[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]





                 HEARING TO EXAMINE NEW AND INNOVATIVE
            WAYS TO IMPROVE NUTRITION AND WELLNESS PROGRAMS

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

                                HEARING

                               BEFORE THE

                 SUBCOMMITTEE ON DEPARTMENT OPERATIONS,
                   OVERSIGHT, NUTRITION, AND FORESTRY

                                 OF THE

                        COMMITTEE ON AGRICULTURE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                      AUGUST 5, 2009, LINCOLN, NE

                               __________

                           Serial No. 111-28


          Printed for the use of the Committee on Agriculture
                         agriculture.house.gov



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                        COMMITTEE ON AGRICULTURE

                COLLIN C. PETERSON, Minnesota, Chairman

TIM HOLDEN, Pennsylvania,            FRANK D. LUCAS, Oklahoma, 
    Vice Chairman                    Ranking Minority Member
MIKE McINTYRE, North Carolina        BOB GOODLATTE, Virginia
LEONARD L. BOSWELL, Iowa             JERRY MORAN, Kansas
JOE BACA, California                 TIMOTHY V. JOHNSON, Illinois
DENNIS A. CARDOZA, California        SAM GRAVES, Missouri
DAVID SCOTT, Georgia                 MIKE ROGERS, Alabama
JIM MARSHALL, Georgia                STEVE KING, Iowa
STEPHANIE HERSETH SANDLIN, South     RANDY NEUGEBAUER, Texas
Dakota                               K. MICHAEL CONAWAY, Texas
HENRY CUELLAR, Texas                 JEFF FORTENBERRY, Nebraska
JIM COSTA, California                JEAN SCHMIDT, Ohio
BRAD ELLSWORTH, Indiana              ADRIAN SMITH, Nebraska
TIMOTHY J. WALZ, Minnesota           ROBERT E. LATTA, Ohio
STEVE KAGEN, Wisconsin               DAVID P. ROE, Tennessee
KURT SCHRADER, Oregon                BLAINE LUETKEMEYER, Missouri
DEBORAH L. HALVORSON, Illinois       GLENN THOMPSON, Pennsylvania
KATHLEEN A. DAHLKEMPER,              BILL CASSIDY, Louisiana
Pennsylvania                         CYNTHIA M. LUMMIS, Wyoming
ERIC J.J. MASSA, New York
BOBBY BRIGHT, Alabama
BETSY MARKEY, Colorado
FRANK KRATOVIL, Jr., Maryland
MARK H. SCHAUER, Michigan
LARRY KISSELL, North Carolina
JOHN A. BOCCIERI, Ohio
SCOTT MURPHY, New York
EARL POMEROY, North Dakota
TRAVIS W. CHILDERS, Mississippi
WALT MINNICK, Idaho

                                 ______

                           Professional Staff

                    Robert L. Larew, Chief of Staff

                     Andrew W. Baker, Chief Counsel

                 April Slayton, Communications Director

                 Nicole Scott, Minority Staff Director

   Subcommittee on Department Operations, Oversight, Nutrition, and 
                                Forestry

                     JOE BACA, California, Chairman

HENRY CUELLAR, Texas                 JEFF FORTENBERRY, Nebraska, 
STEVE KAGEN, Wisconsin               Ranking Minority Member
KURT SCHRADER, Oregon                STEVE KING, Iowa
KATHLEEN A. DAHLKEMPER,              JEAN SCHMIDT, Ohio
Pennsylvania                         CYNTHIA M. LUMMIS, Wyoming
TRAVIS W. CHILDERS, Mississippi

               Lisa Shelton, Subcommittee Staff Director

                                  (ii)
                             C O N T E N T S

                              ----------                              
                                                                   Page
Baca, Hon. Joe, a Representative in Congress from California, 
  opening statement..............................................     1
    Prepared statement...........................................     3
Fortenberry, Hon. Jeff a Representative in Congress from 
  Nebraska, opening statement....................................     4

                               Witnesses

Sitorius, M.D., Michael A., Waldbaum Professor of Family 
  Practice, Professor and Chair, Department of Family Medicine, 
  University of Nebraska Medical Center, Omaha, NE...............     7
    Prepared statement...........................................    10
Yaroch, Ph.D., Amy L., Executive Director, Center for Human 
  Nutrition, Omaha, NE...........................................    14
    Prepared statement...........................................    16
Russel, Kimberly A., President and CEO, BryanLGH Health System, 
  Lincoln, NE....................................................    18
    Prepared statement...........................................    20
Edwards, M.B.A., M.S., R.D., Pamela J., Assistant Director, 
  Dining Services, University of Nebraska-Lincoln; President-
  Elect, Nebraska Dietetic Association, Lincoln, NE..............    21
    Prepared statement...........................................    23
Sensor, Wayne, President and CEO, Alegent Health, Omaha, NE......    36
    Prepared statement...........................................    38
Williamson, M.D., M.S., Blake J., Vice President and Senior 
  Medical Director, Blue Cross and Blue Shield of Kansas City, 
  Kansas City, MO................................................    39
    Prepared statement...........................................    41
    Supplemental material........................................    77
Lommel, Marsha, President and CEO, Madonna Rehabilitation 
  Hospital, Lincoln, NE..........................................    43
    Prepared statement...........................................    44
    Supplemental material........................................    90
Fosdick, F.A.C.H.E., Glenn A., President and CEO, Nebraska 
  Medical Center, Omaha, NE......................................    47
    Prepared statement...........................................    51
Heinen, M.P.P., LuAnn, Vice President, National Business Group on 
  Health; Director, Institute on the Costs and Health Effects of 
  Obesity, Washington, D.C.......................................    56
    Prepared statement...........................................    60

                           Submitted Material

Janda, Dr. David, submitted material.............................    75

 
    HEARING TO EXAMINE NEW AND INNOVATIVE WAYS TO IMPROVE NUTRITION
                         AND WELLNESS PROGRAMS

                              ----------                              


                       WEDNESDAY, AUGUST 5, 2009

                  House of Representatives,
             Subcommittee on Department Operations,
                Oversight, Nutrition, and Forestry,
                                   Committee on Agriculture
                                                       Lincoln, NE.
    The Subcommittee met, pursuant to call, at 10:00 a.m., at 
the Madonna ProActive Gymnasium, 7111 Stephanie Lane, Lincoln, 
Nebraska, Hon. Joe Baca [Chairman of the Subcommittee] 
presiding.
    Members present: Representatives Baca and Fortenberry.
    Staff present: Jamie W. Mitchell

    OPENING STATEMENT OF HON. JOE BACA, A REPRESENTATIVE IN 
                    CONGRESS FROM CALIFORNIA

    The Chairman. I'd like to call the hearing of the 
Subcommittee on Department Operations, Oversight, Nutrition, 
and Forestry together to order to examine new and innovative 
ways to improve nutrition and wellness programs.
    I'll begin my opening statements. I'll first introduce 
myself, and then I'll defer to Jeff Fortenberry, Congressman.
    I'm Congressman Joe Baca, Chairman of the Subcommittee, and 
I'd like to welcome each and every one of you to this hearing 
on improving nutrition and wellness. This is not about the 
health bill. I just wanted to remind everyone in the audience 
of that. I'm pleased to be here with my friend and colleague, 
Jeff Fortenberry, to learn about some of the innovative ways 
communities and businesses are working to improve the nutrition 
and health of Americans.
    I'd like to thank Mr. Fortenberry and his staff, who've 
done a tremendous job putting together an impressive list of 
witnesses with experience in ways to promote healthy lifestyles 
and prevent lifelong disease, and I really want to say to 
Congressman Fortenberry, thank you for bringing Washington, 
D.C., to Lincoln, Nebraska. We believe that this is making 
history, because I don't believe we've had a hearing right here 
in Lincoln, Nebraska, so I want to thank you for being a part 
in respecting concerns for Nebraska and the citizens of this 
area in saying that it's time that Washington came to Lincoln, 
Nebraska, instead of Washington--instead of Lincoln, Nebraska, 
going to Washington, so we're now here.
    This is a topic of great interest to me, as a legislator, 
of course, but also as a husband, father, grandfather, and 
community member. I'm quite active and care a lot about this 
particular subject as an individual that believes that we can 
increase the quality of life through wellness and nutrition and 
appropriate diet, and, of course, I see the gym and the 
activities that you have here. And back in Washington, D.C., I 
do a lot of bipartisan exercise; and we play a lot of 
basketball.
    We play basketball and we play golf. I think it's good for 
a lot of us. Any form of activity is good in terms of wellness, 
and then, of course, fresh fruits and vegetables and eating 
right is important to a lot of us. In my district, I come from 
the San Bernardino area. It's similar to Lincoln in terms of 
size, but we also have something else in common, and that's in 
terms of health and welfare of our communities.
    I'd like to state some of the statistics that point out how 
much we have in common between Lincoln, Nebraska, and San 
Bernardino. According to the Census Bureau, the rate of 
diabetes in Lincoln County and San Bernardino County are not 
too far apart. We're basically about the same. Diabetes impacts 
a lot of us when we look at diabetes and obesity and its impact 
on our nation and our country and especially the cost factors 
that we'll hear about from some of the witnesses here.
    Over the last 4 years, this Subcommittee and the House 
Agriculture Committee, as a whole, has built a record that 
links the importance of nutrition and health, and I think we 
can look at nutrition and health and how it's tied together. In 
the 2008 Farm Bill, we provided a record level of funding for 
nutrition and for safety net programs like SNAP versus the old 
food stamps.
    We also included a provision to make sure good nutrition is 
available to all 50 states in the schools. Before the bills 
passage, the SNACK program was only available in 14 states. 
It's important we have good nutritional programs in our schools 
because a healthy body in school also leads to productivity in 
terms of learning, the ability to progress, and the attitudes 
and behavior within the classroom as well.
    I wanted to stress that we included in the farm bill 
healthy eating by funding pilot programs that encourage the 
consumption of more fruits and vegetables, especially in 
America's schools.
    Last year in July this Subcommittee heard testimony on the 
economic costs of poor nutrition in the United States.
    Researchers detailed that hunger costs our country $90 
billion per year in lost work productivity, the need for 
special education, and other factors. Also testimony from 
California Advocates demonstrated how a lack of participation 
in Federal nutrition programs means lost revenues to 
California, and that probably applies right here in Nebraska, 
as well. Whether it's a senior, disabled or youth, we should 
take advantage of Federal dollars that come back to the state, 
the counties, and the cities.
    That revenue then can be utilized in nutritional programs 
that are available, especially for a lot of our veterans, 
disabled and other individuals like seniors. That's money we're 
all losing because we're not using it, yet it's available from 
the Federal Government. We need to take advantage of these 
programs to help stimulate and get over the negative stigma of 
being on food stamps for nutrition, and I'm an example. I was 
on food stamps.
    But it's about a healthy body, it's about nutrition, it's 
about wellness, and it's about living longer. It's important we 
look at these other programs, and I'm sure that Congressman 
Fortenberry and others realize it's important in the State of 
Nebraska to help individuals that need food during this time of 
a slow economy.
    In March of this year, the Subcommittee took on the topic 
of obesity. We had a hearing in Washington, D.C., on obesity 
and, the cost to the nation. Roughly $75 billion is spent on 
obesity each year, so that's a direct correlation when we look 
at, obesity what it means to us. With indirect costs, it goes 
as high as $173 billion per year.
    You can imagine using that money for other programs, and 
what it could mean to us, as taxpayers, and within our 
communities. That's why I really appreciate what Congressman 
Fortenberry is doing now in bringing this kind of awareness to 
Nebraska.
    And I'm encouraged when I look back here to my left and I 
see the gym out here and the people exercising.
    What you're doing here is very positive. It's estimated 
that the cost of obesity and being overweight could range from 
$860 billion to $956 billion by the year 2030, so when you look 
at those figures, that's a high cost. Who's going to pay? We, 
the taxpayers, are going to pay if we don't do something in 
that area.
    The average American today is 23 pounds overweight. This 
burden is a major factor in the skyrocketing health costs. I 
indicated that research that's been done in that area tells us 
what it costs on a daily basis. This accounts for about ten 
percent of all the health spending in America and is more than 
double the amount spent on obesity-related issues over a decade 
ago. Make no mistake: we must find real solutions to the 
obesity epidemic if we are to protect the economic and physical 
health of the American people, and this is what this hearing is 
about here today, Washington, D.C. is making history in 
Lincoln, Nebraska.
    With that I'm excited to be here with a friend. I know he's 
a strong advocate. He's legitimate. I know he practices what he 
preaches. It's important that we're practicing the practices we 
are preaching, and Congressman Fortenberry is practicing what 
he is preaching, because he is physically active working out in 
the gym every day. He knows what it means to him and what it 
means to the citizens of Nebraska and Lincoln and the district 
he represents.
    With that I want to thank you for being here and the 
witnesses who have agreed to be here today, and I look forward 
to hearing your testimony.
    [The prepared statement of Mr. Baca follows:]

Prepared Statement of Hon. Joe Baca, a Representative in Congress From 
                               California
    Thank you all for being here today.
    I am pleased to be here in Lincoln with my friend and colleague, 
Jeff Fortenberry, to learn about some of the innovative ways 
communities and businesses are working to improve the nutrition and 
health of Americans.
    Mr. Fortenberry and his staff have done a tremendous job of putting 
together an impressive list of witnesses with experience in ways to 
promote healthy lifestyles and prevent lifelong disease.
    This is a topic of great interest to me as a legislator, of 
course--but also as a husband, father, grandfather, and community 
member.
    By way of introduction, I am from San Bernardino County, 
California, an area not too far outside of Los Angeles.
    And, while the District I represent is a much different in 
geography and demographics than here in Lincoln, we share a common 
interest in the long term health and welfare of our communities and our 
nation.
    And, some of the statistics I've read point out how much we have in 
common.
    According to data from the Census Bureau, the rate of diabetes in 
Lincoln County, and San Bernardino County are not too far apart.
    Just over seven percent for Lincoln, and just under seven percent 
for San Bernardino.
    Over the past 4 years, this subcommittee, and the House Agriculture 
Committee as a whole, has built a record that links the importance of 
nutrition and health.
    In the 2008 farm bill, we provided record levels of funding for 
nutrition for safety net programs like SNAP and food banks.
    We also made important changes that promote healthy eating, by 
funding pilot programs that encourage the consumption of more fruits 
and vegetables, especially in America's schools.
    Last year, in July, this Subcommittee heard testimony on the 
economic costs of poor nutrition in the United States.
    Researchers detailed that hunger costs our country $90 billion per 
year in lost work productivity, the need for special education, and 
other factors.
    Also, testimony from California Advocates demonstrated how a lack 
of participation in Federal nutrition programs means lost revenues to 
California counties.
    This compounds the costs of hunger and poor nutrition.
    In March of this year, the Subcommittee took on the topic of 
obesity in the U.S.
    Experts from the Centers for Disease Control and Prevention 
testified that both nutrition education and a lack of access to healthy 
foods contribute to the obesity epidemic.
    Obesity--and with it the subsequent increase in diabetes--continue 
to be growing problems in America.
    More than \2/3\ of American adults are either overweight or obese.
    The average American today is 23 pounds overweight.
    This burden is a major factor in the skyrocketing health care costs 
of the past 2 decades.
    Research released just last week shows us that medical spending 
averages $1,400 more a year for an obese person than someone who is 
normal weight.
    Overall, obesity related health spending reached $147 billion in 
2008!
    This accounts for 10% of all the health spending in America, and is 
more than double the amount spent on obesity related issues only a 
decade ago.
    Make no mistake--we must find real solutions to the obesity 
epidemic if we are to protect the economic and physical health of the 
American people!
    I am excited to be here today--to hear about ways to improve 
health, and at the same time save America hundreds of billions of 
dollars as we move forward.
    It is quite possible that some of the successes here in Nebraska 
can be used as models for improving Federal policies across the 
country.
    Again, my thanks to you and your staff, Mr. Fortenberry, and to 
everyone who has been so kind and helpful in putting this hearing 
together.
    Special thanks to the fine witnesses who have agreed to be here 
today and to share their expertise with us.
    I look forward to your testimony.
    And, with that, I will turn things over to Mr. Fortenberry..
    The Chairman. So at this time I would like to turn it over 
to Congressman Fortenberry.

OPENING STATEMENT OF HON. JEFF FORTENBERRY, A REPRESENTATIVE IN 
                     CONGRESS FROM NEBRASKA

    Mr. Fortenberry. Thank you. First, let me thank Chairman 
Baca for his willingness to hold this hearing in Lincoln, 
Nebraska. We're very honored that you would travel to our home, 
Lincoln, here to make history, as you said, and to review the 
important issues of nutrition, health and wellness. Congressman 
Baca made mention that he enjoys sports. He's being a little 
bit humble in that statement. We recently had a Congressional 
baseball game, and you're looking at the winning pitcher of 
that game. Now, he revealed to me--and I don't think he'll mind 
me saying this publicly--that he's 62 years old, and he was 
clocked at throwing between 62 and 72 miles per hour, so 
congratulations, Mr. Chairman.
    I'd also like to give a little bit of background on our 
Chairman. He has served in Congress since 1999, and he is a 
Representative of the 43rd District of California which, as he 
mentioned, is the San Bernardino Valley in the southern area of 
the state. He is Chairman of this Subcommittee, which is an 
agriculture Subcommittee on Department Operations, Oversight, 
Nutrition, and Forestry, and I am the Ranking Member of the 
Subcommittee.
    Chairman Baca formerly served in the United States Army as 
a paratrooper from 1966 to 1968, and following his military 
service he earned a degree in sociology from the California 
State University of Los Angeles and then for 15 years worked in 
community relations with General Telephone and Electric. He has 
served both in the California State Assembly and its state 
Senate, and he now lives in Rialto with his wife of 41 years. 
They have four children, and his son is the new Mayor of 
Rialto, California, so, again, congratulations.
    I'd also like to thank Marsha Lommel, who is the CEO of 
Madonna and Madonna ProActive, for allowing us to hold the 
hearing today. I called Marsha, and, of course, this is a 
wonderful new facility that augments the extraordinary services 
that Madonna Hospital provides, and we thought it would be 
somewhat creative, given the topic of today's hearing on 
nutrition and wellness and health, to place us in the center of 
some very innovative activity that is going on in that regard. 
So, Marsha, thank you very much for your generosity in opening 
this facility. It's absolutely lovely.
    I also wish to thank the witnesses who are here today. For 
those of you in the audience who can stay with us, we actually 
have two panels, nine persons, testifying who are all experts 
in the various areas of health and wellness, nutrition and 
health care, so I invite you to stay for our entire discussion, 
but I certainly understand if you need to leave. Throughout the 
country we are engaged in a very important debate about the 
directions of our nation's healthcare system.
    The debate is critical to the well-being of families and 
small business and to all of us, as American citizens, and I 
believe our deliberations must be very thoughtful and center on 
two essential questions: How do we improve healthcare outcomes 
and reduce costs while protecting vulnerable persons? And one 
important piece of the solution is to understand that a major 
driver of our ever increasing healthcare costs is the rise of 
chronic diseases. As alluded to by the Chairman, we are seeing 
an epidemic in chronic diseases across the country.
    Public health statistics and economic data show that 75 
percent of all healthcare spending in the country--and that's 
about $2.2 trillion of total amount of healthcare spending--is 
related in some way to treating lifestyle-related chronic 
conditions. Seven out of every ten deaths in the country are 
caused by chronic conditions. The top four killers are heart 
disease, diabetes, cancer, and strokes, and these are largely 
related to lifestyle. They could be potentially prevented or 
certainly better managed and, in some cases, even reversed 
through healthy lifestyle changes.
    But, sadly, according to recent statistics the average 
American is now 23 pounds overweight. Obesity among young 
people has tripled since 1980. Obesity is a major risk factor 
that leads to the onset of those described chronic conditions. 
I believe as a result it is imperative that our healthcare 
system promote incentives for healthy nutrition practices and 
wellness, and we must foster a culture of wellness and reward 
behaviors that reduce the onset of these diseases.
    I believe that billions, if not hundreds of billions, of 
dollars could be saved if we reduced or at least delayed their 
onset, and as responsible individuals and citizens, I hope that 
we will personally implement wellness and preventive measures 
that can reduce our risk factors for these conditions. And, 
similarly, I support a paradigm shift in the practice of 
medicine in our country. We pay doctors to fix or cut or 
prescribe. I think it's time we pay doctors to prevent as well.
    So these are all reasons that we are gathering at the 
hearing today, and as Ranking Member of this Subcommittee, I'm 
personally committed to exploring the ways in which good 
nutrition happens and wellness principles promote policy that 
support chronic disease prevention efforts. I'm eager to hear 
from our experts who are here today from across the state and 
the Midwest to speak on these topics, as well as to hear their 
suggestions as to what is working and what could be potentially 
duplicated throughout the country to promote this culture of 
wellness and chronic disease prevention.
    Again, Mr. Chairman, it is a privilege to have you join us, 
a real honor for you to be here in the First Congressional 
District. I want to thank you again for holding this hearing, 
and I look forward to the insights that we will learn today 
together. Thank you.
    The Chairman. Thank you very much. At this point we'll 
begin with the first panel that will address obesity and 
chronic illness and nutrition.
    I'll welcome them, and I'll start by having our 
Congressman, your Congressman, introduce each one of the 
panelists. Each one of you will have 5 minutes. The light will 
go on. Don't panic. Continue to do your presentation even if 
the light goes on. We'll allow you to go through that process.
    And if you were in D.C., we would hit the gavel and tell 
you, time is up for your statement, and it's a little bit more 
flexible here in that process. We'll allow you to go through 
the presentation you have so we can hear from you. So with that 
Congressman Fortenberry, again, will introduce the first 
panelists, and then you'll begin.
    Mr. Fortenberry. Thank you, Mr. Chairman. Our first witness 
is Dr. Michael Sitorius. He is the Chairman of the Department 
of Family Medicine at the University of Nebraska Medical Center 
in Omaha. He is also a professor at the College of Medicine at 
the University of Nebraska Medical Center, and he was appointed 
to the Governor's Rural Health Advisory Commission, so welcome, 
Doctor. I'll introduce you all. Then we'll begin with you, Dr. 
Sitorius.
    Our second witness is Amy Lazarus Yaroch. She is a Ph.D., 
the Executive Director of the Center For Human Nutrition in 
Omaha. Ms. Yaroch has led skin cancer research at the National 
Cancer Institute and National Institutes of Health, so welcome 
as well.
    Our third witness is Kim Russel, the President and CEO of 
BryanLGH Health System in Lincoln. Ms. Russel has formerly 
served as president and CEO of another institution in Iowa and 
before that served as Chief Operating Officer of a hospital in 
Kansas. She is a fellow of the American College of Healthcare 
Executives, currently serves on the board of directors for the 
Lincoln Partnership of Economic Development and the Lincoln 
Medical Education Partnership, so welcome, Ms. Russel.
    Our fourth and final witness for panel one is Pam Edwards, 
a registered dietitian, and she is the President elect of 
Nebraska Dietetic Association. She is also the Assistant 
Director of the University Dining Services at the University of 
Nebraska in Lincoln.
    So, again, thank you all for taking time. We look forward 
to your testimony. Dr. Sitorius.

