[Senate Hearing 110-997]
[From the U.S. Government Publishing Office]
S. Hrg. 110-997
PREVENTION AND PUBLIC HEALTH: THE KEY TO TRANSFORMING OUR SICKCARE
SYSTEM
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HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
ON
EXAMINING DISEASE PREVENTION AND PUBLIC HEALTH, FOCUSING ON
TRANSFORMING THE HEALTH CARE SYSTEM
__________
DECEMBER 10, 2008
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
Available via the World Wide Web: http://www.gpoaccess.gov/congress/
senate
----------
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
EDWARD M. KENNEDY, Massachusetts, Chairman
CHRISTOPHER J. DODD, Connecticut MICHAEL B. ENZI, Wyoming
TOM HARKIN, Iowa JUDD GREGG, New Hampshire
BARBARA A. MIKULSKI, Maryland LAMAR ALEXANDER, Tennessee
JEFF BINGAMAN, New Mexico RICHARD BURR, North Carolina
PATTY MURRAY, Washington JOHNNY ISAKSON, Georgia
JACK REED, Rhode Island LISA MURKOWSKI, Alaska
HILLARY RODHAM CLINTON, New York ORRIN G. HATCH, Utah
BARACK OBAMA, Illinois PAT ROBERTS, Kansas
BERNARD SANDERS (I), Vermont WAYNE ALLARD, Colorado
SHERROD BROWN, Ohio TOM COBURN, M.D., Oklahoma
J. Michael Myers, Staff Director and Chief Counsel
Ilyse Schuman, Minority Staff Director and Chief Counsel
(ii)
C O N T E N T S
__________
STATEMENTS
WEDNESDAY, DECEMBER 10, 2008
Page
Harkin, Hon. Tom, a U.S. Senator from the State of Iowa, opening
statement...................................................... 1
Coburn, Hon. Tom, a U.S. Senator from the State of Oklahoma,
opening statement.............................................. 2
Sanders, Hon. Bernard, a U.S. Senator from the State of Vermont.. 4
Prepared statement........................................... 5
Wright, Donald, M.D., M.P.H., Principal Deputy Assistant
Secretary for Health, U.S. Department of Health and Human
Services, Washington, DC....................................... 11
Prepared statement........................................... 13
Levi, Jeffrey, Ph.D., Executive Director, Trust for America's
Health, Washington, DC......................................... 26
Prepared statement........................................... 28
Thorpe, Kenneth E., Ph.D., Robert W. Woodruff Professor and
Chair, Department of Health Policy & Management, Rollins School
of Public Health, Emory University, Atlanta, GA................ 39
Prepared statement........................................... 42
Dodd, Hon. Christopher J., a U.S. Senator from the State of
Connecticut.................................................... 53
Prepared statement........................................... 54
Mahoney, John J. (Jack), M.D., Chief Consultant for Strategic
Health Initiatives, Pitney Bowes, Stamford, CT................. 56
Prepared statement........................................... 59
Hibbs, Carol, Executive Director, Community Y, Marshalltown, IA.. 61
Prepared statement........................................... 62
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.:
Enzi, Hon. Michael B., a U.S. Senator from the State of
Wyoming, prepared statement................................ 84
Hatch, Hon. Orrin G., a U.S. Senator from the State of Utah,
prepared statement......................................... 85
Question of Senator Clinton to Jeffrey Levi, Ph.D............ 86
(iii)
PREVENTION AND PUBLIC HEALTH: THE KEY TO TRANSFORMING OUR SICKCARE
SYSTEM
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WEDNESDAY, DECEMBER 10, 2008
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The committee met, pursuant to notice, at 10:09 a.m. in
Room SD-192, Dirksen Senate Office Building, Hon. Tom Harkin,
presiding.
Present: Senators Harkin, Dodd, Reed, Sanders, and Coburn.
Opening Statement of Senator Harkin
Senator Harkin. Good morning. I would like to thank
everyone for coming this morning to discuss why a new emphasis
on prevention and strengthening our public health system are
critical to transforming America's healthcare system.
I especially want to thank Senators Kennedy, Enzi, and
Coburn for giving us the opportunity to come together this
morning.
When we look at our healthcare system nationwide, we see a
system that I say is fundamentally broken. It squanders
countless of hundreds of billions of dollars. It underserves
some 45 million Americans because they don't have health
insurance, lags behind many other countries in the use of
information technologies and other systems that can reduce
errors and improve quality.
We need to fundamentally change this system. We need to get
healthcare costs under control. This will not happen, however,
unless we place a major new emphasis on wellness and disease
prevention while strengthening America's public health system.
To be honest about it, I have often said we don't have a
healthcare system in America. We have a ``sickcare'' system. If
you are sick, you get care, some way or another--through
insurance, Medicare, Medicaid, community health centers,
emergency rooms, charity, one way or the other.
The problem is that this approach is about patching things
up after the fact. We spend untold hundreds of billions on
pills and surgery and hospitalization and disability. We spend
peanuts--I am told about 3 percent of our healthcare dollars--
for prevention.
There are huge untapped opportunities in the area of
prevention, wellness, and public health. We think about the
status quo, we spend a staggering $2 trillion annually on
healthcare, more than any other Nation in the world. Yet the
World Health Organization ranks U.S. healthcare only 37th among
nations. Out of 21 industrialized nations, we are 20th in the
quality of healthcare for our children.
When I look at these statistics, it seems as though we have
lost our capacity to be shocked or outraged. Just how much
evidence do we need that America's approach to healthcare, I
should say sickcare, is simply not working?
It is not enough to talk about how to extend insurance
coverage and how to pay the bills, as important as those things
are. If all we are going to do is figure out a better way to
pay the bills for the current broken, unsustainable system,
then I think we are sunk.
Indeed, I want to lay down a marker right here at the
outset of this forthcoming great debate about healthcare
reform, and this is my marker. If we pass a bill that greatly
extends health insurance coverage but does nothing to create a
dramatically stronger prevention and public health
infrastructure and agenda, then we will have failed the
American people.
It simply makes no sense to legislate broader access to a
healthcare system that costs too much and delivers too little,
largely because it neglects prevention and public health. We
need to craft a bill that mobilizes our society to prevent
unnecessary diseases and conditions, things like obesity and
type 2 diabetes, heart disease, mental health conditions, and
some forms of cancer.
A robust emphasis on wellness is about saving lives, saving
trips to the hospital, saving money. It is the only way--I
repeat, the only way--we are ever going to get a grip on
skyrocketing costs. There are tremendous opportunities here,
both in terms of cost savings and in terms of helping people to
live healthier and happier and more productive lives.
That is a whole other area that I am not going to get into
right now, but it has something to do with people's
productivity also. And I think we are going to hear from some
businesses on that.
So, to that end, I look forward to hearing from our
witnesses in this, sort of our kickoff hearing on this. To
date, prevention and public health have been the missing pieces
in our national conversation about healthcare reform. It is
time to make them the centerpiece of the conversation, not an
asterisk, not a footnote, but the actual centerpiece of our
healthcare reform debate.
And with that, I will yield to my friend and colleague from
Oklahoma, Senator Coburn.
Statement of Senator Coburn
Senator Coburn. Thank you, Senator Harkin.
Much of what you just said I adamantly agree with. We have
to change the paradigm on health in this country. Seventy-five
percent of all the dollars we spend on healthcare are for five
preventable chronic diseases, two of which I have. I wish I
would have prevented them.
Nevertheless, how we do that is important. We had asked
that Dr. Cooper from Texas be a witness. We were not allowed to
do that. He has made great strides in prevention in this
country, one of the leaders in prevention.
One of the things that he has gotten instituted in the
State of Texas is physical exercise again in the schools. If we
talk about problems in terms of prevention, childhood diabetes
and obesity is a totally preventable disease, and type 2.
Obesity leads to increased risk of cancer, leads to
increased risk of hypertension, coronary vascular disease as
well as peripheral vascular disease. It leads to all sorts of
other types of complications.
We have to change the paradigm, and I look forward to the
debate this year. I think the Government is not the best place
to provide healthcare, but I am anticipating a great debate on
how we solve our Nation's problem.
This is a great country to get sick in because we do a
great job once you are sick. We don't do a good job preventing
you from getting sick. And so, I will join my colleagues in
looking forward to changing the paradigm.
But I would also caution that, oftentimes, we are not the
best at actually performing the procedures. We are good at
messaging them. And we spend billions of dollars right now in
this country on prevention, through NIH, which was just
reformed and is much more streamlined; CDC, which needs to be
reformed so that the prevention dollars--we say it is CDC. It
is really CDCP. And we have dropped the emphasis of
``prevention'' from CDC.
When we look at the total, which is about $15 billion a
year minimal that is being spent supposedly on prevention in
this country, we don't have any metrics. We don't have any
metrics to measure whether we are successful.
I visualize a time when every American--either through
their schools, public service or coordinated efforts through
public health and the private health in this country--where
every American is educated to the degree they need to be on the
risks of the behaviors and the lifestyle choices that they
make. We do a poor job on that.
We know when we start prevention screening that we have
good results, whether it is with Pap smears or mammograms or
colon screening, or other tests. What we know is we make a big
difference in terms of productivity, in terms of decreasing the
cost. More importantly, we ought to be about decreasing the
things that cause the disease in the first place, not in
preventing the advanced disease.
I look forward to hearing from our witnesses. I appreciate
the opportunity to be here with you, Senator Harkin. And my
hope is, is that as we start this debate, we will have a
vigorous debate about what gets us the most efficient and the
best message on prevention.
Americans are not stupid. If we teach and put out there the
information they need with which to make decisions, they will
make good decisions, and we know that in a lot of areas. It is
if we try to mandate it and run it, which I think Government
has not proven to be great at, I don't think we will see the
kind of results than if we do it through an encouraging and
economic incentive- based system.
I thank you again for the hearing. I look forward to it.
Senator Harkin. Thank you, Senator Coburn.
Senator Sanders.
Statement of Senator Sanders
Senator Sanders. Thank you very much, Senator Harkin. And
thank you very much for the work that you have done over the
years in this particular area.
I don't think there is anybody in the Congress who has been
stronger in understanding that the key to healthcare reform has
to be disease prevention, (A), in keeping people healthy and in
saving us hundreds of billions of dollars. So thank you for
what you have done.
In my view, we are living in a non-healthcare system, which
is disintegrating. It is beyond comprehension that in this
great country, 47 million Americans have zero health insurance.
Even more are underinsured, with high deductibles and
copayments.
In the midst of that nonsystem, what is even worse, even in
more dire circumstances, is the disastrous efforts that we make
in terms of primary healthcare. Today, we are looking at some
56 million Americans in medically underserved areas throughout
this country who do not have access to a doctor and, in many
cases, to a dentist as well.
The issue of the crisis of primary healthcare is an issue
that we, as a Nation, must begin to address. There are
approximately 20,000 Americans who die every single year
because they can't find a doctor.
I have talked to physicians in the State of Vermont who,
when people walk in, the doctor says, ``Why didn't you come in
6 months ago when your condition was treatable? We can't treat
you now.'' People die because of that. And people say, ``Well,
I don't have any health insurance.'' ``I don't want charity.''
``I couldn't find a doctor.'' ``I thought it would get
better.''
People are dying. People are becoming much sicker than they
should be. And then the cost is that people end up in the
emergency room. People end up in the hospital because they do
not have access to a doctor when they should have access.
I think the issue of disease prevention and primary
healthcare has to be at the top of any list in terms of
healthcare reform. Now that is the bad news. Let me give you
some good news--what we are doing is, in fact, very, very good.
There is a program that started many, many years ago led by
Senator Kennedy, Senator Harkin, and many others called the
Federally Qualified Community Health Centers. There are about
1,100 of them all over America.
What these centers do in an extremely cost-effective way is
they say if you have Medicaid, come in. If you have Medicare,
come on in. If you have private insurance, come in. If you have
no health insurance, we are going to treat you on a sliding-
scale basis. You make $30,000 a year, maybe it costs you $10 to
come in.
The results have been enormously impressive. Widespread
support for this program from conservatives, progressives,
Republicans, Democrats, President Bush. We have 1,100 of these
centers. In my State, we went from 2 to 7 in the last 6 years
with tremendous gains in terms of disease prevention.
My hope is that in the coming years, we will expand that
program so that every medically underserved area in this
country will have a Federally Qualified Community Health
Center, affordable primary healthcare, dental care, mental
health counseling, and low-cost prescription drugs.
Now, in picking up on Senator Harkin's point and Senator
Coburn's point, let me give you an example of what happens when
people have access to a community health center as opposed to
when they do not. What community health centers stress is just
the point that Senator Coburn made. We all know that if people
have physical activity, they are much more likely to stay
healthy.
Community health centers stress that point. The results are
there to be seen. Of the people who go to the health centers,
63.7 percent get information about physical activity as opposed
to 39.4 percent of adults who don't.
In terms of smoking, the idea that in my State--it breaks
my heart to see young kids, girls now more than boys, who are
smoking. When you go to a community health center, you are
educated. A doctor sits down and talks to you about the
stupidity of smoking and what it does for cancer, what it does
for heart disease in general.
The results are very, very clear. Low-income people who
walk into a community health center will end up smoking less,
and that is true with drugs and with abuse of alcohol as well.
We have a real crisis among African-American women in terms
of low-weight babies. Again, the result is in that when people
have a regular physician--they are treated on a regular basis--
their prenatal care is much better, and the results in terms of
not having a low-weight baby is much better with access to a
community health center.
There was a study in South Carolina recently. We talked
about diabetes, obesity, and again, the results are the same.
Common sense suggests that when you have access to a regular
physician who cares for you, who treats you on a regular basis,
whom you trust, you will get better healthcare in general, and
you will do a better job in preventing disease.
So, I would hope, Senator Harkin, that in the stimulus bill
and within the next couple of years that what we will do is
make sure that every American has access to primary healthcare.
I think the evidence is overwhelming that Federally Qualified
Community Health Centers are the most cost-effective way of
delivering that. And I hope in a bipartisan way that we can
work together on that.
So thank you very much, Senator Harkin.
[The prepared statement of Senator Sanders follows:]
Prepared Statement of Senator Sanders
America's health care system is badly in need of an
overhaul. It is shameful that the richest country in the
history of the world does not guarantee health care as a right
to all citizens. Nowhere is this failure more apparent than in
the provision of basic public health and preventive care. While
the United States spends more than any other country on health
care, most of it is spent on treating diseases that could have
been prevented. Various estimates indicate that only 2-4
percent of health care spending is for prevention and public
health in America. The result is that we lag far behind other
developed countries on key health status measures.
Rather than concentrate on this failure, I know that
Senator Harkin is interested in positive solutions. While
overall the health care system is failing us, we do have one
part of it that has been in place for a long time and that has
done a good job in primary care and prevention.
The Community Health Center program provides a model for
the impact that a concentration on prevention can have in
improving health and reducing costs. I believe we need to do
much more to make sure all Americans have access to community
health centers, and I look forward to hearing from our
panelists regarding their place in a national prevention
strategy. A look at just a few indicators shows why I believe
community health centers play a vital role in prevention for
our most vulnerable citizens.
Two of our biggest public health problems relate to the
obesity epidemic and tobacco use. They are responsible for most
of the chronic disease and preventable deaths in this country.
If we could get people moving more and smoking less, we could
prevent a huge number of chronic illnesses, including heart
disease and cancers. We also know that people are likely to
change their behaviors and adopt a healthier lifestyle if they
discuss it with their physician. Community health centers
invest in this effort. Here are just two examples:
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Physical Activity--Providers in health centers are
more likely to discuss the amount of physical activity with
their patients than those in other health care settings. About
two thirds of health center patients have had discussions about
physical activity, which exceeds the Healthy People 2000 goals.
Only 40 percent of all adults seen elsewhere have had these
discussions.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Tobacco Use--Four out of every five Medicaid
patients in health care centers and nearly three quarters of
all patients going to health care centers have had their
tobacco use discussed with them, compared to only about half of
insured adults who don't use health centers.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Another important component of prevention is
assuring early prenatal care to reduce the incidence of low-
birth weight babies. Low-birth weight babies have more health
problems at birth and as they grow. Low-birth Weight--We
usually think that minorities in rural America have less access
to health care.
Yet significantly, rural African-American women going to
health centers have a rate of low-birth weight babies
significantly lower than the national average for African-
American women, and better than the overall national rate.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
In addition to primary prevention, managing
chronic diseases is an important secondary prevention strategy.
Early and consistent intervention will pay dividends in
enhancing health and reducing costs, given our chronic illness
epidemic. Health centers have been developing strong care
management programs. Diabetes--A study of health centers in
South Carolina found that costs of physician care and
hospitalization for diabetic Medicaid patients were
substantially less for patients who use health centers.
Besides fully investing in community health centers, there
are several other important prevention initiatives that I
believe will be indispensable as we move forward. Let me
highlight just a few.
We need to invest in disease registries to give
epidemiologists the information needed to figure out the
determinants of disease and how to correct them. Without such
registries, it's like driving without a roadmap or a
destination.
We need to fully fund CDC nutrition and physical
activity grants to States. Increasing physical activity and
eating right are the two keys to obesity prevention. Several
States, including Vermont, recently lost programs because of
funding cuts.
Oral health is an all-too-often neglected part of
prevention efforts. I believe that dental clinics in the
schools make sense, where screenings can be provided for our
kids to educate them on how to keep their mouths healthy and to
provide them with sealants to prevent cavities.
And finally, Medicare and Medicaid need to be
reformed to put more emphasis on preventive care. Coverage for
preventive services has too often been neglected in our public
programs.
For one example, I understand that Medicare won't reimburse
for smoking cessation methods and programs until after a doctor
has diagnosed a respiratory illness. That isn't prevention and
it just doesn't make sense.
Let me conclude by returning to my earlier point on the
value of assuring good primary care as a major prevention
strategy. My home State of Vermont was recently cited as the
healthiest in America. The report noted that a key element in
this result is the adequate and well-distributed supply of
primary care physicians throughout the State. I believe that
contributing to this is that our most underserved areas are
served by community health centers which invest in prevention.
So, while we have much to do, we do have solutions and I
look forward to hearing from our panelists about more of them.
Thank you.
Senator Harkin. Thank you very much, Senator Sanders.
I might just say that the Chairman of the committee,
Senator Kennedy, had asked me to chair the Working Group on
Prevention, Wellness, and Public Health. I take that seriously.
This is the beginning of that process, just for general
knowledge purposes. We will be focusing on this strongly in
this month and next month as we move ahead.
I look forward to working with the Senator on this aspect
of healthcare reform. And I appreciate what you have to say
about community health centers because we have them in Iowa,
too. They do a great job in my State of Iowa.
Senator Reed.
Senator Reed. Mr. Chairman, I want to commend you for
holding this hearing. It is absolutely important in terms of
not only health, but also in affording healthcare going
forward.
So thank you, Mr. Chairman.
Senator Harkin. Thank you very much.
Again, I thank all of my witnesses. I will just ask consent
that the hearing record be left open for 10 days.
We are joined by an outstanding panel of witnesses. I thank
all of you for taking your time to be here. We will have our
first panel, and then we will move on to the second panel.
Our first panel would be Don Wright. Dr. Don Wright is the
principal deputy assistant secretary for health at the
Department of Health and Human Services, where he acts as an
advisor to the assistant secretary for health on matters
involving our public health and science.
His responsibilities include the planning and execution of
public health policy as it relates to disease prevention,
health promotion, women's and minority health, the fight
against HIV/AIDS, blood safety, pandemic influenza planning.
Dr. Wright received his undergraduate degree from Texas
Tech University, his medical degree from the University of
Texas, and completed his family medicine residency training at
Baylor. In addition to his medical degree, Dr. Wright holds a
Master of Public Health from the Medical College of Wisconsin,
board certified in both family medicine and preventive
medicine, and is a fellow of the American College of
Occupational and Environmental Medicine and the American
Academy of Family Physicians.
So, again, Dr. Wright, thank you very much for being here.
I am going to ask whoever is controlling the clock--whoever's
presence is back there someplace that controls these things--so
if you can just take 10 minutes, I am going to ask each
witness, give them up to 10 minutes to state their testimony.
All of your written testimonies will be made a part of the
record in their entirety. I just ask you to sum it up.
Dr. Wright, thank you for being here.
STATEMENT OF DONALD WRIGHT, M.D., M.P.H., PRINCIPAL DEPUTY
ASSISTANT SECRETARY FOR HEALTH, U.S. DEPARTMENT OF HEALTH AND
HUMAN SERVICES, WASHINGTON, DC
Dr. Wright. Thank you. Good morning, Mr. Chairman and other
distinguished members of the committee.
I am Dr. Don Wright, and it is a pleasure to appear before
you as the principal Deputy Assistant Secretary for Health at
the U.S. Department of Health and Human Services. I speak for
the department from my position in the Office of Public Health
and Science, also known as OPHS.
Today, I would like to focus on the essential contribution
of prevention to our Nation's health and the Administration's
leadership since the launch of the President's Healthier U.S.
Initiative in 2002.
Clearly, we need more than improved access to care and
enhanced performance in our healthcare system. We need to
develop a comprehensive system that not only delivers disease
care and services to those who are ill, but also promotes and
protects the health of those who are well. This is prevention
at its best.
Before we move forward, let me tell you a little bit about
my division. Led by the assistant secretary for health, OPHS is
housed within the Office of the Secretary. We are charged with
leadership and development of policy recommendations on
population-based public health and science and, at the
discretion of the secretary, with coordination of initiatives
that cut across agencies and operating divisions within HHS.
We believe a focus on prevention will bring our vision--a
nation in which healthy people live in healthy communities,
sustained by effective, efficient, and coordinated health
systems--significantly closer to reality. The purpose of
prevention is to protect and promote good health when possible
through healthy lifestyles and environments, avoiding risky
behaviors, and participating in preventive screenings and
vaccines through all stages of life.
Unfortunately, time does not permit me to discuss the
multiple prevention and wellness activities that HHS and its
agencies support in collaboration with partners at the State,
regional, and community level. I can say that our activities
are embodied by the HHS prevention priority, which builds on
existing and emerging prevention policy and programs, based on
the best available evidence on how to prevent or limit the
effects of chronic disease through promotion of healthy diet,
physical activity, medical screenings, and avoidance of tobacco
use and other unhealthy behaviors.
The principal public health planning guide, upon which the
department and literally tens of thousands of our partners and
stakeholders have relied over a period of three decades to make
progress toward that vision, is Healthy People. Healthy
People's current overarching goals are to increase the quality
and years of healthy life and to eliminate health disparities.
Healthy People is broadly premised on our understanding
that the risk of many diseases and health conditions are
reduced through preventive actions and that a culture of
wellness deters and diminishes debilitating and costly health
events.
Healthy People's underpinning is the recognition that
disease prevention is not only desirable, it is doable, and it
is achievable. Indeed, disease prevention and health promotion
choices are useful wherever people may be as they go about
their daily lives.
The vision of Healthy People and healthy communities
involves broad-based prevention efforts, which are integrated
into neighborhoods, schools, workplaces, clinics, families, and
community health promotion programs. HHS is joined in the
development of Healthy People by many nontraditional partners
in the Federal Government, such as the U.S. Department of
Agriculture, Education, Housing and Urban Development, Justice,
Interior, Veterans Affairs, and the Environmental Protection
Agency.
The Government Accountability Office has held Healthy
People up as an example of a way to help enhance and sustain
collaboration among Federal agencies that have significant
differences in agency missions and organizational cultures.
There are two cross-departmental activities that are part
of our prevention priority that I would like to mention.
Through the coordinated and collaborative effort of the Office
of Disease Prevention and Health Promotion, the NIH, the
President's Council on Physical Fitness and Sports, and the
Centers for Disease Control and Prevention, HHS recently
released the first-ever Federal Physical Activity Guidelines
for Americans.
Becoming and remaining physically active is one of the most
important steps that Americans of all ages can take to improve
their health. The guidelines provide science-based information
to help Americans, aged 6 years and older, improve their health
through appropriate physical activity.
In addition, there is also the Healthy Youth for a Healthy
Future campaign, led by the Office of the Surgeon General with
input from across the department to help prevent overweight and
obesity in children. This initiative seeks to increase public
awareness of the child overweight and obesity epidemic and to
share information about effective community efforts to reduce
this problem and its consequences.
To date, the acting surgeon general has visited more than
30 cities to promote awareness of successful community
interventions that encourage healthy living. He has also
participated in community roundtable discussions with public
health stakeholders and local leaders to discuss prevention and
physical activity and nutrition problems.
In closing, the department's investment in a comprehensive
prevention infrastructure with the support of a growing
prevention and communication science base, sets the stage for
healthcare reform in which the public should be able to expect
seamless coordinated care and the best support for making
healthy decisions that science has to offer.
I am confident that broad consensus has emerged across
health professions and among stakeholders who care about
improving public health. Prevention has added value, and
ultimately, increased focus on prevention will save untold
numbers of lives and dollars.
Thank you very much.
[The prepared statement of Dr. Wright follows:]
Prepared Statement of Donald Wright, M.D., M.P.H.
Good afternoon, Mr. Chairman, and other distinguished members of
the committee. I am Dr. Don Wright and it is a pleasure to appear
before you as the Principal Deputy Assistant Secretary for Health of
the U.S. Department of Health and Human Services (HHS). I speak for the
Department from my position in the Office of Public Health and Science,
OPHS.
Today, I would like to share with you how we have invested the tax
payers' dollars in building the prevention evidence base and the
infrastructure that will help launch a reformed health care system: one
that is person-centered, provides seamless care in the clinic and in
the community, delivers disease care and services to those who are ill,
and also puts prevention first by promoting and protecting the health
of those who are well.
The Department's commitment to prevention is strong and as you will
see is reflected in the broad and diverse activities across the
Department.
I am proud to provide testimony about our Department's
comprehensive approach to prevention, coordinated by OPHS which is led
by the Assistant Secretary for Health. We are working every day to
realize our vision of a Nation in which healthy people live in healthy
communities, sustained by effective, efficient and coordinated health
systems.
the case for prevention
Largely preventable, chronic diseases have replaced infectious
diseases as major killers in the United States. Chronic diseases cause
7 out of every 10 deaths each year. We know that 40 percent of deaths
are caused by modifiable behaviors, such as poor nutrition, physical
inactivity, and tobacco. Smoking, which causes heart disease, chronic
bronchitis, emphysema and contributes to a host of other chronic
diseases, costs our citizens' untold suffering and loss of years of
potential life every year and our economy billions of dollars in direct
and indirect costs.
