, those who are not covered by insurance, those who are, the prices are astronomical. I don't understand. I don't understand why american consumers have to pay 250 percent more.
▶ 1:39:47Sen. Hawley: Senator welch and I have a bill on international reference pricing. The pharma companies can set the price. The market, the global market, where they want it. They cannot do -- I am a former prosecutor. We called this price gouging. They can't gouge the american consumer by saying we will pay $100 for insulin and the same companies are charging $10 in canada. I think that's totally outrageous. On the subject of the pharma companies, can I as something as a matter of policy?
▶ 1:40:15Sen. Hawley: Is it a good idea for the american taxpayer to subsidize the television commercials of pharma companies advertising all of their overpriced drugs on tv? Do you have an opinion on this?
▶ 1:40:27Dr. Feldman: I don't think that's a good idea, but I would love to hear more about what you are referring to.
▶ 1:40:33Sen. Hawley: What happens currently is the pharma companies can write off as a business expense their advertising costs. So, they can put up on television these ads about their drugs and then they charge us 200% to 300% more than other countries and consumers, and then they can take all of those costs that they use on their advertisements and write them off. Effectively the american taxpayer is subsidizing these big pharma companies.
▶ 1:41:01Sen. Hawley: They don't seem to me they need any more subsidies than they already get and yet they are being subsidized by the U.S. tax code. We ought to end that. If you want to advertise on tv, which I'm not sure is a great idea anyway, but putting that to one side, if you want to advertise direct to consumer, do it on your own dime. Why are we subsidizing you? I think that's insane. Do you have a reaction?
▶ 1:41:23Dr. Feldman: I agree. I think it's a terrible idea we have these commercials in the first place. We are the only -- one of the only places in the world where you can advertise direct to consumers. I agree to you -- with you.
▶ 1:42:04Sen. Hawley: Do you have a view on the rapid consolidation of pharmacies, the loss of independent pharmacies, pbm's buying up pharmacies left right and center. In some cases buying up doctors practices, hospitals, integrating all of them? Basic economics would tell us when we have that kind of integration, vertical integration, you'll get an increase in prices. Do think that has anything to do with the increase in drug prices and can we do anything about it?
▶ 1:42:13Dr. Feldman: I think it can contribute for sure. Having these big consolidated entities that control all aspects of care is not a good idea. I think that efforts to restrict that, limit that, would be helpful.
▶ 1:42:20Sen. Hawley: I do too. Frankly, we shouldn't allow the pbm's to buy up other parts of the supply chain. We have two counties -- I will finish with this -- we have two entire counties in missouri now that have no pharmacies. Zero. We used to have more independent pharmacies than just about any state in the nation and now some of the fewest. We have whole counties we could not find a pharmacy. Big companies, big pbm's, they make more money than ever before. It is a racket.
▶ 1:42:49Chair Cassidy: Senator hickenlooper.
▶ 1:42:54Sen. Hickenlooper: This is one of those days where five minutes won't be enough. Appreciate the other members of the committee and witnesses for being here. My appreciation for senator baldwin and senators kain, mullin, capito, and moran I.
▶ 1:43:21Sen. Hickenlooper: Will not dare relitigate the issues around the 15 million more americans are going to find themselves uninsured with increasing costs. I do think there is a point in looking at how our country is divided. It's not 50-50, but large numbers between people who think that our safety net is strong and a global model, but not strong enough. And efficiency, better allocation of resources can make the safety net stronger.
▶ 1:43:52Sen. Hickenlooper: Others think our safety net is too lavish, too filled with too often fraudulent activity and waste. I obviously come down on the side that I think we want to focus on improvements, but at the same time cutting waste and fraud, but making sure we get those improvements in place. Dr.
▶ 1:44:19Sen. Hickenlooper: Feldman, given the cuts to the health care safety net, do you think that 340b will be more or less critical to expanding access? Really expanding and improving the safety net?
▶ 1:44:33Dr. Feldman: I think it will be more important. I come down on the same site is you that I think our safety net is not strong enough. I see patients in the clinic and in the hospital that need more. I worry that all of the cuts we are seeing are going to leave more patients without an ability to afford their care, which will only put more strain on community health centers and hospitals we are here to talk about today.
▶ 1:45:00Sen. Hickenlooper: When we expanded medicaid in colorado, medicaid is a great in power of community health centers, as I'm sure you know as well as anyone. -- great empowerer of community health centers, as I'm sure you know as well as anyone. How do you closer to 100% coverage?