        STATEMENT OF MICHAEL A. SITORIUS, M.D., WALDBAUM
 PROFESSOR OF FAMILY PRACTICE, PROFESSOR AND CHAIR, DEPARTMENT 
               OF FAMILY MEDICINE, UNIVERSITY OF
               NEBRASKA MEDICAL CENTER, OMAHA, NE

    Dr. Sitorius. Thank you, Chairman Baca and Representative 
Fortenberry for permitting me this opportunity to testify 
before this Subcommittee about the relevance and importance of 
promoting proper wellness and nutrition practices.
    My name is Michael A. Sitorius. I'm the Waldbaum Professor 
of Family Practice and Chair of the Department of Family 
Medicine at the University of Nebraska Medical Center. I'm 
testifying today about an issue I feel is critical to the 
effective delivery of health care in America: The coordinated 
promotion of proper lifestyle and nutrition practices in the 
prevention and treatment of chronic illnesses. During 30 years 
as both a practicing family physician and educator of future 
physicians, physician assistants, nurse practitioners, and 
other medical practitioners, I have witnessed firsthand a 
significant increase in the presentation of chronic illness 
among my patients.
    Indeed, my personal experience seems to reflect a national 
trend. Over 125 million people in the United States currently 
experience at least one chronic illness, and over half of those 
125 million have two or more chronic illnesses. Fifty percent 
of these chronic illnesses are attributable to five causes: 
Asthma, diabetes, high blood pressure, coronary artery disease, 
and depression are seen on a typical day in my office. Of the 
remaining 50 percent, a substantial portion are related to 
cancers and osteoporosis that are nutrition related.
    Annually, chronic illness is the leading cause of 
disability and death in the United States, exacting enormous 
tolls on the American population, both in human and economic 
terms. In a recently published health affairs on-line study, 
July 29, 2009, the CDC reported 973,000 deaths attributable to 
chronic illnesses up to that date.
    Chronic illness is not a discrete medical disorder 
displaying specific symptoms. It is an injury, illness or 
condition with long duration with no predictable end date that 
does not require immediate hospitalization but is likely to 
require frequent treatment. Research indicates that poor 
nutrition and an inactive lifestyle increases one's likelihood 
of experiencing one of these chronic illnesses. This suggests 
that care including implementation of lifestyle modifications 
and nutrition may be effective in reducing the risk of 
acquiring a chronic illnesses and in treating those that are 
present.
    Obesity has long been associated with poor nutrition and 
inactive lifestyle and is associated with cardiovascular, 
expiratory, inspiratory.
    According to Health Affairs (July 2009), the cost of health 
care related to obesity rose from $78.5 billion in 1998 to over 
$147 billion in 2008. Incidentally, 18 percent of the U.S. 
population in 1998 was considered obese; 25 percent in 2008. 
Further, 23 states report a rising level of obesity in 2008, 
and over 30 states report a 30 percent child obesity rate.
    Dr. Risa Lavizzo-Mourey, President and CEO of Robert Woods 
Johnson Foundation, has expressed that a key to any healthcare 
reform is a solution to the epidemic of child obesity. I 
totally agree with that statement, but would add that 
addressing the rise in adult obesity is equally important in 
creating effective healthcare reform.
    The solution to obesity and the solution to caring for 
chronic illness both require the implementation of more 
effective methods of directing lifestyle, but identifying a 
need for more efficient care of chronic illness belies the 
complexity underlying these forms of illness and the related 
care.
    Of the five general factors affecting health status, only 
\1/10\ of an individual's health status is accounted for by 
medical care. Overwhelmingly, a person's health status is 
determined by social, genetic and behavioral factors. Indeed, 
the largest contributor to personal health status is behavioral 
decisions. Unfortunately, the current healthcare system allows 
for practitioners to do little more than admonish patients to 
``stop smoking,'' ``adjust your diet,'' or ``engage in regular 
exercise.'' Truthfully, while recognized as important factors 
of health status, the current healthcare system is not designed 
to effectively promote proper wellness and nutrition practices 
among patients who are either preventing or suffering from 
chronic illnesses.
    I believe the explanation as to why medical care accounts 
for such a small percentage of the factors influencing health 
care is directly related to this inability to properly promote 
healthy lifestyle choices and is the result of a healthcare 
model that is essentially reactive in nature. The current 
priority in medical education and care is the assessment and 
treatment of acute and episodic conditions and not the 
underlying chronic illness. While providing immediate relief of 
a patient's distress, this model does little to address the 
needs of the patient.
    One might say that knowing the description of chronic 
illness, the solution should be simple: Treat the underlying 
disease. Indeed, it's not that simple. There are three reasons 
why I feel this solution is improbable under the current 
healthcare system.
    The first constraint limiting the effective treatment 
chronic illness is the limited training and familiarity most 
healthcare professionals have with monitoring and supporting 
patients with chronic illness. The limited abilities of 
practitioners to monitor and support patients is an extension 
of the lack of coordinated office systems designed to monitor 
and support clinical decisions.
    Second, even in systems that provide protocols for 
physicians to follow when dealing with chronic illness, the 
time constraints current systems place on physician-patient 
interaction simply do not allow comprehensive care. Indeed, the 
system promotes treatment of periodic symptom care as opposed 
to prevention because it can be dealt with more quickly.
    Third, current reimbursement systems favor episodic 
treatment over preventive treatments, which may span extensive 
time.
    These three factors pose significant barriers to the 
effective treatment of chronic illness; however, in dealing 
with these factors, I believe we should look towards creating a 
healthcare system that is proactive and team oriented.
    When I use the terms ``proactive'' and ``team oriented,'' I 
have a very specific model in mind. That is the Patient 
Centered Medical Home, which consists of six components: A 
personal physician, physician directed medical care; whole 
person orientation; coordinated and integrated care, a team 
approach; quality and safety as the cornerstones; enhanced 
access; and payment reform.
    This system favors cumulative care plans versus single 
interventions, a coordinated comprehensive care in multiple 
venues over time. This system would provide care providers with 
clearly defined protocols, IT support to facilitate real-time 
communication, evaluation feedback, and educational information 
between patients, physicians, and the patients' community.
    With increased guidance and support both within the 
clinical and community settings, physician-directed lifestyle 
modifications shall become the heart of a proactive healthcare 
system aimed at decreasing the incidence of chronic disease and 
treating those that exist. The natural products of a more 
efficient and proactive healthcare system could include both 
increases in health and satisfaction and a decrease in overall 
healthcare cost.
    I hope that my words today emphasize my belief that 
lifestyle modifications such as nutrition and physical activity 
are the center of a more effective healthcare system. I hope to 
impress upon you the systematic approach to coordinating and 
effectuating communication and treatment between physician, 
patient and community, which creates a successful physician-
patient partnership provided by the Patient Centered Medical 
Home, is one way to create an environment in which physicians 
may influence behavioral, social and environmental factors 
affecting health status. Thank you.
    [The prepared statement of Dr. Sitorius follows:]

Prepared Statement of Michael A. Sitorius, M.D., Waldbaum Professor of 
 Family Practice, Professor and Chair, Department of Family Medicine, 
            University of Nebraska Medical Center, Omaha, NE
    Thank you Chairman Baca and Representative Fortenberry for 
permitting me this opportunity to testify before this subcommittee 
about the relevance and importance of promoting proper wellness and 
nutrition practices from a medical care provider's perspective.
    My name is Dr. Michael A. Sitorius. I am the Waldbaum Professor of 
Family Practice and Chair of the Department of Family Medicine at the 
University of Nebraska Medical Center. I am testifying today about an 
issue I feel is critical to the effective delivery of healthcare in 
America: the coordinated promotion of proper lifestyle and nutrition 
practices in the prevention and treatment of chronic illness by medical 
care providers. During thirty years as both practicing family 
physician, and educator of future family physicians, physician 
assistants, nurse practitioners, pharmacists, nurses, and registered 
dietitians, I have witnessed first hand a significant increase in the 
presentation of chronic illness among patients. Indeed, my personal 
experience seems to reflect a national trend. Over 125 million people 
in the United States currently experience at least one chronic illness 
and over half of this population is afflicted by two or more chronic 
illnesses. Fifty percent of these chronic illnesses are attributable to 
five causes: asthma, diabetes, high blood pressure, coronary artery 
disease, and depression. Of the remaining 50 percent of chronic 
illnesses a substantial percent are attributable to breast, 
endometrial, colon and prostate cancers; and osteoporosis.
    Annually, chronic illness is the leading cause of illness, 
disability, and death in the United States and exacts enormous tolls on 
the American population both in human and economic terms. As of July 9, 
2009 the CDC reports 973,000 deaths attributable to chronic illness 
this year.
    Chronic illness is not a discrete medical disorder displaying 
specific symptoms. The term chronic illness defines an injury, illness, 
or condition expected to be of long duration with no predictable end-
date that does not require immediate hospitalization but is likely to 
require regular periodic care or treatment. Research indicates that 
poor nutrition and an inactive lifestyle increase one's likelihood of 
experiencing one of these chronic illnesses. This suggests that care 
including implementation of simple lifestyle modifications may be 
effective in reducing the risk of acquiring a chronic illness and in 
treating those that are present.
    Obesity has long been associated with poor nutrition and an inert 
lifestyle, and is associated with several cardiovascular and 
respiratory chronic illnesses. However, when one examines the incidence 
of obesity in America one notices a startling trend. According to 
Health Affairs (July 2009) the cost of healthcare related to obesity 
rose from 78.5 billion dollars in 1998 to 147 billion dollars in 2008. 
Further, at least 23 states report a rise in adult obesity for 2008, 
and over thirty states report a 30 percent child obesity rate.
    Dr. Risa Lavizzo-Mourey, M.D. M.B.A., president and CEO of the 
Robert Woods Johnson Foundation has expressed that a key to any 
healthcare reform is a solution to the epidemic of child obesity. I 
agree with this statement, but would add that addressing the rise in 
adult obesity is equally important in creating effective healthcare 
reform.
    The solution to obesity and the solution to caring for chronic 
illness both require the implementation of more effective methods of 
directing lifestyle modifications between physician and patient. But 
identifying a need for more efficient care of chronic illness belies 
the complexity underlying these forms of illness and the related care.
    Of the five general factors affecting health status one may note 
that medical care accounts for only one tenth of an individual's health 
status. Overwhelmingly, a person's health status is determined by 
social, genetic, and behavioral factors which lie outside the scope of 
traditional care provision. Indeed, the largest contributor to personal 
health status are factors related to behavioral decisions. 
Unfortunately the current healthcare system allows for practitioners to 
do little more than admonish patients to ``stop smoking'' ``adjust your 
diet'' or ``engage in regular exercise''. Truthfully, while recognized 
as important factors of health status, the current healthcare system is 
not designed to effectively promote proper wellness and nutrition 
practices among patients suffering from chronic illness.
    I believe the explanation as to why medical care accounts for such 
a small percentage of the factors influencing health is directly 
related to this inability to properly promote healthy lifestyle choices 
and is the result of a healthcare model that is essentially reactive in 
nature. The current priority in medical education and care is the 
assessment and treatment of acute and episodic conditions and not the 
underlying chronic illness. While providing immediate relief of a 
patient's distress this model does little to address needs of both the 
patient and healthcare system in receiving and providing effective 
economical care.
    Now, one might say, if this description of chronic illness care is 
accurate the solution to both the financial and treatment burdens 
created by chronic illness is simple: address the underlying illness. 
Indeed, this is the simple articulation of a solution. However, I would 
like to cite three reasons why this solution is improbable under the 
current healthcare system.
    The first constraint limiting the effective treatment of chronic 
illness is the limited training and familiarity most health care 
professionals have with monitoring and supporting patients with chronic 
illnesses. The limited abilities of practitioners to monitor and 
support patients are really an extension of the lack of coordinated 
office systems designed to monitor and support clinical decisions.
    Second, even in systems that provide some protocol for physicians 
to follow when dealing with chronic illness, the time constraints 
current systems place on physician-patient interaction simply do not 
allow for the comprehensive care required by chronic illness. Instead, 
the system promotes treatment of acute and periodic symptoms of the 
illness which are discrete and typically dealt with more quickly.
    Third, current reimbursement systems favor episodic treatment over 
preventive treatments, which may span extensive periods of time.
    These three factors pose significant barriers to the effective 
treatment of chronic illness, and they must be dealt with if we wish to 
effectively address the health concerns facing this country. However, 
in dealing with these factors I believe we should look towards creating 
a healthcare system that is more proactive and team oriented.
    When I use the terms proactive and team oriented, I have a very 
specific model in mind. This model is the Patient Centered Medical Home 
(PCMH). The PCMH consists of six main components:

      Physician Directed Medical Care

      Whole Person Orientation

      Coordinated and Integrated care

      Quality and Safety

      Enhanced Access

      Payment Reform

    This model favors the systems oriented approach to treating an 
underlying illness, which does not consist of single interventions but 
of cumulative care plans. This type of system would provide care 
providers with clearly defined care protocols and a support staff 
consisting of members with clearly defined roles designed to facilitate 
usable and affordable diagnostics at the clinical level. Further, this 
system would integrate an Information Technology (IT) support system 
that is patient centered, and is designed to facilitate real time 
communication, evaluation feedback, and related educational information 
between patient, physician, and patient's community.
    With increased guidance and support both within the clinical and 
community settings, physician directed lifestyle modification 
suggestions will become the heart of a proactive healthcare system 
aimed at decreasing the incidence of chronic disease among the American 
population. The natural products of a more efficient and proactive 
healthcare system would include both an increase in patient 
satisfaction and a decrease in overall healthcare cost.
    While I can not provide specifics for creating this system, I can 
say that a systems oriented approach which includes both patient and 
community as key partners in the care and prevention of chronic illness 
will provide the support necessary to effectuate better care for 
chronic illness.
    I hope that my words today emphasize my belief that lifestyle 
modifications such as nutrition and physical activity are the center of 
a more effective healthcare system. Further, I hope to impress upon you 
that the systematic approach to coordinating and effectuating 
communication and treatment between physician, patient, and community, 
which creates a successful physician patient partnership provided by 
the PCMH, is the way to create an environment in which physicians may 
influence behavioral, social, and environmental factors affecting 
health status.
                               Appendix I

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


 STATEMENT OF AMY L. YAROCH, Ph.D., EXECUTIVE DIRECTOR, CENTER 
                 FOR HUMAN NUTRITION, OMAHA, NE

    Dr. Yaroch. Congressman Baca and Congressman Fortenberry, 
thank you for this opportunity to testify. My name is Dr. Amy 
Yaroch, and I'm the Executive Director of the Center For Human 
Nutrition in Omaha, Nebraska. I'm here as a public health 
nutrition researcher and also as a mother of two young children 
who I would like to protect in the battle against obesity and 
related chronic diseases. I just moved to Nebraska about 4 
months ago. Before that I was a Project Officer at the National 
Cancer Institute, part of the National Institutes of Health in 
Bethesda, Maryland. I'm going to talk about both of my 
experiences as a researcher as well as a Project Officer.
    Obesity, which has steadily been on the rise over the past 
30 years, is associated with several debilitating chronic 
diseases, including diabetes, heart disease, and many of the 
major cancers. Most cases of childhood obesity develop because 
of an imbalance of energy input and output, a phenomenon that 
is sustained by our obesogenic environment. A healthy diet 
which is characterized by an increased intake of fruits and 
vegetables is linked with a decreased risk of obesity and 
chronic diseases; but, unfortunately, fruit and vegetable 
intake is still not adequate, and most of the population does 
not consume the recommended five or more servings per day.
    National data show that only about one in four adults 
report eating five or more fruits and vegetables per day, and 
most people do not even know that they should be eating five or 
more a day for good health.
    I'm going to focus on some obesity estimates to help give 
you an idea of the great magnitude of this problem for children 
and adults alike. National data indicate that \2/3\ of adults 
are overweight or obese and \1/3\ of children are overweight or 
obese. African Americans have the highest rates of obesity, 
followed by Hispanics and then whites, and the highest rates 
are generally found in the South and Midwest compared to the 
West and Northeast.
    We also see high rates among American Indians.
    A recent study reported that among Native American tribes 
in North Dakota, South Dakota, Iowa, and Nebraska, a whopping 
47 percent of children and adolescents were overweight or 
obese. Overweight and obese children and adolescents are also 
more likely to become obese adults and die at an earlier age 
than their healthier weight peers. In addition, they are more 
likely to be less healthy, less happy, and absent from school 
more than their lower weight peers.
    Unless we act now, today's children are likely to be the 
first generation to live sicker lives and die younger than 
their parents' generation. I find this statement deeply 
troubling, especially given that I have two young children and 
how this can play out for them if something is not done. Rising 
obesity rates are attributed to many diet and physical activity 
related factors.
    A couple of diet-related factors that I would like to 
highlight are: Americans eat an average of 300 more calories 
than they did a quarter of a century ago, and these consist of 
less nutritious foods. Unfortunately, nutritious foods such as 
fruits and vegetables are a lot more expensive than fatty, 
sugary, less nutritious foods. In addition, many supermarkets 
have been vacating poorer more underserved communities, leaving 
residents who live there with limited or no access to healthy 
and affordable foods. Regrettably, these so-called food deserts 
have spread across the U.S.
    Financial health costs also merit discussion.
    A paper just released reported that obesity costs the 
country an estimated $147 billion a year, a number that has 
almost doubled since the last time the CDC calculated it in 
1998. A main point that I want to raise here is that prevention 
is absolutely key to curbing the obesity epidemic and its 
medical and economic consequences. We are currently in the 
powerful position to reverse and/or prevent obesity and chronic 
diseases by improving diet and increasing physical activity 
among the U.S. population, both young and old, rural and urban, 
and white and other ethnic minority populations.
    As a Project Officer at the National Cancer Institute from 
2002 until this past March, I had the opportunity to oversee a 
portfolio of diet and obesity prevention studies. What is 
heartening is that I saw a sharp rise in the studies getting 
funded in the area of obesity prevention while I was at the 
National Cancer Institute. You may have heard obesity referred 
to as the ``new tobacco,'' and I think that many are beginning 
to truly acknowledge the extent of this national challenge.
    In addition, I saw a shift in the types of studies being 
funded from purely individual level approaches to those 
incorporating more environmental and policy strategies. An 
example of an individual level approach would be going into a 
classroom and telling children that they should eat more fruits 
and vegetables. This type of approach on its own has met with 
limited success, but it appears that combining this with other 
more macro level strategies, such as taking sugar sweetened 
beverages out of schools, could prove to be very fruitful in 
the long run.
    I was invited here to talk about the problem, and others 
will address potential solutions. However, I want to end with 
urging consideration of a multi-level approach in moving 
forward. Using a systems level three-pronged approach can have 
great promise in addressing obesity and chronic disease 
prevention. First, we know that the individual has been 
genetically programmed at an early age to desire fatty and 
sugary foods, and so we need to engage the individual to help 
provide them with the knowledge and tools to make healthier 
choices.
    Next, we need to provide a supportive environment where 
healthy eating choices are easily accessible, available, and at 
a low cost. Finally, we need to have local, state, and Federal 
policies in place to ensure that the communities in which 
people live, work, and play are indeed healthy communities.
    Thank you again for giving me the opportunity to testify, 
and I'd be pleased to answer any questions.
    [The prepared statement of Dr. Yaroch follows:]