Expenditures for health care in the United States continue to rise.
The vast majority of health care dollars are spent on direct medical
care, despite the fact that clinical care is credited with only 5 of
the 30 years that were added to life expectancy during the last
century. Chronic disease consumes more than a trillion dollars every
year. That's $3 out of every $4 we spend on health care compared to
approximately 5 percent of total U.S. health care dollars spent on
public health and preventive measures.
There is broad agreement among experts that prevention reduces
health care costs. Precisely how much money preventive medicine saves
is not clear, but certainly a stronger commitment of resources to
prevention could significantly reduce rates of chronic illness and
dramatically relieve the suffering of millions of Americans. Through
successful prevention efforts we could reduce or even eliminate health
care spending on preventable diseases and conditions. By making
prevention the cornerstone of our health system and policies, we could
realize one of our overarching goals--to increase the quality and years
of healthy life. We could improve productivity and move toward
eliminating illness, injury, suffering, pain and deaths that ought not
to occur.
According to the Trust for America's Health, with an investment of
$10 per person per year in proven community-based disease prevention
programs, the Nation could yield a net savings of more than $2.8
billion in 1 to 2 years; more than $16 billion within 5 years, and
Return on Investment (ROI) of $5.60 for every $1; and more than $18
billion within 10-20 years, and ROI of $6.20. The Congressional Budget
Office notes that ``. . . Proposals that encourage more prevention and
healthy living can help promote better health outcomes, although their
net effects on Federal and total health spending are uncertain.''
hhs focus on prevention
In 2006, Secretary Mike Leavitt named prevention one of his top
priorities to improve the Nation's health and to help prevent
debilitating and costly health problems. Good individual health is
built on a foundation of personal responsibility for wellness, which
includes participating in regular physical activity, eating a healthful
diet, taking advantage of medical screenings, and making healthy
choices to avoid risky behaviors. To foster this preventive culture of
wellness, the Department is investing in strengthening the prevention
infrastructure and science base that offer the public the support they
need to make informed healthy decisions whether at the individual,
community, or State level.
the national prevention infrastructure: the healthy people initiative
For three decades the Department has built a national prevention
infrastructure, focused upon establishing national health goals and
measurable benchmarks tracking our success. This infrastructure of
government and private sector stakeholders in health, the Healthy
People Initiative, provides a comprehensive set of national 10-year
health promotion and disease prevention objectives aimed at improving
the health of all Americans. Since its inception, Healthy People grass
roots input has helped identify the most significant preventable
threats to health and establish national goals to reduce these threats.
Healthy People is founded upon the notion that establishing
objectives and providing benchmarks to track and monitor progress over
time can motivate, guide, and focus action. Each iteration of Healthy
People has been the product of a multi-year, comprehensive
collaborative process that reflects the ideas and expertise of a
diverse range of individuals and organizations, both Federal and non-
Federal, concerned about the Nation's health.
Currently, the Department is leading the development of Healthy
People 2020. The initiative, in the tradition of its predecessors, will
provide the definitive vision and strategy for building a healthier
Nation. Healthy People is used by virtually all of our States and
numerous foreign governments to develop their health plans.
We have gathered testimony from around the country that has shaped
the framework for Healthy People 2020. The stakeholders believe that
now is the time for our Nation to join together to address determinants
of health--factors that directly influence health--such as physical
environment, social environment, individual behavior, genetics and
health care delivery systems. It is an exciting time at HHS as we begin
to consider the objectives for the next decade that could have the
greatest impact on these determinants of health.
prevention science
Thanks to the Department's investment in prevention science, there
is a growing evidence base confirming the benefits of multiple
prevention practices. Today, I will highlight the solid science of
physical activity, nutrition, clinical preventive services, community
preventive services and communication.
This year, the Department, through a collaborative effort developed
and released the first-ever Federal Physical Activity Guidelines for
Americans. Additionally, OPHS, in collaboration with CDC and other
agencies, developed easy to understand, actionable guidance to help
Americans fit a healthy level of physical activity into their lives.
Becoming and remaining physically active is one of the most
important steps that Americans of all ages can take to improve their
health. The Guidelines provide science-based information to help all
Americans aged 6 years and older improve their health through
appropriate physical activity. A communications toolkit for supporting
organizations was developed to provide resources to encourage people to
get the amount of physical activity they need.
Another important influence on health, nutrition, also has an
impressive emerging science base which illustrates how to stay healthy
by making healthy food choices. HHS works with the Department of
Agriculture to develop the Dietary Guidelines for Americans. Issued
every 5 years, the Dietary Guidelines reflect the most accurate
science, serve as the cornerstone for Federal nutrition policy, and are
one of our most important tools for empowering Americans to enhance
their health and help prevent lifestyle-related chronic disease. This
year, HHS published the first-ever bilingual ``Road to a Healthy Life,
Based on the Dietary Guidelines for Americans'' for Hispanic and Latino
families nationwide. Obesity rates have increased in this population,
and research shows that this audience needs better understanding of how
to apply our national nutrition guidelines.
This publication is just one example of HHS's focus on Eliminating
Health Disparities and work toward achieving a nation where children,
families, and communities have equitable opportunities for attaining
optimal health, regardless of race/ethnicity, geography or any other
demographic characteristic.
Two additional factors that impact health are taking advantage of
proven clinical preventive services and community-based prevention
support services.
The Agency for Healthcare Research and Quality (AHRQ) supports the
U.S. Preventive Services Task Force--an independent panel of experts in
primary care and prevention that systematically reviews the evidence of
effectiveness and develops recommendations for clinical preventive
services [http://www.preventive
services.ahrq.gov]. The task force rigorously evaluates clinical
research to assess the merits of preventive services, including
screenings, counseling services and preventive medications, for people
without signs or symptoms of disease. The USPSTF library of
recommendations currently includes over 125 evidence-based
recommendations. In 2008, the USPSTF released 12 recommendations: 3
preventive services for pregnant women; 3 services for children; and 6
services for adults. These included new recommendations on screening
for diabetes; prostate and colorectal cancer; and, counseling to
promote breastfeeding.
AHRQ ensures that Americans receive these proven clinical
preventive services by developing tools and products to facilitate the
dissemination and use of the evidence-based USPSTF recommendations.
Each year, AHRQ publishes The Guide to Clinical Preventive Services, a
pocket-sized book formatted for clinicians to consult for prevention
guidance in their daily practice. AHRQ also has created the electronic
Preventive Services Selector, a Web site that allows clinicians to
search USPSTF recommendations during an office visit based on a
patient's age, sex and risk factors. The Selector can also be
downloaded to a clinician's PDA or Blackberry. AHRQ is currently
working to embed the Selector into electronic health records.
To accomplish this work, AHRQ also builds and leverages public-
private partnerships. Partnering with the National Business Group on
Health and CDC, AHRQ supported the publication, A Purchaser's Guide to
Clinical Preventive Services, to move the science of clinical
prevention into benefit coverage decisions. Over 250,000 copies have
been distributed. In its Hispanic Elders Learning Network, AHRQ,
working with Federal and local partners, mobilized, organized, and
coordinated local DHHS and community resources to reduce disparities in
health outcomes among Hispanic elders in eight communities.
In addition, AHRQ is moving the field of prevention science by
investing in research to improve our understanding of the preventive
health care needs of patients with multiple chronic conditions. The
ultimate goal of this work is to develop personalized, patient-centered
decision aids for patients and their providers. In collaboration with
the Office of Disease Prevention and Health Promotion, the Web site, My
healthfinder (www.healthfinder.gov) provides personalized prevention
recommendations specific to the user's age, gender and pregnancy
status. It was designed to be understandable and actionable for
everyone, including people with limited health literacy.
The Guide to Community Preventive Services summarizes what is known
about the effectiveness, economic efficiency, and feasibility of
interventions to promote community health and prevent disease. The Task
Force on Community Preventive Services, an independent decisionmaking
body convened by CDC for HHS, makes recommendations for the use of
various interventions based on the evidence gathered in rigorous and
systematic scientific reviews of published studies conducted by review
teams for the guide. The findings from the reviews are published in
peer-reviewed journals and also are made available online. The task
force has published over 100 findings across 16 topic areas, including
tobacco use, physical activity, cancer, oral health, diabetes, motor
vehicle occupant injury, vaccine-preventable diseases, prevention of
injuries due to violence, and social environment.
additional hhs prevention activities
As I mentioned earlier, there is tremendous work going on within
HHS in the area of prevention which supports and expands upon the
framework established by the Healthy People initiative. I'd like to
share some other examples which represent the diversity of the
contributions that HHS makes.
The HealthierUS initiative is a national effort to improve people's
lives, prevent and reduce the costs of disease, and promote community
health and wellness. It focuses the Nation's attention on high impact
prevention practices: getting and staying physically active, eating a
nutritious diet, avoiding risky behaviors and getting preventive
screenings.
Among its many educational and scientific efforts, the Office of
the Surgeon General heads a prevention initiative, Healthy Youth for a
Healthy Future to help prevent overweight and obesity in children. This
initiative seeks to increase public awareness of the child obesity
epidemic and to share information about effective community efforts to
reduce child overweight and its consequences. To date, the Acting U.S.
Surgeon General visited more than 30 cities to learn about local
programs and meet with public health stakeholders and community leaders
to discuss local prevention, physical activity and nutrition programs.
The Office of HIV and AIDS Policy (OHAP) is using the power of new
media to reach untapped audiences who are at risk for HIV/AIDS--giving
people the information they need on HIV at the time and in the format
they want. New media is a highly effective, low-cost way of reaching
at-risk individuals with HIV prevention, testing, and treatment
messages--and AIDS.gov is spearheading HHS' use of new media to prevent
the spread of HIV/AIDS.
The Office of Population Affairs (OPA) manages the title X program,
the only Federal program solely dedicated to family planning services
with a mandate to provide ``a broad range of acceptable and effective
family planning methods and services,'' and related preventive health
services such as information and education, routine gynecological care,
clinical breast examinations, Pap tests, and sexually transmitted
diseases (STDs) and HIV/AIDS prevention education, testing and referral
services. In addition, the Adolescent and Family Life (AFL) program
provides discretionary demonstration grants to develop, to implement
and to test innovative approaches through two initiatives: (1)
prevention programs promoting abstinence among adolescents; and (2)
care programs providing health, education and social services to
pregnant and parenting adolescents, their infants, teen fathers, male
partners and their families.
The Office on Women's Health (OWH) educates and advocates for
healthy behavior and choices among women and girls to prevent illness
and improve health outcomes. To address this priority, the OWH conducts
media campaigns such as the National Lupus Awareness Campaign to
increase awareness of the disease and to promote early detection of it;
supports programs to end violence against women on college and
university campuses; funds programs to encourage the use of a public
health systems approach with an evidence-based strategy and a gender
focus to improve service delivery and to increase access to care; and,
implements programs that address cardiovascular diseases, obesity
prevention, and other diseases that affect the health and well-being of
women and girls. These efforts and others, address another OWH priority
area--reduction of the leading causes of death for women and girls.
The President's Council on Physical Fitness and Sports is an
advisory committee of volunteer citizens who advise the President
through the Secretary of Health and Human Services about physical
activity, fitness, and sports in America. Among other activities, it
leads and oversees the President's Challenge--a program that encourages
all Americans to make being active part of their everyday lives.
The Office of the Assistant Secretary for Planning and Evaluation
(ASPE) is the principal advisor to the Secretary on policy development
in health, disability, aging, human services, and science, as well as
economic policy. ASPE conducts research and evaluation studies,
develops policy analyses, and estimates the cost and benefits of
policies and programs including the Department's prevention activities.
The Office on Disability (OD) works collaboratively with Federal
agencies and non-Federal partners to develop and coordinate policies
aimed at improving the health and lives of persons with disabilities,
for example, promoting the Surgeon General's Call to Action (CTA) to
Improve the Health and Wellness of Persons with Disabilities through
the national action plan, and physical activity for youth with
disabilities in conjunction with the President's Healthier U.S.
Initiative through the OD's ``I Can Do It, You Can Do It!.'' During
emergency or catastrophic events, OD helps to ensure that medical and
general shelters are accessible for persons with disabilities.
The Administration on Aging (AOA) has been a principal partner with
the Centers for Medicare and Medicaid Services (CMS) in providing
outreach, education and personalized counseling, through the Aging
Services Network, to inform and encourage beneficiaries to take
advantage of Medicare's Part D and preventive benefits including: flu
and pneumonia shots; screenings for cardiovascular disease, colorectal
cancer and diabetes, the ``Welcome to Medicare'' physical exam, and
diabetes self-managing training. AOA is partnering with CDC, AHRQ, CMS
and HRSA and private philanthropy to help community-based aging
services provider organizations, such as senior centers, to implement
science-based prevention-focused models that have proven effective at
helping seniors to better manage their chronic conditions, reduce their
risk of falling, and improve their nutrition and physical activity. AOA
and its HHS partners are working with eight metropolitan communities to
address the serious health disparities affecting Hispanic seniors, the
fastest growing minority group within the older population.
The Centers for Disease Control and Prevention's (CDC's) primary
focus is on protecting health, rather than treating illness, and
carries out that mission through health promotion, prevention and
preparedness, rather than disease care; and on creating holistic
approaches for improving the population's health across all stages of
life, not narrowly defined activities. CDC efforts on a set of
fundamental Health Protection Goals are designed to accelerate health
improvement, reduce health disparities, and protect people at home and
abroad from current and new health threats. These goals drive research
priorities, policy development, and programs and interventions.
The National Institutes of Health (NIH) supports a broad spectrum
of research on prevention, including efforts to improve nutrition,
increase physical activity, and reduce sedentary behaviors. In the area
of obesity prevention, for example, NIH-funded scientists are
investigating a variety of behavioral and environmental interventions
in children and adults; in diverse populations, with an emphasis on
those disproportionately affected by obesity; and in a variety of
sites, including schools, the home, worksites, primary care practices,
and other community settings. Preventing the serious diseases
associated with obesity is also a research focus. For example, the
multi-center HEALTHY study is testing a middle school-based
intervention to reduce risk factors for type 2 diabetes, including
overweight and obesity. Components of the HEALTHY study include changes
in school food services and physical education classes, along with
activities to promote healthy behavior and family outreach. Through its
translational research efforts, the NIH supports studies to explore
potentially cost-effective ways to bring the results of intervention
studies to broader community settings and medical practice.
At the same time, the NIH is pursuing research that may inform the
development of new strategies to prevent (as well as treat) obesity.
These include basic research avenues as well as epidemiologic and other
studies to provide insights into potential contributors to obesity,
such as economic factors and aspects of neighborhoods that may
influence eating patterns and activity. Finally, through its
information, education, and outreach activities, the NIH is
disseminating research results to patients, healthcare providers, and
the public. For example, the NIH is currently updating its Clinical
Guidelines on the Identification, Evaluation, and Treatment of
Overweight and Obesity in Adults. In a major national public education
and outreach effort for children, the NIH's We Can! (Ways to Enhance
Children's Activity and Nutrition) program is designed to help children
8-13 years old stay at a healthy weight. We Can! is based on evidence
from research findings. The program focuses on parents and families in
the home and community settings, and many national partners and
supporting organizations are promoting We Can! messages and materials.
The Substance Abuse and Mental Health Services Administration
(SAMHSA) has made progress in reducing drug and alcohol misuse and
abuse.
SAMHSA reports that illicit drug use has dropped more than 20
percent among teens. To continue to drive these numbers down, SAMHSA
supports community-driven substance abuse prevention and mental health
promotion programs through Strategic Prevention Framework State
Incentive Grants and Drug-Free Community grants.
SAMHSA is concurrently emphasizing mental health prevention
activities. It is important to note that half of all lifetime cases of
diagnosable mental illnesses begin by age 14 and three-fourths by age
24. Furthermore, 1 in 12 adolescents experience a significant
depressive episode each year, underscoring the need for an upstream
approach. This past year SAMHSA expanded its efforts in prevention
beyond Suicide Prevention to include a new imitative called Project
LAUNCH.
Project LAUNCH promotes the wellness of young children 0 to 8 years
of age. It is grounded in the public health approach by promoting
coordinated programs that take a comprehensive view of health,
addressing the physical, emotional, social and behavioral aspects of
wellness. The first six grants under this program were awarded this
past September.
centers for medicare and medicaid services
Promoting preventive health is an underlying component of all
Centers for Medicare & Medicaid Services (CMS) programs, initiatives,
and outreach efforts to Medicare beneficiaries, providers, partners and
caregivers. Preventative health efforts are thoroughly entrenched in
the CMS' outreach and education activities.
Medicare: Medicare covers many important screenings and other
prevention benefits to help people with Medicare live healthier and
more active lives. When beneficiaries become eligible for Medicare,
they are offered a ``Welcome to Medicare'' physical to assess their
overall health condition. Medicare also covers cardiovascular disease
and diabetes screenings, glaucoma tests, osteoporosis screenings,
mammography, cervical cancer screenings, prostate cancer screenings,
colorectal cancer screenings, influenza and pneumococcal vaccinations,
and smoking cessation counseling.
Most recently, the Medicare Improvements for Patients and Providers
Act of 2008 (MIPPA) authorized the HHS Secretary to add coverage
(beginning in 2009) of additional preventive services recommended by
the U.S. Preventive Services Task Force and determined through the
Medicare National Coverage Determination process to be reasonable and
necessary for Medicare beneficiaries. In making such determinations,
the Secretary may consider the relation between predicted outcomes and
the cost of such services.
CMS is currently conducting or developing several prevention
demonstration projects, for example, the Cancer Prevention and
Treatment Demonstration for Racial and Ethnic Minorities and a Senior
Risk Reduction Demonstration.
Medicaid: While States are the primary administrators of Medicaid
and State Child Health Insurance Program (SCHIP), CMS is responsible
for supporting States in their efforts to achieve safe, effective,
efficient, patient-centered, timely and equitable care.
CMS works with States to implement several quality/prevention
efforts including smoking cessation counseling, prenatal care, neonatal
improvement outcomes, asthma management, immunizations for children and
adults, and Early and Periodic Screening, Diagnostic and Treatment
(EPSDT) services, lead screening, cancer screenings, and obesity
prevention initiatives.
The mission of Food and Drug Administration (FDA) is to prevent
illness and injury through the regulation of foods and medical
products. FDA continues to implement recommendations contained in the
FDA Obesity Working Group Report of 2004.
In an Advance Notice of Proposed Rulemaking (ANPRM) on the Revision
of Reference Values and Mandatory Nutrients, November 2007, FDA
addressed comments on two prior food labeling ANPRMs (serving size &
prominence of calories).
FDA is increasing awareness/use of nutrition facts on labels in
making individual choices regarding food through the following
activities:
Promoting ``Spot the Block--Get Your Food Facts First''
launched with the Cartoon Network, March 2007.
Expanding ``Make Your Calories Count,'' an interactive
learning tool.
Developing curriculum with National Science Teachers
Association.
The Health Resources and Services Administration (HRSA) is the
primary Federal agency for improving access to health care services for
people who are uninsured, isolated or medically vulnerable including
people living with HIV/AIDS, pregnant women, mothers and children. For
example, community-based and patient-
directed Community Health Centers serve populations with limited access
to health care, low income, no insurance, limited English proficiency,
as well as migrant and seasonal farm workers, individuals and families
experiencing homelessness, and those living in public housing.
Health centers provide comprehensive, primary health care and
preventive care services. In 2007 health centers served over 16 million
patients. Many programs within HRSA contain prevention as a key
component such as The Maternal and Child Health Services Block Grant
Program providing grants to States to reduce infant mortality, to
provide access to comprehensive prenatal and postnatal care for women,
and to increase the number of children receiving health assessments and
follow-up diagnosis and treatment. In addition, the Healthy Start
program provides intensive services tailored to the needs of high risk
pregnant women, infants and mothers in communities with exceptionally
high rates of infant mortality. To increase the healthcare workforce
who can provide preventive services to vulnerable populations, HRSA
funds programs to recruit and retain physicians in rural hospitals and
clinics. HRSA's telehealth program uses information technology to link
isolated rural practitioners to medical institutions over great
distances.
The Indian Health Service (IHS) has a Prevention Initiative to
bring more focus on preventive health care within IHS and among
Tribally operated programs. The IHS Prevention Task Force (PTF), with
broad representation from IHS and Tribal programs, is responsible for
identifying the key components for a coordinated and systematic
approach to preventive health activities at all levels of health care
for American Indians/Alaskan Natives. The work of the IHS Prevention
Task Force is fully integrated with past and on-going health
initiatives within HHS, such as Healthy People 2010 and more recently
the Secretary's Steps to a Healthier U.S.
The focus areas of the Prevention Initiative are also entirely
consistent with the priorities of the IHS Strategic Plan and
performance measures identified in the congressionally directed
Government Performance and Results Act (GPRA) reporting system.
Additionally, the PTF receives guidance from the Policy Advisory
Committee which consists of Tribal leaders, at the national and local
levels, and representation from other Federal agencies (e.g., CDC, NIH)
that focus on health promotion and disease prevention.
hhs prevention budget
I am profoundly honored to be a part of this robust Prevention
Infrastructure and Science Base that holds great promise for helping us
realize our vision, which is worth repeating here--A Nation in which
healthy people live in healthy communities, sustained by effective,
efficient and coordinated health systems.
The FY 2009 President's Budget includes discretionary funds to
support prevention activities across the Department and to sustain this
Prevention Infrastructure and Science base. Additionally, the FY 2009
Budget includes mandatory funds for prevention efforts in Medicaid and
Medicare.
summary
As my description of HHS activities illustrates, our disease
prevention efforts cut across agencies and missions. Encouraging
Americans to make healthy choices, contributes to the creation of a
culture of wellness, which is, after all, everybody's business.
The Department's investment in a comprehensive prevention
infrastructure and growing prevention and communication science base
sets the stage for health care reform in which the public should be
able to expect seamless, coordinated care and the best support for
making healthy decisions that science has to offer.
It is accurate to say that whatever the specifics of future efforts
to reform American health care, a consensus exists that the system of
the future will be founded upon prevention and recognition of its
value. Put another way, if prevention is the future--and it is--then
the future is now.
Senator Harkin. Thank you very much, Dr. Wright. Thank you
for your service.
You know, I want to start off by just saying, I asked my
staff for the organizational chart for HHS. I can't find you.
It is not there. Where are you?
Dr. Wright. I am in the Office of Public Health and
Science, report to the assistant secretary for health.
Senator Harkin. Public Health and Science? Well, there is
an assistant secretary for health, and I guess if I looked
further, I would find some different things that that person is
in charge of, right, in different boxes and things like that?
Dr. Wright. Yes, sir. Sir, the Office of Public Health and
Science is within the Office of the Secretary, and it is our
responsibility to try to coordinate activities across the
various operating divisions. So many of the issues of HHS have
contributions made by the various operating divisions and
staff.
Senator Harkin. My point is that your office ought to be
right up there. I mean it ought to be one of the first things
that people see when they go to HHS, and they see an--quite
frankly, there ought to be an assistant secretary. Is that the
next in line, or is that the deputy secretary? The assistant
secretary for prevention, wellness, public health.
They ought to be able to look and say that is where you
are, right there. Can't find you. You are buried someplace down
there. My point being is that, again, we have not elevated this
to the position it ought to be.
As we move ahead in our health reform debate, I think one
of the things we ought to look at is your office and where it
is and why it isn't in a more strategic position in the
secretary's office, with a higher level of public knowledge of
you and where you are in there and what you do. Because there
are things that you are doing that the public ought to know
about.
That is my first point. I am not denigrating you. I am just
saying that that office ought to be boosted up and made into a
very key position in HHS.
The second thing is, and I think it is very clear--Senator
Coburn alluded to that--and we all know that when we are
talking about prevention and wellness, a lot of it occurs not
just under the health umbrella, as we think about it. It occurs
outside someplace--transportation, schools, exercise in our
schools, nutrition, what our kids are eating.
I wear another hat. I had an earlier hearing this week on
the reauthorization of the child nutrition bill--the school
lunch, school breakfast, WIC programs. That is a big part of it
also in terms of prevention.
It reaches into all kinds of areas, and then you get down
to the States and what are States doing. Some States are doing
some really interesting things. Some local jurisdictions are
doing very good things on wellness, but it is all disconnected.
We don't have, as Senator Coburn said, we don't have the
metrics to measure what is really good, what really works and
what is not working. We need to know that also.
So, I guess my second question has to do with whether there
is any structure or office, where your office would be working
with Agriculture, with Transportation, with Education, on and
on and on, on prevention and wellness? Is there such a
structure?
Dr. Wright. Thank you, Senator.
I think that is a very good question. And clearly, for us
to impact the healthcare system in a positive manner, we do
have to reach out further than the healthcare system--schools,
community centers, communities--and look at how we can have a
positive impact in health from a variety of standpoints.
The answer to your question, Is there an office within OPHS
or within the HHS that reaches out and across departments to
seek their help with these issues?, and the answer to that is
yes. It really is the overarching Healthy People program that
provides the organizational framework.
We have realized that we clearly need to help with the
other departments as we try to advance health issues in this
country. The Department of Education has been so important with
the issue that Senator Coburn mentioned about physical
education and the part that plays in childhood obesity.
Clearly, the Department of Interior has been involved, the
Department of Housing and Urban Development, the Veterans
Administration, and others.
These are part of the Federal interagency working group
that creates the Healthy People 2010 goals that we are working
on now. But we have also started looking into the next decade,
and the Federal interagency working group for Healthy People
2020 is now meeting, and we have representation across the
Federal family to seek their input. Clearly, the more support
we have from the various departments, the greater success we
will enjoy on down the road.
Senator Harkin. Thank you very much, Dr. Wright. Thank you.
Senator Coburn.
Senator Coburn. Dr. Wright, a couple of questions. You have
released the guidelines on physical fitness. How were they
promoted?
Dr. Wright. That is a great question, and clearly, it is
one thing to have guidelines and then see that that is actually
carried at the community level. I think one of the areas that
we have learned in public health is clearly there has to be
grassroots campaigns to ensure that what we know are quality
guidelines are translated into actions at the local level.