▶ 1:45:24Sen. Hickenlooper: We had a survey in colorado that 91% of community health centers are using 340b to reduce costs for patients through a sliding scale fee. One of our safety net hospitals has 76% of patients un or underinsured. That is higher for people in rural parts of the state. Ms. rosenberg, I will go to you.
▶ 1:45:53Sen. Hickenlooper: Over the years, hrsa clearly has as finn discussed lacks the authority to address certain challenges within the 340b program, like duplicative discounts. When we think about how to best strengthen the program and make it better, ensuring that it meets its mission, should congress also be -- should congress also consider which entity is best equipped to manage reforms?
▶ 1:46:24Sen. Hickenlooper: Things like increased transparency measures? This committee has a checkered history in terms of foxes in hen houses. Making sure we have the right people making the decisions relative to their own self-interest. It has to be kept top of mind.
▶ 1:46:41Ms. Rosenberg: Certainly I think making sure whatever entity is responsible for overseeing 340b, that they have the necessary authority to do so. As you mentioned, hrsa told us they don't think they have the necessary enforcement capability.
▶ 1:47:01Ms. Rosenberg: And has on multiple occasions asked for additional regulatory authority and we can't -- and it can't put in recommendations until they have such authority.
▶ 1:47:11Sen. Hickenlooper: Dr. sen, when we look at some of those issues around responsibility and who has the appropriate responsibility, in terms of improving the 340b program, where do you think some of that oversight should be centered?
▶ 1:47:28Dr. Sen: Well at cbo we wouldn't recommend a specific approach. I believe cbo in the past has considered shifting responsibilities for different programs. Not in the context of 340b specifically, and generally it matters more what the scope of the oversight and activity is than which agent. -- which agency.
▶ 1:47:55Sen. Hickenlooper: I was hoping to get your personal preference, but I will let that go. There is the quick gavel at the chair.
▶ 1:48:04Chair Cassidy: It is red for 12 seconds so far. Senator banks.
▶ 1:48:10Sen. Banks: . Your report suggests drug spending is higher at 340b hospitals, as you mentioned. Are you confident about what's causing that?
▶ 1:48:20Dr. Sen: Thank you for the question. As we note in the report, in many cases the evidence about the behaviors that 340b incentivizes an increased federal spending is limited. 340b hospitals are different from other hospitals in many different ways, a different patient population. They tend to be larger.
▶ 1:48:44Dr. Sen: The studies that we looked at and si -- and cite and therefore take those into account. The findings don't always agree. In our assessment, the body of work provides credible evidence that 340b contributes to higher drug spending.
▶ 1:49:01Sen. Banks: Your report notes that the 340b program incentivizes the consolidation of hospitals and clinics. Consolidation generally increases drug spending. Can you tell us more about why that's happening?
▶ 1:49:14Dr. Sen: There are a number of factors that incentivize consolidation in health care markets. We say in the report that 340b is one. Other reasons include gaining leverage with private health insurers to charge higher prices, a lack of neutral payments, interest in controlling the referral pipeline, and building scale to handle complexity.
▶ 1:49:38Sen. Banks: Some show patients spend more on drugs from 340b hospitals than other hospitals. What did you find in your work?
▶ 1:49:46Ms. Rosenberg: About 10 years ago, gao looked at medicare part b drug spending at 340b and non-340b hospitals. We found spending was higher at 340b hospitals, noting that these hospitals prescribed more drugs, more expensive drugs compared to non-340b hospitals. I believe that's one of the studies that sen used in her report as well.
▶ 1:50:11Sen. Banks: Is there any requirement that a hospital company use the revenue from the 340b hospital at the same hospital where it is generated?
▶ 1:50:19Ms. Rosenberg: It is not. There are no requirements as to how 340b entities use their revenue.
▶ 1:50:26Sen. Banks: Should there be?
▶ 1:50:28Ms. Rosenberg: I think that is something congress could consider.
▶ 1:50:31Sen. Banks: There is not much information about how hospitals and health centers use the 340b program, but what do we know about that? How do you share the discounts that they receive with their patients, for example?
▶ 1:50:47Ms. Rosenberg: Because there is no requirement for how they use the program or the revenue from the program, we don't know a lot. They are not required to report that kind of information. We have done some reviews where we have looked at a sample of covered entities, and have found that some passed discounts onto patients and others have not.
▶ 1:51:12Ms. Rosenberg: Entities have reported to us using the revenue to do things such as expand services, expand locations, to keep their locations open to makeup for short-comings and other resource revenues. Hrsa has told us that they do not have sufficient enforcement capability to manage the program.
