Re: Senate Committee on Health, Education, Labor & Pensions

 “Nominations of Vivek Murthy to serve as Medical Director in the Regular Corps of the Public Health Service and Surgeon General of the Public Health Service, and Rachel Levine to serve as Assistant Secretary of Health and Human Services”

Date: February 25, 2021

Witnesses:

  • The Honorable Vivek Hallegere Murthy, to serve as Medical Director in the Regular Corps of the Public Health Service and Surgeon General of the Public Health Service, Testimony
  • Dr. Rachel Leland Levine, to serve as Assistant Secretary of Health and Human Services, Testimony

Opening Statements

Chair Patty Murray (D-WA) opened the hearing by saying that to end the current pandemic, and rebuild the nation stronger and fairer, the Biden administration needs an all-hands-on deck approach, highlighting the importance of considering and confirming qualified nominees like Murthy and Levine. She talked about the 500,000 Americans who have died from COVID-19, as well as the countless lives that have been upended in other ways. She said it is important to have trusted public health experts that can debunk misinformation and rumors, promote guidance on mask wearing and social distancing, and encourage vaccinations and inform people about vaccine safety and efficacy. Murray said Dr. Murthy is a crisis-tested leader who is qualified to help the American people navigate the health challenges ahead. Murthy has already done the job of Surgeon General and did it will. During his last tenure, he proved himself as a trusted voice and saw the nation through public health emergencies like Zika, the opioid crisis, and shown a light on the negative impacts of mental health issues. She also supports the nomination of Dr. Levine who is highly qualified to serve as Assistant Secretary of Health. She would be the highest ranking openly transgender official in the U.S. government. She is a public health expert who has firsthand experience in understanding of the challenges that states face and the support that they need. She was Pennsylvania’s highest-ranking health official and led the state’s COVID-19 response. She focused on transparency and clear science-based communication and gave daily briefings. She served Pennsylvania as the Physician General and was confirmed to that post unanimously by the state’s Republican controlled state senate, and then as the state’s Secretary of Health. Murray said a pandemic is not a time to focus on politics, it is a time to focus on getting people reliable information, getting states, tribes, and communities the support and resources they need and getting testing, tracing, and vaccinations up. She said they need to focus on providing mental health care and eliminating health inequities. 

Ranking Member Richard Burr (R-NC) said both nominations are for critical public health positions at HHS. He said everyone seeks bipartisan votes on nominees, but that does not mean that answers to questions don’t need to be sufficient. The Assistant Secretary of Health would oversee a range of health issues, including human research protections and research integrity. The Surgeon General would be responsible for providing Americans with the best scientific information available and overseeing the Public Health Service Corps. Burr said the question today is if both nominees are ready and qualified to take on the responsibilities required. Burr said he was more concerned about a nomination that hadn’t been made yet, the Assistant Secretary of Emergency Preparedness and Response (ASPR). It is a top advisor to the Secretary of HHS during public health emergencies and the coordinator between the Surgeon General and Assistant Secretary for Health. He said the law calls for strong leadership during public health emergencies but the nominations before the Committee, while important, do not fill the ASPR role and the new administration has had ample time to choose an individual for that critical role. He then said the role of Assistant Secretary of Health evolved under the previous administration, playing an integral role in the COVID-19 response. He said that Dr. Levine’s state of Pennsylvania faced great challenges with testing capacity in the early days of the pandemic and with their vaccine rollout to this day. In March of last year, the state’s Public Health lab was only able to perform six tests per day. Along with testing challenges, Burr said the state failed to adequately protect nursing home residents from the virus and is making unacceptable mistakes in the vaccine distribution process. He said 52 percent of COVID-19 deaths came from nursing homes. He said only 16 percent of nursing homes received infection control inspections. He then said that recent reports said that tens of thousands of Pennsylvania residents mistakenly received the dedicated second dose of the Moderna vaccine. He said that at each step, testing, treatment, and vaccination her state’s response has fallen short and that reflects on her track record. Burr then turned to Dr. Murthy. He said that the American people will be putting their trust in the Surgeon General to communicate without political preference or pressure, the best ways to keep families safe. Burr said he was worried about Murthy’s ability to separate political influence from his ability to communicate healthcare decisions. He said Murthy spoke at the Democratic National Convention just a few weeks ago. In closing Burr said he has concerns with both nominees. 