We are trying to get the message out. This is a new
guideline that was actually only released in October of this
year. So we are very much in the rollout.
Senator Coburn. So what is the plan to get the message out?
Dr. Wright. We are using the President's Council on
Physical Fitness, the members of that group, to speak on behalf
of the physical activity guidelines.
Senator Coburn. Is there an advertisement that runs next to
a McDonald's advertisement?
[Laughter.]
No, I am serious. The fact is, we spend $834 million a year
at CDC for chronic disease prevention, alright? NIH spends
$6.74 billion a year on chronic disease research. SAMHSA spends
$1.8 billion on prevention and treatment. The Administration
for Aging and Nutrition spends $779 million.
Where are the ads to teach American people what they need
to know? The question I have is--you can have all of the
guidelines in the world. You can rearrange the deck chairs all
you want, but there are no metrics to say that we have
accomplished anything--and it doesn't matter what the
guidelines are if they are not communicated.
So, my question is, where is the package that says here is
what we want the American people to know, and here is how we
are going to make sure they know it? And it doesn't sound to me
like you all have a package to communicate it.
Now you may have a plan, but the fact is, is if you have a
plan and you haven't communicated it, you haven't had any
impact on health. That is my big problem with most of what we
are doing on prevention. We have great people working on
prevention. They are right on.
But when we are not teaching people that their body mass
index has a direct correlation with their long-term health, and
there is nothing on the airwaves and there is nothing on the
Internet that pops up that says, ``What is your BMI? Your
future risk for cancer, diabetes, or hypertension is related to
it,'' we have not begun getting in the game of teaching
prevention.
That is why I said we need to change the paradigm, and we
need a plan that says we are going to go out and compete with
the private sector that are destroying the health of the
American people by giving them the message on the things they
can do, whether they do it or not. The vast majority are going
to make good decisions, but we are not even out there with the
message.
What is the plan, what is the exact plan to get the
guidelines for physical fitness out to the American people so
they know what it is?
Dr. Wright. Right. Senator Coburn, your point is well
taken. The guidelines are only as good as they are implemented
at the person level. And clearly, we will move forward in this
area.
The statistics are not promising. There are 40 percent of
Americans that have no physical activity whatsoever, and so
there is a great opportunity for improvement in that area. We
really have reached out to many of the external stakeholders,
and we have over 1,000 that have agreed to help us on the
outside actually get the message of the physical activity
guidelines out.
We will make increased efforts to reach the people. The
community health centers will be one area that we get our
message out. And we are also putting together a community tool
kit that will allow communities to try to make individuals
within that community aware of the value of physical activity
and what needs to occur at the local level to encourage that.
Senator Coburn. You don't have a promotional kit to go with
Ad Council ads that says here is what you need to know about
your physical activity? If you are a parent, if your child
isn't getting this much exercise, your child is going to be at
risk for this, this, and this?
I understand that your examples are the way we have done
it. That is my whole point in saying we have to have a paradigm
change. If we are going to go after prevention, we have to
educate the American people on prevention.
We can have the best guidelines in the world, if they don't
know what they are and the physicians in this country don't
know what they are, and they are not part of the graduate
medical education recertification test of knowing what they
are, so that it is an important part of their getting
recertified, if we don't have a master plan that says we are
going to put this information out, and then we are going to
make sure it gets communicated.
We see the Ad Council ads all of the time, but we hardly
ever see one related to prevention. And that is, most of the
people that are out there are doing that as a public service. A
great public service would make sure parents knew what their
kids need to do in terms of exercise or addressing the school
board. Why don't we have physical fitness anymore in our
schools?
I will guarantee you I behaved a lot better in school as a
youngster because I was more tired after physical exercise than
when I wasn't doing physical exercise.
Thank you, Mr. Chairman.
Senator Harkin. Thank you, Senator Coburn.
Senator Reed.
Senator Reed. Well, thank you very much, Mr. Chairman.
Mr. Secretary, welcome.
One aspect of prevention is an old, reliable one. That is
immunization. The CDC estimates that full immunization would
cost about $1.1 billion a year, and the 317 program, which is
the major program assisting State and local governments, the
request this year is $465 million.
I understand these are difficult budget times, but could
you give me a sense of how the figure was arrived at, given the
need and given the fact that immunization is something that
obviously seems to be central to every discussion of preventive
healthcare, of health quality throughout the Nation?
Dr. Wright. Senator, first of all, let me say I agree with
you that immunization programs are one of the most effective
public health strategies and one of the most effective
preventive measures that we can invest in.
You know, as a member of OPHS, my role is one of
coordination across the various operating divisions within HHS,
and I am really not familiar with the details of the
immunization budget and the shortfalls that occur. I do know
over my lifetime as a physician, the number of recommended
childhood immunizations has markedly increased, and we have
seen decreased childhood morbidity as a result of that.
That comes with a price, and the cost of immunizing the
child is much higher now than when I was in my training. We do
have a National Vaccine Program Office in OPHS that looks at
these issues as well. I am happy to get back with you as it
relates to the immunization budget, but I don't have those
numbers at my fingertips.
Senator Reed. Part of this touches, I think, on the theme
that Senator Coburn was addressing, which is that a strategy
prioritizes the most important initiative and then the next
most important, etc. In your deliberations with your
colleagues, it would seem to me that immunization sort of has
to be at the top of any of these lists, and sometimes it is
overlooked or underfunded.
Not only do I think it is appropriate to look at
immunization, but also it would help us, I think, if you could
clearly articulate sort of what are--the first issue is
immunization. The second would be addressing obesity. The third
would be whatever. If you have that strategy, we would
appreciate it.
Dr. Wright. Sure. Well, certainly, we want to invest
prevention dollars where we will have the greatest impact, and
immunizations would fit into that category. But the areas that
I think are really the pillars of prevention are healthy diet
and encouraging Americans to eat nutritious meals every time
they sit down and make the appropriate dietary choices each
time they pull up to the dinner table.
The issue that I just brought up is physical activity. We
have 40 percent of Americans who are not receiving any physical
activity, and yet the science is replete in examples and in
evidence of the value of physical activity. So that is another
cornerstone that we really need to move forward with.
Medical screenings, making sure that individuals receive
the appropriate medical screenings at the appropriate time as
recommended by the U.S. Preventive Services Task Force.
And then, avoiding risky behaviors. Clearly, at the top of
the list of risky behaviors would be tobacco use, and we need
to continue to invest our energies, first of all, in preventing
the initiation of the tobacco habit among America's youth and
among American adults. But we also need to invest our energies
in helping those that are already addicted to tobacco to stop
that health behavior.
Senator Reed. Final question, Doctor. Many of the benefits
that accrue from these strategies will be seen 10 years, 20
years ahead, but the cost is immediate. Is there any thought
being given to a longer-term budget authority, or more in
general terms, how do you consciously take into consideration
the gap between the cost and the benefit?
Dr. Wright. Thank you, Senator.
That is a very insightful question. In reality, some of the
dollars we invest in prevention will result in reduced
healthcare costs, but it may be years down the road before we
realize those costs.
I look at the dollars we spend on prevention of initiation
of tobacco smoking. Clearly, the individual that we prevent
from starting that habit has reduction in healthcare costs down
the road. But quite frankly, those may not be realized for
decades. So it is an important issue.
When we look at the cost of healthcare and the value that
prevention plays in that, I want to strike a cautionary note.
Clearly, subject matter experts in this area differ as to the
savings that can come out of a comprehensive prevention
program.
There is no question that some of our interventions can
prevent diabetes and other chronic illnesses. Will there be a
net savings? I think that is debatable. There are subject
matter experts that think the savings will be significant and
others that think that they will be somewhat negligible.
But from my vantage point, the justification for prevention
programs are ample. Clearly, if we can prevent chronic
diseases--and over 40 percent of chronic diseases are
preventable--we can alleviate human suffering, we can improve
the quality of life for Americans, and we can increase the
productivity, a point that Senator Harkin made in his opening
statements. Those facts alone provide the justification to move
forward with a prevention agenda.
Senator Reed. Thank you, Mr. Secretary.
Senator Coburn. Mr. Chairman, I just wanted to add for the
record the CDC's numbers on the vaccine for children was $2.7
billion. It will be 2.766 this next year. Immunizations for
respiratory disease, pandemic influenza is $157 million, and
discretionary non add-ons is $466 million. So, in total, they
are spending about $4.6 billion through CDC on programs for
immunization and the like.
Senator Harkin. Dr. Wright, I see you have Dr. Royal behind
you, who is with the uniformed services. In the next panel, Dr.
Levi points out the commissioned services and how we are not--
there is a congressionally mandated cap right now, which I was
really, quite frankly, unaware of. And that cap is about 2,800
right now.
At some point, but not today, I intend to delve into this
in a future hearing about the role of the uniformed services in
public health. It seems like we haven't utilized them enough,
and we haven't gone out to recruit young people to be in the
Public Health Service and the benefits that accrue and how they
can take this as a career path.
Hopefully, at one of my next hearings, we are going to have
the uniformed services up here to talk about their role and
what they could do. And I just wonder if you have any thoughts
on that?
Dr. Wright. Senator, I agree with the value you place on
the Commissioned Corps. They are invaluable to what we do at
HHS, and the Admiral is just one example of numerous
Commissioned Corps officers that we have carrying out the very
important business of HHS.
I will make you aware of the fact that we are in the
process of transforming the corps, and there has been an effort
to increase the enrollment in the corps. There is a
transformation office that is increasing their efforts to reach
out and recruit potential corps members.
I am pleased to say that over this past year, the year that
I have been at HHS, the number of corps members has increased
by approximately 200. So we are moving in the right direction.
Senator Harkin. Well, that is good to know. It needs to be
a little bit more accelerated than that, I think. And I think
there are some things we can do in terms of scholarships, loan
repayments, all kinds of things that we could focus on to build
up this public health corps sector in the United States with
public health workers through the commissioned services.
Dr. Wright. All the things you have mentioned would be
valuable strategies to help us achieve that goal.
Senator Harkin. Do you have anything else?
Dr. Wright, anything else you would like to say?
Dr. Wright. No, thank you very much.
Senator Harkin. Well, thanks for being here, Dr. Wright.
Thank you.
Now we will move on to the second panel.
Again, I would like to welcome our second panel. Thank all
of you for being here.
Thanks for submitting your testimony earlier so I could
read it all yesterday. And again, all of your written
testimonies will be made a part of the record in their
entirety. I will ask each of you if you could just take 10
minutes or less to summarize so we can get into a discussion.
I will introduce each of you. We will just go from left to
right. Our first witness will be Dr. Jeff Levi. ``Lee-vee'' or
``Lee-vi? ''
Mr. Levi. Lee-vee.
Senator Harkin. Dr. Levi, the executive director of the
Trust for America's for Health. He is also an associate
professor at the George Washington University's Department of
Public Health and previously served as deputy director at the
White House Office of National AIDS Policy.
Dr. Levi has a Master's from Cornell University, a Ph.D.
from George Washington University.
Trust for America's Health advocates for a modernized
public health system and addresses many of the critical
problems threatening the health of our Nation. They have
released several reports this year that are of great interest.
I think the chart that I was referring to was from you, Dr.
Levi, and all these other ones that came out. I was privileged
to be at your rollout this summer with former Senator Lowell
Weicker. I have read a good bit of this and walked through it,
and there are some great things in these documents.
I thank you, and I thank Trust for America's Health for all
that they are doing, and please proceed. And if you will set
that clock at 10 minutes so Dr. Levi knows--whoever is setting
these clocks. More time than I expected.
Senator Harkin. Thank you very much, Dr. Levi. Please
proceed.
STATEMENT OF JEFFREY LEVI, PH.D., EXECUTIVE DIRECTOR, TRUST FOR
AMERICA'S HEALTH, WASHINGTON, DC
Mr. Levi. Good morning, and thank you for this opportunity
to testify.
Senator Harkin, your leadership and that of Chairman
Kennedy give us great hope in the public health community that
this round of health reform discussions will really be about
the health of Americans, not just about healthcare.
Trust for America's Health believes that a strong public
health system and public policies focused on disease prevention
should be a cornerstone of the health reform plan. My written
testimony develops seven points related to prevention and
health reform.
First, universal quality coverage and access to healthcare
is critical to protecting and promoting the health of
Americans.
Second, investment in both community-based and clinical
prevention is critical to ensuring that universal coverage is
as cost-effective as possible.
Third, stable and reliable funding for core public health
functions and community-based prevention is essential.
Fourth, a national prevention plan that harnesses the
potential of existing Federal programs across the Government is
long overdue.
Fifth, the public health workforce must be strengthened to
maximize the potential of public health to contribute to better
health and lower healthcare costs.
Sixth, the concept of quality assurance and evidence-based
interventions should be extended to all public health programs,
including community-based prevention.
And seventh, a reformed healthcare system must be prepared
to react and mitigate the consequences of a public health
emergency.
In the brief time I have, I want to focus on three
elements--the importance of community prevention, assuring a
reliable funding stream, and development of a national
prevention strategy.
Mr. Chairman, as you mentioned, last July we issued a
report based on an economic model developed by the Urban
Institute that found that an investment of $10 per person per
year in effective community-level prevention programs to
improve physical activity and good nutrition and prevent
smoking could result in more than $16 billion in savings and
healthcare costs annually within 5 years. This is a return of
$5.60 for every $1 spent.
As a part of health reform, we need to jump start broad-
scale community prevention in this country. Our written
testimony has a detailed proposal for creation of a targeted
community makeover grant program to provide funding for a
comprehensive, coordinated approach to community-based
prevention activities, with a particular focus on reducing
chronic disease rates and addressing health disparities.
I would argue that the community makeover grant program is
that paradigm shift that Senator Coburn was talking about. In
our prevention report, we describe some of those kinds of
programs, many of which involve social marketing campaigns to
target changes in certain types of behavior.
We have done a significant amount of research that actually
does polling and focus groups to see what the American people
want from the Government in terms of public health. And I think
Senator Coburn is correct. They don't want to be lectured at,
and they don't want to be mandated to do things.
They want to know what is the best guidance. I think it is
actually true that the new physical activity guidelines that
HHS has issued are phenomenal guidelines. They are clear. They
are evidence-based. But what we don't have is a plan to then
get the American people to adopt them.
Our mantra is that we need to help people make healthy
choices. Some of that is about giving them the right
information. But sometimes when we look at communities, we also
have to address what is happening in their communities that is
making it hard for them to actually implement those guidelines.
If we are telling people to walk more and there aren't
sidewalks in their community, then we have to address that. If
we are telling people to eat healthier and there aren't
supermarkets in their neighborhoods, then we have to address
that.
Senator Harkin's proposal about changing how the food stamp
program works, the demonstration program he is hoping to see
implemented soon, would actually give people higher
reimbursement if they buy healthier foods. It is those kinds of
things that the evidence shows actually results in behavior
change and can dramatically reduce the chronic diseases that we
are concerned about.
But community prevention will only be fully effective if
there is a reliable funding stream and well-trained workforce
to implement these programs and the core public health system
that supports prevention. Therefore, we recommend the creation
of a trust fund mechanism to support clinical and community-
based prevention along with related public health functions and
infrastructure.
I would note, parenthetically, that a critical component of
the public health infrastructure is the workforce. And as
Senator Harkin mentioned earlier, that is a real issue that we
need to address, both in the context of the Commissioned Corps
and its status, but also in terms of having more community
health workers.
They don't necessarily have to be master's trained public
health folks, even though I teach in a school of public health.
We need more people out in the community educating folks,
helping people make those healthy choices.
It is my hope that you will be able to work with the folks
developing the economic stimulus package to give more attention
to training and workforce development in public health. There
is an opportunity to train people and to rapidly increase the
community health workforce that is out there.
Finally, Trust for America's Health (TFAH) recommends that
public health and prevention be elevated throughout the Federal
Government by creating a national prevention strategy. The
strategy needs to direct all Federal agencies and departments
to consider how their budgets, policies, and programs influence
health.
The Healthy People 2010 document is a very useful document
in terms of setting goals for the Nation, but it is not a
strategy. It does not crosswalk the goals that are set in
Healthy People 2010 to specific programs and specific
investments that the Government is making to help Americans
reach those goals.
It is our hope that in a new administration, that this
direction will actually come from the White House so that all
agencies recognize that it is important to have a defined
strategy with clear milestones to achieve a healthier
population. And I think, Senator Harkin, you were absolutely
right in terms of the diversity of the Federal agencies that
need to be part of that process.
This Administration did a phenomenal job in developing a
national strategy for pandemic influenza that recognized that
it is not just the Department of Health and Human Services that
has a role, but every agency across the Federal Government. And
we need to think about that in the same way when we are
thinking about prevention, particularly as we focus on chronic
diseases.
Thank you again, Mr. Chairman, for your tremendous
leadership in focusing our Nation's health efforts on
prevention, and we look forward to working with you to assure
that prevention remains a central element of health reform.
Thank you.
[The prepared statement of Mr. Levi follows:]
Prepared Statement of Jeffrey Levi, Ph.D.
Good morning. My name is Jeffrey Levi, and I am the Executive
Director of Trust for America's Health (TFAH), a nonpartisan, nonprofit
organization dedicated to saving lives by protecting the health of
every community and working to make disease prevention a National
priority. I would like to thank the members of the committee for the
opportunity to testify on this very important issue--the role of
prevention and public health as a component of the health reform
debate. Senator Harkin, your leadership and that of Chairman Kennedy,
give great hope to those of us in the public health community that this
round of health reform discussions will really be about the health of
Americans, not just about health care.
TFAH believes that America must provide quality, affordable health
care to all. A strong public health system and public policies focused
on disease and injury prevention should be a cornerstone of a health
reform plan. I want to focus on seven critical points related to
prevention and health reform in my testimony today:
1. Universal, quality coverage and access to health care is
critical to protecting and promoting the health of Americans.
2. Investment in both community-based and clinical prevention is
critical to ensuring that universal coverage is as cost-effective as
possible.
3. Stable and reliable funding for core public health functions and
community-based prevention is essential.
4. A national prevention plan that harnesses the potential of
existing Federal programs across the government is long overdue.
5. The public health workforce must be strengthened to maximize the
potential of public health to contribute to better health and lower
health care costs.
6. The concept of quality assurance and evidence-based
interventions should be extended to all public health programs,
including community-based prevention.
7. A reformed health care system must be prepared to react to and
mitigate the consequences of a public health emergency.
universal coverage
Any health reform plan must assure universal, quality coverage and
access to health care to give all Americans the opportunity to be as
healthy as they can be. All individuals and families should have a high
level of services that protect, promote, and preserve their health,
regardless of who they are or where they live. Full coverage of
preventive services, without copayments or deductibles will maximize
the potential of evidence-based prevention. But coverage alone is
insufficient. A reformed system must also assure access to care. State
and local health departments often provide direct primary care and/or
clinical preventive services to significant portions of the population,
and therefore, need to be assured adequate funding streams if that role
continues in a reformed system.
clinical and community-level prevention
As we chart a new course for our Nation's health care system, it is
important that we look for ways to achieve greater cost efficiency.
America spends $2.2 trillion on health care each year, far more than
any other nation, while spending a few cents on every dollar on public
health. Clearly, we must begin to control these skyrocketing health
care costs, but achieving better health outcomes must be the driving
force behind our investments and choices. With that in mind, disease
prevention must be at the center of our efforts. Two important
components that Congress should consider in a prevention-centered
health reform initiative are clinical and community-level prevention
programs.
Expanding clinical preventive services, including immunizations,
screenings and counseling, could save many lives. A report by the
Partnership for Prevention found that increasing the use of just five
preventive services would save more than 100,000 lives each year in the
United States.\1\ To maximize our investment in prevention, it is
essential that we support both clinical and community-level prevention
programs, as the two work hand-in-hand. Many clinical preventive
interventions require a strong community-level base to be effective.
For example, a doctor can encourage a person to be more physically
active, including writing a prescription for a person to get more
exercise. However, unless a person has access to a safe, accessible
place to engage in activity, he or she will not be able to ``fill''
this prescription.
---------------------------------------------------------------------------
\1\ Partnership for Prevention. Preventive Care: A National Profile
on Use, Disparities, and Health Benefits. August 2007. http://
www.prevent.org/content/view/129/72/.
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Community prevention can also be very cost effective. Earlier this
year, TFAH released a report, Prevention for a Healthier America:
Investments in Disease Prevention Yield Significant Savings, Stronger
Communities, which examines how much the country could save by
strategically investing in community-based disease prevention programs.
The report concludes that an investment of $10 per person per year in
proven community-based programs to increase physical activity, improve
nutrition, and prevent smoking and other tobacco use could save the
country more than $16 billion annually within 5 years. This is a return
of $5.60 for every $1.00 spent. The economic findings are based on a
model developed by researchers at the Urban Institute and a review of
evidence-based studies conducted by the New York Academy of Medicine.
The researchers found that many effective prevention programs cost less
than $10 per person, and that these programs have delivered results in
lowering rates of diseases that are related to physical activity,
nutrition, and smoking cessation. The evidence shows that implementing
these programs in communities reduces rates of type 2 diabetes and high
blood pressure by 5 percent within 2 years; reduces heart disease,
kidney disease, and stroke by 5 percent within 5 years; and reduces
some forms of cancer, arthritis, and chronic obstructive pulmonary
disease by 2.5 percent within 10 to 20 years, which, in turn, can save
money through reduced health care costs to Medicare, Medicaid and
private payers.\2\
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\2\ Trust for America's Health. Prevention for a Healthier America:
Investments in Disease Prevention Yield Significant Savings, Stronger
Communities. July 2008. http://healthyamericans
.org/reports/prevention08/.
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To take advantage of this potential return on investment, TFAH
recommends the creation of community makeover grants, an infusion of
funding to be used to support rapid implementation of the policy,
programmatic and infrastructure improvements needed to address the
social determinants of health and reduce chronic disease rates. These
grants would build upon existing programs with a more significant
investment in a coordinated set of population-wide interventions aimed
at helping to keep people healthier for a longer time and ensuring that
universal coverage is as cost-effective as possible. These grants would
have a strong evaluation component, and their ultimate success would be
measured by the change in prevalence of chronic disease risk factors
among members of the community. (See Appendix A for a full description
of this grant proposal.)
We strongly recommend that these community makeover grants be
initiated as soon as possible--prior to implementation of the reformed
health system to assure that as many Americans as possible are as
healthy as they can be as they enter the reformed health care system.
An initial investment of $500 million, especially if targeted at
underserved communities with high rates of uninsurance, could reach
tens of millions of Americans and dramatically improve their health
status.
stable and reliable funding for prevention
We strongly urge Congress to ensure that any health care financing
system that is developed as part of health reform will include stable
and reliable funding for core public health functions and clinical and
preventive services. A strong public health system is necessary to help
promote better health, monitor the health of the country, and protect
people from health threats that are beyond individual control,
including bioterrorism, foodborne disease outbreaks, and natural
disasters. The Nation must adequately fund Federal, State, and local
public health departments and programs so that they can fulfill their
responsibility for protecting the health of the public. Public health
needs a predictable, sustainable funding stream. Effective
implementation of community-level prevention programs requires
providing support to community organizations and coalitions that
directly carry out this life-saving work.
To that end, TFAH recommends the creation of a trust fund mechanism
to support clinical and community-based prevention, along with related
public health functions. There are various approaches that could be
taken to assure this reliable funding stream for prevention. One
example would be the creation of a Wellness Trust, an independent
entity that would become the primary payer for preventive services and
would recommend priority prevention activities. A Wellness Trust would
put prevention and wellness at the center of our healthcare system. S.
3674, introduced by Senator Clinton, and H.R. 7287, introduced by
Congresswoman Matsui, are variations of this concept and would vastly
improve access to clinical and community preventive services,
information and resources.
a national prevention plan
We can also promote prevention through leadership, planning and
modest structural changes at little to no cost--by focusing existing
Federal programs on health promotion. TFAH recommends that public
health and prevention be elevated throughout the Federal Government by
creating a national prevention strategy. The strategy will outline a
few priority national prevention goals and direct all Federal agencies
and departments to consider how their budgets, policies and programs
influence health. The National Strategy to Combat Pandemic Influenza
serves as a good example of the way in which Federal agencies, under
White House leadership, can coordinate their efforts to deal with a
public health threat. A national prevention strategy would serve a
similar coordinating role. It could be overseen and evaluated by a
newly created public health board, which could serve as an independent
voice on science and public health. Such a board would ensure that the
strategy is properly coordinated and that progress toward achieving
interim chronic disease reduction goals is being made. Since a broad
range of policies, ranging from transportation to agriculture to
education, all influence the public's health, it is important that we
develop a strategy to organize and coordinate government-wide
prevention efforts involving an array of departments and agencies not
all traditionally involved in public health.
Better coordination of health programs and policies is also
necessary within the Department of Health and Human Services (HHS).
There is currently no senior official with medical, scientific, and
public health expertise with the authority to assure consistency in
policy and coordination among the various agencies addressing health
and public health issues, and to champion the allocation of necessary
resources and require accountability for such investments. To address
this problem, Congress should consider creating the position of
Undersecretary for Health (USH) in the Department of Health and Human
Services to whom all the Public Health Service (PHS) agencies, the
Office of the Assistant Secretary for Preparedness and Response (ASPR),
and the Centers for Medicare and Medicaid Services (CMS) would report.
This would ensure better coordination within HHS, which will be
essential as the new administration implements policy and programmatic
changes. (See Appendix B for a full description of this proposal.)
the public health workforce
In order to assist in the implementation of the structural and
funding recommendations addressed above, we need a well-trained
workforce. There is a well-documented shortage of healthcare workers,
and it is very important that we continue to provide financial
incentives to encourage individuals to enter the healthcare workforce.
At the same time, we are also facing shortages in the public health
workforce.
A 2007 survey by the Association of State and Territorial Health
Officials (ASTHO) found that the State public health agency workforce
is graying at a higher rate than the rest of the American workforce,
and workforce shortages continue to persist in State health agencies.