▶ 1:51:39Ms. Rosenberg: They have on multiple occasions requested regulatory authority from congress to improve their oversight of the program.
▶ 1:51:44Chair Cassidy: Senator markey.
▶ 1:51:51Sen. Markey: Thank you, very much. I just want to start by pointing out that we are holding this hearing on the 340b program and hospital finances in the middle of the health care shut down in our country. Over the summer, the republicans passed the bill to gut medicaid and our entire health care system. Hospitals in massachusetts are expecting to lose between 350 and $600 million over the next decade.
▶ 1:52:21Sen. Markey: I commissioned a report at the university of north carolina that found over 300 rural hospitals are at risk of closure or having to cut services because of the bill. The hospitals that survive will have to find a way to balance the books while caring for a surge in uninsured patients. Republicans are blocking a continuation of the premium tax credits that help millions of americans afford health insurance.
▶ 1:52:51Sen. Markey: The ticking time bomb is about to go off. Over 300,000 people in massachusetts alone are finding this month that their premiums are about to skyrocket. Many will decide they can no longer afford health insurance. Trump's make america sick again agenda hurts families.
▶ 1:53:21Sen. Markey: Dr. feldman, thank you for joining us. Thank you for your work on the investigation that I lead with other members of this committee on the extreme prices companies have been charging for inhalers. Our investigation led companies to lower the price of inhalers, a critical win for patients. Dr. feldman, you worked in massachusetts for more than a decade, so it probably won't surprise you that more than 60% of them operate in the red.
▶ 1:53:55Sen. Markey: What impacts on hospitals and patients can we expect to see cuts to medicaid and premium tax credits not reversed especially for hospitals already losing money this year?
▶ 1:54:06Dr. Feldman: I think we could see really devastating effects on the help of patients in massachusetts and other states in our country. I think we could see less screening. Less management of blood pressure. Less diabetes care. We could see more hospitalizations for heart disease and respiratory disease.
▶ 1:54:29Dr. Feldman: I think you are absolutely right to point out how these cuts will translate into health losses and how hospitals in your state and other states will bear the brunt of patients losing their insurance coverage.
▶ 1:54:45Sen. Markey: We know that the republican bill was passed and will have a dramatic impact on medicaid. It will force medicaid work requirements, which we know is just new paperwork requirements nationwide. Last month, the gao issued a report on medicaid work requirements in georgia. Ms.
▶ 1:55:08Sen. Markey: Rosenberg, how much do gao determined that it costs to administer these onerous requirements?
▶ 1:55:16Ms. Rosenberg: We found between fiscal year 20 21 and the second quarter of 2025 georgia spent about $54 million on administrative spending for its work requirements demonstration.
▶ 1:55:31Sen. Markey: $54 million in just one state, spent on red tape of making americans healthier and lowering their bills. That's just wrong. Just an absolutely inefficient way of dealing with all these issues. Dr. feldman, if someone loses their health insurance because they were unable to complete time-consuming and complicated forms, how would you expect that to impact their health?
▶ 1:56:02Sen. Markey: With that make them more or less likely to be able to find and keep their job?
▶ 1:56:06Dr. Feldman: I think it could have that consequences for their health, and he could make them less likely to be able to work. I think about someone who can't afford their inhaler who is not taking the maintenance therapy that's prescribed to them, who then finds themselves dealing with a copd exacerbation, out of work, unable to contribute.
▶ 1:56:30Sen. Markey: Preventative health care is a moral imperative that keeps families healthy and patients out of the emergency room and health care affordable. Community health centers are key providers of preventative and primary care. 340b is crucial to health centers trying to keep the lights on. Dr. feldman, can you share from your experience as a physician what happens when patients are not able to access primary care in their communities?
▶ 1:56:57Dr. Feldman: When patients cannot access primary care they end up in the hospital. For example, I think about a patient who I saw in the icu from an opioid overdose. How do someone land in an icu following an opioid overdose? They may not have had treatment for their addiction.
▶ 1:57:22Dr. Feldman: There are all sorts of health conditions, problems that arise years later because you didn't get the cancer screening that you needed or you couldn't treat your high blood pressure which results in heart disease down the road. I think you have immediate effects of loss of health insurance coverage. You have a far downstream effects that can be equally as problematic.
▶ 1:57:47Sen. Markey: Yale university is saying 50,000 people per year are dying because of this health care coverage. Thank you.