Prepared Statement of Amy L. Yaroch, Ph.D., Executive Director, Center 
                     for Human Nutrition, Omaha, NE
    Congressman Baca and Congressman Fortenberry, thank you for this 
opportunity to testify about the important issue of obesity, chronic 
diseases, and nutrition. My name is Dr. Amy Yaroch and I am the 
Executive Director of the Center for Human Nutrition in Omaha, 
Nebraska. I am here as a public health nutrition researcher and also as 
a mother of two young children, who I would like to protect in the 
battle against obesity and related chronic diseases. I just moved to 
Nebraska about 4 months ago and before that, I was a Project Officer at 
the National Cancer Institute, part of the National Institutes of 
Health in Bethesda, Maryland. I am going to talk both about my 
experiences as a researcher as well as a Project Officer.
    Obesity, which has steadily been on the rise over the past 30 years 
is associated with several debilitating chronic diseases including 
diabetes, heart disease and many of the major cancers. 
\1\-\6\ Most cases of childhood obesity develop because of 
an imbalance in energy input and output, a phenomenon that is sustained 
by our ``obesogenic'' environment \7\-\12\. A healthy diet 
which is characterized by an increased intake of fruits and vegetables 
is linked with a decreased risk of obesity and chronic diseases; but 
unfortunately fruit and vegetable intake is still not adequate and most 
of the population does not consume the recommended five or more 
servings per day. National data show that only about one in four adults 
report eating five or more fruits and vegetables per day \13\ and, most 
people do not even know that they should be eating five or more a day 
for good health. \14\-\18\
---------------------------------------------------------------------------
    \1\  World Cancer Research Fund/American Institute for Cancer 
Research, Food, nutrition, physical activity, and the prevention of 
cancer: a global perspective. 2007, AICR: Washington, D.C.
    \2\  Hung, H.C., et al., Fruit and vegetable intake and risk of 
major chronic disease. J. Natl. Cancer Inst., 2004. 96(21): p. 1577-84.
    \3\  Key, T.J., et al., Diet, nutrition and the prevention of 
cancer. Public Health Nutr., 2004. 7(1A): p. 187-200.
    \4\  Hu, F.B., Plant-based foods and prevention of cardiovascular 
disease: an overview. Am. J. Clin. Nutr., 2003. 78(3 Suppl): p. 544S-
551S.
    \5\  Van Duyn, M.A. and E. Pivonka, Overview of the health benefits 
of fruit and vegetable consumption for the dietetics professional: 
selected literature. J. Am. Diet. Assoc., 2000. 100(12): p. 1511-21.
    \6\  Lampe, J.W., Health effects of vegetables and fruit: assessing 
mechanisms of action in human experimental studies. Am. J. Clin. Nutr., 
1999. 70(3 Suppl): p. 475S-490S.
    \7\  Dietz, W., Childhood obesity, in Modern nutrition in health 
and disease, M.E. Shils, et al., Editors. 1999, Williams & Wilkins: 
Baltimore. p. 1071-80.
    \8\  Sallis, J.F. and K. Glanz, The role of built environments in 
physical activity, eating, and obesity in childhood. Future Child, 
2006. 16(1): p. 89-108.
    \9\  Glass, T.A. and M. McAtee, Behavioral science at the 
crossroads in public health: extending horizons, envisioning the 
future. Soc. Sci. Med., 2006. 7: p. 1650-71.
    \10\  Papas, M.A., et al., The built environment and obesity. 
Epidemiol. Rev., 2007. 29: p. 129-43.
    \11\  Bellisari, A., Evolutionary origins of obesity. Obes. Rev., 
2008. 9(2): p. 165-80.
    \12\  Maziak, W., K.D. Ward, and M.B. Stockton, Childhood obesity: 
are we missing the big picture? Obes. Rev., 2008. 9(1): p. 35-42.
    \13\  Blanck, H.M., et al., Trends in fruit and vegetable 
consumption among U.S. men and women, 1994-2005. Prev. Chronic Dis., 
2008. 5(2): p. A35.
    \14\  Stables, G.J., et al., Changes in vegetable and fruit 
consumption and awareness among US adults: results of the 1991 and 1997 
5 A Day for Better Health Program surveys. J. Am. Diet. Assoc., 2002. 
102(6): p. 809-17.
    \15\  Van Duyn, M.A., et al., Association of awareness, 
intrapersonal and interpersonal factors, and stage of dietary change 
with fruit and vegetable consumption: a national survey. Am. J. Health 
Promot., 2001. 16(2): p. 69-78.
    \16\  Marcus, A.C., et al., Increasing fruit and vegetable 
consumption among callers to the CIS: results from a randomized trial. 
Prev. Med., 1998. 27(5 Pt 2): p. S16-28.
    \17\  Havas, S., et al., Factors associated with fruit and 
vegetable consumption among women participating in WIC. J. Am. Diet. 
Assoc., 1998. 98(10): p. 1141-8.
    \18\  Krebs-Smith, S.M., et al., Psychosocial factors associated 
with fruit and vegetable consumption. Am. J. Health Promot., 1995. 
10(2): p. 98-104.
---------------------------------------------------------------------------
    I am going to focus on some obesity estimates to help give you an 
idea of the great magnitude of this problem for children and adults 
alike. National data indicate that \2/3\ of adults are overweight or 
obese and \1/3\ of children are overweight or obese. African Americans 
have the highest rates of obesity, followed by Hispanics, and then 
whites and the highest rates are generally found in the South and 
Midwest compared to the West and Northeast \19\. We also see high rates 
among American Indians. A recent study reported that among Native 
American tribes in North Dakota, South Dakota, Iowa, and Nebraska, a 
whopping 47% of children and adolescents were overweight or obese \20\. 
Overweight and obese children and adolescents are also more likely to 
become obese adults and die at an earlier age than their peers at a 
healthier weight. In addition, they are more likely to be less healthy, 
less happy, and absent from school more than their lower weight peers 
[20]. Unless we act now, today's children are likely to be the first 
generation to live sicker lives and die younger than their parents' 
generation \21\. I find this statement deeply troubling, especially 
given that I have two young children and how this can play out for them 
if something is not done. Rising obesity rates are attributed to many 
diet and physical activity related factors. A couple of diet-related 
factors that I would like to highlight are: Americans eat an average of 
300 more calories a day than they did a quarter of a century ago and 
these consist of less nutritious foods. Unfortunately, nutritious foods 
such as fruits and vegetables are a lot more expensive than fatty, 
sugary less nutritious foods \22\. In addition, many supermarkets have 
been vacating poorer more underserved communities, leaving residents 
who live there with limited or no access to healthy and affordable 
foods. Regrettably, these so-called food deserts have spread across the 
U.S.\23\
---------------------------------------------------------------------------
    \19\  Differences in prevalence of obesity among black, white, and 
Hispanic adults--United States, 2006-2008. MMWR Morb. Mortal Wkly Rep., 
2009. 58(27): p. 740-4.
    \20\  Key facts about childhood obesity. 2009, Robert Wood Johnson 
Foundation. p. 18.
    \21\  Olshansky, S.J., et al., A potential decline in life 
expectancy in the United States in the 21st century. N. Engl. J. Med., 
2005. 352(11): p. 1138-45.
    \22\  F as in Fat: How obesity policies are failing in America 
2009. 2009, Robert Wood Johnson Foundation.
    \23\  Larson, N.I., M.T. Story, and M.C. Nelson, Neighborhood 
environments: disparities in access to healthy foods in the U.S. Am. J. 
Prev. Med., 2009. 36(1): p. 74-81.
---------------------------------------------------------------------------
    Financial health costs also merit discussion. A paper just released 
reported that obesity costs the country an estimated $147 billion a 
year, a number that has almost doubled since the last time the CDC 
calculated it in 1998. A main point that I want to raise here is that 
prevention is absolutely key to curbing the obesity epidemic and it's 
medical and economic consequences. We are currently in the powerful 
position to reverse and/or prevent obesity and chronic diseases by 
improving diet and increasing physical activity among the U.S. 
population, both young and old, rural and urban, and white and other 
ethnic minority populations.
    As a project officer at the National Cancer Institute from 2002 
until this past March, I had the opportunity to oversee a portfolio of 
diet and obesity prevention studies. What is heartening is that I saw a 
sharp rise in the studies getting funded in the area of obesity 
prevention while I was at the National Cancer Institute. You may have 
heard obesity referred to as the ``new tobacco'' and I think many are 
beginning to truly acknowledge the extent of this national challenge. 
In addition, I saw a shift in the types of studies being funded from 
purely individual-level approaches to those incorporating more 
environmental and policy strategies. An example of an individual-level 
approach would be going into a classroom and telling children that they 
should eat more fruits and vegetables. This type of approach on its own 
has met with limited success but it appears that combining this with 
other more ``macro'' level strategies such as taking sugar sweetened 
beverages out of vending machines in schools could prove to be very 
``fruitful'' in the long run.
    I was invited here to talk about the problem and others will 
address potential solutions. However, I want to end with urging 
consideration of a multi-level approach in moving forward. Using a 
systems-level three pronged approach can have great promise in 
addressing obesity and chronic disease prevention \24\, \25\. First, we 
know that the individual has been genetically programmed at an early 
age to desire fatty and sugary foods and so we need to engage the 
individual to help provide them with the knowledge and tools to make 
healthier choices. Next, we need to provide a supportive environment, 
where healthy eating choices are easily accessible, available, and at a 
low cost. Finally, we need to have local, state, and Federal policies 
in place to ensure that the communities in which people live, work, and 
play are indeed healthy communities.
---------------------------------------------------------------------------
    \24\  Huang, T.T., et al., A systems-oriented multilevel framework 
for addressing obesity in the 21st century. Prev. Chronic Dis., 2009. 
6(3): p. A97.
    \25\  Huang, T.T. and T.A. Glass, Transforming research strategies 
for understanding and preventing obesity. JAMA, 2008. 300(15): p. 1811-
3.
---------------------------------------------------------------------------
    Thank you again for giving me the opportunity to testify. I would 
be pleased to answer any questions you may have.

 STATEMENT OF KIMBERLY A. RUSSEL, PRESIDENT AND CEO, BryanLGH 
                   HEALTH SYSTEM, LINCOLN, NE

    Ms. Russel. It's a pleasure to be here today to represent 
BryanLGH Health System, a locally owned healthcare system 
anchored by BryanLGH Medical Center here in Lincoln. Our 
mission statement is to provide excellent care and to promote 
health with a focus on quality, collaboration and compassion. 
This mission statement, with its emphasis on health promotion, 
showcases the importance to us of prevention and wellness.
    What I was asked today to address the financial impact of 
chronic diseases on the medical system. According to CDC, 
chronic diseases are the leading cause of death in the U.S. 
and, therefore, the leading cause of admission to U.S. 
hospitals. Also per the CDC, almost half of all Americans live 
with at least one chronic condition. Chronic diseases account 
for 70 percent of all deaths in the U.S. Medical care costs for 
people with chronic diseases account for more than 75 percent 
of the nation's $2 trillion in medical care costs.
    Chronic diseases account for about \1/3\ of the years of 
potential life lost by the year 65 and, after decades of 
relative stability, increased by 37 percent between 1998 and 
2006. Obesity accounts for over nine percent of all medical 
spending--$147 billion in 2008--and annual per capita increase 
in Medicare spending due to obesity is 36 percent and is 47 
percent for Medicaid. So from the perspective of an acute care 
health system, the number one chronic condition that impacts 
all of the chronic diseases is obesity.
    We now commonly hear the phrase ``obesity epidemic'' to 
describe this phenomenon, and I totally agree that obesity is 
an epidemic in America today.
    We would not be able to find a hospital or a physician's 
practice that has not been impacted by an increasingly obese 
patient population. At BryanLGH we have made many adaptations 
to better serve people of larger sizes. Manufacturers have 
adapted medical equipment such as operating room tables, 
patient lifts, MRI scanners, et cetera, to accommodate this 
patient population.
    Over the years BryanLGH, like other hospitals, has 
purchased this new equipment of this nature to safely provide 
care to these patients. Every hospital, including BryanLGH, is 
battling an increasing number of back injuries among our staff 
as a result of lifting larger patients. Obesity can also 
complicate a patient's discharge from the hospital. Some long-
term care facilities limit the number of obese patients they 
will accept due to the additional staff and lifting needs.
    In other cases, it is obesity, not the underlying medical 
condition, that prevents a patient from being discharged from 
the hospital to their own home. Patients who are obese carry 
much higher risks of medical complications. Whatever the 
underlying disease, obesity makes nearly everything worse for 
the patient and truly impacts or reduces that patient's quality 
of life.
    Today I want to share with you some new research that we 
are studying in collaboration with other Lincoln partners to 
help establish new health and living culture in our community.
    In June the Community Health Endowment at BryanLGH 
cosponsored a site visit to Lincoln by Dan Buettner, who is a 
researcher and author of a book called The Blue Zones.  The 
book presents Dan's research of four areas of the world where 
people are living longer and healthier (into their 90s and 
beyond). The four areas Dan studied are in Italy, Japan, Costa 
Rica, and Loma Linda, California. Dan is coining the phrase 
``blue zone'' to describe areas of the globe that are longevity 
hot spots. The blue zone or longevity hot spots are striking, 
because in these areas of the world, there are greatly reduced 
rates of chronic disease compared to rates in the U.S., 50 to 
70 percent less.
    We had standing only room only in the BryanLGH Medical 
Center Conference Center with over 400 people in attendance to 
hear the results of Dan's work.
    I found his message particularly interesting in the context 
of the national discussion that is ongoing about national 
healthcare reform. The common themes that Dan discovered when 
researching longevity trends in these disparate areas of the 
world are actually quite simple, practical and, frankly, don't 
rely upon legislation. Although some of the advice are things 
we've heard our whole lives, such as walking, sustaining 
regular low intense activity throughout the day and adding 
activity into our daily routines, et cetera, others are perhaps 
newer concepts to many Americans. Dan's basic premise is diets 
and exercise programs in the U.S. have, for the most part, been 
a failure. They fail to impact our culture, and what's really 
needed is a cultural change in our country.
    For example, one thing he discovered, that in Okinawa it's 
built into the culture to stop eating when one's stomach is 80 
percent full, and there's even a little saying to remind you of 
that that is said before each meal, almost like a prayer. 
Another study showed that people who place their food on the 
plate in the kitchen and put the food away before taking the 
plates to the table to eat consumed 14 percent less food than 
those who placed the serving dish on the table and ate family 
style.
    Another very simple tip that Dan found in his studies were 
the longevity or ``blue zone'' people used smaller dinner 
plates and glasses than most of us tend to use. Other advice 
relates to social activity and family time, adding time to our 
faith, surrounding yourself with people who share the same 
wellness values, kind of like a support group concept.
    Well, Dan is now working in Albert Lea, Minnesota. He is 
trying to create a new blue zone.
    The other blue zones in the world were naturally occurring, 
have been occurring over generations of time. His experiment 
now is to see if he can take a typical American community and 
actually create a new blue zone. The entire Albert Lea 
community is working together to implement the principles of 
the blue zones. This involves making the communities walk-able, 
working with local restaurants on nutritional options, adding 
life trails absolutely everywhere. In fact, interestingly, many 
of Dan's blue zone principles were incorporated into the CDC's 
recently announced community strategies to prevent obesity in 
the U.S. that was just brought out by the CDC a year or so.
    Dan returned to Lincoln earlier this week for further 
discussion with partners including BryanLGH, the Community 
Health Endowment, the City of Lincoln, Lincoln Public Schools, 
and others to see what more we can learn about making Lincoln 
the next blue zone. I invite Congressman Fortenberry and other 
interested individuals to keep abreast of these developments as 
we all learn more.
    In summary, we have an epidemic of obesity and other 
chronic diseases in our country. What's needed is a change in 
the American culture. Certainly, Federal health policy and 
insurance reform can greatly contribute to this effort. So can 
enlightened employers who give employees incentives to lead 
healthier lifestyles, but our basic practices as a country must 
change. I'm hoping that here at home we can learn some simple 
lessons from researchers like Dan Buettner and his colleagues 
that will make a difference here in Nebraska. Thank you.
    [The prepared statement of Ms. Russel follows:]

 Prepared Statement of Kimberly A. Russel, President and CEO, BryanLGH 
                       Health System, Lincoln, NE
    It's a pleasure to be here today to represent BryanLGH Health 
System, a locally owned health care system anchored by BryanLGH Medical 
Center here in Lincoln. The Mission Statement of BryanLGH Medical 
Center is to provide excellent care and promote health with a focus on 
quality, collaboration and compassion. This Mission Statement, with its 
emphasis on health promotion, showcases the importance of prevention 
and wellness.
    Today, I will share with you some new research that we are studying 
in collaboration with other Lincoln partners.
    In June, the Community Health Endowment and BryanLGH Health System 
cosponsored a site visit to Lincoln by Dan Buettner, a researcher and 
author of a book called ``The Blue Zones.'' The book presents Dan's 
research of four areas of the world where people are living longer and 
healthier (into their 90's and beyond). The four areas Dan studied are 
in Italy, Japan, Costa Rica, and Loma Linda, California. Dan and his 
team of researchers have recently begun another study in Albert Lea, 
Minnesota.
    We had standing room only in the BryanLGH Medical Center Conference 
Center with over 400 people in attendance to hear the results of Dan's 
work.
    I found his message particularly interesting in the context of the 
national discussion that is ongoing about health care reform. The 
common themes that Dan discovered when researching longevity trends in 
these disparate areas of the world are actually quite simple, practical 
and do not rely upon legislation. Although some of the advice are 
things we have heard our whole lives such as walking, sustaining 
regular low intense activity throughout the day and adding activity 
into our daily routines, others are perhaps newer concepts to many 
Americans.
    For example, Dan discovered that in Okinawa it is built into the 
culture to stop eating when one's stomach is 80% full. Another study 
showed that people who place their food on the plate in the kitchen, 
then put the food away before taking the plate to the table to eat, 
consume 14% less food those who place the serving dishes on the table. 
Another simple tip that Dan found in his studies were that the 
longevity or ``blue zone'' people used smaller dinner plates and 
glasses.Other advice relates to adding social activity and family time 
to one's schedule every day and to surround yourself with people who 
share the same wellness values (kind of a support group concept).
    Dan is now working in Albert Lea, Minnesota, where he is trying to 
create a new ``blue zone''. The entire Albert Lea community is working 
together to implement the principles of the ``blue zones'' found around 
the world.
    Dan returned to Lincoln earlier this week for further discussion 
with Lincoln partners including BryanLGH, Community Health Endowment, 
City of Lincoln, Lincoln Public Schools and others to see what more we 
can learn about making Lincoln the next blue zone. I invite Congressman 
Fortenberry and other interested individuals to keep abreast of these 
developments as we all learn more.
    In summary, we have an epidemic of obesity and diabetes and other 
related complications in this country. What is needed is a change in 
the American culture. Certainly, Federal health policy and insurance 
reform can greatly contribute to this effort. So can enlightened 
employers who give employees incentives to lead healthier lifestyles. 
But, our basic practices as a country must change. I am hoping that 
here at home we can learn some simple lessons from researchers like Dan 
Buettner and his colleagues that will make a difference here in 
Nebraska.

      STATEMENT OF PAMELA J. EDWARDS, M.B.A., M.S., R.D.,
  ASSISTANT DIRECTOR, DINING SERVICES, UNIVERSITY OF NEBRASKA-
               LINCOLN; PRESIDENT-ELECT, NEBRASKA
               DIETETIC ASSOCIATION, LINCOLN, NE

    Ms. Edwards. Good morning and thank you, Chairman Baca and 
Congressman Fortenberry. My name is Pam Edwards. I'm a 
Registered Dietician and the Assistant Director of the 
University Dining Services at the University of Nebraska in 
Lincoln.
    I'm also currently the President-elect of the Nebraska 
Dietetic Association and speak on behalf of 600 registered 
dietitians who are Nebraska's food and nutrition experts. I 
thank you for the opportunity to address the role nutrition, 
diet, and Registered Dietitians play in the prevention of 
obesity and chronic diseases and the expanding role of local 
foods in wellness.
    To start, nutrition and diet have a significant impact on 
the leading causes of death in the United States which are also 
considered chronic diseases and include heart disease, cancer, 
stroke, diabetes, pulmonary disease, and others.
    Chronic diseases are the most common and costly of all 
health problems, yet the good news is they are the most 
preventable. Nutrition is a key component of this prevention. 
An example is pre-diabetes, a condition in which the blood 
sugar level is higher than normal but not high enough to be 
classified as type 2 diabetes. Research has shown that 
nutrition therapy by Registered Dietitians is more effective 
than medication in slowing and/or preventing type 2 diabetes. 
Another example is heart disease. For every dollar spent on 
medical nutrition therapy provided by a Registered Dietician, 
$3 are saved.
    These chronic conditions are exacerbated by being 
overweight and obesity. In fact, in Nebraska there has been a 
steady increase in adult obesity at a rate of 16 percent in 
1995, to 27 percent in 2008. These are problems that defy an 
easy cure. Overall, the dilemma today is that our population is 
overfed and undernourished. This paradox is the most 
significant nutrition problem facing the nation. It has been 
reported that after the age of 8, the percentage of children 
consuming the daily recommended intake of key nutrients drops 
significantly, but obesity continues to rise.
    Prevention is the answer. Nutrition is a key component of 
prevention because diet can help prevent and/or delay the onset 
of both chronic diseases and obesity. We know that it is far 
more cost effective to prevent obesity and chronic diseases 
rather than to have to treat them. This prevention must be made 
in childhood when poor eating practices begin and are carried 
forward to adulthood.
    These poor eating practices include the following: Too many 
calories, too much saturated fat and trans fat, too much 
sodium, too many refined grains and sugars, and at the same 
time too few fruits and vegetables, too few whole grains, and 
too few legumes. The Centers for Disease Control reported that 
60 percent of United States children and adolescents eat more 
than the recommended daily amounts of saturated fats, and only 
one in four adults and one in five children eat the recommended 
amounts of fruits and vegetables.
    The overall strategy for prevention should center on plant-
based foods (fruits, vegetables, whole grains, nuts, seeds, and 
legumes) enhanced by lean meats, fish, poultry and eggs, 
healthy fats and oils, low-fat and fat-free dairy, and 
occasionally refined grains, sweets, and salt.
    Today we are also experiencing a surge of interest in good 
quality, safe and local food, and Registered Dietitians are 
playing a leading role in reconnecting individuals of all ages 
to the food they eat. The education--this education is being 
accomplished through local foods, a growing and important area 
of the overall wellness of our population.
    I want to now focus on my experience with our University 
local foods residence hall dining and catering program, known 
as The Good, Fresh, Local, or GFL, University of Nebraska-
Lincoln Sustainable Food Project that began in September of 
2005, with the goals to promote the value of local, meaning 
Nebraska, food; educate students about sustainable agriculture; 
and provide a new distribution channel for farmers and 
producers.
    The popularity of our GFL program with students has grown 
each year. Types of local foods served include free-range beef, 
poultry and eggs, fresh fruits and vegetables, whole grains, 
walnuts, pecans, cheese, and many other items. With GFL there 
has been an expanded and marked interest in eating fresh fruits 
and vegetables. Students are actually eating things like Swiss 
chard, beets, purple carrots, and cabbage, and when we ask them 
why, they tell us simply, ``They just taste good,'' and when 
foods and--fruits and vegetables taste good, more are eaten, 
therefore having a beneficial impact on health and wellness.
    Local foods can move university students in a direction of 
wellness and away from obesity and the development of chronic 
diseases. Students also learn how the local foods market can 
improve and help sustain the wellness of our communities 
environmentally, economically and socially. There are other 
successful Nebraska nutrition prevention and wellness programs, 
and more information about these is in my written testimony.
    Nutrition is the common denominator for preventing, 
decreasing and treating chronic diseases and obesity. 
Registered Dietitians are the food nutrition experts, and using 
their expertise will have a positive impact on preventing and 
reducing the incidence of obesity and chronic diseases of the 
United States. They are uniquely trained to address these 
issues and are playing a leading role in reconnecting 
individuals of all ages to food and health. The best strategy 
for health must be prevention. The most effective time for this 
to begin is childhood, and local food connections provide an 
exciting way to expose children of all ages to healthful foods 
that lead to wellness for life. Thank you.
    [The prepared statement of Ms. Edwards follows:]

Prepared Statement of Pamela J. Edwards, M.B.A., M.S., R.D., Assistant 
 Director, Dining Services, University of Nebraska-Lincoln; President-
           Elect, Nebraska Dietetic Association, Lincoln, NE
    Good morning and thank you Chairman Baca and Congressman 
Fortenberry. My name is Pam Edwards. I am a Registered Dietitian and am 
the Assistant Director of University Dining Services at The University 
of Nebraska-Lincoln. I am also currently the President-elect of the 
Nebraska Dietetic Association and speak on behalf of 600 dietitians who 
are Nebraska's food and nutrition experts. I thank you for the 
opportunity to address the role nutrition, diet, and Registered 
Dietitians play in the prevention of obesity and chronic diseases and 
the expanding role of local foods in wellness.
    Nutrition and diet have a significant impact on the leading causes 
of death in the United States (U.S.) and many of these are also 
considered chronic diseases.