This workforce shortage could be exacerbated through retirements: 20
percent of the average State health agency's workforce will be eligible
to retire within 3 years, and by 2012, over 50 percent of some State
health agency workforces will be eligible to retire.\3\ Further,
according to a 2005 Profile of Local Health Departments conducted by
the National Association of County and City Health Officials (NACCHO),
approximately 20 percent of local health department employees will be
eligible for retirement by 2010.\4\
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\3\ ASTHO. 2007 State Public Health Workforce Survey Results.
http://www.astho.org/pubs/WorkforceReport.pdf.
\4\ NACCHO. Profile of Local Health Departments. http://
www.naccho.org/topics/infrastructure/profile/resources/2005reports/
index.cfm.
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Public health departments serve an important function by helping to
promote health and prevent disease, prepare for and respond to
emergencies and potential acts of bioterrorism, investigate and stop
disease outbreaks, and provide other services such as immunizations and
testing. Yet, the average age of new hires in State health agencies is
40, according to the 2007 ASTHO survey. Public health needs a pipeline
of young workers.
Thus, TFAH recommends that as Congress addresses the overall
workforce shortage in the health sector, the public health workforce
must be included in such efforts. Specifically, we recommend that
Congress provide financial incentives such as loan repayment,
scholarship assistance, or retraining opportunities to encourage
individuals to work in governmental public health. Congress should also
provide funding for a regular enumeration of the public health
workforce, as well as a dissemination of public health workforce
training, recruitment, and retention tools. This will enable us to have
the necessary data available to establish a baseline that we can use to
measure the impact of workforce initiatives. Congress should also
continue its revitalization of the Commissioned Corps to ensure that
our Nation's premier public health professionals have the resources
they need to serve our Nation most effectively.
It is important to note that the workforce problem is being
exacerbated dramatically by the current economic downturn. Even prior
to consideration of health reform, TFAH urges that steps be taken to
address the workforce crisis as part of the economic stimulus package
for two reasons. First, many States and localities have been forced to
cut back on their staffing because of budget shortfalls. One survey by
the National Association of County and City Health Officials, showed
that more than half of local health departments have lost positions
either due to layoffs or attrition. Second, as we develop workforce
retraining programs as part of the stimulus package, there is an
opportunity to train workers for community-level prevention work that
would dramatically improve our ability to implement prevention
programs. (See Appendix C for a full description of TFAH's workforce
recommendations.)
quality assurance for evidence-based prevention
TFAH believes that our investment in prevention should be based on
evidence-based interventions with a strong level of accountability for
outcomes. Every effort should be made to ensure the country and
communities are investing in the most effective programs possible. To
that end, we recommend creating, within the Centers for Disease Control
and Prevention, a Public Health Research Institute, that would build
the evidence base for prevention and help develop the new field of
public health systems and services research, which is committed to
providing a strong evidence base for all public health activities.
In order to control costs and use Federal funding most efficiently,
it is essential that we promote accountability and measure progress
toward improving health outcomes. All Federal programs should set aside
sufficient funding to evaluate their effectiveness so that we can
target our resources and maximize our investments in public health.
preparedness
A final area to be addressed is emergency preparedness. Funding for
State and local preparedness and hospital preparedness has decreased
year after year. Especially at a time when States are cash-strapped,
Federal funding for preparedness is necessary to protect our safety.
TFAH urges Congress to ensure that a reformed health care system will
be prepared to react to and mitigate the consequences of a public
health emergency. The health system must contribute to critical public
health functions such as surveillance, surge capacity, reimbursement
for preparedness and response, and community resilience. Congress
should provide ongoing financial support for health facilities to build
the capacity to manage a sudden increase in demand. Toward that end,
Congress should consider linking hospital reimbursement to emergency
preparedness by offering bonus payments or other financial incentives
to hospitals that meet a certain baseline of preparedness. A consistent
level of funding for preparedness must be achieved, and as we consider
health reform, we must remember the essential link between our
preparedness and our health.
conclusion
In conclusion, TFAH believes that these seven elements are critical
to assure that a reformed health system is truly about the health and
wellness of the American people--assuring that they are as healthy and
as productive as they can be. Focusing on prevention will not only
reduce the burden on the reformed health care system, but it will
assure that we have a healthier, more economically competitive
workforce. In this time of economic crisis, a focus on prevention and
wellness is that much more important.
Thank you again for the opportunity to testify--and thank you again
for your continued leadership in assuring that prevention is central to
this health reform effort.
______
Appendix A.--Community Makeover Grants Outline
Goal: Provide funding for a comprehensive, coordinated approach to
community-based population-level prevention activities in order to
reduce chronic disease rates, address health disparities, and develop a
stronger evidence base demonstrating the effectiveness of wide-scale,
rapid implementation of community-based prevention activities.
Rationale: Communities across the Nation are eager to combat the
epidemics of obesity and chronic disease. Research has shown that
effective community level prevention activities focusing on nutrition,
physical activity and smoking cessation can reduce chronic disease
rates and have a significant return on investment. A report from Trust
for America's Health entitled Prevention for a Healthier America:
Investments in Disease Prevention Yield Significant Savings, Stronger
Communities concluded that an investment of $10 per person per year in
proven community-based programs to increase physical activity, improve
nutrition, and prevent smoking and other tobacco use could save the
country more than $16 billion annually within 5 years. This is a return
of $5.60 for every $1.00 spent. The Centers for Disease Control and
Prevention funds a number of programs that focus on chronic disease
prevention; yet currently, there is no one program that funds the
planning, wide-scale implementation and evaluation of a holistic,
coordinated approach to prevention that engages key stakeholders from
all sectors of a community.
The Community Makeover Program would build on the strategies and
approaches of a number of CDC's programs (REACH, Steps to a Healthier
U.S., Pioneering Healthier Communities, the School Health Program) to
provide and fully fund a unified, comprehensive prevention strategy for
a community or State. Demand for this program is expected to be high,
and the program will likely encourage State and local investment, as
well. When CDC puts out a solicitation for community funding, for every
community the agency funds, at least 10 communities cannot be funded.
Furthermore, when States and communities receive funding from CDC, they
are able to leverage additional local funds. For example, in Minnesota
a $5 million investment by CDC has led to a $47 million investment by
the State.
Timeline: 5 years.
Funding: CDC would provide grants for the planning, implementation,
evaluation, and dissemination of best practices for community makeover
grants. CDC would also provide training for key policymakers at the
State and local level regarding effective strategies for the prevention
and control of chronic diseases. Grantees would receive an infusion of
funding for rapid implementation of a variety of programs, policies and
infrastructure improvements that would enhance access to nutrition and
activity and promote healthy lifestyles. To the extent permissible by
law, grantees would be expected to leverage funding from other Federal,
State, local governmental or private funding. Grantees would be
encouraged to provide in-kind resources such as staff, equipment or
office space. When awarding grants, CDC would be permitted to consider
an applicant's ability to leverage support from other sources. CDC
would also be required to consider the extent to which a grantee's
application addresses social determinants of health. CDC would be
permitted to provide preference to low-income communities addressing
disparities when awarding funds.
Funding would be based on the population of the community, up to
$10 per person per year.
Sites: Competitive grants would be awarded to governors, mayors,
and/or a national network of a community-based organization. The number
of grants should be limited, based on funding available, so that
meaningful change can be supported.
Activities: (A) Planning.--Grantees would be required to develop a
detailed community makeover plan, including all of the policy,
environmental, programmatic and infrastructure changes needed to
promote healthy living and reduce disparities. Communities or States
previously funded through the Pioneering Healthier Communities, REACH,
Steps to a Healthier U.S., Achieve Program, the Division of Adult and
Community Health, the Division of Nutrition, Physical Activity and
Obesity, or an equivalent privately funded program would be given
preference for funding. To formulate the community makeover plan, they
would convene key constituencies in a community or State, such as
elected officials, urban planners, public health representatives,
businesses, media, educators, parents, religious leaders, city/State
transportation planners, local park and recreation directors, public
safety/law enforcement, food companies, insurance carriers, community
organizations, community or other foundations, and other stakeholders.
Grantees would be required to coordinate their planning and
programming with other programs in their community or State that focus
on chronic disease prevention, including those listed above, in
addition to Safe Routes to Schools, farm to cafeteria programs, and
other nutrition and physical activity programming. Grantees would also
be expected to work with other programs funded by CDC, and to detail
their evaluation methodology. The community makeover plan would be
submitted to CDC for approval, and CDC would provide ongoing technical
assistance.
Key areas of focus for the plans would include all of the
following:
creating healthier school environments, including
increasing healthy food options and physical activity opportunities;
creating the infrastructure to support active living and
access to nutritious foods in a safe environment (examples include:
green space, such as parks, walking and biking paths, farmers' markets,
street lights, sidewalks, and increased public safety);
developing and promoting programs targeted to a variety of
age levels to increase access to nutrition, physical activity and
smoking cessation, enhance safety in a community, or address any other
chronic disease priority area identified by the grantee;
reducing barriers to accessing nutritious foods and
physical activity;
assessing and implementing worksite wellness programming
and incentives;
working to highlight healthy options at restaurants and
other food venues; and
prioritizing strategies to reduce racial and ethnic
disparities, including social determinants of health.
(B) Implementation.--Grantees would be fully funded to implement
community makeover plans. CDC would convene grantees at least annually
in regional and/or national meetings to discuss challenges, best
practices and lessons learned. Using the Healthy Communities model and
processes developed at CDC as a guide, grantees would be required to
develop models for replication. Pending successful evaluation, they
would be required to serve as mentors for other States and communities.
(C) Evaluation.--The effectiveness of the program would be measured
by the change in prevalence of chronic disease risk factors among
members of the community. Decreases in weight and fat consumption and
increases in minutes of physical activity and fruit and vegetable
consumption could be used as measures for children whose schools
participate in the community makeover plan, as well as for adults who
participate in physical activity and nutrition programs. Other process
measures, such as the number of restaurants that highlight healthier
options on menus or the number of participants who self-report that
they have increased their physical activity levels, could also be used.
CDC would provide a literature review and framework for the evaluation,
and grantees would work with an academic institution or other entity
with expertise in outcome evaluation and be required to report to CDC
on the evaluation of their programming and to share best practices with
other grantees. Community specific data from the BRFSS would be used to
assess changes in risk factors and health behaviors across communities.
Appendix B.--Undersecretary for Health
Proposal: Create the position of Undersecretary for Health (USH) in
the Department of Health and Human Services to whom all the Public
Health Service (PHS) agencies, \5\ the Office of the Assistant
Secretary for Preparedness and Response (ASPR), and the Centers for
Medicare and Medicaid Services (CMS) would report. The USH position
would assume the elevation of the current position of Assistant
Secretary for Health (ASH), which currently is a scientific advisory
position, but until 1996 had line authority over the PHS agencies.
---------------------------------------------------------------------------
\5\ The Public Health Service agencies are: Agency for Healthcare
Research and Quality, Agency for Toxic Substances and Disease Registry,
Centers for Disease Control and Prevention, Food and Drug
Administration, Health Resources and Services Administration, Indian
Health Service, National Institutes of Health, and the Substance Abuse
and Mental Health Services Administration.
---------------------------------------------------------------------------
Rationale: There is currently no senior official with medical,
scientific, and public health expertise with the authority to assure
consistency in policy and coordination among the various agencies
addressing health and public health issues, and to champion the
allocation of necessary resources and require accountability for such
investments. At a minimum, the USH should oversee the PHS agencies and
ASPR; ideally CMS would also report to the USH. While the Deputy
Secretary provides some level of administrative coordination, one of
the biggest challenges facing HHS is to restore the scientific
integrity of policymaking and assure that there is coordination among
the various public health and safety net programs.
Process: Creating the USH, with authority over PHS, CMS and ASPR,
would require new legislative authority. In the meantime, the Secretary
has the authority to restore the line authority of the ASH over the PHS
agencies. This would send a strong signal about the need for scientific
leadership and coordination and would make the position of ASH more
attractive to potential nominees. The Secretary should take this action
immediately as a precursor to legislative action creating the USH.
Examples of Lack of Coordination: There has been no health/
scientific official to resolve or address:
Ongoing difficulties in assuring coordination of
preparedness activities between ASPR and CDC;
Poor coordination between CDC and CMS with regard to best
approaches for addressing hospital-acquired infections;
Coordination of Medicaid and HRSA safety-net programs
(community health centers, the Ryan White program) to assure seamless
provision of care and maximize access to services;
Consistency and appropriate divisions of labor between NIH
and CDC with regard to prevention research;
Coordination of mental health and health care services
provided by HRSA and SAMHSA;
Challenges to the scientific judgment of agency officials
on questions such as the efficacy of condoms; and
Coordination and consistency of programs, grants, and
policies affecting State and local governments as developed across the
health agencies.
Appendix C.--Public Health Workforce
u.s. public health service commissioned corps
Establish a dedicated funding stream for the Commissioned
Corps under the management and fiscal control of the Surgeon General.
Currently, the Commissioned Corps does not receive an annual
appropriation. The salaries of the physicians, pharmacists,
environmental health experts, nurses, and other Corps officers are paid
by the Federal agency in which they serve. Without an established
funding stream, recruitment for the Corps is difficult. Members of the
Corps must volunteer their time and often pay out-of-pocket for
recruitment materials or trips, and new recruits must find their own
commission. A dedicated funding stream for the Corps would centralize
payment for salaries and recruitment.
Lift the cap on the number of active duty, Regular Corps
members. The Commissioned Corps consists of approximately 6,000
officers who serve in the Regular Corps and the Reserve Corps. At
present, the Regular Corps has a congressionally mandated cap of 2,800,
which has almost been reached. There are nearly 3,200 Reserve Corps
members, also on active duty, who work in similar jobs and receive the
same pay and benefits as Regular Corps members. Many new enrollees
enter the Reserve Corps with hopes of securing a slot in the Regular
Corps since only these Corps members are eligible for promotion to the
highest ranks. They are less likely to lose their jobs in a force
reduction. Additionally, an estimated 25 percent of those entering the
Corps in previous years came from the armed services, as all of the
federally commissioned uniformed services have equal pay, rank, and
retirement benefits. As the cap is approached, there is a disincentive
for new recruits and members of the Armed Forces to join the Corps and
for Reserve Corps members to remain in the Corps.
Establish a new ``ready reserve'' component within the
Corps. The Commissioned Corps needs a highly skilled and well-trained
reserve in place that is able to respond to emergencies and urgent
public health threats, along similar lines as the uniformed services'
reserve. The ready reserve would be comprised of retired Corps members
who would keep their day jobs, submit to an appropriate number of
drills and training throughout the year, and would be available and
ready to be deployed on short notice. Additionally, ready reserve
members would backfill routine positions at Federal agencies when
active Corps members are deployed. Current Corps structure does not
provide for someone to fill in and resume the responsibilities of an
active member's day job when he or she is deployed. Ready reserve
members could also be used in underserved communities to assure access
to care, particularly for vulnerable populations.
Create health and medical response (HAMR) teams to be
Federal first responders deployed in the event of a terrorist attack,
natural disaster, or other public health crisis. HAMR teams would
consist of full-time Corps members who would organize, train, and be
equipped to provide public health preparedness and response throughout
the year. When not responding to a crisis, members could also be sent
to State and local public health departments with severe workforce
shortages. They would still be paid by the Federal Government so as not
to further burden State public health budgets.
Incentivize retired Corps members to move into faculty
positions in public health-related disciplines. Many academic
institutions across the country are experiencing faculty shortages in
the public health field. Retired Corps members could alleviate this
shortage and also inform students about the Corps. An existing program,
``Troops to Teachers,'' could be modified to include teaching in the
public health field, thus addressing the faculty shortage and
encouraging students to pursue a career in governmental public health.
public health research institute
A new Public Health Research Institute should be established to
conduct and coordinate the following services:
Identify and disseminate public health best practices and
provide information about career categories, skill sets, and workforce
gaps. With this information, States and localities will be better
informed to make decisions about policies and program implementation.
The institute would also help ensure greater accountability for the use
of tax dollars.
Conduct a public health workforce enumeration survey to
determine current distribution of jobs including trend lines, wages,
benefits, training, and pathways to enter public health. The institute
would be responsible for conducting an enumeration survey every 2 years
and publicizing information about career categories, skill sets, and
workforce gaps.
Address complex issues such as social determinants of
health and generate data on health outcomes.
Build on existing partnerships within the Federal
Government while also considering initiatives at the State and local
levels and in the private sector. Accountability measures will be
established. The institute will evaluate and report on Federal, State,
and local public health workforce initiatives, as well as those in the
private sector.
interagency advisory panel
Various Federal Government agencies play a role in
workforce policy. For example, most Federal dollars expended on job
training and workforce development are overseen by the Department of
Labor. The Department of Education also coordinates with the Department
of Labor on workforce efforts through various loan and grant programs.
The Department of Health and Human Services, the Department of Defense,
the Veterans Administration, the Environmental Protection Agency, and
the Department of Transportation are all involved in the public health
workforce area.
To ensure that there is a comprehensive public health
workforce strategy, an interagency advisory panel to coordinate
workforce development at all levels of government should be created.
The purpose of the panel would be to:
Help link Federal, State, and local public health
workforce development;
Coordinate recruiting and training efforts; and
Coordinate technical assistance to expand the public
health workforce.
The interagency advisory panel should also be replicated
at the State level.
area health education centers
The public health workforce needs an influx of better
trained and younger workers. State public health departments have an 11
percent vacancy rate and face looming mass retirements.
Area Health Education Centers (AHEC's) are federally
funded programs that link university health science centers with
community health delivery systems to provide training sites for
students, faculty, and practitioners.
A few States, such as Connecticut, have used some of their
AHEC funds to establish Youth Health Service Corps initiatives which
train and then place high school students as volunteers in community
health agencies. The students, who may include those enrolled in
vocational and technical education, not only provide some relief to the
workforce shortage problem, but may also help develop a pipeline for
future public health workers. Under the Youth Health Service Corps
model, an AHEC may partner with not only health entities, but also
programs such as Learn and Serve America, a part of the Corporation for
National and Community Service.
All AHECs should be required to establish Youth Health
Service Corps initiatives to assist in the recruitment of young people
into health fields.
community colleges and vocational schools
State and local public health departments should partner
with community colleges and vocational and technical education and job
corps centers to identify candidates for the field. Since nearly 40
percent of community college attendees are first generation college
students, and many are nontraditional students, they are an ideal group
to target for recruitment. Course offerings at community colleges are
very flexible, making it easier to partner with State or local public
health departments to address needed training.
Health-focused career academies and health apprenticeship
programs should be established at vocational and technical education
centers. Health departments should partner with Tech-Prep programs and
Job Corps centers where they exist, to help diversify the public health
workforce.
state and local workforce boards
The Federal Workforce Investment Act of 1998 established State and
local workforce boards to oversee, coordinate, and improve State and
local employment and training programs. Currently, the composition of
these boards warrants reform. The following are recommendations:
All boards should include members representing the public
health field in order for public health to be part of overall workforce
development in all States and local communities.
State and local workforce boards should establish
initiatives that encourage the development, implementation, and
expansion of health sector programs.
______
November 18, 2008.
Hon. Harry Reid,
Senate Majority Leader,
S-221,
Washington, DC 20510.
Hon. Mitch McConnell,
Senate Minority Leader,
S-230,
Washington, DC 20510.
Hon. Nancy Pelosi,
Speaker of the House,
H-232,
Washington, DC 20515.
Hon. John Boehner,
House Minority Leader,
H-204,
Washington, DC 20515.
Dear Majority Leader Reid, Speaker Pelosi, and Minority Leaders
McConnell & Boehner: From first responders to scientists searching for
ways to prevent disease, our public health workforce is vital to
protecting our Nation's health and economy. But our public health
workforce is in crisis. There is a serious shortage of public health
workers with the expertise needed to meet the depth and breadth of the
responsibilities they are expected to carry out.
We are writing to express our support for inclusion of funding for
job creation, recruitment and training in a potential stimulus package.
In particular, we request that support for the State and local public
health workforce be a specifically permissible use of any funding that
may be allocated for infrastructure and job training priorities. We
believe that in addition to providing funds for infrastructure projects
that can immediately create jobs, the stimulus can serve as a vehicle
to promote long-term growth and economic development by helping to
build a pipeline of well-trained workers, including those entering the
public health workforce.
A 2007 survey by the Association of State and Territorial Health
Officials (ASTHO) found that the State public health agency workforce
is graying at a higher rate than the rest of the American workforce,
and workforce shortages continue to persist in State health agencies.
This workforce shortage could be exacerbated through retirements: 20
percent of the average State health agency's workforce will be eligible
to retire within 3 years, and by 2012, over 50 percent of some State
health agency workforces will be eligible to retire. Further, according
to a 2005 Profile of Local Health Departments conducted by the National
Association of County and City Health Officials (NACCHO), approximately
20 percent of local health department employees will be eligible for
retirement by 2010.
Public health departments serve an important function by helping to
promote health and prevent disease, prepare for and respond to
emergencies and potential acts of bioterrorism, investigate and stop
disease outbreaks, and provide other services such as immunizations and
testing. Yet, the average age of new hires in State health agencies is
40, according to the 2007 ASTHO survey. Public health needs a pipeline
of young workers, and the stimulus offers an important opportunity to
begin to cultivate interest in public health among the Nation's youth.
Governmental public health can be an important career pathway for
displaced workers whose jobs have been eliminated. Public health offers
a wide array of possibilities, from epidemiology to information
technology (IT) to environmental engineering. Re-training workers to
tailor their skills to public health careers would help stimulate job
growth and improve the quality of life in communities that are
currently underserved due to habitual vacancies in State and local
health departments.
As you develop a stimulus package and consider broad infrastructure
projects, we ask that you consider the public health workforce to be an
important dimension of State and local infrastructure. A sustainable
public health workforce is crucial to our economic development and
quality of life. Thank you for your attention to this request.
Sincerely,
American Public Health Association; Association of State &
Territorial Dental Directors; Association of State and Territorial
Directors of Nursing; Association of State & Territorial Health
Officials; Association of State & Territorial Public Health Social
Workers; Commissioned Officers Association of the U.S. Public
Health Service; Council of State and Territorial Epidemiologists;
National Alliance of State and Territorial AIDS Directors; National
Association for Public Health Statistics and Information Systems;
National Association of Chronic Disease Directors; National
Association of County and City Health Officials; State and
Territorial Injury Prevention Directors Association; Trust for
America's Health.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Senator Harkin. Thank you very much, Dr. Levi.
Now we move to Dr. Ken Thorpe, Robert W. Woodruff professor
and chair of the Department of Health Policy and Management at
the Rollins School of Public Health at Emory University in
Atlanta, GA. He is the executive director of the Institute for
Advanced Policy Solutions, co-directs the Emory Center on
Health Outcomes and Quality.
Dr. Thorpe is also the executive director of the
Partnership to Fight Chronic Disease, a national coalition of
patients, providers, community organizations, business and
labor groups, and health policy experts committed to raising
awareness of policies and practices that save lives and reduce
healthcare costs through more effective prevention and
management of chronic disease.
Thank you very much for being here, Dr. Thorpe. Please
proceed.
STATEMENT OF KENNETH E. THORPE, PH.D., ROBERT W. WOODRUFF
PROFESSOR AND CHAIR OF THE DEPARTMENT OF HEALTH POLICY &
MANAGEMENT, ROLLINS SCHOOL OF PUBLIC HEALTH OF EMORY
UNIVERSITY, ATLANTA, GA
Mr. Thorpe. Thank you, Senator Harkin, Senator Coburn,
Senator Reed. I look forward to working with you in this next
session of Congress on these issues.
I am going to make four very brief points, starting with
some of the statistics we know, but I think it is important to
frame the discussion to talk about how critical prevention can
be in solving some of our Nation's healthcare ills.
Second is to focus on the issue that seemingly and sort of
inexplicably to me is still under debate--does prevention work?
Third, to talk about some of the lessons we have learned
about successful programs.
And finally, to start to lay out what can we do right now,
as part of the healthcare reform debate, to take some of those
best practice lessons and implement them?
Let me start with the first set of points on the data. You
heard Senator Coburn already mention the fact that three
quarters of what we spend nationally is linked to chronically
ill patients. In the public programs, it is even worse. Ninety-
five percent of what is spent in Medicare is linked to
chronically ill patients. Eighty- three percent of what we
spend in Medicaid is linked to chronically ill patients.
Obviously, unless we deal with the issue of chronic disease
and prevention, we are never going to deal with long-term
entitlement to spending reform and get entitlement spending
under control, let alone reduce the cost of private health
insurance.
The second fact is that we know obesity in this country has
doubled since the mid-1980s. That doubling of obesity, by
itself, accounts for 15 to 25 percent of the growth in
spending. Put another way, if we could have magically found a
way to have frozen the obesity levels in this country at 1987
levels, we would have spent about $220 billion less today on
healthcare.
Third fact, Medicare. Three conditions, largely
preventable--diabetes; hypertension; hyperlipidemia, bad
cholesterol--by itself over the last decade accounts for 15 to
20 percent of the growth in Medicare spending.
And the final fact is that if you look at lifetime spending
for people entering the Medicare program who are obese versus
Medicare beneficiaries who are normal weight, a normal weight
adult spends 15 to 35 percent less over the course of their
lifetime in the Medicare program than an obese adult does with
one or more chronic healthcare conditions.
Those are the facts. And I think Senator Harkin's point,
unless we make this a centerpiece of healthcare reform, we are
never going to deal with the issues around cost and
affordability and quality. So we really need to take it, I
think, more seriously as a centerpiece of what we do on
reforming our healthcare system.
Second set of issues. Does prevention work? I think,
unfortunately, my colleagues in the academic field have
confused the issues quite substantially because most of the
studies out there looking at prevention are focusing on
secondary prevention, which is disease detection. And they are
looking at does disease detection work?
Well, the fact is some can save money, colorectal screening
and immunizations. But the fact is we do disease detections to
get people into the system quicker to improve their healthcare
outcomes.
What is missing from the debate is does primary prevention
work? Primary prevention is the ability to try to prevent
disease in the first place, and I think the answer to that
question is really twofold. One, yes. Two, design matters a
lot. That is, there are programs that are poorly designed that
don't work, but there are very effective programs in the
schools, in the community, and in the workplace that, if put
together in a coherent way, can save money and can improve
health outcomes.
