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HHS Secretary Xavier Becerra was getting heat from both sides of the aisle at a House Energy & Commerce Health Subcommittee hearing on the president's proposed HHS budget for fiscal year 2025.

Subcommittee chair Rep. Brett Guthrie (R-Ky.) started things off Wednesday afternoon. "I'm disappointed that the budget request does nothing to address the influx of illicit drugs like fentanyl coming across our border at a rapid rate," he said. "We have policies passed out of this very committee that I'm disappointed weren't included in the budget request, such as the and the . Both of these bills would give law enforcement the tools to crack down on drug traffickers and keep these drugs off our streets."

Questions on Treatment of Unaccompanied Migrants

Next came Rep. Anna Eshoo (D-Calif.), the committee's ranking member, who asked Becerra why he hadn't answered her questions about the "horrendous exploitation of [refugee] children that were discharged by the Office of Refugee Resettlement (ORR). She referred to reports that unaccompanied migrant children under brutal conditions."

Eshoo said her questions to HHS about what was being done to change the culture at ORR "were ignored. There was no answer from you on that. I think one of the most alarming aspects of this issue is that ORR employees claimed they face pressure to expedite [processing these children] at the expense of their safety."

Becerra said that once the ORR releases the children to their sponsors, "they are no longer in our care and custody. We don't have jurisdiction over them."

But that response did not satisfy Eshoo: "Have you done anything? Share with us what you have done ... These are children! We have to answer to God for them. I'm asking you to commit to working with me on this." Becerra pushed back, saying he "disagree[d] with the way you characterize" his agency's response.

What About Site-Neutral Payment?

Rep. Michael Burgess, MD (R-Texas) asked about healthcare marketplace consolidation and its effect on independent physician practices. "Is [provider consolidation] a problem that needs to be addressed?" asked Burgess.

"Any consolidation which isn't for the purpose of efficiency can be a problem," Becerra said.

"I personally think the presence of independent physicians is an invaluable counterweight to the rise of consolidation that we see in our healthcare markets," said Burgess. "So what is this administration doing to help preserve independent practice as an option for physicians and patients?"

"We continue to work within the industry to make sure that no consolidation is occurring for monopolistic purposes," said Becerra. "We try to keep prices competitive." He added that removing independent practitioners from the marketplace would likely lead to higher prices.

Burgess mentioned the annual issuance of Medicare's proposed Physician Fee Schedule, which will come out in a few months. "It seems intuitively obvious to the casual observer that this administration prefers larger healthcare systems and neglects smaller providers," he said. "Why hasn't this administration embraced ideas such as site-neutral payment reform to lower costs and reduce consolidation -- something that's been included in the president's budget for over a decade?"

Becerra said he would be "more than willing" to work with Congress on the issue but added that HHS has to follow the budget neutrality rules set forth by Congress. "But if it doesn't really deal with the reality of what the practitioner on the ground has to face, we all should take a closer look."

Becerra said the administration supports smaller providers because they are "typically the ones that are in rural America, they're typically the ones that are in lower-income America, and we desperately need to keep them in place. And so we have promulgated a number of policies that support smaller providers. We want to avoid them being gobbled up by the big guys."

The No Surprises Act and its rules for independent dispute resolution were the focus for Rep. John Joyce, MD (R-Pa.). He focused on the qualifying payment amounts (QPAs) that health insurers set for procedures and services during the dispute resolution process.

"I have heard multiple widespread concerns that the QPAs calculated by health plans are artificially low, in some cases lower than the Medicare fee-for-service payment rates," Joyce said. He noted that since 2022, HHS has been required to report on the audits it has done on the health plans and their participation in the dispute resolution process. Joyce asked Becerra how many audits have been initiated and completed.

"The way the [independent dispute resolution] process launched really made it difficult to proceed forward with a clearer understanding of how it would be implemented well, because much of the implementation went to court," Becerra replied, adding that the number of dispute resolution cases filed was "dramatically" higher than anticipated. "And much of the data that will help us explain how the No Surprises Act will function moving forward ... is barely beginning to come in."

Enforcing Price Transparency

Rep. Cathy McMorris Rodgers (R-Wash.), chair of the full Energy & Commerce Committee, homed in on the proposed $250 million for subsidizing the health insurance sold on the Affordable Care Act's health insurance exchanges. "Does the money go to insurance companies?" she asked.

"The investments make sure that Americans can afford to purchase the insurance they need to get healthcare coverage," Becerra replied.

Rodgers pressed on, asking him how high a deductible he'd consider affordable given that the U.S. median income for a single adult is $70,000 a year. Becerra didn't answer directly, saying only that four out of five shoppers on the exchanges "are finding a health insurance coverage plan that gives them real quality coverage for less than $10 a month in premiums."

"Do you know the average [annual] deductible of a Silver plan?" Rodgers asked, referring to one of the mid-level plans -- from a choice of -- available on the exchanges, based on the coverage level offered. Becerra started to answer that deductible levels vary, but Rodgers interrupted him. "It's over $5,000," she said.

She also noted that "we've been waiting for years for this administration to enforce price transparency requirements for pharmacy benefit managers and insurance" that were finalized under the Trump administration. "Ranking Member [Frank] Pallone [D-N.J.] and I applauded CMS when they announced enforcement was coming last September, but it still hasn't happened," Rodgers said. "So when can we expect HHS to enforce the drug price transparency rule?"

"We are currently enforcing that law; we're doing it as best we can, but as you know, it has gone through a number of iterations in the courts," said Becerra. Rodgers seemed impatient. "It's only been 3 years," she said sarcastically.

For his part, Pallone took a gentler approach on enforcement of a rule on hospital price transparency. "I do think that it's unacceptable that some hospitals continue to make it difficult for consumers to access price information and I'm concerned with the lack of compliance by some hospitals. So could you briefly discuss what additional steps the department will take to increase enforcement of this final hospital transparency rule?"

"We continue to work with hospitals throughout the country" to help them implement the rule, Becerra said. "But after a while, if they're not making progress that we believe they should, we're prepared to take enforcement action against them." Pallone seemed to like that answer. "This [rule] went into effect 3 years ago, so any enforcement action I would really appreciate," he said.

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