   Heart disease.

   Cancer.

   Stroke.

   Diabetes.

   Pulmonary disease.

   Liver disease.

   Kidney disease.

   Pneumonia and influenza.

   Prenatal complications.

   Septicemia.

    Chronic diseases are the most common and costly of all health 
problems. Half of all Americans suffer from chronic diseases and 
alarmingly seven of ten die from them. The good news is that we can 
prevent some of these diseases and delay the onset of others. Diet is a 
key component of this prevention. For example, pre-diabetes is a 
condition in which the blood sugar level is higher than normal, but not 
high enough to be classified as type 2 diabetes. Research has shown 
that nutrition therapy by Registered Dietitians is more effective than 
medication in slowing and/or preventing type 2 diabetes. Another 
example is heart disease. For every $1 spent on medical nutrition 
therapy provided by a Registered Dietitian, $3 are saved.
    The alarming rate of overweight and obesity throughout all ages has 
exacerbated all of the chronic conditions. Two out of every three adult 
Americans are reported to be overweight or obese while one out of every 
three children is overweight or at risk for being overweight. There has 
been a steady increase in the percent of Nebraskans who are obese (BMI 
30 and above) from 16.3 percent in 1995 to 27.2 percent in 2008.
    The dilemma today is our population is overfed and undernourished. 
This paradox is the most significant nutrition problem facing the 
nation. Data shows that after the age of 8 the percent of children 
consuming the daily recommended intake of key nutrients drops 
significantly.(see attached chart) But at the same time obesity in 
children continues to increase. These are problems that defy an easy 
cure.
    Prevention is the answer. Nutrition is a key component of 
prevention because diet prevents and/or delays the onset of both 
chronic diseases and obesity. We know that it is better to prevent 
obesity and chronic diseases, rather than to have to treat them.
    Thus focusing on our children's nutrition and health is critical. 
Poor eating practices begin in childhood. These poor eating practices 
include consuming too many calories, too much saturated fat and trans 
fat, too much sodium, and too many refined grains and sugars. At the 
same time we are eating too few fruits, vegetables, whole grains, and 
legumes. The Center for Disease Control reported that 60 percent of 
U.S. children and adolescents eat more than the recommended daily 
amounts of saturated fats. Only one out of four U.S. and Nebraska 
adults and one out of five U.S. children are eating the recommended 
amounts of fruits and vegetables.
    The overall strategy for prevention should center on plant- based 
foods (fruits, vegetables, whole grains, nuts, seeds, and legumes) 
enhanced by lean meats, fish, poultry and eggs, healthy fats and oils, 
low-fat and fat-free dairy and occasionally refined grains, sweets, and 
salt. Including a variety of these foods as part of healthful eating 
practices is recommended so that complex carbohydrates, healthy fats, 
protein, vitamins, minerals, phytonutrients and fiber are obtained 
through the food eaten.
    The American Dietetic Association's (ADA) research shows that 
American parents are reluctant to help their children because they 
don't know how to help and they are disengaged from their children's 
eating habits. Registered Dietitians (RDs) are uniquely trained to help 
parents; however, few people are referred to RDs because their services 
are rarely covered by insurance. Registered Dietitians are the food and 
nutrition experts and are uniquely trained to focus on nutrition and 
prevention. Using RD's expertise in counseling individuals of all ages 
about healthful nutrition practices will have a positive impact on 
reducing the incidence of obesity and chronic diseases in the U.S.
    While there is understandably great concern about obesity and 
chronic disease, there is at the same time a surge of interest in good 
quality, safe, and local food occurring throughout the United States 
and Registered Dietitians are playing a leading role in reconnecting 
individuals of all ages to the food they eat. This includes teaching 
not only about the nutritional impact different foods have on health 
but also where and how food is grown and raised and how to prepare and 
experience the exciting taste of a variety of food. For we all know if 
food doesn't taste good it is not eaten and no nutritional benefits are 
received.
    I will now focus on unique and practical approaches to prevention 
by Nebraska RDs. The first is my experience with a local foods 
university dining program. Fresh locally-grown foods have a positive 
impact on wellness due to students eating more healthfully. Why? 
Because it tastes good and replaces higher calorie foods.
    Our program is known as The Good. Fresh. Local. (GFL)_The 
University of Nebraska-Lincoln Sustainable Food Project. This local 
foods residence hall dining and catering program began in September 
2005 with the goals to:

   Promote the value of local (Nebraska) food.

   Educate students about sustainable agriculture and the 
        positive impact it can have on the environment, local economy, 
        and communities.

   Provide a new distribution opportunity for local farmers and 
        producers in the world of university dining service.

    At the time GFL began there were approximately 200 college and 
universities throughout the United States with local foods programs on 
their campuses. This number continues to grow along with college 
students' consumption of and interest in local foods.
    Examples of local foods served in the GFL program include a variety 
of fresh fruits and vegetables, pasture-raised ground beef and poultry, 
free-range eggs, organic oat flakes, natural pork, walnuts and pecans, 
homemade whole grain bread products, cheese, jams, honey and dressings. 
Today the program includes approximately 75 Nebraska farmers/producers 
and manufacturers which is up from 25 when the program began. 
    The popularity of the GFL program has grown each year with students 
proclaiming ``It's GFL time.'' Students have connected with local foods 
as evidenced by an average of 35 percent increased attendance when GFL 
meals are served. There has also been a marked expanded interest in 
eating fresh fruits and vegetables. Students have willingly tried and 
enjoyed vegetables such as Swiss chard and beets along with purple 
carrots, broccoli and cabbage. When students are asked why they are 
willing to try the various local fruits and vegetables--the simple 
response is ``They just taste good.'' And when fruit and vegetables 
taste good--more are eaten, therefore having a beneficial impact on 
health and wellness.
    The overall goal is for the university students to incorporate 
these healthful nutrition practices so that when they graduate they 
will be moving in a direction of wellness and away from obesity and 
development of chronic diseases. Another major benefit of the GFL 
program is that students gain an appreciation for Nebraska agriculture 
in rural communities and begin to understand how the local foods market 
can improve and help sustain the wellness of our communities--
economically, environmentally, and socially.
    Nebraska RDs are involved in nutrition settings where program goals 
are aimed at prevention by increasing the consumption of fruits and 
vegetables and other types of foods that result in healthful meal 
practices. The following highlight programs that increase the 
consumption of fresh fruits and vegetables including those with local 
food connections.

   The USDA's Fresh Fruit and Vegetable Program (FFVP) is 
        administered by Bev Benes, RD, PhD, Director of the Nebraska 
        Department of Education--Nutrition Services. The FFVP serves 
        fresh fruits and vegetables to elementary school students as 
        healthy snack options that are alternatives to snacks high in 
        fat, sugar and salt. Participating schools must have at least 
        50 percent of students eligible for free and reduced-priced 
        meals and the snacks are provided in addition to other school 
        meal programs. A goal of the FFVP is to help combat childhood 
        obesity by teaching children the importance of developing 
        healthy eating habits. In addition, schools are required to 
        provide nutrition education to accompany the snacks. Ideally, 
        children will experience the great taste of a variety of fresh 
        fruits and vegetables and will begin to include those as part 
        of their eating practices for the rest of their lives. An 
        exciting dimension of the FFVP is that schools can support 
        local agricultural producers by buying fresh produce at 
        farmers' markets, orchards, and growers in the school's 
        community. By serving locally grown produce, schools can 
        support their communities and also educate students about the 
        local agriculture in their communities and state. In 2008/2009 
        Nebraska had 28 participating schools and there will be 59 
        schools participating in 2009/2010.

   A study to determine the impact of local fruits and 
        vegetables on a school lunch program was conducted at the 
        Central City Middle School in Central City, Nebraska. Because 
        USDA now allows schools to purchase local produce, Joyce Rice, 
        School Food Service Manager, wanted to determine if students 
        would eat more fruits and vegetables if offered a variety of 
        fresh local fruits and vegetables. The program goal was to 
        increase fruit and vegetable intake for healthier students. The 
        study was conducted during first semester 2008-2009 and 
        involved 500 students from kindergarten through eighth grade. 
        Local fresh fruits and vegetables were purchased from local 
        growers in the St. Libory area. The impact of the program 
        resulted in fresh fruit and vegetable intake that increased by 
        199 percent by serving local fruits and vegetables. Because of 
        Nebraska's weather, the program was limited by the seasonality 
        of local fresh fruits and vegetables

   The garden-to-school connection has been planted at Beattie 
        Elementary School in Lincoln, Nebraska by Karen Creswell, M.S., 
        R.D. and Master Gardener. Elementary school children are taught 
        about food through planting, tending, and harvesting produce 
        from their school garden. This experience is enhanced by 
        learning how to `compose' a meal made of the following:

     The cook, the food and the eaters.

     A balance of food groups 1-2-3-4-5.

     Inspiration from the season.

     Flavor.

     Variety and contrast.

    The overall goal of the program is to work with children on 
        becoming `skilled eaters' so they know how to handle themselves 
        around new and strange food. This type of positive experience 
        in a safe environment under the direction of a Registered 
        Dietitian leads children toward to the development of a 
        positive relationship with food `from seed to plate'. When 
        children can expand their food preferences they do better with 
        eating for good health and good weight regulation.

   In July, 2008, the Nutrition and Activity for Health Program 
        within the Nebraska Department of Health and Human Services was 
        selected as one of 23 states to receive support from the Center 
        for Disease Control (CDC) for chronic disease and obesity 
        prevention. Work in these areas is centered on promoting 
        healthy eating and physical activity and creating or enhancing 
        environments and systems that support healthy eating and 
        greater physical activity. One of the focus areas of the 
        funding is to make it easier for Nebraska residents of all ages 
        to eat more fruits and vegetables. This is facilitated through 
        CDC's Fruits and Veggies_More Matters initiative which 
        encourages the consumption of fruits and vegetables by 
        explaining the impact fruits and vegetables have on promoting 
        good health and reducing the risk of chronic diseases--stroke, 
        cardiovascular disease, and certain cancers. Within the 
        Nebraska Department of Health and Human Services, Holly 
        Dingman, M.S., R.D. serves as Coordinator for the Nutrition and 
        Activity for Health program and the Coordinator for CDC's Fruit 
        and Veggies--More Matters initiative. Holly has successfully 
        collaborated with two different state agencies to promote more 
        fruit and vegetable consumption in the following ways:

     Supporting the Nebraska Department of Education with 
            the Fresh Fruit and Vegetable Program (FFVP) for elementary 
            school students.

     Working with the Nebraska Department of Agriculture to 
            start a weekly produce market outside the state office 
            building designed so that state employees and individuals 
            working in downtown Lincoln can purchase locally grown 
            produce. This project demonstrates how two state agencies 
            share a desire to improve the health of Nebraska residents 
            and the economy of Nebraska agriculture.
Conclusion
    Nutrition is the common denominator for preventing, decreasing, and 
treating chronic diseases which are the most common and costly of all 
health problems. The alarming rate of overweight and obesity has 
exacerbated all the chronic conditions. Registered Dietitians are 
uniquely trained to address these nutrition issues. And they are 
playing a leading role in reconnecting individuals of all ages to food 
and health.
    The best strategy for health must be prevention. Nutrition is key 
to prevention because diet prevents and/or delays the onset of both 
chronic diseases and obesity. The most effective time for this to begin 
is in childhood. Local food connections provide an exciting way to 
expose children to healthful foods that lead to wellness for life.
Note:
     American Dietetic Association's research has documented that most 
Americans have no idea of their own nutritional status, weight or 
eating patterns. Even when a diet-linked condition as serious as pre-
diabetes is identified, a patient is likely to encounter very real 
barriers to professional nutrition care and services. In other words, 
few people are referred to Registered Dietitians to begin with as their 
services are rarely covered by insurance. To explain: Medicare is the 
template for most insurance plans. Medicare currently covers screening 
for pre-diabetes. A patient can be tested as frequently as every 6 
months to check his or her status. However, there is no referral--no 
covered care by Medicare or most private insurance--until pre-diabetes 
deteriorates to full blown diabetes. Only when the diagnosis has 
reached a dire situation will Medicare meet patients' needs through 
covered diabetes services. If the patient is very lucky his or her 
physician may send them to a Registered Dietitian for Medical Nutrition 
Therapy or an accredited Diabetes Self Management Training program.
    A children's nutrition and activity program is being piloted that 
uses the expertise of Registered Dietitians. Thanks to the work of the 
Alliance for a Healthier Generation, a pilot program has been developed 
to help overweight children see their physicians and Registered 
Dietitians to learn better nutrition and activity habits. Several 
health insurance organizations are part of this ground-breaking effort 
which will reach nearly one million children during the first year. The 
long-term goal of the initiative is that within the first 3 years, 26 
percent of all overweight children (approximately 6.2 million) will 
have access to the benefit.
                               Attachment