Dr. Vivek Murthy spoke about his family and the challenges his parents faced as first-generation immigrations and doctors in Miami. They saw their patients as family and took care of them as such. Murthy said he tried to live by the values they embodied, to alleviate suffering and give back to the country that gave them so much. He said this is a moment of tremendous suffering with over half a million Americans dying from COVID-19, including members of his own family. Millions more are suffering financial stress. In his work over the past year, Murthy said he knows the importance of providing clear, science-based guidance on how to protect themselves and others. He said he knows how urgent it is to communicate the safety and effectiveness of vaccines and get them to people as quickly as possible, especially those in underserved communities and communities of color. He said, even with COVID-19, they can’t forget the other health crises the country is facing, like the opioid epidemic, mental illness, and racial and geographic health inequities. During his previous stint as Surgeon General, he learned to listen to people from rural communities and big cities alike. He welcomes the chance to work with Congressional leaders on both sides of the aisle as he did previously. He said he would never forget that at its core, the role of the Surgeon General is that of a doctor, charged with serving every single American.

Dr. Rachel Levine said her career has been based around helping people live healthy lives. She was a physician that specialized in pediatrics and adolescent medicine and managed educational and departmental responsibilities at a major academic hospital system. In 2015 she was named to be the Physician General of Pennsylvania. She was confirmed twice more on a bipartisan basis to be Secretary of Health. In those roles, she focused on addressing the opioid misuse and overdose crisis in the state and worked with HHS on those efforts. She said they focused on opioid stewardship; the safe, appropriate, and responsible prescribing of opioids. She also worked to save rural hospitals by transitioning them from fee for service to global budget payments. The model aligned incentives for providers to provide value-based care and for rural hospitals to transform their care to better meet community health needs. Last year, COVID-19 became her most urgent focus and focused on three major priorities: containment with expansion of testing and contact tracing; mitigation with masks and social distancing; and medical countermeasures such as distribution of medications and authorized vaccines. Pennsylvania created a Health Equity Task Force as part of those efforts as well as a faith-based testing strategy. 

Q&A

Chair Murray said the previous administration’s response to the pandemic was marked by rejection of science, dissemination of misinformation, and the erosion of trust in scientific agencies. Under President Biden, the country now has a science-led coordinated national response, and the past month has seen increases in testing, tracing, and vaccination and downward trends in new cases, hospitalizations, and deaths. But she said there is still a lot of work ahead, especially combating fears and hesitancies people have around getting vaccinated. She said an important role of the Surgeon General is being a clear and prominent voice on the importance of science. 

  • She asked how he would promote confidence in public health agencies and vaccines. Murthy responded that it is essential to communicate in a way that is driven by science. He said they have been responding to the virus while learning about it at the same time. As knowledge has changed, it hasn’t been easy to communicate those changes. His goal would be to work with CDC and NIH to be clear on what the science says and to go out to where people are and communicate that information. 
  • Murray asked how Levine’s previous experience would inform her efforts to work with state, local, and tribal public health and community leaders. Levine said she has a unique perspective on the pandemic working as a state public health official. She knows firsthand the importance of collaboration and coordination between federal public health officials, state public health officials, and local public health officials. 

Murray said the pandemic has shown a bright light on health inequities. She said the country needs to build a more equitable healthcare system, outside of just the pandemic. She said hopefully that is a priority for both nominees. 

Ranking Member Burr asked Levine how she can assure the Committee that the same challenges that faced Pennsylvania under her watch will not occur again if she is confirmed. Levine said there were significant challenges in Pennsylvania, especially in the spring as they were learning about the new virus. They lacked PPE. Under President Biden’s leadership, she would use her experience to help address those issues. 

  • Burr said NIH has been investigating researchers who have failed to disclose support from foreign governments and other entities who have diverted IP or have sought to undermine the peer review process. Her asked how she would seek to address attempts by foreign governments to influence U.S.-funded research. Levine said she commits to working with Congress and experts at HHS and NIH to make sure that research standards are of the highest quality and that there is no interference in that research.
  • Burr said vaccine hesitancy is not limited to COVID-19. He asked if Dr. Murthy would be able to effectively communicate the safety and efficacy of vaccines. Murthy said he approaches issues like vaccines as a doctor. It doesn’t matter someone’s political stance; each person deserves dignity and respect. He would listen to people’s concerns, not demonize them, and then bring the best of science forward in a way that people can understand what the data says about these vaccines. He would also interact with trusted leaders in communities who might have more trust than the Surgeon General from the federal government. 
  • Burr asked how the role of Surgeon General differs today from when Murthy previously held the role. Murthy responded that the country is evolving, and people’s needs are evolving as well. That means the role of Surgeon General has to change to meet those needs. The fragmentation of how people get their information is greater now. That increases the importance of engaging with local partners who can speak to and access people where they are. 