There are at least 13 published studies out there that have
shown that well-designed workplace studies--and you are going
to hear an example of one from Pitney Bowes--can be effective
in saving money. On balance, those studies show that the well-
designed programs save $3.50 for every $1 invested, and that is
just looking at the medical care costs. Because one thing we do
know is that for every $1 that we lose to chronic disease on
medical care costs, we lose $4 on productivity.
The productivity component of this is even bigger than the
medical care cost piece of this. There are several examples of
the successful firms that have done this--Johnson & Johnson,
Citibank, Hannaford Brothers grocery chain, Caterpillar,
Safeway. You are going to hear from Pitney Bowes.
There are a lot of good examples out there of successful
programs that have saved money. There are community-based
programs that have saved money. You have heard from Jeff, and
you are going to hear from the YMCA about some of their
experience.
And there are school-based interventions to Senator
Coburn's point that we need to look at and understand what is
it that they are doing in the schools in terms of getting more
physical activity of those kids that is actually reducing
childhood obesity? If you look at what Governor Huckabee did in
the State of Arkansas to reduce those obesity rates among kids,
I think that is a program and a set of initiatives that deserve
a second look.
Third issue, it seems to me that what we need to do is,
rather than ask the question does the average program work, let
us look at the good ones. Let us look at the effective programs
that have been shown to and demonstrated to save money and
improve health outcomes and identify the key design features of
those programs about why they are effective.
For example, we know in workplace programs that several
design aspects of those programs are effective and need to be
more widely used in American business. Giving people financial
incentives to participate in health risk appraisals. Reducing
or eliminating cost sharing for things that we want to deliver
to chronically ill patients like annual eye exams and extremity
exams and so on.
Carefully crafted individual care plans to do both
population health for people that are healthy, but also for
people with diagnosed chronic disease to work with them to meet
key objectives. By making even healthcare services available at
the workplace, to have nurse practitioners and others coming in
and working with patients to achieve some of those care
guidelines is very effective.
And leadership from the top. This has to be something that
the corporate CEO level shows that this is a priority, that
there is buy-in from the very top, and that it shows that the
company is serious about working with its workers to improve
productivity and reduce costs.
Those are just some things that have shown to be effective
in designing this.
So getting to the last point, what can we do right now that
I think are just common sense initiatives? And in the
testimony, I laid them out. They are in more detail, but I am
just going to mention three of them very quickly.
No. 1, it seems to me that we are going to have a long
debate about health insurance and healthcare reform. But what
we can do right now to get patients into the system is provide
a universal wellness benefit to all uninsured individuals in
this country that focuses on prevention--health risk
appraisals, a physical exam, screening.
And most importantly, for each of the patients coming in,
you put together a care plan for people who are healthy, people
who are asymptomatic--that is, they are pre-diabetic. We put
together a care plan for them. And for people who are diagnosed
with disease, we get them care right now because, let us face
it, we are spending money on this population anyway.
We are spending $50 billion a year on the uninsured in one
form or another. We do it in a very reckless, I think, and
thoughtless way. Too late, they show up in the emergency rooms.
Why not get people into the system early, right off the bat?
I think one thing that we can do is take some of these key
design features we have learned about how to change behavior
and make them available to people who don't have health
insurance right now.
Second, I think the big challenge we face in Medicare is
what are we going to do to coordinate care in the traditional
Medicare program? So if all of the money is in chronically ill
patients and most of the beneficiaries are in traditional
Medicare, we know that that program is not set up to do a very
good job to prevent and provide healthcare services to
chronically ill patients.
I think you heard Senator Sanders talk a lot about
community health centers. I think if we expanded that concept
at the State level to build community health teams of nurse
practitioners and others that would work with small physician
practices, to manage Medicare for beneficiaries who have
chronic disease, would be a step in the right direction.
If you think about it, 83 percent of physician practices in
this country are in groups of one or two. So there is a lot of
talk about medical home and building that kind of capacity,
most of American medicine, unfortunately, does not flow through
the Mayo Clinic. It flows through small physician practices.
And the final point that I would make is we need to take
some of the lessons from Jeff 's work and from the YMCA and
identify what is it about those interventions that generates
those savings in the design of them and challenge the States
and communities to put those types of programs in place. Let
them innovate in the design.
We don't want to mandate and tie their hands on this, but I
think we want to provide the information and provide some
financial incentives to communities that get those programs out
into the schools and into the communities as soon as possible.
Those are things that I think are common sense initiatives
that we could do right off the bat. We could do it as part of
the overall healthcare reform debate. I think that they would
have, I would hope, bipartisan support because they are not
particularly the usual ideological flashpoints that we get into
the debate on healthcare reform, and I would like to see,
hopefully, in the upcoming Congress some discussion and
attention to some of these prevention issues as part of the
overall debate.
Senator Harkin, Coburn, Senator Dodd and Reed, I look
forward to working with you on these issues. Thanks for
inviting me.
[The prepared statement of Mr. Thorpe follows:]
Prepared Statement of Kenneth E. Thorpe, Ph.D.
Good morning, Senators, and thank you for the opportunity to speak
today about the importance of science-based prevention in assuring
health security for all Americans, reducing the burden of ill health,
and stemming rising health spending. I would like to thank Senator
Kennedy, Senator Enzi, and Senator Harkin for your leadership in this
area. Thanks also to the members of the committee for holding this
important hearing today. My name is Ken Thorpe; I am a professor of
health policy and chair of the department of health policy and
management at Emory University in Atlanta, GA. I am also executive
director of the Partnership to Fight Chronic Disease, a nonpartisan,
nationwide group focused on reducing health care costs through disease
prevention and more effective care.
My testimony today will focus on three issues fundamental to health
reform:
1. What are the key drivers of rising health care spending overall
and in the Medicare program?
2. What role can primary prevention and more effective care
management assume in slowing the rise in spending? Specifically, is
there evidence we could build on from successful programs?
3. How could we adopt these lessons into a broad health reform
initiative, as well as reforms in Medicare and Medicaid?
key drivers of increased health spending
Increases in health expenditures, and how to rein them in, are
among the critical policy challenges the United States faces. National
health spending is estimated to have grown almost 7 percent in 2007,
reaching over $2 trillion, or roughly $7,800 per person. Medicare and
Medicaid together now account for 23 percent of Federal spending and
nearly 6 percent of gross domestic product (GDP), including the States'
share of Medicaid.\1\ Absent policy re-direction, the growth rate is
expected to hold steady at nearly 7 percent through 2017, reaching more
than $4 trillion. Health spending is expected to be in excess of 16
percent of gross domestic product (GDP) in 2007 and nearly 20 percent
in 2017.\2\
Crafting effective solutions to the high and rising costs of health
care requires a clear understanding of where we spend our health care
dollar and the factors accounting for rising spending. First, patients
with chronic diseases such as diabetes, hypertension, and pulmonary
disease account for 75 percent of national health spending, and an even
higher proportion in public programs: 96 cents of every dollar in
Medicare is spent on patients with chronic disease and 83 cents of
every dollar in Medicaid.\3\
Chronic diseases have played a major role in the rise in health
care spending:
The increase in treated disease prevalence accounts for
about two-thirds of the rise in spending over the last 20 years.\4\ \5\
The rising rate of obesity--which has doubled for adults
and tripled for children since 1980--accounts for about 20-25 percent
of the overall rise in spending.
Within the Medicare program, just three obesity-associated
chronic conditions--diabetes, hypertension, and high cholesterol--
accounted for more than 16 percent of the rise in spending between 1987
and 2002.\6\
The residual is due to improved technology, enhanced
disease screening and detection, and changed clinical guidelines.\7\ It
is not clear what percentage of the rise is traced to innovations per
se. The unexplained component of rising health care costs--ascribed by
some observers to technology--includes a broad range of effects,
encompassing, for example, more intensive treatment of asymptomatic
patients with one or more cardiovascular risk factors (increased
treatment intensity of adults with metabolic syndrome is a case in
point),\8\ as well as changes in the definition of treatable disease
and targeted patient populations for medication therapy for asthma,
diabetes, hypertension, and abnormal cholesterol.\9\
Until very recently, most proposals for reducing Federal health
care spending have focused on re-directing national government spending
onto other payors. These proposals include reducing provider
reimbursement, increasing beneficiary cost sharing, increasing the age
of Medicare eligibility, tightening eligibility or means testing, and
reducing optional services in Medicaid, among others. But none of these
proposals addresses the underlying factors driving the rise in health
spending. Their adoption would merely shift Federal spending to others,
and likely would result in higher costs in the long run, as chronically
ill beneficiaries with limited financial resources forgo needed
preventive and restorative care.\10\ The following sections present
strategies to address key health spending drivers and effectively
reduce expenditure growth.
role of obesity and smoking
Over the past quarter century, obesity has increased dramatically
in the United States. The most recent data from the Centers for Disease
Control and Prevention (CDC) report that 32 percent of adults aged 20
and older are overweight and 34 percent are obese.\11\ \12\ In 2007
more than a third of U.S. adults--over 72 million people--were obese.
Obesity rates differ only slightly by gender but vary significantly by
both age and race/ethnicity, resulting in significant health
disparities. See Figures 1 and 2. Forty percent of adults ages 40-59
are obese, compared with about 30 percent of both older and younger
adults. African-American women are more likely than other adults to be
obese.
As obesity prevalence has increased among Americans, so have rates
of associated chronic conditions. In 1958, 1.6 million Americans were
living with diagnosed diabetes.\13\ By 2008, that had increased to 17.9
million--a rise in diagnosed prevalence of more than 1,000 percent.
Another 5.7 million people are undiagnosed, bringing the total diabetes
burden to nearly 24 million people--almost 8 percent of the entire
American population.\14\ Virtually all the increase in diabetes
prevalence during this period is associated with rising rates of
overweight and obesity. Overall, more than a quarter of the increase in
U.S. health spending is attributable to the rise in obesity over the
past two decades. If the prevalence of obesity were the same today as
in 1987, health care spending in the United States would be 10 percent
lower per person, or about $200 billion less each and every year.
Health care costs would have risen 0.7 percentage points less per year,
every year--a hefty amount over time.\15\
Although tobacco use has sharply declined over the last 40-plus
years, more than one in five U.S. adults still smoke, about 46 million
people. The majority--70 percent--say they would like to quit. Smoking-
related chronic diseases include cancers, cardiovascular disease, and
respiratory diseases.\16\ Prenatal exposure to tobacco smoke is a major
risk factor associated with Sudden Infant Death Syndrome (SIDS),\17\
infant prematurity and low birthweight.\18\ Parental smoking is
associated with higher rates of childhood asthma, an increased
likelihood of using asthma medications, and an earlier onset of the
disease.\19\ Tobacco use causes 440,000 deaths in the United States
every year. Deaths associated with smoking account for more deaths than
AIDS, alcohol use, cocaine use, heroin use, homicides, suicides, motor
vehicle crashes, and fires combined.\20\ Additionally, about 8.6
million people are disabled by a disease caused by smoking, such as
lung cancer or chronic obstructive pulmonary disease.\21\ \22\ For
every person who dies of a smoking-related disease, 20 more are living
with at least one serious illness. Smoking cost the United States over
$193 billion in 2004, including $97 billion in lost productivity and
$96 billion in direct health care expenditures, or an average of $4,260
per adult smoker.\23\
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
To slow the rise in health spending, our Nation must significantly
reduce obesity and smoking in order to reduce the incidence and
prevalence of chronic diseases. Figures 3 and 4 show how spending is
concentrated among patients and conditions, respectively.
Investing in effective primary prevention is essential. The long-
term financial incentives are substantial, particularly for Medicare to
fight obesity and improve the health status of both newly enrolled and
current beneficiaries. At least 80 percent of older Americans are
living with at least one chronic condition, and 50 percent have at
least two. More than half of Medicare beneficiaries are currently
treated for five or more medical conditions annually, accounting for
over three-quarters of total program spending.\24\ More than a third
report having a disabling condition that limits their daily activities;
these adults are less likely to be physically active and more likely to
be obese.\25\
Two recent studies have demonstrated that seniors aged 65-70 who
are normal weight, with no chronic diseases, spend 15-35 percent less
over their lifetime than do obese adults with chronic diseases.\26\ The
cost of providing health care for a patient aged 65 or older is three
to five times greater than the cost for someone younger than 65,\27\
and thus sizeable potential downstream savings accrue to Medicare if
beneficiaries are in better health prior to enrolling in the program. A
large study of both men and women found that those with favorable
cardiovascular risk profiles before age 65 had substantially lower
average Medicare charges: overall, two thirds lower for men and half as
low for women. Charges related to both cardiovascular disease and
cancer, specifically, were less for those who entered Medicare heart-
healthy.\28\ Another large study found that spending even in the last
year of life, when charges are generally highest, was lower for those
who entered Medicare at low risk for heart disease.\29\ Unfortunately,
that is not true for many soon-to-be-eligible beneficiaries: In 2005,
CDC documented that half of Americans aged 55-64-years-old had high
blood pressure and 40 percent were obese.\30\ Reducing the number of
Americans who enter Medicare chronically unhealthy is a cornerstone to
reducing costs over the long term, and so is keeping them as healthy as
possible once they are enrolled. Effective lifestyle interventions that
reduce the share of adults 65 and older who are obese and overweight by
10 percentage points could lower the average growth in Medicare
spending over the next decade or two by approximately 0.3 percentage
points annually.\31\
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
effective primary prevention
Addressing the high and rising rates of chronic disease will
require effective disease prevention programs (primary prevention),
disease detection (secondary prevention), and disease treatment
(tertiary prevention). Most of the academic literature has historically
focused on the role that secondary prevention--disease detection--has
assumed in reducing health care spending. Most clinical preventive
services--by design--add modestly to overall health costs. However,
several clinical screens, such as diabetes screening targeted to
patients with hypertension, especially those 55 to 75;\32\ one-time
colonoscopy screening for colorectal cancer among men ages 60 to 64
\33\; and influenza vaccination appear to reduce total health care
spending. Determining the most cost-effective applications for clinical
preventive services requires answering the basic questions of who,
what, when, where, and how. A leading source of information and data is
the U.S. Preventive Services Task Force, an independent panel of
experts in primary care and prevention that systematically reviews the
evidence of effectiveness and develops recommendations for clinical
preventive services. The task force is an important, though perhaps
underappreciated, national resource.
Far less attention has been paid to the role that primary
prevention--a key policy tool highlighted in both Senator Obama's and
McCain's health care proposals--could assume in reducing health care
spending and improving overall health outcomes. Figure 5 shows our
Nation's relative investment in prevention.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
The Preventive Services Task Force has a public health analog, the
Task Force on Community Preventive Services, which examines the
evidence for population-based prevention services. A growing body of
research supports the effectiveness of individual and population-based
primary prevention for obesity and smoking, as well as other needed
interventions. Considerable and growing evidence shows that well-
designed, targeted interventions designed to prevent disease (primary
prevention) save money. Relatively little attention has been given to
identifying the key design features of these effective interventions
and to making them more widely used and available.
Research points to multiple examples of effective primary
prevention interventions that, if more widely adopted, could reduce
health care spending and improve patient outcomes. These include
school-based programs, community-based interventions, and worksite
health promotion (WHP) combining primary prevention to forestall
disease as well as secondary prevention to improve health.
Several scientific reviews report that WHP programs reduce medical
costs and absenteeism and produce a positive return on investment. For
example: At Citibank, a comprehensive health management program showed
an ROI of $4.70 for every $1 in cost. A similar comprehensive program
at Johnson & Johnson reduced health risks including high cholesterol
levels, cigarette smoking, and high blood pressure, and saved the
company up to $8.8 million annually.\34\ Other companies such as
Hannaford Brothers ($6 million in savings) and Safeway grocers have
reported similarly positive results. These empirical studies have
demonstrated two significant results: First, lifestyle interventions
can be effective in reducing the prevalence of chronic disease and
overall health care spending, and, second, program design is critically
important to program success. The key to successful programs is
evidence-based design and delivery. Based on these rigorous assessments
of best practices, key design features of successful programs include:
financial incentives to participate in health risk
appraisals,
reducing or eliminating cost sharing for preventive
services,
carefully crafted individualized care plans with
incentives to meet key objectives,
the availability of health care personnel at the
workplace, and
leadership from the top.
There is also substantial evidence of the cost reductions that
accrue from well-designed smoking cessation programs. One recent study
examining Florida results found that each $1 spent on a cessation
program produced savings of $1.90 to $5.75.\35\ Identifying these key
design features of these programs and providing both information and
financial incentives to smaller firms to adopt them would be a wise
investment.
Evidence-based community and school-based programs show similar
returns on investment. A recent analysis from the Trust for America's
Health and others found significant reductions in total health care
spending linked to well-designed and implemented community-based
lifestyle interventions. Savings ranged from a short-term return on
investment of $1 for every dollar invested, rising to more than $6 over
the longer term.\36\
Our Web site, www.fightchronicdisease.org, contains a comprehensive
catalog of school, community, and workplace-based programs that have
been effective in reducing disease prevalence and or costs. A
multifaceted approach--reaching people where they live, play, work and
go to school--will be critical.\37\ In addition, health coverage policy
tools are available, including a universal wellness benefit for adults
and eliminating (or sharply reducing) co-pays on prevention services.
The benefits of these policy strategies are proven, and they should be
widely implemented.
four policy options for integrating best practice approaches to
prevention and care management into health care reform
The key spending facts presented above provide a clear framework
for interventions that reduce disease prevalence through reductions in
obesity and smoking and more effective management of chronically ill
patients. These initiatives are important for Medicare and Medicaid as
well as for private health plans and employers, employees, and
retirees. I will very briefly outline four policies that could improve
health and reduce health spending:
1. Implementing a universal wellness, prevention, and treatment
benefit encompassing chronic disease risk reduction, screening, and
treatment for uninsured adults modeled on existing CDC programs for
low-income, uninsured adults. This benefit would not substitute for
universal coverage, but would provide immediate population health and
treatment options for the uninsured. This benefit could incorporate
some of the key design elements of successful workplace health
promotion programs outlined above. As a result, the benefit could
significantly improve the health of working age adults as well as their
health profile as they enter Medicare, offering significant long-term
cost savings. The comprehensive program should include population
health management, disease screening, and treatment designed to prevent
disease, detect and diagnose early and, where appropriate, provide care
in the most appropriate health care settings.
Over time, this wellness benefit could be extended via Federal
grants to States and to small employers, allowing them to offer similar
benefits to younger uninsured adults (and children) in community
settings, schools, and small businesses. Within 2 years, the wellness
benefit should be available to all uninsured adults and children on a
temporary basis as the discussion over expanded insurance unfolds.
The new wellness benefit should adopt the key design features of
workplace and community-based primary prevention interventions
demonstrated in the research literature to improve health outcomes and
reduce costs. To fully realize the benefit's gains, those without
insurance who are diagnosed with any of the most common serious chronic
medical conditions (cancers, diabetes, heart disease, hypertension,
stroke, and pulmonary conditions and co-morbid depression and mental
disorders) should receive clinically appropriate medical treatment. An
existing model for this approach is CDC's Breast and Cervical Cancer
Treatment Program.\38\ Uninsured and underinsured women at or below 250
percent of Federal poverty level are eligible for cervical screening
(ages 18 to 64) and breast screening (ages 40 to 64). Services include
clinical breast examinations, mammograms, Pap tests, diagnostic testing
for women whose screening outcome is abnormal, surgical consultation,
and referrals to treatment. Another CDC program, WISEWOMAN, provides
screening and lifestyle interventions for many low-income, uninsured,
or under-insured women aged 40-64 (also women eligible for Medicare,
but unable to pay the Part B premium), including blood pressure,
cholesterol, and diabetes screening/testing; dietary, physical
activity, and smoking cessation interventions/classes; and medical
referral and follow-up as appropriate.\39\ Using these successful
programs as a model, though applied to a broader range of conditions,
the wellness benefit should cover all clinically indicated preventive
maintenance care (e.g., annual eye and foot exams, hypertension
screening and treatment, HgA1c testing, nutritional counseling), all
with no cost sharing.
Prevention services such as physical exams in Medicare should also
be at no cost to beneficiaries. Although Medicare has several
preventive benefits, they chiefly cover screenings, not lifestyle
modification, and are designed to detect disease earlier--but, with few
exceptions, detection may not reduce spending and likely actually
increases it, as more people are diagnosed and treated. Deductibles and
cost sharing that apply to these benefits discourage their use and
limit potential effectiveness. For example, new beneficiaries bear the
full cost of the ``Welcome to Medicare'' physical exam if they have not
yet met their annual deductible; if they have, they have a 20 percent
co-pay. This is penny wise and pound foolish--Medicare has a
substantial incentive to make sure beneficiaries entering the program
are healthy, normal weight, non-disabled, and without chronic illness.
2. Sustaining science-based community-level interventions with
community challenge grants. The Steps to a Healthier U.S. Cooperative
Agreement Program is a national, multi-level program that funds
communities to implement chronic disease prevention and health
promotion programs that target three major chronic diseases--diabetes,
obesity, and asthma and their underlying risk factors of physical
inactivity, poor nutrition, and tobacco use. This program should be
expanded with the stipulation that grantees must use evidence-based
approaches from data collected by the CDC and others.
3. Supporting evidence-based worksite health promotion. As Senator
Harkin noted in submitting Senate Resolution 673--which was agreed to
by unanimous consent--the Healthy People 2010 national objectives for
the United States include the workplace health-related goal that at
least 75 percent of employers, regardless of size, will voluntarily
offer a comprehensive employee health promotion program. Workplace
health interventions have a proven track record, and should be
incentivized.
4. Finally, creating more effective care management in the
traditional Medicare program is a key priority. Today's chronically ill
patients receive just 56 percent of the clinically recommended
preventive and maintenance care they need.\40\ Changing this will
require creating more integrated health care delivery models, bundling
payments to health care providers, and accelerating the diffusion of
health information technology. Moving in this direction is particularly
challenging given fragmentation of benefit design (Parts A, B, D), and
of clinical information, and thus, of treatment. Most physician
practices (83 percent) consist of just one or two doctors \41\--they
account for nearly 45 percent of all physicians nationally. While
larger groups may move toward a medical home concept, an alternative
approach will be required for most smaller-group practices. This could
occur by strengthening primary care by linking smaller physician
practices with community health teams (CHT) comprising care
coordinators, nurse practitioners, social and mental health workers,
community health and outreach workers. This model can help ensure that
evidence-based clinical preventive services reach those who need them.
In combination, CHT and physician practices would meet the criteria for
a medical home. Recent evaluations of care management interventions
have found the potential for substantial savings in high per capita
cost Medicare areas, including one in Florida that resulted in a 9.6
percent reduction in spending for congestive heart failure patients in
high cost areas near Miami.\42\
In addition to Medicare, other payors, such as Medicaid, private
health plans, and self-insured firms could voluntarily contract with
the CHTs to provide prevention and care management, particularly in
areas with underdeveloped care management capacity. These teams have
proven effective in North Carolina, demonstrating cost savings,
improved health outcomes, and increased access to needed services.\43\
Another is under development for patients in Vermont, following State
legislation passed in 2007.\44\ Pennsylvania has established a similar
initiative.\45\ The CHT model capitalizes on missed opportunities for
prevention and better case management that can trim overall health
costs, particularly by reducing poor medical management outside
physicians' offices, thereby reducing preventable hospital admissions.
Incentives for improving health outcomes and reducing unnecessary
care are an essential element of integrated care. Integrated care
teams, both the primary care practices and the CHT staff, should be
eligible for additional payments if key performance measures are met.
The National Quality Forum is working to develop consensus measures
focused on preventable hospital readmissions.\46\ Lower re-admissions
for key chronic conditions should be a major focus of these new and
expanded primary care practices. MedPAC has estimated that 18 percent
of all hospital stays resulted in a readmission within 30 days.\47\
Medicare paid $15 billion for those re-admissions, of which
approximately $12 billion were potentially avoidable. Other measures
could include improvement in clinically recommended services, such as
blood sugar and blood pressure exams, which are often not provided,
resulting in unnecessary hospital, clinic, and emergency room visits
when more acute stages of chronic illnesses occur. Improvements in
other measures with clinical consensus in the management of diabetes,
hypertension, and pulmonary disease, among others, could also be used
to incent better care quality and health outcomes.
conclusions
Reforming the way in which the U.S. health system provides care to
chronically ill patients is an essential first step in rationalizing
our Nation's health investment. Reforming the traditional FFS Medicare
program would go a long way in spurring this transformation. The United
States leads industrialized nations in per capita and total health
spending.\48\ But we are last in preventable mortality.\49\ Good
preventive benefits alone are not sufficient to achieve high rates of
preventive care. The major reasons for low uptake are beneficiary cost-
sharing, lack of comprehensive coverage for all recommended services,
patients' health literacy and knowledge of preventive services,
language barriers, physicians' time/payment for preventive services,
and the lack of a regular source of care or provider.\50\ Care itself--
along with how we finance and pay for that care--must change.
The broader use of primary prevention efforts in schools,
workplaces, and communities can reduce the growth in chronic disease
and with it health care spending. Coupled with enhanced primary,
secondary, and tertiary prevention in clinical settings, the
opportunities for cost savings are substantial. These elements should
be carefully coordinated in the design of health insurance benefits
(e.g., no cost sharing for services clearly needed to manage and treat
chronic disease) and in the re-design of our health care delivery
system. Placing more emphasis on prevention and re-
designing the care management process in the traditional Medicare
program presents a clear and immediate opportunity and challenge. I
look forward to working with all of you on this issue.
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Senator Harkin. We are graced with the presence of Senator
Dodd, and I will yield to him for any statements he wants to
make, obviously, and for the purpose of introducing our next
witness.
Statement Of Senator Dodd
Senator Dodd. Well, thank you very much, Senator Harkin.
Let me thank our witnesses and thank you, Senator Harkin, for
the hearing this morning on prevention.
This is going to be a major part of the debate, and just
listening to you, Dr. Thorpe, and knowing of the work at Pitney
Bowes, I am pleased to introduce Dr. Mahoney to this audience.
You have made reference already to some of the very creative
things that are occurring already. We don't have to invent
ideas. There are a lot of them being executed as we gather here
this morning.
This will be a major part of this debate and discussion in
the coming weeks. So I would ask consent, Mr. Chairman, to have
an opening statement included in the record regarding the
issues here.