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



    The Chairman. Thank you very much. I want to thank all of 
the witnesses for their expertise.
    You've been extremely patient, and now we'll begin with a 
series of questions from myself and, of course, Congressman 
Fortenberry as well. But before I do, I just want to make a 
statement. As you look at obesity and longevity and the cost 
factors: I was watching ESPN, and I was watching a broadcast 
where the Texas Rangers were playing someone, and a community 
lady--she happened to be a hundred years of age--and they asked 
her who's her favorite player, and she said, ``Well, my 
favorite player is young third baseman from there.''
    And then as the game went on, of course, someone came over 
the loudspeaker and said the lady was celebrating her birthday, 
and then they asked her, ``Well, what are you going to do after 
the game?'' And she said, ``I am going to ask for my own 
exit.'' I mean, it's amazing. So that happens when we're 
talking about nutrition and proper health, and as I looked at 
the woman, she was not overweight, and that has a lot to do 
with it. When you look at longevity in terms of living a lot 
longer and exercising, as we see here to the left, we'll live a 
lot longer if we diet right and have the appropriate nutrition 
and then also reduce our costs to each one of our states, 
counties and cities that are bearing the costs to provide a 
service to someone who is chronically ill. Not only will it 
prevent obesity and being overweight, but diabetes was 
mentioned earlier in terms of adding to these costs and its 
impact it has on our family members.
    Personally, I've lost my father, who was diabetic, 
overweight. He originally lost toes and then half a leg and a 
full leg. Two of my brothers ended up dying, my sister, nieces 
and nephews, and then my brother-in-law, who was a great 
athlete, played ball, but didn't take care of himself, and 
ended up having dialysis, needed a kidney transplant because 
his health wasn't there, and he ended up dying. The effects it 
has on us and the effects it has on others are very important.
    That's why I really appreciate the leadership and vision 
that Ranking Member Fortenberry has, and I appreciate that 
vision and leadership in bringing awareness and addressing the 
issue and tying it into wellness, nutrition, and the cost to 
our society. We can coordinate how it is all interrelated, how 
it would benefit our society and our nation, and the impact 
it's having on children. Obesity at a younger age is related to 
learning abilities when we don't provide fresh fruits and 
vegetables.
    That's why one of the things we have to do--and I mentioned 
that by changing the culture we have to change attitudes and 
behaviors and make adjustments, and that's a hard thing for all 
of us. Some of us have habits because of traditions from one 
family to another. We ended up eating because our parents put 
it on the table. I remember eating a lot of flour tortillas 
and, once in a while, noodles.
    Mr. Fortenberry, remember our first meeting that we had on 
obesity. A Member from Ohio had asked a question of all of us, 
how many of you still weigh the same as you did in high school. 
With a show of hands, there was only one person that weighed 
the same amount as they weighed when they graduated from high 
school.
    Mr. Fortenberry. It wasn't me.
    The Chairman. I have a little bit more. But with that I'd 
like to begin the questions for all of the panelists right now, 
and anyone of you, you can chime in and give a response. You're 
all experts in the fields of nutrition, obesity and chronic 
illness. In your expert opinion--and I state, in your expert 
opinion, what is the one most important thing that we can do as 
a nation to help fight the obesity epidemic, the one thing? 
Anybody begin.
    Ms. Russel. I really believe it's a cultural change in our 
society. It's building activity into our daily lives. It's not 
building our lives around a screen. It's have a lot of family 
involvement, et cetera. To me, it's a total cultural change 
compared to the way that we live.
    The Chairman. Can you sort of define ``cultural change''? 
Because I know we've got a recording of this, and there are a 
lot of definitions for cultural change. Elaborate a little bit 
on that.
    Ms. Russel. It's figuring out how we can build low 
intensity sustained exercise into our daily lives. I'm not 
suggesting that we all give up on cars, but that we plan time 
in our daily activities and schedules for more walking, for 
example. An example is, like I was mentioning in my comments, 
what is going on in Albert Lea, Minnesota. One of the things 
that they've done there to help children get more exercise in 
their daily lives is the school buses in the public schools are 
now stopping a quarter mile away from the front door of the 
school, so the children are walking a quarter mile from the bus 
into the school and then reversing it at the end of the day. 
You know, simple things like that.
    Dr. Yaroch. I just attended a meeting about 2 weeks ago, 
and it was called The Weight of the Nation Meeting, and it was 
held in Washington, D.C., and was very interesting. 
Policymakers were researching and getting together to talk 
about this issue, and one of the things I mentioned in my 
testimony is I really do think that it's going to take a very 
comprehensive approach in order to address the situation, so 
from my standpoint, I'm a researcher.
    There are different models that are proposed, like a social 
and ecological model, so I mentioned it briefly in my 
testimony, but one of the things, you know, that's really 
important is to think of all these different factors we have. 
Individual level factors, as you mentioned, we do have level 
factors like knowledge, attitudes, so we need to do things 
about changing those, whether it be among kids or adults.
    Environmental level changes that I mentioned vending 
machines in schools, and then really having those policy level 
changes in order to support all of this, so I wouldn't say that 
it's just one thing. I mean, I'm just racking my brain 
thinking, All right, is there one? But I really do think that 
we need a comprehensive approach that really incorporates all 
of these factors.
    Ms. Edwards. I guess I would say that this is very 
practical, but it's exemplified by what's at the table, and 
that is that people need to reconnect with food, just basic 
food and how great it is. It sounds very simple, but we just 
have to make the move of getting to know what fruits and 
vegetables are, what are whole grains, as a first step toward 
reducing obesity and the rate of chronic diseases.
    Dr. Sitorius. I'm going to add one thing. You said one 
thing, and I can't think of that one thing, but I think 
education and building teams, because I think it's education 
for the providers of health care, and it's having them team 
together. We have a lot of examples of individual projects, and 
I think it's education of the citizens, but it's going to 
happen through that kind of education.
    The Chairman. Thank you. That's a very important point, 
because as we look at the comprehensive approach, change in 
attitudes and behaviors and adjustments and side effects; you 
can't make change unless you're educating the entire country. 
That's a good point. Thank you very much. I have several 
questions, but I know that my time has run out, and as I look 
at the little red light, it indicates to me there's no time to 
ask another question, but I'm going to ask one more question of 
all of you, and then I'll hand it over to our Ranking Member, 
for his questions. Then, we'll come back, and we'll have some 
additional questions we may ask. How can we best raise the 
awareness of obesity and its cost in relation to chronic 
illnesses in America?
    Dr. Sitorius. Well, one is by holding hearings that are 
outside of the purview of Washington, D.C. I think it's very 
important to be out where the people are and having these kinds 
of discussions where you have people present who can listen.
    Dr. Yaroch. I think our sociological campaigns are very 
important so, for instance, I know I've just said that I moved 
to Nebraska a few months ago, but there is 54321 Go! Campaign 
that's going on right now with the Omaha kids. We begin to 
raise awareness by providing information, whether it be kids, 
adults alike, on how they actually go about improving dietary 
and physical activity efforts.
    Ms. Russel. I would say I think the media has done a good 
job of covering the point of the costs of obesity. I think our 
problem is individuals simply don't know what to do about the 
problem. They're helpless, so to speak, or feel helpless to 
attack their own overweight problem.
    Ms. Edwards. I think we talk about everything starting with 
children, and I would think that the education in the school 
systems with the children, as well as their parents, would be a 
very good way of starting. When you give to the children and 
their parents, you're starting momentum for later in life.
    The Chairman. Thank you very much.
    Dr. Yaroch. Can I just add one more point? I do want to 
point out that I think education is key and very important, but 
we also know that giving people the knowledge doesn't 
necessarily change their behaviors, so education, to me, in 
addition to all these other things like social marketing, and 
other things that we can do and actually giving people the 
tools to make the changes.
    The Chairman. Thank you. I think all of you have brought up 
some very interesting points and ways to address it, and the 
media can also help us in creating this kind of awareness. Now 
that we have a hearing, as I stated before, we have foresight. 
We can look at the costs to our society in reference to 
obesity. We have $75 billion in direct costs and $139 billion 
in indirect costs just now. Then we look at what's projected if 
we don't do anything in terms of the year 2030.
    I mean, we're not talking about millions. We're talking 
about billions when we look at $160 billion if--it's billions 
if we don't address the issue, and the media can play a very 
important part in helping us get that kind of awareness and 
knowledge along with nonprofit organizations. With that I'd 
like to turn it over to Ranking Member Fortenberry to ask some 
questions.
    Mr. Fortenberry. Thank you, Mr. Chairman.
    Dr. Sitorius, I want to pick up a comment you made, and 
then I'm going to refer to you after I point out some of the 
particular findings that I'd like to highlight from all of your 
testimony. If you all would be willing to respond as well to 
the questions I generate to Dr. Sitorius. You said our 
healthcare system is not properly designed for wellness, it is 
reactive, and then you laid out a couple of critical factors 
regarding specifically the medical culture to the patient 
centered approach.
    I think that's an important point, and all of you, if you'd 
like to respond back too as we unpack that a little bit 
further, that's a key point in your testimony, but the key 
finding is I think that all of you touched on one way or 
another, again, the cost of the significant difficulty of 
obesity in our country being $7 to $8 billion or so 10 years 
ago. It now has doubled. You have pointed out that we consume 
300 more calories today than 25 years ago, obesity being 
particularly acute as well with Native American populations, 
and there are two very large reservations in the First 
Congressional District, by the way.
    Dr. Russel, you pointed out the blue zones, and, again, 
Japan, Costa Rica, Italy, and Loma Linda. You also suggested 
that if I just serve myself in the kitchen, I could lose these 
extra, or something like that. Interesting key points, Ms. 
Edwards, you pointed out that even in Nebraska the issue of 
obesity rises from 1995 at 60 percent up from 27. I think we 
have a pretty good idea of the trend line here.
    I think we also have a pretty good idea in general of what 
we have to do, but in terms of systematic changes, going back 
to what you said, Dr. Sitorius, our healthcare system is not 
properly designed for wellness, this interplay between 
nutrition and lifestyle practices, meaning the healthcare 
system being reactive in nature, creating a gap of what we all 
want to achieve, all--what we all are watching happen in the 
wrong direction. Can you further unpack this idea of looking to 
a more patient-centered approach?
    Dr. Sitorius. Well, it's not new. Pediatrics has been doing 
this since about 1967 or the early 1960s, but it is going to 
require a change in the incentives for patients and incentives 
for the providers of health systems to really jump into this.
    I think I stated it as clearly as I can think about it, and 
that is we currently reward people for doing something to 
somebody after they've already had a problem, and we need to 
really look at a system that recognizes and rewards both the 
patients, lawyers, and the health professionals to work--
working at prevention. Not just preventing it, the chronic 
illness initially, but dealing with it secondarily and 
interpolate prevention.
    Mr. Fortenberry. I agree with your key point there. I think 
our next panel will actually have some experience in some of 
those incentives so, again, that will be unpacked later. You 
talk about the limited ability to monitor and support patients, 
time constraints, as well as just episodic treatment that all 
link itself to the rethinking of a team type of approach to 
patient care. Did I get your----
    Dr. Sitorius. Yes. You're right, and I think there's a 
great deal of expertise to manage a lot of medical problems 
that's done in silence or individually, and I think we have to 
find a way to put the systems together better and to allow them 
to communicate. IT is going to be--information technology is 
going to be very important in that to allow that communication, 
but I also think we have to enjoin the patient and community to 
be part of the solution to these chronic illnesses, because 
they are equally important, as I heard some of my colleagues 
talk about, as the support system changes.
    Mr. Fortenberry. The rest of the panel, would you like to 
respond to the issue that I just laid out?
    Dr. Yaroch. Yes. Actually, there have been studies to show 
that doctors are the most trusted source for people to get 
their information from. However, physicians don't even 
typically get training in nutrition. So, for instance, where I 
got my doctorate was Emory, and the people who were getting 
their MDs were only required to take one short course in 
nutrition, so I feel that there's a breakdown in the system 
there.
    And just the whole idea that this is an interrelated 
system, so connecting doctors with patients, patients with 
other important things, and just one of the things I didn't 
have a chance to say that I brought up a little bit in my 
testimony is that really there are some of us who don't have 
access and availability to healthy foods. So the idea of some 
populations, low income, African American, American Indian, 
Hispanics who live in food deserts who don't even have the 
choices. They don't have it there to be able to make it.
    Mr. Fortenberry. This is actually a phenomenon in some 
urban areas as well, as the Chairman and I learned about on the 
last hearing on obesity. It's not just education, but it's 
access, and that was a key finding.
    Ms. Russel. I really agree with Dr. Sitorius's point that 
our system is not set up well to focus on prevention, and 
absolutely I agree as well that the physician has such an 
ability to make an impact with the patient when they--in that 
exam room when they look at them eye to eye and tell them they 
need to stop smoking, or they have an obesity problem, or 
whatever the chronic condition might be.
    The problem with our system, of course, as you well know, 
because you made this comment, Representative Fortenberry, in 
your opening remarks, is that our physicians are paid, frankly, 
on piecework, and they have--with the physician shortage in our 
country, there are tremendous volumes of patients to be seen 
every day, and our extremely busy physicians simply have very 
limited time to have these very deep, meaningful conversations 
which can be very impactful with patients, so I think that's an 
example of how our system is not put together well.
    The support needs to happen with prevention and wellness.
    Ms. Edwards. It's now been said that a team approach is the 
best way to do anything, whether it's in the hospital setting, 
whether it's in the organization, whether it's in the school, 
wherever it might be. I think that you find the people who are 
best suited to provide the care in those types of organizations 
and, as far as nutrition goes, speaking for Registered 
Dietitians, in those kinds of settings, I would like to see 
that Registered Dietitians are the people who are trained in 
nutrition and are the ones who are spoken to and asked for 
their advice in working with these types of different 
situations for obesity and reducing obesity and chronic 
diseases among the population.
    The Chairman. Thank you. We begin with a series of 
questions that all start up with Ms. Russel. Ms. Russel, thank 
you for your testimony. As a Californian, my Congressional 
district borders the area of Loma Linda University, and you 
mentioned that as one of the cities researched, as referred to 
in your testimony. I believe you're right. We need to change 
the culture of America when it comes to food.
    As a Hispanic, I was raised to view food in a particular 
way, but I had to learn I couldn't always eat tamales and 
menudo, so I had to change that. Do you believe there's any 
particular guidelines we must follow as we work to change the 
culture around food?
    Ms. Russel. Again, the research that I was quoting, one of 
the commonalities among all of the four areas of the world was 
that the diets of people were plant based with a heavy dose of 
beans and nuts and just a small amount of wheat, so take 
whatever you want from that. That was the common dietary theme 
among those four areas in the world with a striking high in 
longevity trends and a striking low in chronic stress.
    The Chairman. Thank you. I know that I've had to change. 
Even this morning I had fruits, and I wanted to have the 
omelet. I was thinking, oh, gosh, these potatoes, these are 
real good, but I had the fruit.
    Ms. Russel. Good for you.
    The Chairman. In your testimony you pointed out one of the 
biggest struggles we have in Congress is how to pay for good 
programs. The Fresh Fruit and Vegetable Program is certainly a 
step in the right direction, but it's costly. Have you 
investigated how much more, if anything, it costs for schools 
to purchase locally produced items than those that are more 
readily available?
    Ms. Edwards. As far as the cost, I'm not representing 
public schools. I can speak for our particular situation, that 
local foods do sometimes cost more, but the benefit far 
outweighs the cost, and in planning properly to give those 
types of foods in the system is certainly something that can be 
accomplished very successfully, and I'd like to add one more 
thing about Loma Linda. Loma Linda is has a very, very high--
not total--vegetarian population; and, therefore, their diets 
are plant based, and for years the research has shown that in 
that area they have a lesser degree of chronic diseases, 
obesity.
    They're more active, they don't smoke, so I think that 
whole population is a very, very good one to study when you 
look at prevention.
    The Chairman. Dr. Sitorius, you know, I was struck by your 
statement in the testimony that the current healthcare system 
is not designed to effectively promote proper wellness and 
nutritional practices. Can you elaborate on your suggested use 
of the Patient Centered Medical Home model?
    Dr. Sitorius. As I said, I think they have been tried. They 
do have some validity with the pediatric groups for the last 40 
years, and I think there is--as we're looking at changing some 
of the direction of our healthcare system, I think this would 
play a tremendous impetus, because you get primary exposure, 
you get teamwork approach. I don't think any of these chronic 
illnesses can be managed by one physician or one health system 
piece by piece.
    I think it really takes a connected system and better 
communication between the providers in the system. It's a 
teamwork approach.
    The Chairman. Do you think this location is the next in 
line to use in terms of exercise and what's available in terms 
of changing actions and behaviors?
    Dr. Sitorius. I think this is an excellent location, and 
again, speaking as an educator at the science center, we have 
to take the young people we get into the health science system, 
teach them interdisciplinarily and also teach them about how to 
practice in this environment that might be out there in the 
future instead of sustaining what has been the past. I think 
that's going to be one of the responsibilities we're going to 
have as academic health science centers.
    Mr. Fortenberry. Well, Doctor, I'd like to follow up on 
that last point. Are you suggesting there is a significant 
under-emphasis in medical school training on this 
interdisciplinary approach?
    Dr. Sitorius. Yes, I would say that's true.
    Mr. Fortenberry. So how do we fix that?
    Dr. Sitorius. Well, I think as the healthcare system 
evolves and if we can build in the popular incentives for 
patients and their providers when it comes to prevention and 
wellness, I think you're going to find a lot more interest and 
a lot more energy to move towards this interdisciplinary 
approach and teamwork approach to providing medical care.
    Mr. Fortenberry. Let me switch now back to Ms. Edwards 
regarding the--what's the full name of the title of the 
cafeteria at the University, local fresh and----
    Ms. Edwards. Good, Fresh, Local.
    Mr. Fortenberry. Good, Fresh and Local.
    That's right. Talk about the demand. Is it significant? Is 
it profitable? You're a nonprofit setting, but is there a 
demand?
    Ms. Edwards. I think the demand has been tremendous. It's 
grown each year, and as far as profitability, one thing that 
we, personally, think is that students now are becoming more 
familiar with local foods, and potential students coming to the 
University are aware of local foods. They're asking, Do you 
have those kind of programs? So that all helps the University 
as far as bringing in potential of more students to come, so 
it's been extremely popular, and students are asking for it, 
and habits are changing, which is the most important thing.
    Mr. Fortenberry. What percentage of the student population 
do you surmise partakes in the purchase of these foods?
    Ms. Edwards. Well, within our housing department, which is 
where it's offered, it's about a fifth of the 25 percent, up to 
50 percent on special occasions, that partake in this.
    Mr. Fortenberry. Excellent. Dr. Yaroch, given your 
background in cancer research, talk about the linkage between 
nutrition and cancer prevention.
    Dr. Yaroch. Just the diet, physical activity, both of those 
behaviors are related to obesity, which then ultimately is 
related to cancer, various cancers, as well as heart disease, 
diabetes, all these other things, so there is a linkage. I 
mean, there's a very clear linkage in the literature showing 
that people with poor diets who are less physically active and 
more overweight have a higher tendency to get various cancers.
    Mr. Fortenberry. So you can do everything right, of course, 
and still get cancer, but the probability of that is, would you 
say, significantly increased with weight, the risk?
    Dr. Yaroch. Oh, yes, absolutely.
    Mr. Fortenberry. Mr. Chairman, that's all the questions 
that I have.
    The Chairman. Thank you very much. Again, we thank everyone 
for their efforts and knowledge in sharing that information. 
We've a lot of work ahead of us in changing health, attitudes 
and behaviors and also as we look at the cost difference of 
proper nutrition, the more we ask that when a child learns 
behavior in school that provides fresh fruits and vegetables in 
practice, the more you can change your attitude and behavior 
and probably the test results too.
    You ought to change how--we talk about no child left 
behind, but it seems like we're leaving them behind in fresh 
fruits and vegetables. So, today we'll look at ideals, making 
sure that every child has some form of fresh fruits and 
vegetables. Again, we change culture and attitudes, and we 
can't change what the advertisers are going to do on TV because 
the media, the first thing they do is they have a fast food 
commercial after something you watch on The Disney Channel.
    They're rushing right on you, we've all got the same bad 
habits, but I've got to change my habits as well. With that I'd 
like to thank you and call our next panelists. Thank you very 
much.
    We'd like to now begin the second panel, and the second 
panel will address wellness and prevention practices. I will 
begin by welcoming each one of you to the table, and we'll 
proceed at this time. I'll ask Representative Fortenberry to 
introduce each of the panelists. As I stated before, if you 
weren't here, you have approximately 5 minutes to give your 
statement. We'll allow latitude. Don't panic if the red light 
comes on, but remember that the first person will set the 
example for the others, I want to remind you.
    I'll make that statement first. So with that we will begin, 
and hopefully the other two panelists are somewhere in here. So 
if I could have Representative Fortenberry introduce the first 
panelist and have the first panelist begin with a 5 minute 
presentation.
    Mr. Fortenberry. Thank you, Mr. Chairman, and today I'd 
like to welcome Mr. Wayne Sensor as our first expert witness. 
He is the President and CEO of Alegent Health, a company of 
nearly 10,000 employees of Omaha. Mr. Sensor brings 25 years of 
experience in leading major healthcare systems and previously 
served as a President and CEO of another large healthcare 
system in Louisiana. He was named to be on the Executive 
Committee of the greater Omaha Chamber of Commerce and was also 
selected as its Chair of the Public Policy Council. He serves 
on the National Governors Association State Alliance on e-
Health and the HealthLeaders Advisory Board. Thank you, Mr. 
Sensor, for being here. I'll introduce all of you, and then 
we'll turn to you for your testimony.
    Our second expert witness is Dr. Blake Williamson, the Vice 
President and Senior Medical Director of Blue Cross Blue Shield 
in Kansas City.
    Dr. Williamson formerly served as Senior Vice President of 
Asante Health System in Oregon and brings over 10 years of 
experience in managing integrated health systems, managed care 
organizations, and physician practices. Welcome, Doctor.
    Our third witness is Marsha Lommel. She is President and 
CEO of Madonna Rehabilitation Hospital in Lincoln, formerly a 
speech pathologist. She has served as CEO since 1989. Marsha 
has served on numerous health and service-related boards at 
committee and state and local levels, including American 
College of Healthcare Executives, Wells Fargo Lincoln Advisory 
Board, VHA of the Midlands, Lincoln Chamber of Commerce, 
Community Health Endowment Board, Friendship Home, Leadership 
Lincoln, Governor's Urban Advisory Task Force, American Heart 
Association, and the American Burn Association. Thank you 
again, Ms. Lommel.
    Our fourth witness is Dr. Glenn Fosdick, President and CEO 
of Nebraska Medical Center, a 687 bed acute care teaching 
hospital that includes over 300 outpatient clinics in four 
states.
    Mr. Fosdick formerly served as Senior Associate Dean for 
the University of Nebraska College of Medicine in Omaha and 
before that as President and CEO of another health center in 
Michigan. Welcome, Mr. Fosdick.
    And our final witness is LuAnn Heinen, the Vice President 
of the National Business Group on Health and Director of the 
Institute on the Costs and Health Effects of Obesity located in 
Washington, D.C. She formerly served as Vice President of the 
Center for Healthcare Evaluation at the UnitedHealth Group in 
Minneapolis and as a Divisional Vice President at Chronimed, 
Incorporated. She also provided consulting services on Federal 
health plans at The Lewin Group, a financial healthcare 
consulting firm, so we'd like to welcome you all.
    The Chairman. Thank you. At this time we'll begin with the 
first panelist.

 STATEMENT OF WAYNE SENSOR, PRESIDENT AND CEO, ALEGENT HEALTH, 
                           OMAHA, NE

    Mr. Sensor. Thank you very much, Congressman Fortenberry 
and Congressman Baca. It's a pleasure to be here to participate 
in democracy at its best, at the grass roots level. I am Wayne 
Sensor. I'm the CEO of Alegent Health. In our brief moment 
together today, I want to talk a little bit about some of the 
specific experiences we've had as an organization in 
stimulating prevention and wellness, both within our own 
workforce and more broadly in the communities we serve.
    I would posture Alegent in a relatively unique position as 
we talk about health and wellness in that we are both a major 
employer with over 9,000 employees, the largest permanent 
employer in the State of Nebraska, but also the largest 
regional provider, which gives us some latitude to experiment 
and innovate ways that might be a bit unique. By way of 
background, Alegent Health is a faith based, not-for-profit 
healthcare system, and we would like to effectually position 
ourselves as what I would call a ``post-reform'' health system.
    That means that we've done things like substantially push 
health information technology across our delivery system. We've 
worked hard to improve quality and safety while reducing the 
cost of the care we provide and to provide a seamless 
transition of patients--for our patients across our entire 
delivery system. We've done that, in part, by the development 
and deployment of evidence-based care protocols across all of 
our delivery sites, and, in part, because of that work we were 
recently recognized by the Network for Regional Healthcare 
Improvement, which is a national coalition of Regional Health 
Improvement Collaboratives, as the number one health system in 
the United States for our CMS Core Measure of Performance as 
well as our HCAHPS patient satisfaction level.
    As we think about ways in which we can support and promote 
wellness and prevention, certainly one of the underlying 
principles must be to help people become more accountable for 
their health and their health care on an individual basis. From 
our vernacular that means we need to develop incentives to 
cause Americans to do the right things that are otherwise in 
their best interest anyway, and we need to provide them with 
good information so that Americans can make better choices 
about how they can be good consumers of health and health care.
    As an organization our journey began over 3 years ago 
really beginning with the petri dish of our own employees and 
broadening out to our community at large. It began with the 
development of a robust benefit plan for our own employees, our 
9,000 employees and their dependents, that would cause people 
to focus on prevention and wellness. Two constructs in our 
benefit plan particularly speak to prevention and wellness.
    The first is if it's preventive care, it is free, no 
deductible, no co-pay for a wide array of things, everything 
from child immunizations to annual physicals, mammographies 
colonoscopies, and everything else you would suggest for a 
particular age cohort. My workforce today seeks 2\1/2\ times 
more preventive care than the nation at large. What a great 
investment.
    The second construct built into our own healthcare program 
is to incentivize people to make health changes, reimburse 
people to lose weight, to get active, to lose weight or to 
manage their healthcare conditions. Just a case in point, 500 
of our employees have quit smoking. We've lost 17,000 pounds as 
a workforce in the last 24 months. The results have been 
relatively phenomenal.
    First, from the cost perspective, I will tell you our 
workforce is now engaged on a daily basis in making choices 
about their health care, making choices about how we can be 
more engaged in their health, and you'll ask me this, so I'll 
say it out loud now. Our motive wasn't lowered costs, but, 
indeed, we've seen increases in our healthcare premiums of 
roughly half what the national average is over the last 3 
years, and just in passing now I want to acknowledge that HRAs 
and HSAs are the vehicles we've chosen to use to be able to 
give people more accountability and control of their own 
healthcare dollars.
    There are also things that we, as a provider organization, 
must do to engage people more readily as consumers of health 
care. We believe in transparency. We believe Americans have a 
right to know how good we are and what are the costs. In 
September of 2005, we began transparently sharing our quality 
stories for our facilities. In January of 2007, we rolled out a 
very unique cost estimation tool which gives people the other 
half of the valid equation.
    In summary, Alegent Health has been working hard to 
literally participate in our own version of healthcare reform 
within the purview of our own control. It started with the 
commitment to dramatically improve quantity, reduce costs, and 
adopt health information technology; but, quite simply, that's 
not enough. If we really, really want to reform this healthcare 
system in America, we need to drive individual and personal 
responsibility for health.
    We speak of consumption of health care in the United States 
of America like it's a mystery. Too many of us smoke. We're a 
nation of junk food and video games. We super-size everything, 
and we love all-you-can-eat buffets. If we're going to really 
reform the system from a public policy standpoint, we must find 
ways to engage consumers in their health and their health care. 
We must incentivize Americans to live healthier lives, to 
practice true prevention and true wellness, and we hope our 
experiences on a very granular level will provide some insight. 
Thank you very much.
    [The prepared statement of Mr. Sensor follows:]

Prepared Statement of Wayne Sensor, President and CEO, Alegent Health, 
                               Omaha, NE
    Good morning, Congressman Fortenberry and Members of the Committee, 
thank you for the opportunity to be here with you today. My Name is 
Wayne Sensor, I am the President and Chief Executive Officer of Alegent 
Health; today I want to give a brief overview of Alegent Health's 
experiences with prevention and wellness. We are both the largest 
private employer in the state and a substantial provider of healthcare, 
which gives us a unique perspective on these issues. In both roles, we 
have made it our goal to partner with people to proactively manage 
their health, as well as make better choices about the care they need.
    Alegent Health is a faith-based, not-for-profit health care system 
that serves eastern Nebraska and western Iowa. Our 9,000 employees and 
1,300 physicians are proud of the care we provide in our ten hospitals 
and more than 100 sites of service.
    As a provider, we believe we are a model of a post-reform 
healthcare system. We employ substantial health information technology 
to improve the quality and safety of the care we provide and to ensure 
a seamless transition for patients across the many services in our 
healthcare system.
    Through the dedication and commitment of our physicians--a 
combination of employed and independent--we have implemented evidence-
based care order sets across more than 60 major diagnoses.
    Our CMS Core Measure and HCAHPS Scores are consistently among the 
highest in the nation. In June 2008, the Network for Regional 
Healthcare Improvement identified Alegent as having the best combined 
healthcare quality scores in the nation.
    And yet, in our estimation, those efforts are only a small part of 
what it will take to achieve true healthcare reform. We adamantly 
believe that people must take more accountability for their health, and 
to do so they must have incentives and good information.
    We began our journey to greater consumer involvement in health care 
3 years ago, when we made a commitment to more fully engage our 
workforce in their health.
Incentives for Preventive Care/Lifestyle Change/Chronic Disease 
        management
    There are two important constructs in Alegent's employee health 
benefit plans. First, preventative care is free. From services like 
annual physicals, and mammographies to childhood immunizations and 
colonoscopies--if it is preventative, it is free. As a result, our 
workforce is consuming more than 2.5 times the preventive care than the 
nation at large.
    That's an investment that we're willing to make, even without 
longitudinal studies that quantify the financial benefit to our 
organization.
    And second, through an innovative ``Healthy Rewards'' program, we 
pay people a cash award to make positive changes in their lifestyles or 
to manage a chronic illness. We also offer a variety of assistance 
programs free of charge--weight loss counseling, smoking cessation 
programs and chronic disease management with the assistance of a free 
health coach.
    Our objective was first and foremost to improve the health of our 
workforce, and we believed by doing so, our costs would decline. And 
while we are still building data on the effect our efforts have had on 
productivity, absenteeism and organizational health care costs, I can 
report that a majority of employees take an annual health risk 
appraisal and to date, we've lost 17,000 pounds as a workforce, and 
more than 500 of our employees have quit smoking.
    Our approach has allowed us to substantially slow the growth of our 
healthcare spending. Over the first 2 years, our cost increases were 
limited to an average of 5.1 percent, despite industry trends in the 8-
10 percent range.
    And, as we approach a new benefit plan year, we are carefully 
constructing an Advanced Medical Home pilot for our chronically ill 
employees and several other large employers in our community. Through a 
dedicated team of physicians, nurses, counselors and care managers, we 
believe we will have an even more profound impact on the health and 
quality of life of people living with chronic disease.
    Key to our results was the use of HSA and HRA accounts, which give 
employees better control of their health care dollars and allow us to 
directly reward people for changing unhealthy behaviors.
Tools to Facilitate Cost and Quality Transparency
    But giving our employees more control required us, as providers, to 
make dramatic changes.
    First and foremost, we created tools to provide meaningful and 
relevant cost and quality information. What other good or service do 
people purchase in this country without knowing how good it is and how 
much it costs?
    Nearly 3 years ago, we began sharing our quality metrics with both 
our employees and the public--the good and the bad--and since then, 
we've seen our quality scores soar. On our Web site we currently 
reports 40 quality measures--the CMS 20,10 surgical measures and ten 
stroke measures.
    Unlike most providers we did not stop there.
    By working with a third insurance database, My Cost is able to 
verify insurance policies and deductibles in order to provide party 
patients an extremely accurate, personally relevant cost estimate on 
more than 500 medical test and procedures. As the CEO of a health care 
organization, I understand the arguments against providing transparency 
on cost and quality and I reject them. Alegent Health is proof that you 
can share cost and quality information and not only be competitive, but 
excel in your marketplace.
Summary
    In summary, Alegent Health began our own ``healthcare reform'' 
efforts several years ago, when we made an organizational commitment to 
dramatically improve quality, lower cost, and adopt health information 
technology. And yet, that will simply not be enough.
    Our challenge as a country--as physicians and nurses, members of 
congress and employers, individuals and families, is to find a way to 
help people become more individually responsible for their health.
    We speak of the tremendous consumption of healthcare as if it is 
some sort of mystery. It's no mystery really, too many of us still 
smoke, we've become a nation of junk food and video games, of ``super-
size'' and ``all you can eat'' buffets. These unhealthy behaviors cause 
expensive chronic diseases like heart disease, diabetes, and obesity. 
Somehow, we must find a way through public policy to engage consumers 
in their healthcare and incentivize all Americans to live better, 
healthier lives. Only then will we be successful in changing health 
care.
    Thank you.