Sen. Bob Casey (D-PA) said that pre-pandemic one in five children suffered from mental health issues and that has only gotten worse with the pandemic. Then there is also the scourge of child abuse which is on the rise and more cases are going undetected without in-person schooling. He asked Levine if these issues would be priorities. Levine responded that she is a pediatrician in her original field and still has that love of children and will do everything possible to work towards the betterment of children and adolescents. The intersection of mental health issues and physical health issues has been one of the bases of her career.  

  • Casey asked Murthy how he would use his platform as Surgeon General to address vaccine hesitancy. Murthy said they have seen concerning rates of vaccine hesitancy around the COVID-19 vaccine. He would seek to understand why people have concerns and then bring the best science and data forward to address those concerns. He said they have to do all that in partnership with local communities. 

Sen. Rand Paul (R-KY) said genital mutilation has been internationally condemned as a violation of human rights. The WHO said most general mutilation is not done by force but by societal pressure. He said that America is now normalizing the idea that minors can be given hormones to prevent the development of their secondary sexual characteristics. He said Levine has supported giving minors hormone blockers as well as surgical destruction of a minor’s genitalia. He asked if minors were capable of making a life changing decision like changing one’s sex. Levine said that transgender medicine is a complex and nuanced field with robust research and standards of care. 

  • Paul reiterated his question about minors and read a story about a girl who later regretted her decision to try and change her sex. Levine then reiterated her response.

Sen. Tammy Baldwin (D-WI) talked about the importance of addressing health disparities. When she was in the House of Representatives, experts who would testify about health disparities could often not answer questions related to health disparities in the LGBTQ community. She asked Levine what the federal government should do to support state and federal efforts to better prioritize and address the healthcare needs of people in the LGBTQ community. Levin said that health equity is a critical aspect to the approach to COVID-19 pandemic and all health issues. COVID-19 has shown the challenge of health disparities, and that would include the LGBTQ community. Pennsylvania has an annual LGBTQ community assessment and they are the only state collecting sexual orientation and gender identity data in terms of COVID-19 testing. Gathering all the data possible is extremely important when combating public health crises. More data will also lead to understanding the health disparities which will make it easier to develop the appropriate policies in order to address them. 

  • Baldwin said the ongoing pandemic has exacerbated challenges in responding to the opioid and substance use disorder crisis. She is concerned about reports of increased overdoses and other harmful effects. She asked what they would prioritize in their response to this crisis, including to make up for lost ground over the past year. Levine responded that the opioid has indeed worsened during the COVID-19 pandemic. She concentrated on this in her time in Pennsylvania, focusing on prevention, rescue with naloxone, and treatment with MAT. Dr. Murthy said the issue of opioids is close to him as he focused on it heavily during his last stint as Surgeon General. In 2016 he laid out a number of steps in a report on alcohol, drugs and health. He feels there is more work to be done on that. There is more that can be done to expand access to naloxone, expand access to MAT and make it easier for providers to prescribe, and do more to invest in prevention. 

Sen. Susan Collins (R-ME) talked about the negative impacts on children from keeping them out of school. Some public health experts have suggested that 3-feet of separation between children would be sufficient to allow more classrooms to reopen. The American Academy of Pediatrics has made similar recommendations in making sure children can get back into school. She asked what Levine would do to get children back into school. Levin said everyone agrees that everything needs to be done to have children safely go back into the classroom. She said the CDC has put out guidance on reopening schools, but she recognizes that this is a local issue, and they have the final decision on opening or not. She reviewed the data Sen. Collins mentioned and found it interesting and wants to examine them more closely. 

  • Collins said that in September 2020, there were reports in Pennsylvania around inaccurate disclosure of COVID-19 cases in nursing homes and asked if the state accurately reported data. Levine said she stands by her statement that Pennsylvania was transparent with their data and deaths from COVID-19 in nursing homes. But there was a lag time between when a death occurred, when it hit their electronic reporting system, and then when it would be reported out. 

Sen. Tim Kaine (D-VA) said the US response to COVID-19 will go down in history as the worst failure of domestic governance in this history of the country. It is now the third most deadly single event in the history of the United States after Spanish Flu and the Civil War. He said many of the deaths were unnecessary compared to other peer countries. 