I would just point out we had hearings in July, two of
them, on obesity. In fact, Senator Harkin has been a leader on
this issue and Senator Bingaman, and others over the years that
have really worked on the issue of obesity and related issues
of prevention.
There are so many things we can do to make such a
difference on these issues. As we said, $2 trillion is spent
each year on diseases that are preventable.
[The prepared statement of Senator Dodd follows:]
Prepared Statement of Senator Dodd
Mr. Chairman, I want to thank you for holding this
important hearing, hopefully the first of several on
comprehensive health care reform. And I want to thank our
distinguished witnesses for being here today and providing us
with their expertise.
As this committee begins examining the health care system
it is fitting that we begin with prevention. As our Nation
spends more than $2 trillion on health care, it is disturbing
that we have not made better progress on preventing disease and
promoting health. When the Senate convenes next year we must
make promoting prevention and strengthening our public health
system high priorities within health care reform.
As the title of this hearing suggests, and many health
policy analysts have commented, our health care system is
really a sick care system--a system that is far more likely to
provide for treatments that are costlier and less likely to be
successful than if the system prevented the disease or
condition in the first place. This is a reality of our system
that we cannot afford to permit. Our health care system should
be designed to prevent diseases and conditions before they
occur or before the worst and most expensive outcomes take
hold.
In July, I held two hearings on childhood obesity. These
hearings focused on the shocking truth that our children may be
the first generation of Americans who will live shorter, less
healthy lives than their parents.
Nearly 1 out of every 3 of America's children are obese or
are at risk of becoming obese--25 million children in all,
Already the health consequences of this preventable condition
are crystal clear. Right now, children are increasingly being
diagnosed with type 2, ``adult-onset'' diabetes, high blood
pressure and high cholesterol. The list goes on--stroke,
certain types of cancers, osteoarthritis, certain liver
diseases. And obesity, in children or adults, is incredibly
costly for our health care system. The obese spend 36 percent
more on health care--they spend 77 percent more on medications.
As health care spending has exploded in the last 20 years, 1
out of every 4 of the added dollars has gone to treat obesity-
related problems. If we can make preventing obesity in children
and adults a priority we can help people be healthier and
reduce the costs of health care. This is just one example of
how prevention can benefit us as we reform health care.
Take for example the costs incurred by the system for
babies born prematurely. As highlighted by a 2006 report by the
Institute of Medicine, preterm births cost the United States
more than $26 billion (or $51,600 per premature infant) in
medical care, treatment costs, and lost household and labor
market productivity. Of course, that number cannot capture the
emotional toll a premature baby takes on the family.
Although in about half of all premature births, we don't
know the exact cause, we do know that the weight of the mother
and use of tobacco products during pregnancy are leading
factors for low-birth weight and premature babies. If we could
address these risk factors early and consistently, we could
make tremendous strides toward preventing preemies and
promoting healthier babies.
Newborn screening, tobacco cessation, and early
intervention with mental and behavioral health are some other
obvious examples. And there are many more.
We must take this opportunity to make prevention a part of
a true health care system. This means that we have to support
both clinical preventive health services such as newborn
screening and immunizations and community public health
efforts.
Many States and communities across the country are eager to
promote healthier living for their citizens but lack either the
resources to act or clarity about where to begin. There needs
to be strong national priority setting and leadership along
with increased Federal funding tied to accountability. Health
care providers from big insurers to small health clinics agree
that patients should get needed preventive clinical services.
The U.S. Preventive Services Task Force shows which clinical
services are both beneficial for health and are cost-effective
for adults. But the incentives in the current health care
system are tilted away from such preventive services and there
is far less information about clinical services for children.
We can and should take on these tasks as part of our efforts to
reform health care.
I am proud to be working with Senator Kennedy and Senator
Harkin on this issue. Senator Kennedy is the strongest champion
of health reform in the Senate and I feel confident he can help
carry this over the finish line next year. And Senator Harkin
has been a long time leader in making prevention a priority. As
we go forward, I know we'll be joined by Senators on both sides
of the aisle. And I look forward to hearing from our witnesses
about how we can accomplish these goals.
Thank you Mr. Chairman.
Senator Dodd. I am pleased to introduce Dr. Jack Mahoney,
who is here with us this morning. He was strategic healthcare
initiatives director at Pitney Bowes. He was a key team player
in the company's innovative healthcare programs, and we admire
you for that work.
His responsibilities included advanced healthcare planning
for employees, integrating disease management and wellness
initiatives, and benefits planning for employees and retirees.
Since retiring, Dr. Mahoney has assumed the role of chief
consultant for strategic health initiatives at Pitney Bowes and
continues to play a very active role in that area.
He was responsible for designing health benefits for
employees, integrating disability and disease management and
wellness initiatives, and has written several books that
analyze value-based insurance and challenge traditional benefit
design programs.
Doctor, we thank you for coming today and being a part of
this, and I am honored to be your Senator and to represent you.
Pitney Bowes is a great company and a great corporation, and
they make great products, obviously. But in addition to that,
have demonstrated real leadership when it comes to their
employees and retirees as well.
So we thank you for being present here this morning.
Dr. Mahoney. Thank you, Senator Dodd.
Senator Harkin. Thank you very much.
Senator Coburn.
Senator Coburn. I will just ask a unanimous request to
submit questions in writing to our panelists.
I have to leave for another hearing, but I want to express
my appreciation for them being here and their testimony. I
think it is valuable, and my hope is that we can do something
on a bipartisan basis on prevention.
Senator Harkin. Absolutely. Thank you very much.
Dr. Mahoney, please proceed.
STATEMENT OF JOHN J. (JACK) MAHONEY, M.D., CHIEF CONSULTANT FOR
STRATEGIC HEALTH INITIATIVES, PITNEY BOWES, STAMFORD, CT
Dr. Mahoney. OK. Thank you, Senator Harkin, Senator Dodd,
Senator Reed. It is my pleasure to be here, and I thank you for
the invitation to be able to talk about some of the things that
we have done at Pitney Bowes over the past 17 years.
Just by way of quick background, Pitney Bowes has 27,000
employees in the United States who are involved in all aspects
of integrated mail and document management services. We have a
very diverse workforce. It is geographically spread. So we have
work groups that are as small as 2 people and as large as 2,500
employees at a single site. So we have quite a variety of
challenges, if you will, in trying to implement programs.
I first started working with Pitney Bowes back in the early
1990s. In those days, Pitney was, as all companies, looking at
their healthcare costs and healthcare cost increases. So under
the leadership of Mike Critelli, who was then head of human
resources, who subsequently became our CEO, we began to look
at, first, the health plans. So we did what most companies
would do in terms of introducing managed care, looked at plan
design and cost sharing.
But the significant difference, I think--and again, this
was under Mike's leadership--is he said,
``If we can afford to invest in computers and other
equipment to increase the well-being and productivity
of our employees, we can certainly invest in
healthcare.''
What happened was, we were able to achieve some savings in
our health plans. We reinvested the money. And some examples of
that, we instituted a comprehensive wellness program. It was
called Healthcare University, and the program was aimed at
helping employees either maintain or adopt healthy habits.
It was an incentive-based program. It still is an
incentive-based program that basically allowed the employee to
accrue credits that translated into dollars with which they
could buy their healthcare for subsequent years. So, in effect,
it was a premium reduction plan.
Simultaneously, we put in onsite medical clinics, and these
were low-level primary care clinics. But the most important
thing is we were able to use those clinics as outreach for our
wellness programs. So we had nurse practitioners and nurses who
were actually working with the employees to improve health.
Another significant investment then was our employee
assistance program. It is one thing to look at physical health.
We thought it was important to look at mental health also. So
we put in a comprehensive employee assistance program, which
basically was free to employees.
I would add that this went in concurrent with a benefit
design, which was full parity in coverage for mental health and
substance abuse. So we were one of the first companies to get
to parity well before we were required to.
The last part of this was the investment in a data
warehouse. It is one thing to look at what you would like to
do. It is another to begin to accumulate the data so that,
again, you have a roadmap of where you have been and where you
are going to.
Well, our progress through the 1990s was acceptable. We
were able to manage costs. We were comfortable with the
wellness program rolling out there. But in the year 2000, we
looked at it and said, ``There is something lacking here.'' You
know, we are just sort of putting out fires, if you will, on
the health plan.
With the wellness program, we were doing what everybody
seemed to think was the right thing to do, but in reality, we
thought we could really do more. So we went into this in a
couple of different veins.
The first, in wellness, we ramped up the program. But it is
one thing to say that you espouse wellness, it is another to
set up the environment for individuals so that they can be
healthy. So it was simple steps, but significant ones.
Changing the food in the cafeteria, and that meant not only
making healthy food available, but making sure that it was
priced affordably. So, quick example--it costs more for a bag
of potato chips in our cafeteria than it does for a fresh piece
of fruit.
Very simple things. Changing the configuration of the
office building so that stairway--in our corporate
headquarters, the stairways were hidden in the corners. We put
in a big central stairway. The idea was to get people to get
out, walk around, socialize, and by that way, they get
exercise.
We were big advocates of public transportation. No. 1,
obviously, it is good for the environment. But No. 2, if you
take public transportation, you probably walk more. You are
walking back and forth to the train station or to the van stop
and back into the building.
Any and every subtle clue that we could possibly do to
enhance the environment. If you will, some people have called
it a culture of health, but it really is the environment.
The other part of that is, OK, so you can do those things,
but then you have to look hard at your benefit plan designs.
Sadly, many benefit plans either inadequately cover preventive
services or put a deductible in front of them. So we said we
can't have that.
We re-designed so that all of our employees, beginning then
and through now, have access--the only plans that are offered
to them are ones that have comprehensive preventive services
with preventive care being offered at either a minimal co-pay
or no co-pay, especially for immunizations, and there is no
front-end deductible. So we wanted to eliminate the access
barrier there.
By the way, that is something, along with the behavioral
health piece, that we could not have done without the ERISA
pre-emption giving us the latitude to do those innovations.
Well, the other area, we have talked a lot about chronic
disease, and we would concur with all of the comments on
chronic disease, but there is a big caveat here. And that is
that, indeed, people with chronic disease are more costly, but
if you dig into it a little bit more deeply, the cost is direct
cost plus disability--is not so much the presence of the
diagnosis, it is the person with the condition who is
inadequately or inappropriately treated, and especially
somebody who is not compliant with their medication therapy.
We took, at that time, a radical step, back in 2001, of
saying we would reduce co-pays for chronic disease medications,
and our targets were asthma, diabetes, and hypertension. We
have been very pleased with the results, and we have expanded
the program now so that it covers osteoporosis and
cardiovascular disease in general, and at this point, it also
covers smoking cessation programs--like the medications for
helping people to quit smoking.
We put that into place, and then, concurrent with that--we
are a manufacturing company, to some extent, although services
are involved there. And supply chain side is something very
valuable, and that is you have to improve your supply chain.
We went out and basically made our health plans accountable
to us for quality and efficiency, not cost. We thought that if
we got to quality and efficiency, then we could manage the
cost.
It was a strenuous exercise. It is an annual exercise. It
is resource-intensive. We have changed health plans many times.
But we are on notice that unless a health plan can deliver all
of those services--preventive services, disease management
services, quality, and efficiency--we will not do business with
them.
So, to wrap up, what have we gained out of all of this?
Well, I can't give you really tight ROIs, but what I can tell
you is that at this point, our costs per employee are 18
percent below what we would expect to see with other comparable
companies. We know that about a third of that is due to our
efficiency in the health plans and quality, but the remainder
is due to the efforts in primary and secondary prevention, our
initial wellness program and the chronic disease management
programs.
We have a benefit that is affordable for the employees.
That is one of our hallmarks. And it is highly regarded by the
employees. It is amazing to see how they will write in positive
comments about it in the annual engagement survey.
What have we learned out of all of this? Well, a few basic
steps. There is value in investing in health. The value is not
only in managing costs, but it is competitive advantage.
One of the offshoots of our programs is that we have seen
our disability rates go down. Translated, that means we have
more effective workers who are able to deliver the services
which are valuable to our customers. So it has delivered cost
savings, competitive advantage.
You can't do this without data. A data warehouse has been
incredibly valuable to us all through the process. We clearly
recognize that the least expensive product is not the best. Buy
quality. Be able to measure quality. Hold people accountable
for the quality.
Clearly, the answer to all of this is not shifting cost to
people. It is really about how do we improve the
infrastructure?
And last, but not least, I would echo what Ken said. It
doesn't happen without effective executive leadership. And we
have been blessed with a CEO who really believed in that,
sponsored it, and has been, if you will--I hate to use the
word, but--cheerleader through the whole process, an
instigator.
Thank you, Senators, for the opportunity, and I am happy to
answer questions later.
[The prepared statement of Dr. Mahoney follows:]
Prepared Statement of John J. (Jack) Mahoney, M.D.
Good morning, Mr. Chairman, Senator Enzi, and distinguished
committee members, I am Dr. John J. (Jack) Mahoney. Recently, I
officially retired from Pitney Bowes. Prior to my retirement, I was the
company's Director of Strategic Healthcare Initiatives. Today, I
continue to work with Pitney Bowes on a consulting basis to assist the
company in its advanced health care planning and wellness initiatives.
Pitney Bowes is the world's leading provider of integrated mail and
document management systems, services and solutions. Pitney Bowes
invented the postage meter in 1920, which enabled the post office to
offer more convenient and secure postage payment at lower cost for
business mailers. Today, Pitney Bowes helps organizations of all sizes
engineer the flow of communication to reduce costs, increase impact,
and enhance customer relationships. Starting in the mail and print
stream, and expanding into digital documents, Pitney Bowes has
developed unique capabilities for improving the efficiency and
effectiveness of the communication flow critical to business.
I joined Pitney Bowes in 1997, as the Corporate Medical Director
and the head of Global Health Care Management. Soon after I joined the
company, our new Chairman, Mike Critelli, asked us to help him
``rethink'' our health benefits programs. Pitney Bowes has a tradition
of offering its employees comprehensive health benefits. However, like
many other companies, health benefit costs at our company were growing
much faster than other costs. Similar to many other companies, we began
to look for ways to control costs while maintaining employee
satisfaction with our benefit offerings.
Like most businesses, we initially considered traditional cost-
cutting techniques, such as cutting benefits or shifting more of the
cost to the employee as a way to contain year-to-year increases in
health care benefit costs. However, as we looked at the experiences of
other companies, we quickly realized that their cost-cutting approaches
did indeed generate savings for a year or two but, by year three, most
of these businesses saw large increases in the cost of employee health
benefits. By the end of the third year, all of the savings of the first
2 years had disappeared.
At Pitney Bowes, we wanted to design a program that would work over
the long term--not just for a year or two. We started with the premise
that health care benefits should be about health, not just about
treating illness. We asked ourselves, ``If we are willing to invest in
new computers and other new equipment to make our employees more
productive, then why shouldn't we as a company be willing to invest in
the health of our employees to make them more productive?'' It is true
that this approach did not offer savings in the first year, or even the
second year but, by year three, Pitney Bowes was able to achieve real
reductions in the cost of employee health benefits.
Pitney Bowes has created health care programs that promote healthy
behaviors. Our benefit programs are predicated on the belief that it is
more effective to maintain health than to attempt to restore it. We
believe that proper nutrition, appropriate levels of exercise, healthy
lifestyles, and early detection, intervention and treatment provide
opportunities for our employees to effectively manage their health.
After much research, we implemented a strategy of linking voluntary,
healthy behavior adoption to financial incentives. We built a platform
called ``Health Care University,'' which enables participants to gain
benefit credits for completing a health risk assessment or for
participating in various kinds of wellness programs. This initiative
exceeded our expectations in terms of employee satisfaction and
improved the overall health of our employee base.
Like many other businesses, we also found that the cost of
providing care to a small number of employees with chronic health
problems accounted for a disproportionate share of our health benefit
expenditures and a decline in productivity. We quickly learned that we
could predict future costs by looking at population-level data from
prior years. For example, we discovered that we were likely to spend
over $10,000 for hospitalization and emergency care of employees with
diabetes who either did not use, or did not have, economical access to
maintenance drugs. The solution was clear. We knew that we needed to
modify our plans to reduce the likelihood that debilitating and costly
health emergencies would happen in the future. In short, we needed to
remove as many impediments to disease management as possible.
Consequently, our company re-designed our benefit plans to reduce
employee co-pays for brand-name chronic disease medications by between
50 percent and 85 percent.
As a result of these measures, we were able to reduce treatment
costs for diabetic employees by 17 percent and treatment for asthma by
18 percent. Similarly, our focus on adherence to treatment plans
reduced emergency department use by asthma patients by 30 percent,
hospitalizations by 38 percent and disability costs by 50 percent.
More recently, we became aware of the many benefits associated with
creating a positive work environment for our employees. As we renovated
our World Headquarters, we reduced the number of walled offices and
shrunk average offices sizes. We also largely eliminated desktop
printers, copiers and fax machines, and replaced them with core area
multi-functional devices. Taking these steps has created more exposure
to natural sunlight for our employees and encouraged them to walk
around more during the day, which we believe produces positive health
benefits.
In addition to these changes to our employees' physical space, we
also altered meal options in our cafeterias to ensure that healthier
food was more plentiful, lower cost, and more easily accessible than
less-healthy options. We also gradually reduced portion sizes for all
meals to reflect the recommended healthy intake. For employees who have
chosen to participate fully in our benefit offerings, the impact of
these initiatives on wellness results has been tremendous.
I recognize that some may question company programs designed to
promote healthy lifestyles, exercise programs, good nutrition and
incentives to treat chronic disease--believing they are only words
crafted by public relations departments. However, Pitney Bowes believes
that a healthy workforce makes us more productive and better able to
compete in the global marketplace. In fact, our health care costs per
employee are 18 percent below that of our benchmark companies. One-
third of our cost savings can be attributed to efforts to improve the
quality and efficiency of care delivery, while two-thirds can be
attributed to improving the overall management of chronic conditions.
We also believe our employees have a responsibility to ``self-
manage'' their own health. However, employers have a responsibility to
provide employees with the necessary tools. Pitney Bowes is one of the
founders of an initiative called Dossia, a non-profit, third-party
organization with members such as Intel, BP, AT&T and Walmart. Dossia's
goal is to fund the development of a Web-based framework through which
U.S. employees, dependents, retirees, and eventually others, can
maintain private, personal and portable health records, as a way of
empowering individuals to pursue health and to reduce provider medical
costs. Dossia's premise is that we cannot overcome the health crisis in
this country until Americans manage their health care.
Pitney Bowes has benefited from the Employee Retirement Income
Security Act (ERISA), which grants self-insured companies like Pitney
Bowes considerable latitude in developing new and innovative approaches
to employee benefits and healthcare. Congress recognized that self-
insured plans assume the risk of employee benefits and therefore have
the greatest incentive to operate efficiently and economically.
Eliminating this incentive by eroding the ERISA pre-emption could
stifle innovation and creative problem-solving.
While government can, and should, play a role in helping those
unable to afford or access health care benefits, employers have the
most direct financial interest in creating and maintaining meaningful
benefit programs. I am particularly concerned about congressional
proposals that purport to retain the employer-based health care system,
but would, in fact, result in what insurers call terminal ``adverse
selection'' for employer-based plans. These types of proposals could
cause employment-based plans to disappear.
In summary, the key to Pitney Bowes' success has been:
viewing health care as an investment, not just another
cost;
developing good data;
promoting and encouraging employees to adopt behaviors
that maximize good health;
recognizing that the least expensive product is not always
the most cost-effective; and
recognizing that shifting more of the cost of some health
care benefits on to the employee does not always save money in the long
run.
Thank you again, Mr. Chairman, for your consideration of these
comments. I would be happy to answer any questions that you or your
colleagues may have.
Senator Harkin. Very good. Dr. Mahoney, that was great. A
great tour de force of what can happen in the private sector,
and we will have more interaction when we are through our last
witness. But thank you very, very much.
Finally, from Iowa, we welcome Ms. Carol Hibbs, the
executive director of the Community YMCA of Marshalltown, IA.
Ms. Hibbs has served as co-coach of the Marshalltown Pioneering
Healthier Communities initiative since September of 2005. She
is a graduate of Iowa State University with a degree in
journalism and mass communications, and we look forward to
hearing about the success of a prevention program at the
community level.
Ms. Hibbs, welcome to the committee.
STATEMENT OF CAROL HIBBS, EXECUTIVE DIRECTOR, COMMUNITY Y OF
MARSHALLTOWN, IA
Ms. Hibbs. Thank you. Thank you for the introduction.
And Senator, I want to thank you for your support and being
a leading role and prioritizing prevention and healthcare and
also for being the honorary chair of the Pioneering Healthier
Communities initiative. Thank you very much for that.
Marshalltown is a rural community. We have about 27,000
people. Over the last two decades, we have rapidly transformed
into a much more diverse community, both culturally and
economically. We estimate that our Hispanic population has more
than doubled since the 1990 census, and in our school district
now, more than 40 percent of the students are Hispanic.
We also have a school district that has more than 50
percent of the students on free and reduced lunch. So we face
some economic challenges. Our Y is very proud of the fact that
we are open to everyone in our community and that we currently
provide financial assistance to about 20 percent of our 6,800
members.
In 2005, we participated in the Pioneering Healthier
Community initiative of the YMCA of the USA. This initiative
focuses on collaborative engagement with community leaders to
influence policies and environments for improved health and
well-being.
Locally, we recruited a high-level team of community
leaders from all sectors to come to Washington to learn about
proven policy and environmental change strategies. Our team
left excited, and we were convinced that we could collectively
influence opportunities for our residents to be healthier
through the planning and implementation of programs and
policies.
Our engagement of the community has brought about healthy
changes, some of which included that we conducted a walkability
assessment of our downtown to achieve our goal of Marshalltown
becoming a bike and pedestrian friendly community. As a result,
a sidewalk task force was created, mapping sidewalks, assessing
needs, and creating a plan for the city with a priority on
sidewalks near schools.
A commitment was made to create a Safe Routes to School
program for the entire community and to secure the necessary
resources for it. Plans were developed for a pedestrian river
walk along Linn Creek, which flows through the heart of our
community.
We have worked with local community college students to
plant more trees along the biking path to increase usage there.
We helped school districts develop wellness policies, and two
of our local schools that focused on physical activity
throughout the day, revising the PE curriculum, establishing
nutrition information for families on school lunches and
healthy vending options.
We have implemented a program called ``Fit Kids,'' an after
school living healthy program that targets low-income children.
Then we also have a program entitled ``Healthy You'' that
serves ages 17 to 78 to offer comprehensive behavior change
strategies. It gives them the environmental and emotional
support that they need to make these important changes.
Now to make this process work, decisionmakers all must be
onboard because many of the decisions they make can influence
the environments in support of healthy behavior. Now I think
you will agree that your Federal investment into our team of
$50,000 is a small change that needs to occur in every city,
town, and neighborhood in America, especially since our team
has been able to leverage those dollars more than six times
over with contributions and grants.
Now today, the YMCA movement has 91 communities engaged in
the Pioneering Healthier Communities model. And for Iowa, we
have Des Moines and the Quad Cities, in addition to
Marshalltown. In Connecticut, there is New Haven. And Senator
Reed's State of Rhode Island, there is Providence, and Senator
Coburn's State, in Oklahoma, there is Tulsa.
And the 2,686 YMCAs across the country stand ready to work
with our communities on this proven change model.
Thank you.
[The prepared statement of Ms. Hibbs follows:]
Prepared Statement of Carol Hibbs
Good morning, I'm Carol Hibbs, Executive Director of the
Marshalltown, IA Community Y. I'm honored to be here to say a few words
about the success of our community change model, focused on chronic
disease prevention. This project has been convened by the YMCA, but is
indeed a community success story.
Before I begin I want to thank my Senator, Senator Harkin for his
leading role in prioritizing prevention in health care and for serving
as the Honorary Chair of the YMCA's Pioneering Healthier Communities
initiative. Without you, Senator, this program would not be what it has
become today--a movement toward the social and cultural change we need
to make the healthy choice the easy choice in our communities.
Marshalltown is a rural community of about 27,000. Over the last
two decades, we have rapidly transformed into a much more diverse
community--both culturally and economically. Experts estimate that our
Hispanic population has more than doubled since 1990. In the school
district, more than 40 percent of the students are Hispanic. Also, more
than 50 percent of Marshalltown students qualify for free or reduced
priced lunch. Our YMCA is proud to be open to everyone in our community
and we currently provide financial assistance to about 20 percent of
our 6,800 members.
In the summer of 2005, our community applied to participate in the
YMCA of the USA's Activate America: Pioneering Healthier Communities
initiative. Pioneering Healthier Communities focuses on collaborative
engagement with community leaders, how environments influence health
and well-being, and the role policy plays in sustaining change. We
believe no one organization can effectively solve the Nation's chronic
disease crisis; therefore YMCAs joined with others to increase
opportunities that ultimately impact healthier lifestyles.
In Marshalltown we recruited a high-level team of community leaders
from all sectors--including the hospital, local business, the school
district, economic development and our Mayor--to come to Washington for
3 days of information and education. We heard from national experts
about evidence-based strategies that build sustainable healthy
communities through changes in policy and the built environment. Our
team left Washington excited and convinced we could collectively help
Marshalltown residents become healthier.
The Pioneering Healthier Communities Model takes the macro approach
to change. Again, combining programs and projects for implementation in
all sectors of our community; and promoting policy changes--all of this
with a constant, healthy dose of information and education in
community-wide forums that explain why we are trying to make a
particular policy change. Our engagement of the community has brought
about healthy changes, including:
Developing a community walking guide distributed through
numerous community sites and events.
Developing wellness policies in two of our local schools
that focused on incorporating physical activity throughout the school
day, revising the PE curriculum, establishing guidelines and nutrition
information for families around school lunches, and providing healthier
options in the vending machines.
Creating a ``Gym in a Box'' with a large local hospital to
promote healthy eating and active living among their employees.
Working with the local community college students to plant
more trees along biking paths in the city to increase usage.
Implementing Fit Kids, an afterschool program targeting
low-income kids to incorporate healthy activity and healthy snacks into
their lives along with the President's Council physical fitness test
every 12 weeks.
Introducing Healthy University for 17-78-year-olds
allowing hundreds of individuals to receive assistance with
comprehensive behavior change strategies to reduce obesity--including
the necessary environmental and emotional support to help individuals
be successful.