    The Chairman. Thank you. Dr. Williamson.

       STATEMENT OF BLAKE J. WILLIAMSON, M.D., M.S., VICE
  PRESIDENT AND SENIOR MEDICAL DIRECTOR, BLUE CROSS AND BLUE 
             SHIELD OF KANSAS CITY, KANSAS CITY, MO

    Dr. Williamson. Well, good morning.
    Congressman Fortenberry, Congressman Baca, thank you very 
much for this opportunity to tell you a bit about some 
breakthrough wellness programs that we have started at Blue 
Cross and Blue Shield of Kansas City for the employees that 
work for us or work with us in the Kansas City area and their 
employees across the country.
    The results of our program to date are very encouraging and 
show positive health outcomes for those who are participating. 
These results are the direct effect of our common significant 
investment in our members, and it is a clear example of the 
innovative contributions that only the private sector can make.
    Further validation of our programs comes from the National 
Committee for Quality Assurance. That's NCQA, a highly 
respected organization that evaluates, accredits and certifies 
a wide range of healthcare organizations, and we recently were 
honored to be the first organization in the country to receive 
accreditation for our programs under NCQA's Wellness & Health 
Promotion program. This is a great honor for us and is leading 
to greater innovations on our side.
    Health and wellness initiatives certainly are not new, and 
many companies and organizations have been in this business for 
a long time. Results of these initiatives have been uncertain 
at best.
    For members enrolled in our wellness programs, however, the 
results are real, and our most innovative program, a program 
called A Healthier You, has been in place for 4 years. We've 
been able to track 15 employers large employer groups who have 
been in that program for those 4 years, and here are just a few 
examples of some of the successes that we've seen in this 
program.
    First, aggregate wellness course from our Health Risk 
Appraisal tool have steadily increased, showing that health 
risks are going down in this population. Blood pressure 
readings in members who are participating in the program have 
decreased.
    Total cholesterol levels have decreased. Emergency room 
visits for those employer groups who are in this A Healthier 
You program have decreased slightly, while our other employee 
groups that are in our insurance company have increased.
    The costs associated with those ER visits have gone down as 
well, and non-participating companies have shown an increase in 
those costs, and the other thing is that we have also seen 
routine medical exams increase in number, which we think is a 
good sign. It is a sign that people are taking some 
accountability for prevention and taking better care of 
themselves.
    After an in-depth analysis of the cost outcomes of this 
program, we feel confident that it does have a return on 
investment of approximately three to one. For every $1 that 
gets spent on this, an employer can return and see $3 in 
savings in their healthcare costs.
    Our health and wellness programs target the needs of all 
our members, regardless of where they are in the continuum of 
health. It's our objective to keep healthy members healthy and 
move those who have some risks or have some chronic health 
conditions back down that continuum toward the healthier end of 
the scale. It's a sad fact that about five percent of our 
members--and this is the truth nationally--account for around 
50 percent of all healthcare costs that get spent. The vast 
majority of these costs are related to unhealthy behaviors and 
lifestyle decisions that people make every day.
    As a company, we lead the market in service and wellness 
initiatives. We use health plan tools to gather data and 
warehouse that in a data warehouse and then personalize 
communications that go out to members with educational 
resources, interventions for people who have a few health 
risks, and individualized approaches for those who have more 
chronic and catastrophic illnesses.
    For members who are healthy and may have just a few health 
risks, our A Healthier You worksite program provides 
personalized counseling, on-line tools, support behavior--
support behavior changes that members may wish to make. Members 
take health risk appraisals and then determine where they fall 
on the continuum, engage in appropriate programs that target 
their needs, and then our employees receive aggregate 
information about their population's health and recommendations 
for their company in the future.
    Members who live with chronic conditions need extra care to 
help them prevent those conditions from progressing into the 
wrong direction and having higher health costs, so we've 
developed special programs for members with chronic diseases, 
and those members work with nursing professionals on a one-on-
one basis to help them get control of their healthcare 
conditions.
    And then, for those that are on the most critical side, 
including those that have life-threatening illnesses or those 
who have transplants or other injuries, we have case management 
nurses who are involved with them. The interventions they make 
are variable depending on the member's particular needs and are 
developed collaboratively between the nurse and that member to 
meet the goals that they share, and that fosters a one-on-one 
relationship allowing the nurse to become an advocate for that 
member.
    So, in conclusion, Blue Cross and Blue Shield of Kansas 
City believes that the future of healthcare cost containment 
lies in disease prevention and the practice of evidence based 
medicine and increasing the accountability that a member or a 
person has for their own lifestyle choices and their behaviors.
    Nationwide, around 70 percent of all healthcare costs are 
the direct result of those lifestyle choices that we make every 
day.
    We believe we have in place--we have placed the right 
programs in place to empower our members to make better 
healthcare decisions so that they can live longer and happier 
lives, and I've provided more detail in the packet that I've 
submitted, and I look forward to answering any questions that 
you might have. Thank you for your time.
    [The prepared statement of Dr. Williamson follows:]

 Prepared Statement of Blake J. Williamson, M.D., M.S., Vice President 
and Senior Medical Director, Blue Cross and Blue Shield of Kansas City,
                            Kansas City, MO
Introduction
    Good morning/afternoon! Thank you for this opportunity to tell you 
about the breakthrough wellness programs that Blue Cross and Blue 
Shield of Kansas City has developed for our clients in Kansas City and 
their employees around the country. Results of these programs to date 
are very encouraging and show positive health outcomes for those 
participating. These positive results are the direct result of our 
company's significant investment in our members--a clear example of the 
kinds of innovative contributions that only the private sector can 
provide.
    Further validation of our programs comes from the National 
Committee for Quality Assurance (NCQA), a highly respected organization 
that evaluates, accredits and certifies a wide range of healthcare 
organizations. We were recently honored to be the first organization in 
the country to receive accreditation for our programs under NCQA's 
Wellness & Health Promotion program. This is a great honor for us, and 
is leading to even greater innovations on our side.
Real Results
    Health and wellness initiatives are certainly not new, and many 
companies and organizations have been in this business for a long time. 
Results of initiatives have been uncertain to this point.
    For members enrolled in our wellness programs, however, the results 
are real. Our most innovative program, A Healthier YouTM, 
has been in place for 4 years, and we've been able to track 15 large 
employer groups that have been in the program for all 4 years. Here are 
just a few examples of the success we are seeing in this program:

      Aggregate wellness scores from the Health Risk Appraisal 
have steadily increased several points over the 4 years, indicating 
health risk levels are going down.

      Blood pressure levels have decreased.

      Total cholesterol levels have decreased.

      Emergency room visits by A Healthier You participating 
companies have decreased slightly, while ER visits by non participating 
companies have increased by 17%.

      The costs associated with these ER visits have also gone 
up significantly for those not participating in the program.

      Overall medical costs have trended up at a slower rate 
for those participating in the program (10% increase); non 
participating companies have seen overall medical costs increase more 
than 17%.

      We have also seen routine medical exams increase in 
number, which we believe is a good sign; it shows prevention is on the 
rise and people are taking care of themselves better.

    After an in-depth analysis of the cost outcomes of this program, we 
feel confident that it has a return on investment of approximately 
three to one--for every $1 spent on the program, the employer will 
receive $3 in return in lower employer healthcare costs.
Continuum of Health
    Our health and wellness programs target the needs of all our 
members, regardless of where there are on the continuum of health. Our 
objective is to keep healthy members healthy, and move those members 
who have some health risks or chronic health conditions back down the 
continuum toward the healthy end of the scale. It's a sad fact, five 
percent of members account for nearly one half of all claims costs, and 
a vast majority of these costs are the result of unhealthy behaviors 
and lifestyles.
    As a company, we lead the market in service and wellness 
initiatives. We use health plan tools and data, gathered in our 
extensive Electronic Data Warehouse, to determine where members are on 
the continuum and personalize our communication with them. We provide 
education and resources for members who are healthy, interventions for 
those who may have a few health risks, and individualized care for 
those members with chronic conditions or catastrophic illnesses.
Overview of Programs
    For those members who are healthy or may have just a few health 
risks, our A Healthier You worksite program provides personalized 
counseling and online tools to support healthy behavior and any changes 
the member may wish to make. Members take health risk appraisals to 
determine where they fall on the continuum and engage in the 
appropriate programs that target their needs. Employers receive 
aggregate results with insights into their employee population's health 
and recommendations for future engagement.
    Members living with chronic health conditions need extra attention 
to prevent their conditions from progressing in the wrong direction on 
the health continuum, leading to higher costs. We have developed 
special programs for members with diabetes, asthma, chronic heart 
failure, chronic obstructive pulmonary disease, coronary artery 
disease, depression, rheumatoid arthritis, hepatitis C, and multiple 
sclerosis. Our Disease Managers, who are also nursing professionals, 
reach out to these members and help them get control over their 
conditions.
    Finally, for our members with the most critical needs, including 
life threatening illness or injury and transplant cases, our Cases 
Management nursing professionals are there to assist them with their 
highly specialized needs. Interventions are variable based on the 
member's needs and are developed collaboratively between the nurse and 
member, fostering a one-on-one relationship and allowing the nurse to 
serve as an advocate for the member.
Conclusion
    Blue Cross and Blue Shield of Kansas City believes the future of 
healthcare cost containment lies in disease prevention, the practice of 
evidence based medicine, and increased member accountability for 
lifestyle behaviors and the care of their health. Nationwide, nearly 
70% of all healthcare costs are the direct result of the lifestyle 
choices we make. We believe we have in place the right programs to 
empower our members to make better healthcare decisions and live 
longer, happier lives. I've provided more detailed information on the 
topics I covered today in the packet that you have. I look forward to 
answering your questions. Thank you for your time today.

    STATEMENT OF MARSHA LOMMEL, PRESIDENT AND CEO, MADONNA 
              REHABILITATION HOSPITAL, LINCOLN, NE

    Ms. Lommel. Chairman Baca, welcome to Lincoln, Nebraska, 
and to ProActive, and Representative Fortenberry, thank you for 
allowing us to participate in this really, really broad and 
important issue. My name is Marsha Lommel, and I am President 
and CEO of Madonna Rehabilitation Hospital. Madonna is the only 
freestanding rehabilitation hospital in Nebraska who specialize 
in rehabilitation for children and adults with traumatic brain 
injury, spinal cord injury, stroke, pulmonary disease, and 
pediatrics.
    ProActive, our medical fitness center, the host for today's 
hearing, was completed in January of 2006. It is based on the 
rehabilitation model of holistic care; that is, it does not 
focus on a body part or a disease like traditional western 
medicine. Rehabilitation is the original holistic medical 
model. It focuses on a person's ability to fulfill their life 
roles through wellness in all dimensions: Emotional, physical, 
vocational, social, spiritual, and intellectual.
    In fact, those are the dimensions of wellness incorporated 
into the ProActive wellness assessment, a tool developed by our 
research institute. Along with a health risk assessment, the 
ProActive Wellness Assessment allows members to focus not just 
on exercise or diet alone, but on the issues that are 
preventing them from making positive changes in their lives. 
Rehabilitation meets each person at their individual level of 
functioning. One ProActive member's goal was to do anything for 
5 minutes. She started by walking in the cross-current water 
track with the current.
    In an early study we found that almost half of our 3,800 
members were non-traditional members of a fitness club; 45 
percent were over 50 years of age, and 40 percent of those had 
significant health impairments or disabilities; 66 percent were 
overweight. We all know that many of the attempts to improve 
the health of society at large is not--have not been 
successful. Often wellness programs attract the healthiest 
people, and those with chronic conditions and obesity are too 
embarrassed or intimidated, or have already experienced too 
much failure to participate.
    We've found that the most important first step for these 
people is to feel comfortable in this situation. The goal for 
the design of ProActive in program and in architecture was that 
everyone from the non-fit to the athlete would feel comfortable 
here. Programs like MedFit for those with medical issues and 
chronic conditions include the expertise of nurses and physical 
therapists. Classes like Adaptive Training are for those with 
physical impairments.
    Our research institute adapted 12 pieces of commercial 
fitness equipment so that it can be used for those with 
physical limitations due to stroke, arthritis, Multiple 
Sclerosis, and a host of other medical conditions. At ProActive 
we have seen thousands of people regain health through that 
holistic rehabilitation approach. A 42 year old woman avoided 
gastric bypass surgery, losing 115 pounds. A 67 year old woman 
who had three strokes and was diabetic is now off most 
medications and is an avid participant in the senior tap 
dancing classes at ProActive.
    Madonna's occupational health service Fit for Work provides 
occupational health and work injury services to Madonna 
employees, as well as 43 other companies. Fit for Work uses the 
holistic ProActive rehabilitation model to develop wellness 
initiatives to augment the occupational health services. 
Wellness programming includes all of the standard health 
screenings, wellness presentations, weight loss programs, 
stress management, fitness classes, as well as medically based 
programs.
    The approach is truly health care and prevention. Fit for 
Work's wellness program has been offered to Madonna's 1,400 
employees with much success. We are self-insured for health 
care, so our results are particularly pleasing. The total cost 
to Madonna for health care per employee has increased eight 
percent in the past 5 years for an average of 1.76 percent per 
year. Thus far 773 employees have participated, and 433 have 
completed at least one wellness Lifestyle Challenge program.
    Outcomes are tracked by each initiative in the program. One 
example is the ``Holiday Jumpstart'' initiative for weight 
maintenance, which led to 71 percent of participants meeting or 
exceeding their goals, with 55 percent even losing weight over 
the holiday season, and that's kind of tough. We also found 
that we were able to attract employees with the highest health 
risks to participate.
    Sixty-nine percent of our employees participating in the 
Lifestyle Challenge had a body mass index of overweight or 
obese; 78 percent of the overweight or obese employees lost 
weight, 23 of whom decreased their weight so significantly that 
they lowered their body mass index risk category.
    We are finding similar results at the companies we serve 
that are served by Fit for Work. Each company has its own 
profile and an individualized program to meet its unique needs 
and budget. For example, in one company almost 90 percent of 
the employees were smokers. In another company sedentary work 
is a contributing factor to health risks. These are measurable 
examples of the outcomes for one approach to improving health 
and wellness.
    As our nation moves forward with the prospect of providing 
health care for all, it should be kept in mind that life saving 
is not the only responsibility we have in health care. If we do 
not put the health back in health care, the economic burden 
will continue to be devastating. We need more medical fitness 
wellness centers like ProActive and BryanLGH's LifePoint. We 
need to include coverage for medical wellness programs in 
insurance plans and in Medicare and Medicaid.
    We need to fund research at the grass roots level to 
identify innovative programs and best practices to achieve 
long-term results. I urge the Committee to include 
rehabilitation and wellness in the healthcare reform bills that 
are weaving through Congress. You may save some lives as well 
as ease the financial burden.
    [The prepared statement of Ms. Lommel follows:]

    Prepared Statement of Marsha Lommel, President and CEO, Madonna 
                  Rehabilitation Hospital, Lincoln, NE
    My name is Marsha Lommel and I am President and CEO of Madonna 
Rehabilitation Hospital in Lincoln, Nebraska. Madonna is the only 
freestanding rehabilitation hospital in Nebraska and the only facility 
in the country with a Long Term Care Hospital and an Acute 
Rehabilitation Hospital under one roof. Madonna also has a nursing 
home, an assisted living facility, a large outpatient program, an 
occupational health program and a medical fitness center, ProActive, 
your host for today's hearing. Madonna specializes in rehabilitation 
for adults and children with traumatic brain injury, spinal cord 
injury, stroke, pulmonary disease and pediatrics. In fact, Madonna has 
one of only seven accredited pediatric brain injury programs in the 
nation and is one of only four to offer an accredited pediatric spinal 
cord injury program.
    What does rehabilitation have to do with wellness? We believe the 
rehabilitation model lends itself to wellness because rehabilitation is 
holistic, that is, it does not focus on a body part or a disease like 
the traditional western model of medicine. Rehabilitation focuses on a 
person's ability to fulfill their life roles through health in all 
dimensions--emotionally, physically, vocationally, socially, 
spiritually and intellectually. In fact, those are the dimensions of 
wellness incorporated in the ProActive Wellness Assessment, a tool 
developed by our research institute. Along with a Health Risk 
Assessment, the ProActive Wellness Assessment allows members to move 
beyond diet and exercise alone, beyond health risk, to address issues 
that are preventing them from making positive changes in their lives. 
One of the most significant of these identified by national studies as 
well as our own experience, is stress management.
    Second, rehabilitation emphasizes that each dimension of a person 
affects all other dimensions. We know, for example, that a simple 
walking program increases satisfaction in social and emotional, as well 
as physical, dimensions. And last, rehabilitation accommodates each 
person at their level of functioning. One ProActive member's goal was 
to do anything for 5 minutes. She started by walking in the cross 
current water track with the current to ease her mobility, and later 
progressed to full participation in water and land exercise.
    We all know that many of the things that have been tried to improve 
the health of society at large have not been successful. These include 
scaring people, one size fits all programs and a sole focus on 
medication or disease management. People are not their diseases. Often 
wellness programs attract the healthiest people, and those with chronic 
conditions and obesity are too embarrassed or too intimidated, or have 
already experienced too much failure, to participate. We have found 
that the most important first step for these people is to feel 
comfortable in the situation, and see that they are on the journey with 
people like them. That is why the non-fit and the moderately fit 
population do not feel comfortable in a traditional fitness facility 
with the younger or more athletic clientele.
    ProActive has almost 3800 members and a little more than half of 
them are considered non traditional members of a fitness club. In an 
early study of our membership, 66% were overweight, 70% had inadequate 
fitness level, 74% were at an elevated risk for cancer, 45% were over 
50 years of age and 40% of those had significant health impairments or 
disabilities, 36% had a moderate to high risk of coronary artery 
disease. These are the health problems of America. But when we look at 
the underlying attitudes and beliefs of this population, it is apparent 
that there are significant obstacles in the ability to change. 33% did 
not feel confident in their ability to succeed in a fitness plan, 17% 
reported excessive stress and poor coping skills.
    At ProActive, we have seen thousands of people regain health 
through a holistic approach. A 42 year old woman avoided gastric bypass 
surgery, loosing 114 pounds and reducing her triglycerides by 100 
points. She states she didn't feel ``one bit intimidated at ProActive'' 
and when she described her outcome, she said ''Emotionally, I'm so much 
happier.'' The women in her aquatic classes have become such good 
friends, they recently rewarded themselves with a group trip to Kansas 
City. That is the power of the holistic approach and a concentration on 
all of the dimensions of wellness.
    A 67 year old woman who has had three strokes, was diabetic and had 
high blood pressure and high cholesterol, is now off most medications 
and is an avid participant in the senior tap dancing classes at 
ProActive. She said ``I needed a place where I felt comfortable. It's 
better than any medicine.''
    Successful programming, we have found, is based on the holistic 
model of rehabilitation. It means including an element of fun, an 
element of competition and a focus on grouping people with similar 
characteristics and problems. It means dance classes with participants 
at any skill level. It means paired and group competitions with prizes 
(even small ones will do), healthy cooking classes, women's and men's 
groups, classes for seniors, programs like MedFit for those with 
medical issues and chronic conditions, and special classes like 
Adaptive Training for those with physical impairments. Our research 
institute conducted a 2 year research project to adapt commercial 
fitness equipment so it can be used by those with physical limitations 
such as those who are partially paralyzed due to strokes, have 
arthritis or have neuromuscular problems such as MS.
    As you look around you at ProActive, you will see that it was 
designed to address the psychological and spiritual aspects of 
wellness, as well as the physical. The goal was to make ProActive 
entirely different from a typical fitness center so that people who 
would never set foot in a traditional fitness center, as well as the 
body building athlete, would feel comfortable here. And they all do. It 
is a place of energy as well as contemplation. It is accessible to, and 
welcoming to, those in wheelchairs and with walkers, the elderly and 
medically fragile. The cross current water track and the simple-to-use 
circuit were all designed for non-fit and moderately fit members.
    The staff of three nurses, two dietitians, five physical 
therapists, exercise trainers, lifestyle coaches, dance instructors and 
group instructors address the needs of each member individually, 
starting with health risk and wellness assessments and individual 
counseling. ProActive provides medically supervised programs for people 
with cardiac conditions, arthritis, fibromyalgia, and diabetes. Our 
success in developing this model has resulted in positive, life 
enhancing outcomes that have exceeded our expectations.
    Madonna's occupational health program, Fit For Work, provides 
occupational health and work injury services to 43 businesses in and 
around Lincoln. Working in partnership with businesses and their 
employees, the expensive costs of worker's compensation, time loss and 
decreased productivity can all be greatly diminished. Fit for Work 
staff provided over 1,300 health screens and delivered over 7,300 flu 
shots to these businesses as well as for the State of Nebraska workers.
    Fit for Work incorporated the holistic philosophy of ProActive and 
developed a wellness initiative to augment its occupational health 
services. Fit for Work is currently providing wellness services to over 
25 companies employing approximately 5,500 employees. Services include 
Health Screenings for early detection of health risks, Wellness 
presentations, Weight Loss programs, Tobacco Cessation programs, 
Nutrition and Wellness Coaching, Walking programs, Stress Management, 
Fitness classes and medically based programming. The approach is truly 
health care and prevention verses sick care.
    Madonna Rehabilitation Hospital also uses the Fit for Work wellness 
program for our 1400 employees. Because we are self insured, our cost 
for employee healthcare can be tracked fairly accurately. In the past 5 
years, the total cost to Madonna for healthcare, per employee, has 
increased 8% or an average of 1.76% per year.
    Thus far, 773 employees have participated and 433 have completed at 
least one Fit for Work wellness program, one of which is the Lifestyle 
Challenge. This program offers free screenings, regular weigh-ins, 
health tips and prizes. Outcomes of wellness programs, like 
rehabilitation, must be tracked over many years to evaluate their true 
contribution to health. Because of the cost involved in applying 
research methodology, it is prohibitive for businesses to obtain 
reliable and valid outcomes or conduct blind studies.
    However, Fit for Work does track outcomes for each initiative and 
program and I can give you a sample of those results. In the ``Get In 
the Game Season Training'' program 97% of the participants stated that 
they learned healthier behaviors at the live events and 70% took action 
steps to incorporate new choices into their lifestyle. The ``Holiday 
Jumpstart'' initiative for weight maintenance led to 71% of 
participants meeting or exceeding their goals, with 55% even losing 
weight over the holiday season between November and January. The impact 
of these events at Madonna has been echoed at the other businesses that 
implemented the Fit For Work wellness plan.
    We also found that we were able to attract employees with the 
highest health risk to participate. which is often cited as a problem 
for wellness programs. For example, 69% of our employees participating 
in the Lifestyle Challenge met the body mass index categorization of 
overweight or obese; 78% of the overweight or obese employees lost 
weight, 23 of whom decreased their weight so significantly that they 
lowered their body mass index risk category.
    Another example of the success of Lifestyle Challenge is the 
subjective evaluation results gathered at the end of each competition. 
Examples of employee's perceptions of their health changes through the 
program include 55% who said they felt happier with themselves, 52% 
reported having more energy and 24% reported a decrease in stress 
levels.
    With 1,400 employees working shifts around the clock and at 
locations scattered throughout Lincoln, Fit For Work wellness 
programming has continued to be creative in finding ways to reach busy 
workers in the challenging field of health care. Program design allows 
for all shifts to participate and often the education comes to them. 
Rolling carts from unit to unit with healthy snacks and educational 
presentations on nutrition or stress management or exercise, our 
wellness staff are able to give personal attention to employees who may 
never attend one of the more formal sessions. The focus is on real life 
challenges such as the miles it takes to walk off a stadium hot dog or 
the best and worst choices for breakfast cereal.
    Another successful example is the walking program, in which 
participants are given pedometers and departments compete for most 
steps, or most improvement or even most participation. Groups of 
employees are now seen walking the 23 acre campus on breaks and over 
lunchtime.
    We saw a ten-fold increase in our wellness programming engagement 
when fun and surprise events were incorporated. Successful wellness 
programs feel private and personal to participants, yet also foster the 
camaraderie of developing a healthier workplace culture. It has to meet 
the needs of the most sedentary staff member and the weekend athlete. 
It has to help each person feel like their day-to-day choices shape 
their health.
    Wellness is about personal touch and connection. With confusion 
generated by sound bite media messages, employees need to be able to 
access information and participate in programs that are relevant to 
them and fit into their lives.
    We are finding similar results at the companies served by Fit for 
Work. Of the 2,400 employees who took the health risk assessment, 74% 
had a higher risk of cancer, 70% had poor fitness levels, 66% were 
above the recommended weight, 64% need to improve nutrition and 35% had 
moderate to high risk of coronary artery disease. Each company has its 
own profile and an individualized program to meet its unique needs and 
budget. For example, in one company, almost 90% of employees were 
smokers. In other companies, sedentary work is a contributing factor to 
health risk.
    The Lifestyle Challenge is one example of a team focused, weight 
and physical activity challenge; 900 members of five different 
businesses who were part of the programming lost over 2,400 pounds and 
logged over 36,400 hours of physical activity above and beyond their 
typical workday activity.
    These are measureable examples of the outcomes for one approach to 
improving health and wellness. As our nation moves forward with the 
prospect of providing health care for all, it should keep in mind that 
life saving is not the only responsibility we have in healthcare. If we 
do not include rehabilitation and wellness, the economic burden will 
continue to be devastating. We need more medical wellness centers like 
ProActive and BryanLGH's LifePoint, we need to include coverage for 
medical wellness programs in insurance plans and in Medicare and 
Medicaid. We need to fund research at the grass roots level to identify 
best practices in wellness and establish long term results.
    I urge the Committee to include rehabilitation and wellness in the 
healthcare reform bills that are weaving through congress. You may save 
some lives, as well as ease the healthcare financial burden.