Sen. Bill Cassidy (R-LA) said that health equity is something that everyone has to care about and take seriously. He said there were biological or scientific reasons to make someone more susceptible to dying from COVID-19, such as being older. He asked about other comorbidities that would raise mortality rates from a COVID-19 infection. Murthy responded that the reasons why some communities are seeing worse outcomes than others is partly understood but they are still learning about it. It is a product of the environment, biology, and preexisting structural inequities. Specifically, co-morbidities include obesity, cardiac disease, preexisting lung conditions, and diabetes. 

  • Cassidy asked if those conditions were generally distributed through the population or more likely to occur in some groups than others. Murthy said they are disproportionately distributed in the population. 
  • Cassidy asked if the federal government should be doing more to address the epidemic of obesity since it plays a role in so many comorbidities. Levine said they absolutely need to focus on the prevention and treatment of obesity, particularly childhood obesity. She also said they need to focus on the social determinants of health that play into these outcomes. 

Sen. Chris Murphy (D-CT) said he wants to build vaccine distribution systems that meet people where they are, instead of expecting them to come to the vaccines. Dr. Murthy agreed with the senator. He said vaccine hesitancy is complex and not experienced solely by members of racial minority groups. He said the disparities in vaccine distribution are often related to preexisting structural challenges that exist. He said that is why it’s important to let FQHCs and mobile units have the ability to distribute vaccines and with the backing of local community leaders. 

  • Murphy said he wants money set aside for summer programing that focuses on the emotional wellbeing of children. He asked what kids need right now and where the focus should be to make sure children are emotionally healthy. Levine said the mental health needs of children should be at the forefront. She said she wants to work on the issue and Murphy’s proposed solution. 

Sen. Roger Marshall (R-KS) said the goal of the current administration is 100 million vaccines in 100 days, even though today they already have 85 million vaccines out the door with the infrastructure to do millions of vaccines a day. He thinks they could do three million vaccines a day in March and get up to 150 million people vaccinated by the end of the March and herd immunity by April or May. He asked if that was possible. Murthy said he loves to think bigger and how to move faster. He would want to work with the administration to understand how to expand capacity of distribution. He said he thinks they can get more vaccines in pharmacies and doctors offices. Levine agree they need to ramp up the vaccine distribution as much as possible. 

  • Marshall asked if they should focus on getting everyone one shot before moving to second doses. Murthy said he thought the new data was very interesting and they should look into what a one dose model could look like. If people achieve sustained protection, he thinks that is a model they should consider. 
  • Marshall asked if kids should be back in school. Levine said the CDC has their recommendations, but she is interested in the American Academy of Pediatrics’ literature. 

Sen. Tina Smith (D-MN) said the pandemic has totally upended the country’s economic and health wellbeing. She then said that LGBTQs people have long faced barriers to healthcare and are much more likely to lack access to insurance and affordable medical care. She then asked about the impacts of social isolation. Dr. Murthy responded that during his first service as Surgeon General, the prevalence of social loneliness and isolation was something that surprised him. He expected to hear about obesity, substance use, depression, and anxiety but he often heard stories of loneliness and isolation even from college students on crowded campuses. He was concerned about the health consequences from these feelings. But he said there is a lot that can be done through communities such as through faith and local based organizations. Government can also name this as an issue that is important to tackle and bring gravitas and awareness of those that suffer from it.

Sen. Lisa Murkowski (R-AK) focused on behavioral health issues in the Artic region. She asked for a commitment to focus on mental health, not only during the pandemic, but really moving forward generally. Murthy said the issue of mental health is disturbing. But the impact in rural communities has been extremely harmful. He said the access to providers in these areas if often far reduced, from levels that are often insufficient where they do exist. He wants to expand telehealth and strengthen the mental healthcare workforce. 

  • Murkowski then talked about homelessness as a public health issue. She asked what the country needs to do to raise awareness and work to address those issues. Murthy said that of all of the social determinants of health that are discussed, housing and homelessness are some of the most important. He believes there is a strong connection between housing and health, and they need to make sure that data and science is clear to the public and policy makers. He wants to engage with HUD to help and try and reduce homelessness. 