Conducted a walkability assessment in our downtown to
achieve our goal of Marshalltown becoming a pedestrian/bike friendly
community. The first meeting was attended by 40 interested community
leaders and was followed by another meeting of 60 leaders. We now have
city government, community walking & biking advocates, Iowa Department
of Transportation officials and the local planning commission working
together toward common goals. As a result:
1. A sidewalk task force was created that mapped sidewalks in the
city to assess needs and prioritized a plan for the city with the
highest priority being around schools.
2. A commitment was made to creating a Safe Routes to Schools
program for the entire community.
3. Plans are underway for the development of a pedestrian river
walk along Linn Creek which flows through the center of the community.
This work is not easy. Silos must come down in communities and
money from local, State and Federal Governments along with that from
the private sector must be leveraged. Community leaders who influence
the environments of where we live, work, and play must all be on board
to create healthy ones. Community leaders in Marshalltown have been
surprised to learn just how many decisions they make weekly or monthly
that influence healthier choices.
We believe keys to our success include:
Recruiting community leaders and key influencers as part
of the team to come to Washington to participate in the initial
conference--we must reach beyond the public health community to
influence public health outcomes.
Creating a healthy community plan that asks all sectors of
our community to make a contribution.
Reaching into so many parts of the community and
encouraging participation along with constant information and
education--several segments of the community are now energized and
unified around this healthy community effort.
Challenging the team to not only implement new programs
and special projects--but to constantly look at policy changes that can
be made in our schools, worksites and neighborhoods so healthy eating
and active living is an easier choice.
Acting as a central coordinating organization, the
Marshalltown Community Y convenes the group and coordinates the work--
but engages everyone. This has worked well in Marshalltown because the
politics of this work with public officials and the private sector is
managed and not a barrier so the community can make these important
changes.
This effort involves more than just telling people to eat less and
exercise more. The YMCA has learned that the majority of kids and
families need support in achieving their health and well-being goals.
We call these individuals ``health seekers''--they want to improve, but
making everyday healthy choices is frequently a struggle, even when it
has obvious advantages. Yes, people are responsible for their own
behavior but too often society creates barriers, or at the least does
not provide enough support, to help kids and families realize their
health goals.
Today, the YMCA movement has 91 communities engaged in the
Pioneering Healthier Communities model (see attached map/list). There
have been significant policy changes, new programs implemented and a
great deal of awareness created around evidence-based models that
result in 91 healthier communities. We are anxious to share our model
with others and there are hundreds of communities interested and ready
to do this work.
I want to emphasis however that there are no shortcuts. We have
faced challenges. I believe everyone on our team would say the learning
process has had a direct correlation on the outcomes and bringing the
community together toward common goals for a healthier Marshalltown.
I'm certain that each of you on this committee would agree that your
Federal investment into this team of about $50,000 since 2005, is a
small investment compared to the change that needs to occur in every
city, town and neighborhood in America. In addition, we have been able
to leverage those dollars more than six times over with contributions
and grants with local funders, hospitals, Safe-Routes-to-School funding
and a Carol White PEP Grant.
America's 2,686 YMCAs, at more than 10,000 sites serving more than
21 million people each year--half of which are children and youth stand
ready to enthusiastically support chronic disease prevention policies
for the individual, the family and our communities. Thank you for
allowing me to share what I believe is one of the best models of
community-based prevention programming.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Senator Harkin. Thank you very much, Ms. Hibbs, and thank
you for your leadership in Marshalltown.
Of course, I am very much aware of what you have been doing
out there. I have visited out there more than once, and the
changes that have been brought about are incredible.
I think our panel here shows, we have the community
involvement. We have the private sector. We have academia and,
in the first panel, the Federal Government. The one thing that
perhaps is missing--but we will get to that at some point down
the line--and that is the States and what can State governments
do and how they would be involved.
But there are so many things that communities can do, and
some of them are doing ingenious things. And as someone said,
we have to find these sort of best practices somehow and get
those out and somehow incentivize those best practices that
work.
I know of another community where they received a grant for
a community wellness program, and one of the things they did,
which I thought at the outset was not--I didn't think it was
going to work that well. I was proven wrong. They convinced the
local grocery store--in this case, it was Hy-Vee, which is a
big chain in Iowa. And this local store, working with
dieticians, nutritionists, they put little arrows along the
aisles of the grocery store with an arrow and a heart on it.
And these were the heart healthy things that you could buy.
I went to the store and looked. Of course, in the candy
section and stuff, you don't see any of those. And in the
cereal sections, where they have the sweetened cereals, you
don't see any. But in the other cereals, you do, and in the
vegetables and fruits, all those arrows are all over. It was
just a visual representation to the average shopper of this is
a good thing to buy.
It had a tremendous effect. You would be amazed at how the
difference in purchasing went up just in that one grocery
store. So just little things like that.
I remember when Tommy Thompson was Secretary of Health. I
went down to visit him once, and I saw a sign by the elevator
at the Department of Health and Human Services. It said, ``The
stairs are this way, and if you climb stairs, you will burn so
many calories,'' that type of thing.
As you pointed out, I think it was, Dr. Mahoney, you
changed so that people would start taking stairs more and using
stairs more. Simple things like that, that can change the
environment. I can't recall exactly who it was, but someone
said you have to build the environment so that people could be
healthy.
While I agree with Senator Coburn that people will make
these choices if they are given the information, but if you
can't find the stairs to climb or they are dark and forbidding,
you don't want to do that. If you want your kids to walk to
school, but there is no sidewalk, well, you might want to make
that choice, but they can't walk along the busy street if there
is no sidewalk.
There are a lot of these things that we have to think about
in terms of if we give this information to people--I think it
was you, Dr. Mahoney, who said you have to build this
environment.
Dr. Mahoney. Right.
Senator Harkin. You have to build the environment so people
will find that these things are sort of easy to do, accessible
to do.
Well, anyway, that is just my editorial comments on this. I
have a series of questions, and I will just start with a
couple, and then I will yield to Senator Dodd.
But Dr. Levi, you have talked about this national
prevention strategy. Again, I would be looking for who would
establish it? How would you implement it? How would it differ
from ongoing Healthy People process?
Can you flesh that out just a little bit more for me on
this national prevention strategy? How do we establish it? How
is it run? How do we get going on it?
Mr. Levi. Sure. I mean, I think our immediate vision would
be for either Congress to mandate the creation of this or for,
one would hope, the President to ask his domestic policy
council staff to convene a working group within the Federal
Government that would bring all of the relevant agencies
together.
They would be tasked for identifying not just what they are
currently doing, but what existing programs could do to promote
health and to really begin to change the--this is a cultural
shift within Government. It is not just about convincing the
American people to think healthier and be more active and think
about health in their own lives, but I think we need a culture
shift in the Government to recognize just how dramatically
almost every agency of the Federal Government can affect
health.
By bringing all of those agencies together, setting some
clear goals, we may want to start with one issue, obesity,
because of its dramatic impact on--obesity and physical
activity and its impact on so many chronic diseases, as Dr.
Thorpe indicated. I think that would give us an opportunity
then to see the range of programs and the range of effects.
Then identify what additional money, what additional
resources, what additional staffing will be needed to really
make those programs health focused. And so, it means certainly
we would argue, within HHS, looking at some of the CDC programs
and saying how much of this money is really getting out into
the community? How can we put Pioneering Healthier Communities
on steroids? I probably shouldn't say that.
[Laughter.]
Some equivalent of that to--that is a different oversight
hearing.
[Laughter.]
But how do we make sure that every community can be not
just doing the coalition building that Pioneering Healthier
Communities does and not require the Pioneering Healthier
Communities to depend on leveraging other resources, but
actually give them the resources to make those changes.
When they think they need more sidewalks, let us help them
provide the resources to build those sidewalks. When they need
to build a supermarket in a neighborhood, if that is something
that is deficit, let us provide the loan payments and the
support. And frankly, that could all be part of an economic
stimulus package or developing the infrastructure.
So it is thinking within HHS along those lines, but then
making sure that the Department of Transportation, when it is
giving grants around transportation, around highways, to make
sure that there are bike paths, to make sure that there are
sidewalks, all those things. And if you think about it over
time, almost every agency of the Federal Government has a role
to play in this, and that is what needs to be brought together.
Once we have identified what those things are, then there
need to be goals set for each of those agencies with milestones
along the way. And again, I referenced earlier the pandemic flu
plan. There are annual 6-month, 12-month, 18-month, 24-month
milestones that agencies have to meet, and they are reported on
publicly. That would be one element of, I think, what we need.
The second element I think is critical within HHS. The
difficulty in finding the Office of Science and Public Health
was not accidental. It is hidden. I think we need to make sure
that public health really is a tremendous focus of everything
that happens within HHS, and it is not just the programs in the
Public Health Service and in CDC, NIH, and so on.
It is also CMS. It is Medicare and Medicaid and their
ability to affect that. Right now, no one below the secretary
has line authority over those agencies. And so, part of what we
mentioned in our written testimony is that the Assistant
Secretary for Health should once again have line authority over
the Public Health Service agencies so that they can be
implementing that national plan and can be all working in the
same direction.
We would also like to see Congress elevate that assistant
secretary position to an under secretary position so that we
could also incorporate the preparedness and response programs
and, particularly relevant to this discussion, the CMS
programs. So that CMS is not just reimbursing for care, but
also thinking about its public health and prevention role.
Senator Harkin. Well, hopefully, these are things that we
can start working on and incorporating. With the new
administration coming in, it is probably an appropriate time to
start looking at how we can restructure HHS to accomplish that.
To all of you who are here, I invite any of your input on
what should be in this stimulus bill that we will probably be
passing, probably in January sometime. But I think one of the
things that we are not looking at is this area of what we ought
to be doing in the stimulus package. Public health workers,
things like that.
Any other thoughts that any of you have on stimulus package
stuff, even Healthier Communities things. A lot of these are
construction-type projects. One community I am aware of built a
walking path around the whole town, but they connected it to
the retirement center and the nursing home and things like that
so that they could get out easy, get right out on it, even in
wheelchairs, and use wheelchairs to move around on the path and
everything.
Just things like that that we ought to be thinking about as
part of the stimulus package also. With that, I would turn to
my colleague, Senator Dodd.
Senator Dodd. Well, thanks, Senator, very, very much.
Let me also commend all of you. In fact, I should have
mentioned earlier Dr. Levi was a very good witness for us back
in July, when we had our hearings on obesity, and I should have
made reference to that when I opened my remarks. Senator Harkin
has raised a good series of questions here about that.
Let me just say, I underscore the point of the under
secretary position. I think you have to create a structure, an
architecture that allows you to get there. And while we get a
lot of these ideas, if you don't have the architecture in place
to do what is being suggested across the board in this area,
then I think you are sort of lurching.
I always find--and Senator Harkin, I know, has probably
encountered this, too--as we go to our colleagues and others to
make an appeal at the various times on various funding schemes
in this area, it is not uncommon to have someone say, ``I will
tell you what. I will help you with the first request and the
second, but not the third and the fourth. I just can't do it.''
Not understanding that if you don't do three and four, one and
two don't work.
You really do have to have a comprehensive, a holistic
approach to this if, in fact, that $10 investment you are
suggesting it would cost would save us some $16 billion. I
think that is a graphic way of describing the kind of
investments that could be made.
Or as Pitney Bowes showed, I think the case that we need to
make strongly is that not only is this smart from a health
standpoint and a moral and ethical standpoint, this is very
good business. Pitney Bowes saved 18 percent, I think is the
number. You correct me if I am wrong.
Dr. Mahoney. On chronic diseases.
Senator Dodd. I am sorry? On chronic diseases?
Dr. Mahoney. I am sorry. We are 18 percent below benchmark
companies.
Senator Dodd. Benchmark companies, which was a very
important point to make to an audience out there that says this
is all well and good. Pitney Bowes is a big corporation. You
can afford to do it. You are healthy and wealthy. We are
struggling. How can we do this?
This is a money saver. If you are only impressed by
economics, that is all you care about, this is the best idea
you are going to have. In a difficult time financially, this is
smart economics, in addition to being right public policy.
I appreciate these ideas. And Senator Harkin is correct, we
ought to be raising ideas as quickly as we can here, with an
administration coming in that is committed to change, these are
some fundamental ideas that we ought to incorporate early on if
we are going to be successful in developing, I think, the kind
of comprehensive plans that we are talking about.
I will leave those questions. I want to get to two quick
questions, if I can, because one of the problems that we have--
and again, it is a practical issue--and that is a public health
workforce. And again, we talk about expanding the needs for
this. We celebrate tremendously the success, but we have a real
shortage in this area.
I think both Senator Harkin and others on the committee
would like to know how we could help in that regard. So let me
ask you to focus on that a bit, what Congress can do. I realize
the quick answer is money, but that is it seems to me there
needs to be more thoughtful strategy about this than just that
answer.
I would like you to comment on that, if you could. The
recruitment, retention, how we do that, if you would? And let
me--I have a couple of other quick questions for our other
panelists. But if you would respond to that, Dr. Levi?
Mr. Levi. Yes. We can submit a longer litany of things for
the record. But I think it falls in several categories. First,
we have delayed in reauthorizing Title VII and VIII of the
Public Health Service Act, and I think those are the core of
making sure that the Federal programs are in place.
But we also need to make sure that we have a pipeline of
new workers. Twenty percent of the average State health
agency's workforce is going to be eligible to retire within 3
years, and that is just keeping things going as it is now, as
opposed to the additional responsibilities and needs we will
have if we really engage in the kind of community prevention
work that we have all been talking about.
There are all sorts of things I think Congress could do
that would not necessarily be highly costly. Some of it could
be scholarships or loan repayment programs. We need to be
thinking not just about master's level trained folks, but
people in community colleges who can receive specific training
to do community health work and work in public health
departments.
Perhaps provide some incentives for juniors and seniors in
colleges to become public health majors. More and more
undergraduate institutions are offering public health programs
as majors.
We also need to be thinking about the ongoing workforce
programs that are out there. The State workforce boards do not
have a requirement that there be someone who can think about
and know about public health jobs that could be created and
have public health expertise. So we could leverage some
existing programs that are already out there for workforce
development that could help us expand the workforce.
There are a number of other things that we have in our
testimony, and we can provide additional detail. But I think
you are absolutely right that we can reform the system all we
want, but if we don't have the workforce in place to actually
carry the message of prevention and implement these programs
and support the public health infrastructure that is so
critical to surround the healthcare system, we are not going to
succeed.
Senator Dodd. Let me jump to two other issues, and I
apologize for kind of jumping around here, but sensitive to
time. And Tom is a tremendous help in this, as he has been on
so many issues, and wrote back--it finally got adopted in 1993,
the Family and Medical Leave Act.
It was a highly controversial effort, surprisingly so. We
were the last country in the world, I think, to provide a leave
program. I remember South Africa, even under days of apartheid,
adopted a family and medical leave policy, and proud of the
fact that something like 75 million Americans have been able to
take advantage of the program over these many years.
Dr. Mahoney, I think Pitney Bowes has a paid family and
medical leave program. At least I have been told that. Is that
the case?
Dr. Mahoney. No, sir. We have a family and medical leave
program, and we also have a disability program. But there is
not a----
Senator Dodd. Not a separate program? Well, what I want to
get at is because we are talking about a paid leave program,
and I won't take the time to go through how it works, but it is
not as just a simple paid leave program. It is scaled and so
forth to understand the obvious concerns of some businesses
about this additional cost.
But I wondered if you might comment, the panel here that
has some knowledge of this, about the benefit of this. Eighty
percent of the people who don't take leave don't do so because
they just can't afford to, which is not a surprise to people, I
suppose, when you are out there struggling at this juncture.
The idea that you could take 12 weeks off to be with a
family member recovering from an illness, I want to talk about
this in the context of prevention. Because it has been more
than mountains of data that will tell you that a person
recovering, in a sense, does so much more quickly when they
have ability to be with loved ones.
I remember Dr. Koop testifying before us as a pediatric
surgeon, just the recovery rates of a child where a parent
could be present. The McDonald houses, just the evidence is
overwhelming. But I wonder if I could get a quick comment on
what your assessment would be of a paid family and medical
leave proposal?
Dr. Mahoney. I would feel ill-equipped to begin to comment
on it. I don't have any experience with that.
I would agree with your comment, though, very much so that
people do heal better and have a quicker recovery if there is a
social environment around them. But I would also add that part
of the issue that we see with medical leave is people having to
care for loved ones who really have a condition that could have
been prevented.
So I think it just re-emphasizes the whole process. If we
focus on the prevention, we are going to see a ripple effect
through many of our programs, whether it is FMLA or disability
or even workers compensation.
Senator Dodd. Any other comments on this, you and Dr.
Thorpe?
Mr. Thorpe. I would just say it is part of a broader
workforce strategy that we need to look at. Most care that is
delivered to people at home or in the community are provided by
informal caregivers. They are under recognized and under
appreciated.
And particularly if you look at the demographics that are
likely to happen over the next 10, 15, 20 years, the demand for
that type of in-home service is going to do nothing but
escalate. So I guess the concern would be do we have the
capacity in the formal care giving setting right now to
actually deal with what is going to happen over the next 15 or
20 years with respect to shifts in the age distribution of the
population?
So it would seem to be a flexible strategy. I think if you
think of it as part of an overall workforce strategy, it makes
some sense.
Senator Dodd. Good.
Dr. Levi.
Mr. Levi. The only other thing that I would add briefly is
certainly if you think about infectious diseases and the lack
of adequate paid sick leave, that can be a real deterrent for
people to stay home, and that can have a dramatic impact on the
workforce. People come to work ill, and they spread infectious
disease. That is a problem with an ordinary flu season, for
example.
But it is a much bigger problem if we face something like a
pandemic influenza, where people will be--if they don't have
healthcare and if they don't have sick leave, they will be
disincentivized from seeking the care and doing sort of the
self-
isolation that is going to be necessary to contain a major
infectious disease outbreak.
Senator Dodd. As the father of a 3-year-old and a 7-year-
old, I am painfully aware about that.
Mr. Levi. You could be in perpetual isolation.
Senator Dodd. I know. I know. Permanent family medical
leave.
[Laughter.]
Let me just mention two other quick things. This Guide for
Clinical Preventive Services is very, very good. But there are
recommendations in here for clinical prevention services. There
are just 10 recommendations for children while there are more
than 50 for adults.
As the author, along with Tom, of several pieces of
legislation designed to ensure that medications and medical
devices have been tested for safety in children, this is
somewhat concerning to me that we have so few recommendations
for children in this.
Again, talking about prevention, obviously we learned--
going back to obesity, we know if you want to really reduce
costs in the long run to the extent we are able to make a
difference in the child's life early on, then obviously the
cost later declines substantially.
Any comments on that at all? Is there a need for more
coordinated Federal work in this area?
Mr. Levi. Well, I think the clinical guide is an incredibly
valuable tool, but I think it has the limitations that you
mentioned. There is a similar effort to have a community guide
for community-based interventions. That is a much smaller-scale
effort, and actually, one of the recommendations we make in our
written testimony is to have a much broader investment in being
able to provide for communities, for health departments, for
clinicians, for health plans much more systematic evidence
about what works, what might be cost effective, both in terms
of community interventions and clinical interventions.
We don't do, particularly on the community side, that kind
of evidence gathering in as robust a way as we might on the
clinical side.
Senator Dodd. Well, I presume there will be updates to this
and, again, coming up this year. I would really strongly
recommend that we put at least as much attention on this area
because I think it goes right to the heart of the prevention
issue with children.
Last, Dr. Mahoney, in your oral testimony, you talked about
how Pitney Bowes has had to change health insurers many times
due to the fact that the company has such a comprehensive view
on what the insurance benefit package should be. I wonder if
you could talk briefly about this, and do you think the company
has had an influence on the private health insurance benefit
design market as a result of the changes that have had to
occur?
Dr. Mahoney. The best way to answer that I think is to give
a little bit of history, and that is we started down this
pathway, as I said in the testimony, we used a standardized
instrument that is called eValu8--little e, big V, and the
number 8. It was developed by the National Business Coalition
on Healthcare.
We participate with 350 other employers in this
standardized assessment of quality metrics from health plans,
and we have made decisions over the years looking at the
quality of the plan, performance in given areas, and
improvement in quality as our benchmark of continuing the
relationship.
I would say that this is a very powerful instrument because
what happens is after the assessment is made, after the health
plan completes the process--and it is an extensive process--
then the health plan gets to meet with the employers who are
involved in the specific business coalition. For example, we
belong to the New York Business Group on Health and also the
Pacific Business Group on Health.
We have an opportunity to meet with the health plan,
articulate where our issues are--not only us, but the other
employers--and set some expectations for improvement. Probably
the best example I can give you is in New York many years ago.
We benchmarked behavioral healthcare services among all of the
health plans, and the performance was not that wonderful. Over
the years, we have seen steady improvement in delivery of
behavioral healthcare services.
So, I think that if you set an expectation, the marketplace
begins to respond to you. And frankly, on an individual basis,
we have had to make the decision that maybe sometimes we could
do better with another health plan.
Senator Dodd. That is great. That is good to know as well.
Mr. Levi. If I could add one point to that----
Senator Dodd. Sure.
Mr. Levi [continuing]. Which is the Federal Government is a
huge purchaser of private health insurance, and the kind of
standards that Dr. Mahoney was talking about and thinking about
a comprehensive wellness approach for Federal employees would
dramatically change the insurance market.
Senator Dodd. Well, I think the fact you do this in a group
setting has to be a dynamic in itself. A one-on-one with that
company, things may slip. But the fact that there are a number
of people sitting around, you take note if you are that
insurer, and that is of value.
Ms. Hibbs, I apologize. I don't have a question, but I want
to thank you and I spent a little time in Iowa in the last year
or so. Enjoyed Marshalltown very much, a nice town to be in.
Ms. Hibbs. Thank you.
Senator Dodd. Thank you for what you are doing with the Y.
They do a great job as well.
Thank you, Mr. Chairman.
Senator Harkin. Thank you, Senator Dodd.
Just a few follow-ups on this. Dr. Mahoney, Pitney Bowes is
27,000 people, big company. And again, you were able to do this
because you had good executive leadership. I understand that.
But I am concerned about all of the small businesses out there.
Businesses that employ 50 people or 25 people, and what they
can do to implement wellness policies.
In many cases, they don't have the wherewithal to implement
big things. When you go to your healthcare plans, and you have
27,000 employees, they listen. If you have 25 or 30 employees,
they say take it or leave it.
I am interested in how we take these kinds of models and
apply them to the small businesses around America, and do you
have any thoughts on that?
Dr. Mahoney. Yes. Actually, subsequent to retiring from
Pitney Bowes, I have worked with a number of regional
healthcare coalitions. And Senator Dodd is right on in the
comments. It is very powerful when a group sits down with a
health plan to negotiate and implement as opposed to
individually.
I would have to say that I have been amazed at the
creativity of small businesses in looking at wellness and
health improvement, and I think it is because they are more
acutely aware both of the direct costs, the hit on their
healthcare premium, but moreover, the indirect cost. Because if
you are a small company of 20 people and you have 2 people out
ill due to a preventable condition, it hits home to the entire
organization.
I have seen great creativity there. I think that the
stumbling block has then been how do you create this
environment? They might not have all of the resources. So I
applaud any of the efforts that can be done on a community
basis.
And just by way of comment, you know I mentioned we have
very small work groups. We have incredibly small work groups in
areas that we can't reach. However, by providing the incentive
through our Healthcare University and then directing them to
community resources, people can participate in those programs.
I think small businesses can make progress there. The
difficult part is changing the health plan environment, if you
will. But there is a way to do that, and that is through the
group action.
Senator Harkin. OK. The other thing is I have seen a lot of
fairly large businesses that have put a wellness center in
their business. They hire a nutritionist or a dietician, plus a
physical exercise person, and they get their people signed up,
and they have wonderful gyms and things like that. They have
all kinds of incentives, are open on the weekends and stuff.
Any time a business does that, that is all tax deductible.
For a big business, that is a tax-deductible expense. Not only
is it tax deductible to the business, it is not a taxable event
to the employee.
However, if a small business employs 50 people or 100
people or 200 people, they can't do that. But if they wanted
to, let us say, purchase a membership in the local Y and have
them go to the Y and enroll in a plan for weight reduction,
smoking cessation, on and on and on, if they do that, that is
not tax deductible for the business. And if they were to do
that, it is a taxable event to the employee. Just again, that
is one of those disincentives that is in our taxing system that
needs to be corrected.
It seems to me that there is a great opportunity in our
communities, as evidenced by what Marshalltown is doing and a
lot of others, where they are utilizing their Ys and others to
reach out to people to get them into these kinds of classes and
smoking cessation, weight reduction/control, diet-related
information.
We have to somehow help our small businesses be able to
access that, and perhaps this is just another thing that we can
do, and that is changing the tax code. But we have to keep the
employees somehow incentivized in this.
I don't know exactly how you do this through your vast
network. I mean you are all over the United States. I don't
know exactly how you do that, but somehow you must keep them
incentivized in this?
Dr. Mahoney. Well, part of the issue, if I may, is keeping
the program fresh and constantly re-inventing the program. The
other is to keep it simple so that people can actually
participate in it.
Our current program is called Count Your Way to Health. And
it is built around simple numbers--0, 1, 5, 25, 30, and 100.
Zero smoking. Floss your teeth once a day. Five fruits and
vegetable a day. Maintain your body mass index at 25. Exercise
for 30 minutes a day. Wear your seatbelts 100 percent of the
time.
Those are all things that you can do without a fitness
facility. You really don't need a nutritionist. It is just
providing both the incentive for people to do it, and we do
that through a self-assessment that people can take. Again,
they get a financial reward. And we also give them access to a
program.
But the key to it was keeping it simple so that if they are
in an area--a rural area or a small town or even a large town--
where we don't have a presence, they can go to a facility and
actually avail themselves of that and report back to us on
their progress.
Senator Harkin. Dr. Thorpe, you mentioned before the North
Carolina community situation. I don't know a lot about that.
Could you help me out? Tell me more about that North Carolina
model in terms of what you called a community care team?
Mr. Thorpe. Right. The community health teams.
Senator Harkin. What is that?