 STATEMENT OF GLENN A. FOSDICK, F.A.C.H.E., PRESIDENT AND CEO, 
               NEBRASKA MEDICAL CENTER, OMAHA, NE

    Mr. Fosdick. Congressmen, good morning. My name is Glenn 
Fosdick, and I am President and Chief Executive Officer of The 
Nebraska Medical Center. It is my intention to share with the 
Committee what healthcare providers are doing in prevention and 
wellness practices to better control healthcare costs. With 
this in mind I would like to note the experiences of The 
Nebraska Medical Center and highlight specific examples where 
costs have been significantly reduced and our employees have 
improved their overall health.
    The Nebraska Medical Center is a 689 bed academic medical 
center providing the most sophisticated tertiary and quaternary 
care in the region. The largest hospital in the state, we 
employ over 5,700 FTEs within a budget over $750 million.
    With the escalating challenges declining reimbursement and 
increasing costs, we experience the same fiscal concerns that 
all healthcare providers do.
    Accordingly, our budgetary process is very sensitive to the 
costs associated with the provision of healthcare benefits for 
our employees.
    As a good employer, it is our goal to provide the most 
possible--the best possible services and ensure the overall 
good health and well-being of our employees and their families. 
Because of the complexities of care that we provide, our 
employees have a very thorough understanding of the healthcare 
delivery system and expect high quality care. Like all 
employers, we have experienced the challenge of the 
inflationary increases associated with healthcare benefits; 
however, it has been our commitment to identify opportunities 
to better control these costs without compromising the service 
provided to our employees.
    Our efforts in this area focus on the basic philosophy of 
improved health and a proactive process to identify and address 
medical issues early (the cause). This, we believe, is 
dramatically more efficient and cost effective than treating 
the inevitable medical problem (the result) when it becomes a 
significant and expensive clinical issue.
    Included in our approach is a dedicated program for 
employee wellness. This collaborative approach, which began in 
1991, incorporates a variety of methods of connection and 
communication with the employee to educate and influence them 
and their dependents on effective and realistic approaches to 
prioritize the individual's personal well-being. These include 
specific initiatives in weight management, fitness, cholesterol 
monitoring, and health prevention, including providing an on-
site fitness center for employees. It has received numerous 
awards in the last several years.
    A second thing I'd like to discuss is our employee 
screening process, SimplyWell, initially developed here in 
Omaha, which we believe has had substantial impact on our 
success.
    In 1998, the SimplyWell program was developed under the 
leadership Dr. James T. Canedy, an orthopaedic surgeon from The 
Nebraska Medical Center who recognized that the long-term 
improvement in healthcare quality depended on the 
implementation of an effective screening and risk reduction 
program.
    The unique capability of this organization is that it 
provides a turnkey operation with components in place, ready to 
implement for all types of businesses and size and scope. It 
incorporates an on-line health risk management assessment which 
helps identify priorities unique to each individual. In 
addition, it combines the traditional blood pressure, height, 
weight, and flexibility screening mechanisms with a lab blood 
draw analysis, which allows for greater problem recognition and 
detail.
    SimplyWell has developed an on-line personal health record 
for each participant. It utilizes health lifestyle coaching, 
which includes a minimum of one telephone call annually per 
participant or more often, as needed, as well as a 24 hour 
nurse call line for follow-up questions information. Of 
particular interest is the capability of the personal health 
record, which provides on-line access to laboratory test 
results and identifies areas of concern above and below 
appropriate ranges, as well as providing over 1,300 individual, 
5 minute or less educational modules on specific health areas 
that may be of interest or concern to the individual. While 
this individual record is not available to the employer, 
SimplyWell examines collaborative data throughout the 
organization to identify trends or particular areas of concern.
    The Nebraska Medical Center has utilized a conservative and 
positive approach to encouraging enrollment, including a $50 
check for employee participation. This will be enhanced this 
coming year with a required $500 contribution for non-
participating employees.
    The program currently serves over 33,000 members 
nationally, including over 200 employers in banking, 
manufacturing, medicine, retail, agriculture, and higher 
education in all 50 states and 20 countries. It has 
demonstrated an audited and consistent return on investment of 
one to one in year one and as much as three to one by the third 
year.
    The individual value of this program is reflected to us 
annually as we identify specific problems associated with our 
employees in a pre-emptive time frame. These include, for 
example, the identification of employees who are in a pre-
diabetic status and who, without proper lifestyle management, 
will face the clinical liabilities of diabetes. This area is in 
itself significant, given that medical expenditures incurred by 
diabetics in the United States are estimated at $116 billion 
per year. The American Diabetes Association has estimated that 
people diagnosed with diabetes on average have medical 
expenditures approximately 2.3 times higher than those without 
diabetes.
    In addition, each year we identify other significant risks. 
These include obesity, pre-leukemic status, heart disease, and 
a variety of other problems of note.
    The comparative value of these efforts has been substantial 
for The Nebraska Medical Center. In examining the average 
participant cost associated with employer-sponsored health 
plans for 2004 through 2008, there has been a national increase 
of 27.7 percent.
    By comparison, The Nebraska Medical Center cost has 
increased only 4.2 percent during this 5 year period. 
Specifically, in 2004, our average participant costs were 97 
percent of the national average. In 2008, they were 79 percent 
of the national average. The impact on our budgeting process is 
significant. Our ability to control our costs neutralized the 
inflationary impact of health care.
    The challenges of controlling healthcare costs by both 
employers and government are formidable. Our culture has 
defined the standard for the critically ill as immune to 
financial limits. We must not compromise our commitment to 
utilize all of our skills and abilities to address their needs. 
This is economically possible if we recognize and take 
advantage of opportunities in other areas, including wellness 
and preventive screening on an annualized basis. The results 
speak for themselves.
    Finally, this effort is one of four specific areas of 
opportunities I would submit can positively influence the 
control of healthcare costs. One is wellness and screening. 
Second is participant contribution. As long as these services 
are free, they are hard to control. End-of-life control, 
recognizing that the last 60 days of life are the most 
expensive in your healthcare history. There are substantial 
opportunities with increased palliative care intervention to 
reduce inappropriate and valueless costs; and, finally, 
malpractice/defensive medicine. With the expense associated 
with defensive medicine estimated as much as ten percent of 
healthcare costs, we cannot ignore this.
    It is my belief that these four areas provide the greatest 
and most reliable realistic opportunities for enhancing control 
of healthcare costs. These may not be the easiest, but it can 
be the most successful. Thank you for allowing me to share 
these thoughts.
    [The prepared statement of Mr. Fosdick follows:]
Prepared Statement of Glenn A. Fosdick, F.A.C.H.E., President and CEO, 
                   Nebraska Medical Center, Omaha, NE

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



       STATEMENT OF LuAnn HEINEN, M.P.P., VICE PRESIDENT,
          NATIONAL BUSINESS GROUP ON HEALTH; DIRECTOR,
          INSTITUTE ON THE COSTS AND HEALTH EFFECTS OF
                   OBESITY, WASHINGTON, D.C.

    Ms. Heinen. Good morning, Chairman Baca and Ranking Member 
Fortenberry. I'm LuAnn Heinen, Vice President of the National 
Business Group on Health. We're a member organization. We 
represent about 300 mostly very large employers that provide 
coverage to more than 55 million U.S. workers, retirees, and 
their families. I've been asked to speak about worksite 
wellness programs and what we know today about whether they 
work.
    The World Health Organization estimates that exercise and 
better diets, along with smoking cessation, can prevent at 
least, at least, 80 percent of all cases of heart disease and 
stroke and type 2 diabetes and up to 40 percent of cancers. 
Now, it's clear that to prevent anything approaching 80 percent 
of today's burden of heart disease or 40 percent of cancers 
will take massive change across many sectors and is much bigger 
than the workplace, but just at the worksite evidence is 
growing that health promotion (also called wellness) programs 
can positively influence employee health risks and achieve a 
positive return on investment.
    I'm going to speak to just three examples of important 
research. First--and I'll summarize it briefly--an 
authoritative review of 50 studies of worksite interventions by 
the CDC Community Guide Task Force found small but cumulative 
significant health benefits, so they concluded that worksite 
health promotion programs reduced tobacco use, reduced dietary 
fat consumption, reduced high blood pressure and cholesterol, 
as well as days off of work and increased productivity.
    The second study was a review of 25 return on investment 
studies of workplace health promotion programs, and they found 
an average cost reduction annually of two to four percent of 
total medical claims costs, so that's across these 25 studies, 
and that translated into a return on investment of a dollar to 
$3 for every dollar spent on health promotion programs. Now, 
this means that looking only at direct medical costs (not 
factoring in productivity, absenteeism, or other indirect 
costs), these worksite health promotion programs showed a small 
but definite positive ROI.
    And then, third, one of our member companies, The Dow 
Chemical Company, has published a return on investment 
projection model to analyze the break-even point for employee 
wellness, and they showed small improvements in health risks 
for Dow employees would yield significant savings in health 
costs for the company. So the break-even point, according to 
Goetzel, at which savings exactly equaled investment dollars 
occurred when each of the health risks they measured was 
reduced by just .17 percent annually.
    So across a large population you didn't need to see a major 
reduction in order to get a benefit, a pretty big dollar 
benefit, so increasingly our membership, large employers, see 
themselves as population health managers, and this works 
especially well in companies with relatively low turnover so 
that small risk reductions over a large workforce over several 
years can dramatically bend the trend.
    Now, notwithstanding the research results cited above, a 
majority of large companies actually do not wait for or fund or 
participate in the types of research that definitively answer 
the question, ``Does this program have a positive return on 
investment?''
    And that's because human resource departments and medical 
departments and safety and occupational health departments tend 
not to have a budget for research, nor are they willing to 
spend the needed time or information technology resources to 
evaluate their programs, and their measures of success are 
going to be different from those of academic researchers.
    And so it happens even effective programs may be eliminated 
when there's a downturn in the company's revenues or market 
capitalization, so this clearly limits the volume and type of 
research that can be conducted on corporate wellness programs, 
and it also slows the development of an evidence base that's 
going to be compelling to academicians and policymakers. Now, 
employers, however, do not require the same level of evidence 
for their own decision-making purposes, so it's worth noting 
that the latest survey data from our own membership--and we had 
a response rate on this of 75 respondents--16 percent of them 
said that wellness initiatives to improve employee health are 
the single most effective tool they feel they have to control 
health costs, and a third of them said wellness is one of the 
top three most effective steps they can take.
    The other two would be employee cost-sharing and the use of 
consumer-directed health plans, so many employers work with 
their health plans, their insurance companies, and other 
partners to be sure that overweight and obesity are included in 
health education and communications that come out from the 
plans that are furthering health benefit plan design. They're 
offering coaching and health improvement programs, and they 
also have disease management and disability/return-to-work 
initiatives.
    Our members often work to ensure that the culture and the 
environment at work promote healthy weight and healthy life-
styles by encouraging physical exercise, offering healthy food, 
and establishing social norms around healthy behaviors, so we 
have a program called the Best Employers for Healthy 
Lifestyles, and just this past June we had our fifth-year 
anniversary of this program. We recognized 63 large employers 
representing the full spectrum of companies across the country 
of the U.S. economy for their exceptional commitment to healthy 
workplaces and helping employees and families make better 
choices.
    So the 2009 class of award winners is the largest ever, 
with companies demonstrating an unprecedented breadth and depth 
of programs to support employee health and wellness, so winners 
were honored in one of three categories: Platinum, for very 
well established programs with measurable success and 
documented outcomes; or the gold level for creating cultural 
environmental changes--cultural and environmental changes to 
support employees and helping them commit to long-term behavior 
change; and then, finally, silver, which is for employers who 
have more recently launched programs and services to support 
healthier lifestyle.
    So we did find that there is strong evidence to the 
increased value employers today are placing on workplace health 
and wellness. The number of advocates, the number of winners, 
it's gone up every year, and in 2009, we gave nearly three 
times the number of awards as we did 5 years ago, and I won't 
go through and read all the award winners, you'll be happy to 
know, but just to give you a feel for them, they are companies 
like Dell, Hannaford Supermarkets, IBM, Occidental Petroleum, 
JPMorgan Chase, Mayo Clinic, Wal-Mart, Xcel Energy, lots of 
different kinds of companies.
    And one of our platinum winners for the last 5 years, Union 
Pacific Corporation, is based right here in Nebraska. Their 
health promotion program, HealthTrack, is a comprehensive 
program to improve the health of employees. It addresses a 
variety of risk factors, including inactivity, weight, 
nutrition, smoking, cholesterol, blood pressure, and 
depression. They include a risk reduction program, tobacco 
cessation program. They have exercise facilities throughout the 
country and have applied for research grants to further develop 
their program.
    Also located in Nebraska is the Wellness Council of the 
Midlands, which is one of the first employer-led wellness 
councils in the country. It may be the first. It was 
established in 1982. And then the national organization, 
Welcoa, also in Nebraska, provides information and recognition 
to thousands of smaller businesses nationally, and that's very 
important, because smaller business today has not embraced 
wellness the way that large business has.
    And so the national--actually, our survey, not their 
survey, of 450 large employers that we did with Watson Wyatt 
said that large employers recognize and identify employees' 
poor health habits as their number one challenge to try to 
maintain affordable health benefit coverage, and so a majority 
of large employers offer health risk appraisals, weight 
management programs, lots of great programs.
    Based on survey data, if you see the growth of the 
suppliers and the vendors in this field who supply corporate 
wellness programs and also what we hear from employers, we 
actually believe that among the group we deal with, a tipping 
point has probably been reached and that large employers now 
have or believe they should have wellness programs in place. 
But, in great contrast to that, only 6.9 percent of small 
employers with fewer than 750 employees--and this was a big 
national representative sample between 1999 and 2004 and 
published in 2008.
    It's called the National Worksite Health Promotion Survey, 
and they found a decline in offerings by small employers and 
only 6.9 percent offering them at this point, so because small 
businesses employ about 50 percent of the workforce in the 
private sector, this survey is an important and very sobering 
perspective on the typical American worksite.
    One of the really important things for us, moving forward, 
is role models, and although an estimated hundred or more very 
large employers have substantial programs affecting millions of 
employees and some small mid-sized employers are following 
suit, many others have been slow to react. Now, certain 
employers have the visibility to be role models and to 
influence the climate for change, and in particular healthcare 
organizations, and I'd like to acknowledge the role of the 
companies on this panel we've heard from today and how much 
they're doing.
    Health organizations and public employers should absolutely 
model best practices in support of employee health, so all 
healthcare companies and delivery organizations should adopt 
wellness programs and policies similar to those we've heard 
about on the panel today, and hospitals in particular are 
houses of healing open to the community and should serve as 
examples by offering healthful dining, healthy vending, and 
tobacco-free campuses.
    Public employers, including state offices, Federal 
buildings, county facilities, and school districts also should 
demonstrate their commitment as well. State employees' wellness 
programs are becoming more common, and at least a dozen states 
have some type of wellness program available to employees. The 
National Conference of State Legislatures reports that King 
County in Seattle projects their health costs will fall by as 
much as $40 million between 2007 and 2009, due to wellness 
initiatives.
    Now, once employers, either public or private, offer 
wellness and health promotion programs, it's up to employees to 
participate and take advantage of these offerings, and 
disappointing levels of program participation are the Achilles 
heel of many corporate wellness programs. Even when programs 
are launched with employee input and leadership support and do 
the right things, they're well communicated, they're subsidized 
or priced for affordability and they're offered at convenient 
times and locations, low participation can be a barrier to 
success.
    So ``build it and they will come'' is not a strategy for 
success. Instead, companies are adopting in increasing numbers 
incentive programs--we've heard a little bit about that today--
to increase participation and to award program completion, so 
you might offer an incentive to get someone to take a health 
assessment and then perhaps another incentive to reward program 
completion, such as a coaching program.
    Premium incentives for nonsmokers are on the rise in the 
wake of new evidence showing financial incentives have an 
impact on smoking cessation that was conducted at General 
Electric among General Electric Corporation employees, and also 
incentives for weight loss can be effective in a corporate 
setting. On the other hand, before we fall to one single 
solution, we also know from survey data that almost half of 
employees say that financial incentives will not encourage them 
to participate in healthy lifestyle programs, so all of this 
reinforces our understanding that purely voluntary wellness and 
health participation programs will fall short of ideal 
participation levels.
    Now, one state has taken an interesting approach. Faced 
with a serious budget shortfall and not being constrained by 
the Health Insurance Portability and Accountability Act non-
discrimination regulations in the same way as private self-
insured employers are, the State of North Caroline employee 
health plan has determined that it will not allow tobacco users 
(beginning next year) to join the more favorable 80/20 health 
plan, and it expects to preclude those with a high Body Mass 
Index from joining the same favorable health plan beginning in 
2011. Instead, those beneficiaries who do not meet the standard 
for the 80/20 plan will be enrolled in the alternative 70/30 
plan.
    So, in closing, the Federal Government should do all that 
it can to help employers set up employee wellness programs and 
encourage employees (and, where possible, dependents) to 
participate, so we'd suggest that Congress help by removing tax 
barriers, particularly for employees, to allow more widespread 
adoption of wellness programs by employers and greater 
participation by employees and by expanding the IRS definition 
of ``qualified medical expenses'' to include expenses primarily 
to maintain health and wellness, and that's including but not 
limited to expenses for exercise, fitness, weight management, 
and nutritional counseling; and then, third, extending the 
current tax deduction for the fees, dues or membership expenses 
paid by employers for their employees at on-site athletic 
facilities to the fees, dues to membership expenses at off-site 
facilities and supporting health reform provisions to expand 
permissible wellness incentives--right now they're only 20 
percent permitted under HIPAA non-discrimination--and providing 
tax credits to employers for wellness programs which would 
include nutrition and weight management programs; and then, 
finally, only targeting Federal subsidies to foods that are 
essential for a healthy diet and removing any obstacles that 
exist to increased fruit and vegetable production.
    So thank you for the opportunity to share the perspective 
of large employers on the preventable health problems of 
employees that lead to chronic diseases and excess costs which 
are borne by employees and employers alike. We believe it's 
essential to combat the tsunami of obesity that threatens to 
overwhelm us, and we think that in terms of lifetime and 
generational impact that actually obesity has ramifications 
greater than those associated with the current economic crisis, 
and we welcome dialogue on this.
    [The prepared statement of Ms. Heinen follows:]

  Prepared Statement of LuAnn Heinen, M.P.P., Vice President, National
 Business Group on Health; Director, Institute on the Costs and Health 
                  Effects of Obesity, Washington, D.C.
    Good morning Chairman Baca, Ranking Member Fortenberry and members 
of the U.S. House Committee on Agriculture. I am LuAnn Heinen, Vice 
President of the National Business Group on Health (Business Group), a 
member organization representing approximately 300 mostly large 
employers that provide coverage to more than 55 million U.S. workers, 
retirees and their families. The National Business Group on Health is 
the nation's only nonprofit organization devoted exclusively to finding 
innovative and forward-thinking solutions to large employers' most 
important health care and related benefits issues.
America's Obesity Epidemic Continues Unabated
    Today's hearing is focused on defining efforts in health care, 
industry and communities that are effective in addressing the problems 
of poor nutrition, obesity, and related chronic disease. These are 
problems affecting every state, including Nebraska. Adult obesity rates 
continue to rise in 23 states, and have not decreased in any state; 
Nebraska ranks 20th among states in adult obesity prevalence (Trust for 
America's Health, 2009). Rates of obesity among children (2-19) have 
more than tripled since 1980 and may have leveled off; CDC research 
reports no statistically significant change between 2003-2004 and 2005-
2006 (Ogden et al., 2008).
    Last week, Health Affairs reported that medical spending on 
conditions associated with obesity has doubled in the past decade and 
could reach $147 billion a year as of 2008. Obesity now accounts for 
almost 10% of all medical spending, up from 6.5% in 1998. Spending 
associated with obesity is almost entirely tied to costs generated from 
treating the diseases that obesity promotes, such as diabetes. For 
example, excess weight is the single greatest predictor of developing 
diabetes, a disease that costs $191 billion a year. The study also 
found that ``if lawmakers are serious about cutting health care 
spending.they should be focusing on ways to reduce obesity and its 
related risk factors since it is increasingly imposing a heavy burden 
on both private and public payers'' (Finkelstein et al., 2009).
    Just last week, the incoming CDC Director, Dr. Thomas Frieden, 
shared some startling statistics at ``Weight of the Nation,'' a CDC-
sponsored conference attended by approximately 1,000 Federal, state and 
local policymakers and public health officials:

      The average American is 23 pounds overweight.