▶ 1:57:52Chair Cassidy: I will take my questions now. I will note california is a medicaid expansion state and has aggressively use the exchanges. When you think of your patient, diabetic ketoacidosis in the icu, that the patient that has been afforded every chance for coverage. I point that out because republicans want people to have access. I'm a doctor who worked in a public hospital for the uninsured for 20 years prior to coming to congress.
▶ 1:58:19Chair Cassidy: We are concerned about structural problems with the un-affordable care act that apparently require large subsidies from the 340b program to make up for an unaffordable health care plan. I will point out that if hospitals in massachusetts are losing -- are losing money when that state has aggressively expanded medicaid, then something is wrong with our structure.
▶ 1:58:44Chair Cassidy: My gosh, in massachusetts california, as close to full insurance rates as possible and hospitals are losing all that money and patients are paying through the nose for their insurance? Employers can't afford the coverage? And we need large subsidies from the sale of pharmaceuticals, which we are told are driving up costs overall to subsidize? We have a structural problem with the un-affordable care act. And that is what republicans want to address.
▶ 1:59:13Chair Cassidy: Frankly, that should be a bipartisan concern. Moving on, Ms. rosenberg, you differentiated between community health centers and hospitals and said that community health centers are more likely, even required, to give a discount to the patient from the benefits of the 340b discounted drug, and that hospitals don't necessarily do so. Did I interpret that correctly?
▶ 1:59:42Ms. Rosenberg: Community health centers, part of their health center grant, they are required to have a sliding fee discount schedule for individuals who are low income. Presumably that would apply to any in-house --
▶ 1:59:49Sen. Markey: Some hospitals --
▶ 1:59:51Chair Cassidy: Some hospitals don't discount the drug. They will still charge them the full amount?
▶ 1:59:56Ms. Rosenberg: Yes. From limited samples we found some hospitals offer discounts and some do not.
▶ 2:00:02Chair Cassidy: I don't know if you have this information, but I've been struck there different types of hospitals. Hospitals who just make the minimum of 340b requirement every year but enjoy the fruitful advantages of 340b. And then there are hospitals which have a bad payer mix, uninsured, medicaid, medicare, knife and gun club victims, which for the audience means that there is a lot of trauma required and the level of trauma center.
▶ 2:00:31Chair Cassidy: In your research, did you differentiate between the hospital that barely meets it every year but takes full advantage of 340b versus the hospital that's really taking care of a lot of sick people?
▶ 2:00:41Ms. Rosenberg: I assume you are referring to the disproportional share metric? We haven't looked at it that way. We've done work looking at the levels of uncompensated care and care across 340b hospitals. And we have found that there are some of the top quartile of a provision of those things and some that are on the bottom quartile when compared to other hospitals.
▶ 2:01:05Chair Cassidy: I understand that the hospital system can use the money's in different ways. I have toured some hospitals in louisiana, that they've taken over, and rural hospitals serving a tough to treat population. They say they are using the 340b for that. So, I want to clearly make that there are other uses for the money besides discounts. Dr.
▶ 2:01:33Chair Cassidy: Feldman, senator tuberville suggested -- asked if there is any fraud in the program. I think it was you or Ms. rosenberg who said that a lot of the daughter sites, child sites are being placed in affluent areas with good coverage? That may not be broad, but it's clearly not the spirit of the program.
▶ 2:01:57Chair Cassidy: In which you are using the discount as a profit center and not to deliver care to those who otherwise would have a difficult time affording care? Is that a fair statement?
▶ 2:02:07Dr. Feldman: I agree with you. To note, the opposing position is that hospitals should put those child sites in more affluent communities in order to get more money in order to fund the community benefits and their hospitals. But I agree with you.
▶ 2:02:30Dr. Feldman: I don't like seeing that all of the new child sites are being put in more affluent suburbs and not in the areas where disadvantaged populations could utilize the services.
▶ 2:02:41Chair Cassidy: I suspect ucla is a well-funded medical center and you don't have to comment on that. They are your employer. That said, if they are putting it in brentwood, at a plastic surgery clinic in an area of l.a., as opposed to watts, which is less well, that seems like mission creep. It sits poorly with me.
▶ 2:03:12Chair Cassidy: That is just an editorial comment. Ms. rosenberg, my staff tells me that crs has reported the sliding fee schedule only applies to medical services and nondrug prices. Any comment?
▶ 2:03:23Ms. Rosenberg: I guess I stand corrected. There are health centers who will apply it, but maybe they are not required to but they will apply it.
▶ 2:03:37Chair Cassidy: Turnabout is fair play. Senator alsobrooks.