Mr. Thorpe. There are really three States doing this now--
North Carolina, Pennsylvania, and Vermont. What they are, are
teams of community health workers. So they do link people up to
community resources, like working with YMCAs, nurse
practitioners, nutritionists, social and health behavior change
workers. They are basically care coordinators.
Senator Harkin. Who set this up, the State or what?
Mr. Thorpe. The State set this up in North Carolina. It was
originally done through the Medicaid program, recognizing that
it is a different way of doing population health in managed
care.
They work with small physician practices, groups of one and
two and three, that don't: (A), get paid to do the care
coordination and prevention; and (B), don't have the capacity
in their offices to do it. It was a very effective way of
really integrating physician practices with care coordination
and paying for it in a way that was far less expensive than how
we do managed care within the Medicare program, for example.
Their results have been very spectacular. Depending on the
year you want to look at, they saved $100 million, $200 million
in terms of preventable admissions to the hospital, preventable
re-admissions to the hospital.
The concept really integrates population health and
prevention with treatment in the same setting. So it doesn't
break it apart. It does the whole continuum of population
health to prevention to treatment.
I think that several States have seen the value in this. I
was suggesting that the Federal Government could accelerate the
development of those types of programs in the Medicare program,
which our big challenge is what do we do to manage chronic
disease for the 80 percent of the population in Medicare that
we are really not doing a very good job of managing right now?
That would be one approach that we could do very quickly by
working with the States to have them set these community care
teams up to work with smaller physician practices to do
prevention and treatment of Medicare patients, Medicaid. I
would presume that a lot of self-funded, self-insured companies
would be very interested in participating in that type of model
as well.
In the North Carolina example, it started with Medicaid,
but the private sector is now starting to participate in it as
well because they see it as a more effective way of preventing
and managing disease than the way that they have been doing it
in the past.
Ms. Hibbs. May I add something to that?
Senator Harkin. Sure, Carol.
Ms. Hibbs. You talked about incentivizing workers. Well, in
the Pioneering Healthier Communities initiative, we have looked
at a lot of ways to do that. We look at build environment in
our community. We look at policies that keep people from doing
things.
But we also have an internal program through the Activate
America Program that focuses on the health seeker population.
And what that tells us is that the majority of the population
need a supportive environment to make the changes and to stay
incentivized. And so, the Y is working on creating that
supportive environment so that people can make the changes that
are very difficult for most of the population to make.
Senator Harkin. What are some of the biggest obstacles that
you had in Marshalltown? I mean, you had to work with the city
council and city manager and all that kind of thing and the
school districts.
In trying to do what you did in Marshalltown, what are some
of the barriers or some of the things that we might be able to
look at if we are going to do a stimulus bill? Maybe I would
even further enlarge the question to say what would you want,
what would you like to see in that stimulus bill that would
lend itself to Healthier Communities?
Ms. Hibbs. Well, one of the things that has been successful
for us is we have engaged decisionmakers from all sectors of
our community, from business, economic development, public
health, and city government, as you mentioned. The barriers for
our citizens are, who is going to pay for it?
We need more than $1 million in sidewalks. That is what our
sidewalk task force says. Now we cannot pay for $1 million in
sidewalks right now. So how do we get the resources to make
sure that areas of our communities, especially those near
schools, have sidewalks. That is a big barrier for us.
Also, we are trying to make our bike and walking trails
connect throughout the community. And to do that, we are also
seeking out other resources.
Senator Harkin. I am going to think about this in that
stimulus bill in terms of getting money directly to communities
for things like this. We ought to really seriously think about
this.
Ms. Hibbs. Well, it may even be as simple as making sure
that our crosswalks and our intersections have the countdown
timers and the crosswalk markings that children need to cross a
busy street safely to get to school.
Senator Dodd. One of the things we could do--and just last
spring and summer, and Senator Harkin was tremendously helpful,
we tried to pass a housing bill to make a difference on
litigation on foreclosure--we wrote a community development
block grant of almost $5 billion targeted to dealing with
foreclosure. To buy foreclosed properties, to be able to
maintain them, to put them back on the market so you would have
property taxes coming back in. It was a local initiative that
has been very, very important to local communities to be able
to do that.
I think by talking about a community development block
grant, where money goes directly to communities, where you are
targeting it for health prevention and so allowing communities
then, whether it is in Marshalltown for sidewalks or someplace
else, for something else. But giving some latitude.
I have found, we have done this with fire grants, local
people do a pretty good job. We have given out 30,000 grants to
fire departments across the country. I hesitate to say this
because it will probably change tomorrow. We have yet to have a
single case where people have pointed up to fraud or waste in
these things. They are pretty good and careful about it.
Now, as I said, I will probably hear a story tomorrow of
something to the contrary, but it works. I think if you defined
it in some way so it gives you the latitude to address these
questions without trying to pinpoint it in a way that makes it
difficult for some community that has a different need or sees
a way for it to make a significant contribution to exactly what
you are talking about, we ought to be able to find a part of
that money, that stimulus, for these kind of public works
projects that will put people to work and address specifically,
prevention areas.
So that worked with the housing----
Ms. Hibbs. Well, one of the nice things about the
Pioneering Healthier Communities model is that it involves all
sectors of the community, and so it allows the community then
to decide what they need and what works best for them.
Mr. Levi. But I think one other thing to point out here is
that here are communities across the country that have plans on
the shelf. It is not just the highway builders who have plans
on the shelf that could be implemented immediately. There are--
it is Pioneering Healthier Communities. There are other CDC
programs, California Endowment and the Robert Wood Johnson
Foundation have supported these kinds of planning efforts as
well.
So there are communities across the country who have the
plans, know what is needed, and, if the resources came, could
begin to implement them immediately.
Senator Harkin. Well, we ought to look at that. We ought to
really work on that because that thing is going to be coming
down in January.
I don't mean to prolong this, but again, thinking about
incentives. All of the incentives in our health system are on
patching, fixing, and mending. Let us be honest about that.
That is where the incentives are. We have to move these
incentives forward.
Now, fortunately, we have some good companies out there
doing things. But incentives. I am thinking of a company in Des
Moines that a long time ago, back in the 1980s--Townsend
Engineering. Ray Townsend had had a heart attack and decided to
quit smoking. Then he noticed all the people working for him
smoking, and he decided to implement a big wellness policy.
This was back in the 1980s. I was very intrigued by that at
the time. And in the 1990s, when I first became aware of it, it
was a manufacturing plant, employs maybe 300 people, 200 and
some people. But the incentives he put in there were
tremendous.
Not only did he build a wellness center for his employees,
he signed them up in comprehensive wellness programs. He hired
a full-time nutritionist and a physical exercise person. Then
he gave incentives to his employees that if you sign up and do
these things, you get certain things. Like if you do this and
this, you will get a day off, an extra day off, for example.
The biggest one, I remember, is that he went on a smoking
crusade. Now I could be off on this. I have to check my records
on this. But it was like if you quit smoking for 6 months, you
got a certain thing. If you quit smoking for a year, you got
something.
I think it was if you could show that you went either a
year or 18 months or 2 years, something like that, without
smoking, he gave you, for you and your spouse, a paid round
trip ticket to Hawaii in the middle of the Iowa winter. That is
a big incentive.
[Laughter.]
Ms. Hibbs. That is a big incentive.
Senator Harkin. And two things on that. I asked him, I
said, ``How could you do that? '' And he said, ``Well, you
understand I own the business. I don't have to answer to a
board of directors. So I can do this on my own. I don't have to
answer to the board on the bottom line. My bottom line may not
have looked that good that year, but I knew it was going to be
better the next year.''
And second, I said what has been the outcome of this? And
the outcome was that in this plant--I will tell you, I have
visited since. No one ever leaves work. They love these jobs.
His productivity has shot through the roof. He just has a very
healthy workforce and his productivity is great, like I said,
is great.
He was concerned because his healthcare costs, his plans
that he was able to get, the health plans didn't really reward
him that much. But he could show the bottom line in terms of
how much money his company was making and no absenteeism. No
one was taking time off because they were sick.
He worked two shifts, and he said it used to be that 15
minutes or 20 minutes before the shift change you really didn't
get any work out of anybody because they were sort of heading
out the door. He said now people stay, and they clean up their
equipment and they take care of things. He said it was just an
amazing transformation of the workforce in his plant. So,
again, thinking about incentives.
Now, again, he received not one tax break for this. Why
shouldn't he? Why shouldn't a small business or someone that
does something like this, why shouldn't this be some kind of a
tax credit or a tax deduction or something for them--if they
can show these kinds of things, why shouldn't they get these
incentives?
So I keep thinking about how we incentivize this--workplace
incentives, community incentives, things like that. How do we
build in extra bonuses for communities? If they do things like
that, would their community development block grant be a little
bit more? Or something that would entice people to get
involved--yes?
Ms. Hibbs. May I add a comment? Incentivizing workers to
reimburse them for physical activity and good nutrition
programs participation is a great idea for companies, and we
actually work with a company in Marshalltown--Fisher Controls,
part of Emerson. They do that in their wellness program. They
have incentives for their employees, and we help them track
that.
That is a great way to do it. There are other programs that
are possible and being done at Ys around the country that also
can help increase physical activity and improve nutrition and
reverse the effects of pre-diabetes.
There is a great model in Indiana for that, and they have
reduced the cost from the original study that was done, which
was $1,400 a person, down to $275 a person.
Senator Harkin. Say that again, Carol. What? I heard about
this Indiana thing, but what is it now?
Ms. Hibbs. Well, there is a Y in Indiana that replicated a
study done by the NIH. The NIH study showed that people with
pre-diabetes conditions, if they were on a program of increased
physical activity and improved nutrition that they could
reverse the pre-diabetes conditions. It figured out to cost
about $1,400 a person.
Now those same people came to the Y in Indiana and
replicated that study with the health and wellness staff of the
Y, and they did it for about $275 a person.
Senator Harkin. Amazing. The Ys around this country are now
playing and are going to play a much bigger role in this. I am
just so thankful for what the Ys are doing right now.
Mr. Levi. If I could add just one thought or two thoughts,
actually? One is, part of what this program was about is that
very small changes can result in very big savings and big
changes in healthcare and health outcomes. And so, we need to
be clear about those kinds of goals.
I think the second part, and I would defer to Dr. Thorpe to
actually confirm this assumption, but I think we do see some
data showing that there is a Federal benefit to these kinds of
workforce wellness programs and having our population get as
healthy as it can be. So that when it enters Medicare, it is
healthier.
If we have fewer people entering the Medicare system with
chronic diseases, then the Medicare costs are going to be
lower. And we have to start thinking about who benefits from
these prevention programs. That is one of the things that our
report looked at, which was Medicare benefits, Medicaid
benefits, private insurers benefit. How can we make sure that
those who are benefiting from these prevention programs
actually contribute to that investment?
One way of thinking about that is, for example, the
Medicare program to be targeting the pre-Medicare population,
55 to 64, and doing work with them and community prevention
efforts that are relatively inexpensive so that when they enter
the Medicare program, they are as healthy as possible.
Senator Dodd. Yes, that idea of going back to the notion of
the physical exam as a precondition of getting Medicare 5 years
before would be--what you could discover and change habits 5
years out in terms of the cost of that person at age 65 is
phenomenal.
Senator Harkin. You said, Doctor, I wrote it down, 95
percent of Medicare is for chronic illnesses?
Mr. Thorpe. Right, and I think to follow up, one of the
reasons I was suggesting to look seriously even as part of a
stimulus package of a universal wellness plan for the uninsured
right now is that anything we can do to change the incoming
health trajectory of people into Medicare is going to save
money long-term.
I mean, the statistic that I threw out was that if you look
at lifetime spending of a person at age 65 who is normal
weight, no chronic disease, versus that same person who is
obese that has one or more chronic conditions, it is 15 to 40
percent less over their lifetime Medicare spent on healthcare.
Senator Dodd. What is the number on chronic illness, the
number that I have used over the years? Every time I have said
it, I wait for someone to jump up and tell me I am just wrong.
But the amount of Medicare money that is spent in the last 20
days of a person's life for intensive care, for instance?
Mr. Thorpe. Well, the data we have--the best data we have
is really more on the last year of life, when we spend about 28
percent of spending is on the last year of life. And I think
the challenge there, too, is that the variation in spending in
terms of how much we spend in the last 6 months and year of
life is really dramatic.
So the whole area of palliative care models and really
looking at some of those models and what accounts for some of
the variation and getting into issues of informed consent is
another area that would be fruitful to look at.
Senator Dodd. I apologize. I didn't mean to interrupt. You
were asking a question?
Senator Harkin. No, no. Go ahead.
Senator Dodd. I have to ask Dr. Mahoney one question. I
can't resist. I love the numbers that you have and keeping it
simple. And also nothing succeeds like success, giving people
things they can actually do.
If you come up with too long a list, then you don't do
anything. It is like too many warnings on a label on something.
It is just so dizzying you don't pay any attention to it.
Flossing. Are you drawing a conclusion about flossing that
it is dental care, or do you correlate the relationship between
plaque and heart conditions?
Dr. Mahoney. It is the latter, the plaque and heart
conditions. And frankly, given some of our covered population,
just plain dental care, just putting the focus on it.
If I could comment just a little bit? We don't, obviously,
have a large population into retiree medical, but we have a
reasonable population. What we are seeing is very interesting.
The investment that we have made in the active population while
people are actively employed at the company is carrying over
into the pre-65 retiree group and also into the post-65.
So we don't have as robust a mechanism to benchmark this,
but we know that our costs per retiree are lower in that group.
We can only think that that has to be a carryover from the
habits that we were able to change earlier, especially in
management of the chronic conditions.
Senator Harkin. Anything else that anybody wants to proffer
here before we call it to a close?
Senator Dodd. Could we leave the record open?
Senator Harkin. Yes, I said that for 10 days.
Senator Dodd. Oh, good. Good.
Senator Harkin. I left the record open for 10 days.
Anybody else?
Mr. Thorpe. I would just end up by saying on the leadership
side that the leadership in terms of prevention innovation
really is coming from the business community because they see
the results directly in their businesses. And I think that we
could help them by really looking at some leadership in the
Medicare program as well, or even the Federal employees program
on two fronts.
One is that, as it is currently designed, we really
discourage prevention in Medicare. If we have a welcome to
Medicare physical, we charge you for it.
If you really are looking at incentives to have a clinical
preventive package in Medicare, well, let us put it out there
the same way the business sector has done in terms of let us
make it so that you don't discourage people from availing
themselves of clinical preventive services. I think that that
is one issue.
The second issue is that Medicare has to think earlier on.
By the time people come into Medicare, it is almost too late. I
think to the extent that we are reaching out earlier with
focusing on primary prevention and getting people into the
system faster in terms of health risk appraisals and physicals
and treating them, if they have diagnosed disease, get them
treatment right now.
We have a model that does that in the breast and cervical
cancer world. This would expand that to other chronic diseases.
I think if we treat them earlier, we diagnose earlier, we are
going to get better outcomes at lower cost.
The final point I would raise is on the 95 percent figure,
the long-term future of the Medicare program really is going to
depend on our ability to prevent the explosion of chronic
disease coming into the program. If you reach out earlier you
can do that, but also how do you manage chronic disease in the
program today? And the Medicare program, as it is currently
constructed, is ill-equipped to do it.
So that is going back to your question about the community
health teams in North Carolina, that model of building the
capacity to really manage patients at home. Do the prevention,
track them in and out of the hospital, to work collaboratively
with the primary care physician practices to prevent things
that should never happen--the admission into the hospital for a
diabetic patient, the readmission into the hospital for
somebody with pulmonary disease. I mean, MedPAC alone has
commented that at least $20 billion or so in savings could be
had if we were managing these patients with chronic illnesses
more effectively.
I think that those are three areas that would all be
fruitful perhaps as part of a stimulus package, but certainly
as a centerpiece of the healthcare reform debate. I just think
that they are common sense things to do.
Senator Dodd. Yes. My last comment as many of you may know,
I know Tom knows, I have been deeply involved over the last
several days in this automobile issue in deciding whether or
not we are going to be able to restructure these three
automobile companies in a way that they can survive. And
obviously, it has just consumed a tremendous amount of time
over the last 2 weeks of trying to fashion some way to get
there between now and then.
Obviously, a lot of what is going on in the financial
community today and so forth is affecting all of this, and
clearly decisions made by the industry itself have brought us
to this point as well. There are a lot of factors. But one of
them is this issue we are talking about, healthcare.
You look at the cost of a foreign-produced automobile. The
healthcare cost per automobile is a fraction of what it is
here. I think it is roughly $2,000 per automobile as a
healthcare cost in that car, something like that. Very close to
that number. I think it is $150 or $200 per car, for a Toyota,
someone told me the other day.
These issues, your point, Dr. Thorpe, made me think of it
here that, obviously, from a business standpoint, I don't
recall back in 1993, by the way, the automobile industry
running up around here talking about universal healthcare and
reducing the costs. In fact, quite the opposite.
At a time when we might have been able to do something
years ago on this issue, there was quite the opposite view.
That has dramatically changed, obviously, I think, and we are
seeing that in contracts and so forth.
But it is one of the factors that we have to grapple with
in all of this, and this is a classic example right now. Not
the only cause of all of this or the problem, but it is a major
piece of it as well. So it is a very worthwhile point.
Thank you.
Senator Harkin. Thank you, Senator Dodd.
Thank you all very much.
This has been an enlightening last couple of hours, and you
are all recognized leaders in this field of prevention and
wellness, and I encourage you to continue to give us the
benefit of your insight and your suggestions as we move ahead.
I just said, Jenelle, get Dr. Thorpe's three things for me
because I want those. Did you say the same thing?
[Laughter.]
Because we have to move on this. We are going to be really
talking about this very soon.
We progress on this, we will be having obviously more
hearings involving more parts of our society in this process. I
just invite you to continue to follow this--I know you will--
and give us your insight, your suggestions, and advice as we
move along.
I would just close up by saying, I will just end it where I
started. If we don't, I said at the beginning, Chris, I said I
will lay down a marker in this whole healthcare reform debate.
And it is this.
If all we do is address how we pay the bills, but we don't
make prevention and wellness the centerpiece of our reform
movement, then we will have failed, because we will just keep
paying more bills. We will rearrange how we pay it perhaps, but
we will just keep paying more bills.
Somehow we have to just quit making prevention kind of a
footnote as a feel-good kind of thing. Oh, everybody likes to
talk about it, but it is too hard to do. It is kind of soft. It
is not hard. The payback period is 20 or 30 years. Trust for
America's Health just showed that the payback period is a lot
sooner than that, and I appreciate that. So somehow we have to
make this work.
Senator Dodd. Senator Coburn, before he left, I think made
a point in, again, predicting where this would all end up. But
if you look at the various areas and where are the flashpoints,
this isn't one of them.
There will be flashpoints, and we know where they are. But
this is one where you hear people who have argued for years
about what ought to be done in healthcare don't argue about
this.
We have a wonderful opportunity to begin on something where
there is a lot, I think, of commonality of purpose and
interest, and I am very, very hopeful that would be a major,
major part, as it should be, if we are really going to address
the long-term need.
And so, I welcome Senator Coburn's comments as saying this
was an area where he really looked for a tremendous amount of
cooperation as well.
Senator Harkin. Well, thank you very much, Senator Dodd.
Thank you all for being here.
[Additional material follows.]
ADDITIONAL MATERIAL
Prepared Statement of Senator Enzi
Thank you for holding this hearing and providing us with an
opportunity to discuss a vital aspect of our work on healthcare
reform--prevention. The information we will receive today from
our witnesses will provide us with a much needed perspective on
that matter that will help us to incorporate this important
component in our health care system in a much more effective
manner.
We are fortunate to have a panel at this hearing that is
made up of individuals and representatives of organizations
with a great deal of practical experience in this area. I am
looking forward to their insights and observations on how we
can more innovatively and creatively integrate successful
prevention interventions. They will have a great deal to say, I
am certain, about how to craft the message of prevention so
that it receives the attention and focus of all Americans in
their day to day lives.
We all know that any successful reform effort must focus on
reducing health care costs to make the system work more
efficiently and effectively. If providing the best care at the
best price is our goal, we will need to make prevention a key
component of any reform measure. There is no question that the
high cost of health care is directly related to the increased
incidence of chronic diseases. The more we direct our efforts
to preventing the onset of these diseases, the less we will
need to spend on treating them in their advanced stages.
Unfortunately, we are still not doing a good job of
educating Americans on how they can prevent the onset of
chronic illnesses. Instead, we have directed our efforts at
treating these diseases after they have already developed.
The statistics are alarming and we ought to be more
concerned. Chronic diseases like heart disease, diabetes and
cancer currently account for 1.7 million deaths in the United
States each year. Although these and other chronic diseases are
among the most common, costly and deadly, current medical data
makes it clear that they are also the most preventable, mostly
by making lifestyle changes that are really just common sense.
With a little willpower, these changes can be put into practice
and the results that can be achieved would have a great impact
on our personal health as well as on our health care system as
a whole.
If Americans would make primary prevention interventions a
part of their daily lives, our healthcare system would, over
time, change dramatically. Primary prevention includes regular
exercise, eating balanced and nutritious meals and eliminating
risky behaviors, like quitting smoking. With all of the
information out there about how successful these primary
prevention interventions would be if they were put into
practice, it is a great disappointment to see how few Americans
have taken advantage of the information many of them are well
aware of and made these changes a part of their daily routine.
Americans also need to be better informed and made more
aware of the price and quality of the healthcare services they
receive. If people had better access to comparative information
on prices and quality, they would take more control over their
health and make the kind of choices that would improve the
quality of their lives.
Secondary prevention interventions are another important
component we must improve if we are to make the system better
as a whole. Having regular check-ups and frequent contact and
interaction with a primary care physician will make patients
more aware of their health risks. It is also important for
patients to get the appropriate screenings for diseases that
can be prevented if detected in their early stages. Cancer is
an example of a disease that can be controlled or cured with
regular screenings. Early detection leads to a 98 percent
survival rate for breast cancer and a 92 percent survival rate
for cervical cancer.
In my Ten Steps to Transform Health Care in America
legislation, prevention is number six on my list, but when it
comes to those things we can all do as individuals to improve
our own health, prevention ranks right up at the top. In my
proposal I emphasize the importance of preventive benefits and
the need to provide assistance to individuals with chronic
diseases so they can better manage their treatment and care. I
believe that any plan purchased with a tax subsidy must include
basic preventive services and a medical self-management
component. This is critically important if we are to prevent
disease, and not just treat its symptoms after it has already
begun to take its toll.
Prevention works and it is time for all Americans to make
it a priority. I have no doubt they will do so if we ensure
they have the information they will need to continue to make
the changes that will make their lives happier and healthier--
and longer. The more we are able to increase the awareness of
prevention programs and the role they must play in our
healthcare reform effort, the better we will be able to
encourage all Americans to take better control of their lives
and promote the behaviors that will lead to better health. It
is time to change our healthcare system from one that is
centered on sick care to one that is more directed toward
preventing illnesses and promoting health which will ultimately
make it possible for us to reduce costs and increase
availability.
I want to thank the witnesses again for their time, their
knowledge and their willingness to join us for this important
discussion. Their expertise will prove to be very useful as
Congress continues to consider the reform of our health care
system.
Prepared Statement of Senator Hatch
I thank our expert panel for being here today as we examine
the benefits of prevention and health promotion. It has been
estimated that the United States spends annually $2 trillion on
its health care system. As we in Congress engage the topic of
health care reform, the financing of health insurance coverage
and access to care will likely be at the top of debate. It is
easy to understand that if people are healthier, health care
costs are less to both the individual and the system as a
whole. Preventive health services reduce hospital stays,
emergency room visits, and long term disability. Simply put,
disease is expensive; and prevention can save people's lives
and money.
According to the Center for Disease Control's (CDC's)
National Center for Chronic Disease Prevention and Health
Promotion (NCCDPHP), chronic diseases like diabetes, cancer,
and heart disease are the leading causes of death and
disability in this country. Accounting for 70 percent of all
deaths in the United States, chronic diseases are among the
most common and costly health problems. They are also among the
most preventable. Better nutrition, being physically active,
avoiding tobacco and alcohol use, and other healthy practices
can prevent or control the destructive effects of these and
other diseases. Yet it has been estimated that less than half
of the most effective preventive services are being delivered
to the people they could help.
Delivering preventive services that are proven to be
effective is essential to improving America's health, and
linking clinical and community preventive services should be
explored as part of the health care reform debate. Clinical
preventive services provided by a healthcare professional, such
as counseling, screening, and immunizations, have helped to
improve the health and lives of millions of Americans; however,
the community components of health promotion should not go
overlooked. We will get a greater return on our investment if
we do not limit focus to the traditional healthcare arena. Many
of the most significant advances in health are the result of
policies aimed at health risks that are not typically addressed
in traditional healthcare settings--such as food safety and
restaurant inspections, clean water and air, speed limits and
seat belt use, fire prevention and building standards, and so
on.
We must also examine other methods of prevention, such as
workplace wellness programs. Employer-sponsored wellness
programs are a good idea because everyone benefits. Healthy
employees are more productive; and healthier people also reduce
the burden on the health care system as a whole. Employers
benefit from lower plan costs and higher productivity. Studies
have shown that health care costs for workers who participate
in wellness programs run below costs for nonparticipating
employees, and that consumer-directed health plans can lower
annual claims-cost increases.
Throughout my Senate career, I have been a strong proponent
for preventive health measures and have helped to create many
of the Federal prevention programs and initiatives that have
been successful in helping States and local communities to
implement prevention and wellness programs. The benefits of
prevention are significant, and spending more on treatment
alone will not bring about the substantial improvements in that
health we seek. We must evaluate the whole picture. Once again,
I thank our panel witnesses for joining us here today to share
their expert testimony as we consider the important role of
prevention and health promotion in health care reform and how
preventive services and programs can save lives, money, and
make people healthier.
Question of Senator Clinton for Jeffrey Levi
Question. In your testimony, you mention the critical importance of
investment in community and clinical prevention, as well as stable and
reliable funding for public health programs. Can you please discuss the
ways in which the establishment of a Wellness Trust within the Centers
for Disease Control and Prevention would help to meet these goals?
[Editor's Note: The response was not available at time of print.]
The committee will stand adjourned subject to the call of
the Chair.
Thank you all very much.