[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 

=======================================================================

                                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


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                                 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

                              ----------                              


                      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/.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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/.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.

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