▶ 2:03:44Sen. Alsobrooks: . We are now in day 23 of the government shut down. I had the opportunity to speak yesterday about the terrible harms that this administration is causing workers in my state during the shutdown. At its core, our government shutdown and federal workers are without a paycheck because the president has made it his mission to throw our health system into chaos. I would love to engage in a conversation on the 340b program today.
▶ 2:04:16Sen. Alsobrooks: Maryland's community health center, safety net hospitals, rely on this program to stretch limited resources to provide essential services to low income and uninsured patients, yet there is a real irony in discussing the need for increased transparency in health care costs days before open enrollment and americans will face sticker shock as they purchased their health plans for next year.
▶ 2:04:40Sen. Alsobrooks: There is a real irony in calling on the increased importance of the 340b program after months of actions that will kick millions off of their health care coverage and exacerbate the uncompensated care crisis in our country. The so-called one big, beautiful bill will kick 10 million people off of their health insurance.
▶ 2:05:00Sen. Alsobrooks: If the president gets his way and fails to extend affordable care act tax credits before americans sign up for next year's plans, 20 million americans will see their health care costs skyrocket. Millender -- marylanders have already previewed the prices before open enrollment and are suffering from sticker shock.
▶ 2:05:24Sen. Alsobrooks: A 60-year-old couple making $85,000 a year will be paying an astronomical $13,700 per year for their coverage. For a family of four making around 120 $8,000 a year, which is a firefighter/teacher salary, they will be paying $7,000 more per year.
▶ 2:05:45Sen. Alsobrooks: If the president and my republican colleagues allow the tax credits to expire, nearly 5 million americans, 90,000 marylanders, could be priced out of health insurance altogether. The reality is hospitals and community health centers across the country have been under attack by this administration.
▶ 2:06:04Sen. Alsobrooks: The one ugly bill will cost community health centers nearly $7 billion annually in uncompensated care costs and maryland' a community care centers, an essential safety net, serve 74,000 people every year. The majority of these patients live below 200% of the poverty level. The bill created a new fund that is woefully underfunded to provide relief to hospitals that will be harmed by the massive medicaid cuts from this ill-conceived law.
▶ 2:06:36Sen. Alsobrooks: The sheer amount of newly uninsured americans with cuts to medicaid and aca tax credits is enough to completely destabilize our health system. Finally, thaad insult to injury, the very agency charged with overseeing the 340b program has been slashed by this administration's reckless reductions in force. The president's budget eliminates it.
▶ 2:06:59Sen. Alsobrooks: Instead of looking for change under the couch cushions for the pharmaceutical industry, I hope that we can work together to fix this mess. My question -- in the time I have -- it is for Dr. feldman. Senator kim asked about the cbo estimate of how many people lose their health care coverage as a result of the big ugly bill. That number is 10 million americans.
▶ 2:07:25Sen. Alsobrooks: If you add up the cuts to the aca tax credits and red tape imposed by the trump administration, the cbo estimates 50 million americans will lose their health coverage. You are a pulmonary and critical care doctor. What happens to health care when millions of people lose their health insurance coverage?
▶ 2:07:45Dr. Feldman: Health care gets much worse and we see worse clinical outcomes. I think that we need more health insurance coverage in our country, not less health insurance coverage. More health insurance coverage would mean more screening, more clinic visits, more treatment of chronic diseases, less need for acute care in emergency departments and hospitals.
▶ 2:08:11Dr. Feldman: I think you are absolutely right that these cuts to insurance in our country could be problematic and devastating for americans.
▶ 2:08:20Sen. Alsobrooks: Also, I wanted to ask, on monday cbo updated their score of the provision of that one big, beautiful bill that will weaken the drug price negotiation program and give a hand out to pharmaceutical companies. How do you think this will impact patients access to affordable drugs?
▶ 2:08:41Dr. Feldman: What you are referring to will limit the number of drugs that are eligible for medicare price negotiation. The cbo estimated that it would cost $8.8 billion. That will mean higher prices for our health care system, for patients. I think that we should be working to expand medicare price negotiation under the inflation reduction act, not shrink it.
▶ 2:09:04Sen. Alsobrooks: Thank you.
▶ 2:09:06Chair Cassidy: As I thought about my remarks, I don't know that you has a plastic surgery center in brentwood. I may have misrepresented them, so I apologize to the bruins. For any senator wishing to ask additional questions, they will be due 5:00 october 26. An incredibly informative hearing and you saw the participation from both sides. Senator baldwin and I noted the quality of the witnesses and importance of the topic.
▶ 2:09:36Chair Cassidy: Thank you for being here. The committee stands adjourned. [gavel falls]