Sen. Jacky Rosen (D-NV) said that Nevada is the highest in the nation in adolescent suicide, particularly now during the pandemic. She also talked about the negative impacts of the pandemic on seniors, especially those who live alone. She asked how they would address the trends of youth suicide and mental health problems. Levine said mental health issues among the youth remains a significant public health problem. Her career focused on this issue and she participated on a suicide prevention task force as Secretary of Health in Pennsylvania. 

  • Rosen asked about the devastation of social isolation for seniors and how to reduce those feelings of loneliness. Murthy said impacts of isolation and loneliness can be very important on health. He said there is a powerful role that community organizations can play here. Organizations that can connect young people with the elderly, that can provide food or resources, or can simply call and check in can make big differences. 

Sen. Mike Braun (R-IN) didn’t understand why Pennsylvania treated all counties the same, regardless of them being rural or urban and asked if there was data on the results of that approach. Levine said there were three tools to address the pandemic when it first started: containment, mitigation, and medical countermeasures. She said testing and PPE was lacking in the spring and vaccines weren’t approved yet, so mitigation was one the best tools they had. They took an iterative approach of going county by county in terms of whether businesses would be closed, even though eventually the whole state had to close. They also took an iterative approach of reopening as well. 

  • Braun asked how Pennsylvania’s vaccine rollout has gone. Levine said at first, they had significant challenges in getting vaccines out. She left the Department of Health in January and so doesn’t really know what they are doing differently now but things seem to be getting better. 
  • Braun asked if guns present a public health emergency. Murthy responded that gun violence, like any sort of violence, is a concern. But the way they approach that issue should be based in science. 

Sen. Ben Ray Lujan (D-NM) asked how Americans can get non-pharmaceutical treatments for pain, and if they do get pharmaceutical treatments, how to make them non-addictive. Murthy responded that appropriately treating pain is a critical issue. He wants to take what research currently says, which is that there are a number of effective strategies like physical therapy, behavioral therapy, and in some cases pharmacology therapy, and use that as a guide. Medications need to be tailored on an individual patient basis. 

  • Lujan asked how to expand telehealth and similar programs and ensure that there is adequate reimbursement for them. Levine said telehealth will be very important, especially in addressing the issues of mental health. Access to broadband is critical to that success. She mentioned Project ECHO and its success. 
  • Lujan said they need to address the current caps and other limitations on rural residency programs. Murthy agreed that there are critical workforce shortages in rural areas. With residency programs, he thinks they can strategically train residents and place them in rural parts of the country. 

Sen. Mitt Romney (R-UT) asked if some school districts are open and some are closed in Pennsylvania. Levine responded that was correct. 

  • Romney asked if there had been an analysis of those that are open in terms of a public health impact. Levine said she was not aware of that analysis. Romney said that was the issue. There needs to be a study of this as it doesn’t seem to lead to COVID-19 spikes. He said it looks like submission to the teacher’s unions, which happen to be large donors to the Democratic party. 
  • Romney talked about concerns of children vaping. He said studies show about a quarter of high school kids vaping tobacco products and some marijuana products. He asked how to get flavored vaping products off the market. Murthy said when he was surgeon general, he issued the first report on e-cigarettes and youth and he is still deeply concerned that there hasn’t been enough improvement. He thinks there are lots of loopholes that allow children to access these products. He also said he is concerned about advertising.

Sen. Maggie Hassan (D-NH) asked about the importance of continued robust federal funding for states to combat the opioid epidemic. Levine agreed that the opioid epidemic continues and has been exacerbated by the COVID-19 pandemic and they have to continue to address it robustly. All the important programs she ran in Pennsylvania required funding to make them work. She said they also need address the stigma of seeking care for mental health and substance use disorders. 

Sen. Tommy Tuberville (R-AL) agreed that they need to address the issues of children and substance abuse and overdose. He then said Alabama is losing its rural hospitals. He said the PBMs are putting rural pharmacies under as well. He asked what the states like his can do. Murthy responded that telehealth is a good start, but they need to also focus on strengthen the rural workforce. He also said they need to support the rural hospitals more directly. The cost structures of these hospitals are different, and a one size fits all approach can’t be applied to them and urban hospitals. 

  • Tuberville asked what Murthy’s number one priority was. He responded that his first priority right now is to address COVID-19 and turn the pandemic around. The pandemic has also worsened issues like mental health and substance use which are his accompanying priorities. 

Ranking Member Burr closed by entering latest survey data on high school student use of marijuana and vaping products to the record. He said it shows that marijuana was used more than tobacco product vaping, and that the least used vaping flavor was menthol.