      As a nation, we have 4.6B pounds of excess weight; if 
this were converted to useable energy, we could power the city of 
Washington D.C. for more than a year and a half.

      The cost of extra food that is needed to maintain the 
nation's excess body weight is greater than $50B per year.

As Obesity Rates Have Climbed, So Have Rates of Associated Health 
        Conditions

      Overweight and obesity associated prevalence of 11 
chronic conditions grew 180% in the 8 years from 1997-2005 (Thorpe et 
al., 2009).The number of working-age adults who report being diagnosed 
with at least one of seven major chronic conditions (heart disease, 
hypertension, stroke, diabetes, emphysema, asthma, and cancer) has 
grown 25% since 1997 to nearly 58 million in 2006 (Hoffman and 
Schwartz, 2008).

      CDC reports that more than 133 million Americans--45% of 
the total population--have at least one chronic disease. Chronic 
diseases kill more than 1.7 million Americans yearly, and account for a 
third of years of potential life lost before age 65 (CDC, 2005).

Obesity Has Played a Major Role in Rising Health Care Costs

      Average per capita health spending increased by 40% from 
1997 to 2005, but the average for the 15 costliest conditions--all 
associated in some way with obesity--jumped 55% (Thorpe et al., 2009).

      Overall, obesity accounts for 27% of the increase in 
inflation-adjusted health expenditures among working age adults. 
Inflation adjusted medical spending for working age adults increased by 
nearly 70% from 1997 to 2005, growing from $316 million to $526 million 
(Thorpe et al., 2009).

      If the prevalence of obesity were the same today as in 
1987, health care spending in the U.S. would be 10% lower per person, 
or about $200 billion less each year (Thorpe et al., 2009).

Do Worksite Wellness and Prevention Programs Work? A Summary of 
        Evidence on Health and Financial Impacts
    The World Health Organization (WHO) estimates that exercise and 
better diets along with smoking cessation could prevent at least 80% of 
all cases of heart disease, stroke, and type 2 diabetes and up to 40% 
of cancers (WHO, 2005). It's clear that to prevent anything approaching 
80% of today's burden of heart disease or 40% of cancers will take 
massive change across many sectors and is much bigger than the 
workplace.
    Just at the worksite, however, evidence is growing that health 
promotion (also called wellness) programs can positively influence 
employee health risks and achieve a positive return on investment 
(ROI).

      An authoritative review of 50 studies of worksite 
interventions by the CDC Community Guide Task Force concluded that 
these worksite health promotion programs reduced tobacco use, dietary 
fat consumption, high blood pressure and total cholesterol levels and 
days if work lost while also increasing productivity (Goetzel and 
Ozminkowski, 2008).

      A review of 25 ROI studies of workplace health promotion 
and disease management programs found an average annual cost reduction 
of 2-4% of total medical claims costs which translated into an ROI of 
1:1.5 to 1:3.0 for health promotion programs. In other words, looking 
only at direct medical costs (not factoring in productivity, 
absenteeism or other indirect costs), these worksite health promotion 
programs showed a small but definite positive ROI (Serxner et al., 
2006).

      An ROI projection model used by The Dow Chemical Company 
to analyze the break-even point for its investments in employee 
wellness showed that even small improvements in health risks for Dow 
employees would yield large savings in health costs for the company. 
``The break-even point, at which savings exactly equals investment 
dollars, occurs when each health risk is reduced by 0.17% annually.'' 
(Goetzel et al., 2005). Increasingly, employers see themselves as 
population health managers--especially in companies with relatively low 
employee turnover--and small risk reductions over a large workforce 
carried out over several years can dramatically reduce health 
expenditures.

    Notwithstanding the research results cited above, a majority of 
large companies do not wait for, fund, or participate in the types of 
research that can definitively answer the question, ``does this program 
have a positive ROI?'' Human resource departments tend not to have a 
budget for research, nor are they willing to spend the needed time or 
IT support to evaluate programs. Their measures of success are usually 
very different from those of academic researchers, and even effective 
programs may be eliminated when there is a downturn in the firm's 
revenues or market capitalization. This clearly limits the volume and 
type of research that can be conducted and slows the development of an 
evidence base that is compelling to academicians and policymakers. 
Employers themselves do not require the same level of evidence for 
decision-making purposes (Heinen and Darling, 2009).
    It is worth noting that the latest survey data from our own members 
(n=75 respondents) show that 16% of respondents said wellness 
initiatives to improve employee health are the single most effective 
tool they have to control health costs, while 30% said wellness is one 
of the top three most effective steps they can take (the other two are 
employee cost-sharing and the use of consumer-directed health plans) 
(National Business Group on Health, 2009).
Employers are Leading the Way to Reduce Obesity and Promote Healthy 
        Lifestyles
    Many employers work with their health plans and other partners to 
be sure that overweight and obesity are included in health education 
and communications, plan design, coaching and health improvement 
programs, as well as disease management and disability/return to work. 
In addition, members of the National Business Group on Health often 
work to ensure the culture and environment at work promote healthy 
weight by encouraging physical exercise, offering healthy food, and 
establishing social norms around healthful behaviors.
    In June, the National Business Group on Health recognized 63 large 
employers--representing the full spectrum of the U.S. economy--as 2009 
Best Employers for Healthy Lifestyles award winners for their 
exceptional commitment to a healthy workplace and for helping their 
employees and families make better choices about their own health and 
well-being. The 2009 class of award winners is the largest ever, with 
companies demonstrating an unprecedented breadth and depth of programs 
to support employee health and wellness. More than ever, employers are 
making investments that should pay substantial dividends over the long 
term. Winners of the 5th Annual Best Employers for Healthy Lifestyles 
awards were honored in one of three categories: Platinum, for 
established ``Healthy Weight, Healthy Lifestyles'' programs with 
measurable success and documented outcomes; Gold, for creating cultural 
and environmental changes that support employees who are committed to 
long-term behavior changes; and Silver, for employers who have launched 
programs or services to promote living a healthier lifestyle.
    As a testament to the increased value employers place on workplace 
health and wellness programs, the number of award-winning employers in 
2009 (a total of 63) grew by 21% compared to 2008 when 52 employers 
were recognized. The 2009 tally is nearly triple the first-year number 
of employers, 22, who were recognized by the National Business Group on 
Health in 2005.

       2009 Best Employers for Healthy Lifestyles Winners Include:
------------------------------------------------------------------------------------------------------------------------------------------------
                                Platinum
------------------------------------------------------------------------
Aetna                   Baptist Health South     Campbell Soup Company
                          Florida
CIGNA                    Dell Inc.                FPL Group
Hannaford Supermarkets   IBM                      Medtronic
Occidental Petroleum     PepsiCo Inc.             Pitney Bowes Inc.
 Corporation
Quest Diagnostics        Texas Instruments        Union Pacific
                          Incorporated
University of            Volvo Group Companies
 Pittsburgh Medical       including Mack Trucks,
 Center, UPMC Health      Inc.
 Plan
------------------------------------------------------------------------
                                  Gold
------------------------------------------------------------------------
American Specialty       AstraZeneca              Blue Cross and Blue
 Health Incorporated                               Shield of Alabama
Boehringer Ingelheim     Chrysler Group LLC       Cummins Inc.
 Pharmaceuticals, Inc.
CVS Caremark             General Dynamics         General Mills
                          Electric Boat
Healthways               Humana                   Intel Corporation
JPMorgan Chase           Mayo Clinic              Paychex, Inc.
Pfizer Inc.              Raytheon Company         Saint-Gobain
                                                   Corporation
Sprint                   The Boeing Company       Unum
Verizon                  Visant Corporation       Wal-Mart Stores Inc.
WellPoint, Inc.
------------------------------------------------------------------------
                                 Silver
------------------------------------------------------------------------
Accenture                American Express         ARAMARK
Cardinal Health, Inc.    H.J. Heinz Company       Lowe's Companies, Inc.
Meijer                   Michelin North America   PRO Sports Club
Qwest Communications     Rockwell Collins         sanofi-aventis U.S.
Target                   Texas Health Resources   The Children's
                                                   Hospital of
                                                   Philadelphia
The Home Depot           Unilever                 Watson Wyatt Worldwide
Wm. Wrigley Jr. Company  Xcel Energy
------------------------------------------------------------------------

Wellness Leadership Here In Nebraska
    One of our Platinum award winners for the last 5 years, Union 
Pacific Corporation, is based right here in Nebraska. Union Pacific's 
health promotion program, HealthTrack, is a comprehensive program that 
seeks to improve the health of Union Pacific's employees. The program 
addresses the following health risk factors; inactivity, weight, 
nutrition, smoking, cholesterol, blood pressure, asthma, diabetes, 
fatigue, stress and depression. HealthTrack includes a health risk 
identification tool, lifestyle management program (risk reduction 
program), a tobacco cessation program, health education programs, 
system health facilities (exercise facilities through the country) and 
research grants.
    In addition, Omaha's Wellness Council of the Midlands, established 
in 1982, is one of the first employer-led wellness councils in the 
country. Its national organization, Welcoa, also in Nebraska, provides 
information and recognition to thousands of smaller businesses 
nationally.
Small Business Has Not Embraced Wellness
    A survey of 450 large employers identified ``employees' poor health 
habits'' as the number one challenge named by employers as they try to 
maintain affordable health benefit coverage (National Business Group on 
Health and Watson Wyatt, 2009). A majority of large employers 
responding to this survey offer health risk appraisals (83%) and weight 
management programs to reduce obesity among employees (74%). Based on 
survey data, observed growth in vendors and suppliers of corporate 
wellness programs, and employers' testimony, a tipping point may have 
been reached that leading large employers now have, or believe they 
should have, wellness programs in place.
    In striking contrast, relatively few small employers have adopted 
comprehensive health promotion (or weight management) programs. The 
most recent National Worksite Health Promotion Survey results actually 
suggest a decline in offerings by employers with fewer than 750 
employees between 1999 and 2004 (Linnan et al., 2008). The survey 
reports that only 6.9% of this nationally representative sample of 
employers offers wellness programs. Reported barriers included a lack 
of employee interest, lack of resources, and lack of management 
support. Because small businesses (fewer than 500 employees) employ 50% 
of the private sector workforce, this survey provides an important, 
albeit sobering, perspective on the typical American worksite.
Role Models Needed
    Although an estimated 100 or more very large employers have 
substantial wellness programs affecting a few million employees, and 
some small and mid-sized employers are following suit, many others have 
been slow to react. Certain employers have the visibility to be role 
models and to influence the climate for change. In particular, health 
care organizations and public employers should model best practices in 
support of employees' health. All health care companies and delivery 
organizations should adopt wellness programs and policies, similar to 
those we've heard about today here in Nebraska. Hospitals, especially, 
are houses of healing open to the community and should serve as 
examples by offering healthful dining, vending and tobacco-free 
campuses.
    Public employers, including state offices, Federal buildings, 
county facilities and school districts all should demonstrate their 
commitment to healthy employees and a health-promoting work 
environment. State employees' wellness programs are becoming more 
common; at least a dozen states have some type of wellness program 
available to employees. The National Conference of State Legislatures 
reports that King County (Seattle) is projecting their health costs 
will fall by as much as $40M between 2007 and 2009 due to wellness 
initiatives.
The Participation Challenge and Role of Incentives
    Once employers, public or private, offer wellness and health 
promotion programs, it is up to employees to participate and take 
advantage of these offerings. Disappointing levels of program 
participation are the Achilles heel of many corporate wellness 
programs. Even when programs are launched with employee input and 
leadership support, are well communicated, are subsidized or priced for 
affordability, and are offered at convenient times and locations, low 
participation can be a barrier to success.
    ``Build it and they will come'' is not a strategy for success. 
Instead, companies are adopting incentive programs to attract 
participation (e.g., in voluntary health assessments) and, 
increasingly, to reward program completion (e.g., health coaching). 
Premium incentives for nonsmokers are on the rise in the wake of new 
evidence showing financial incentives have an impact on smoking 
cessation and weight loss in a corporate setting. However, we also know 
from survey data that almost half of employees say that financial 
incentives will not encourage them to participate in healthy lifestyle 
programs.
    This reinforces our understanding that voluntary wellness and 
health participation programs will always fall short of ideal 
participation levels.
    Faced with a serious budget shortfall and not constrained by the 
Health Insurance Portability and Accountability Act (HIPAA) non-
discrimination regulations in the same way as private self-insured 
employers, the State of North Carolina employee health plan (655,000 
covered lives) has determined it will not allow tobacco users 
(beginning in 2010) to join the more favorable 80/20 health plan, and 
it expects to preclude those with a high Body Mass Index from joining 
the 80/20 plan beginning in 2011. Instead, beneficiaries who do not 
meet the standard for the 80/20 plan will be enrolled in the 
alternative 70/30 plan.
Federal Leadership Can Help
    The Federal Government should do all that it can to help employers 
set up employee wellness programs and encourage employees (and, where 
possible, dependents) participation. Congress can help by:

      Removing tax barriers, particularly for employees, to 
allow more widespread adoption of wellness programs by employers and 
greater participation by employees to lead to a healthier America;

      Expanding the IRS definition of ``qualified medical 
expenses'' under Section 213(d) to include ``expenses primarily to 
maintain health and wellness, including but not limited to expenses for 
exercise, fitness, weight management and nutritional counseling;''

      Extending the current tax deduction for the fees, dues, 
or membership expenses paid by employers for their employees at on-site 
athletic facilities to the fees, dues, or membership expenses at off-
site athletic facilities;

      Supporting health reform provisions to expand permissible 
wellness incentives under HIPAA to 30% of premiums and providing tax 
credits to employers for wellness programs (including nutrition and 
weight management programs); and

      Only targeting Federal subsidies to foods essential for a 
healthy diet and removing any obstacles to increased fruit and 
vegetable production.

    Thank you for the opportunity to share the perspective of large 
employers on the preventable health problems of employees that lead to 
chronic diseases and excess costs borne by employers and employees 
alike. We believe it is essential to combat the tsunami of obesity that 
threatens to overwhelm us. In terms of lifetime and generational 
impact, obesity has ramifications greater than those associated with 
the current economic crisis. The National Business Group on Health 
welcomes further dialogue with the Subcommittee on this or related 
matters.
References
    CDC, Leading Causes of Death--United States, 2005. Accessed at 
http://www.cdc.gov/NCCdphp/overview.htm#2
    Finkelstein, E.A., Trogdon, J.G., Cohen, J.W. and Dietz, W., Annual 
Medical Spending Attributable to Obesity: Payer- and Service-Specific 
Estimates, Health Affairs (online), July 27, 2009.
    Goetzel, R.Z., Ozminkowski, R.J., Baase, C.M. and Bilotti, G.M., 
Estimating the Return on Investment from Changes in Employee Health 
Risks on The Dow Chemical Company's Health Costs, Journal of 
Occupational and Environmental Medicine 47 (6): 759-768, 2005.
    Goetzel, R.Z. and Osminkowski, R.J., The Health and Cost Benefits 
of Work Site Health Promotion Programs, Annual Review of Public Health 
(online), January 3, 2009.
    Heinen, L. and Darling, H., Addressing Obesity in the Workplace: 
The Role of Employers, The Milbank Quarterly, March 2009.
    Hoffman, C. and Schwartz, K., Eroding Access Among Nonelderly US 
Adults with Chronic Conditions: Ten Years of Change, Health Affairs 
(online), July 22, 2008.
    Linnan, L., Bowling, M., Childress, J. et al., Results of the 2004 
National Worksite Health Promotion Survey, American Journal of Public 
Health 98 (8):1503-9, 2008.
    National Business Group on Health, Large Employers' 2010 Health 
Plan Designs: Membership Survey, July 2009.
    National Business Group on Health and Watson Wyatt, The One Percent 
Strategy: Lessons Learned from Best Performers, Thirteenth Annual 
Employer Survey on Purchasing Value in Health Care, 2008.
    Ogden, C.L., Carroll, M.D., and Flegal, K.M., High Body Mass Index 
for Age among U.S. Children and Adolescents 2003-2006, Journal of the 
American Medical Association 299 (20): 2442-2443, 2008.
    Serxner, S., Baker, K. and Gold, D., Guidelines for Analysis of 
Economic Return from Health Management Programs, American Journal of 
Health Promotion, July/August 2006.
    Thorpe, K.E., Ogden, L. and Galactionova, K., Weighty Matters: How 
Obesity Drives Poor Health and Health Spending in the U.S., National 
Business Group on Health, 2009.
    Trust for America's Health, F as in Fat: How Obesity Policies are 
Failing in America 2009, July 2009.
    World Health Organization, Preventing Chronic Diseases--A Vital 
Investment: WHO Global Report, 2005.

    The Chairman. Thank you very much for your expertise and 
your knowledge and sharing the information with us about the 
wellness and prevention and practices that can be implemented, 
both in the private sector and also in the public sector. I 
know that a lot of us are very much concerned, and we realize 
during a time of crisis in the economy, for example, right now 
that these are part of the first programs that go, both in the 
private and public sector. Yet, they're the ones that will 
actually save an employer on health costs to that employer for 
that individual due to their productivity, absenteeism, 
illnesses that occur.
    Wellness programs are important. That's why I think that 
both public, and private sector it is important we have these 
programs. The problem is that once we have the programs, how do 
we get the employees to participate in these kind of programs? 
And like Ms. Heinen said at the very end, when we talk about 
different kinds of incentives to make sure that we have the 
employees become involved in the programs.
    Not only will it greatly reduce employers' costs in private 
health care, but the individuals can get these tax deductions 
and tax credits for the small businesses involved. That's 
important, but let me start with my first question, and I'd 
like to ask Mr. Sensor, thank you for your testimony today. You 
mention that you provide preventative care without charge, and 
I state without charge, but that you do not quantify savings.
    How difficult would it be to assess the cost-benefit? 
That's question number one. And number two, that would be a 
very helpful piece of information for anyone interested in 
copying your program model in Nebraska.
    Mr. Sensor. Thank you, Chairman Baca. I appreciate the 
nature of the question. It is quantifiable. We know exactly 
what we spend on a yearly basis, and we do certainly have some 
glimpse of the impact that has on the consumption of healthcare 
services. The challenge that all of us face is the lack of 
longitudinal studies over a period of years, which we normally 
use in these sorts of areas, we'd like to prove definitively 
the impact.
    In addition to that, of course, we all suffer from some 
level of turnover, and so you're making an investment today in 
employees that, frankly, may or may not be there in the long 
haul with you. That said, we certainly do have quantitative 
information we would love to share with the Committee that 
gives you some pretty good glimpse of the return on investment 
of prevention specifically, and, yes, it is great.
    The Chairman. Dr. Williamson, again, thank you for your 
testimony. Congratulations on the recent honor your 
organization received from the NCQA. Can you explain in 
layman's terms what the continuum of health you mentioned in 
your testimony means?
    Dr. Williamson. Sure. You know, the continuum of health 
really is not about the fact that we have a large portion of 
our population which is healthy or doesn't have any significant 
health risks. We have some who have some lifestyle-related 
issues and risks. There are some who have already developed 
chronic diseases, and there are those who are undergoing some 
kind of acute event, they were in the hospital for one reason 
or another; and then on the far end are people who have 
something catastrophic--they've been in a major car accident, 
had head injuries, or they need a transplant, those kinds of 
things.
    So there--people range from one end of that continuum to 
the other and, a lot of times, move from one side to the other, 
so the important thing is to keep those who are healthy from--
in that area of the continuum and then to take those who have 
some kind of risk or chronic condition and trying to help them 
improve their overall health status and live a better life and 
spend less money.
    The Chairman. Ms. Lommel, thank you for giving your 
testimony. I appreciate your organization's commitment to 
finding the personal touch in your report and connection that 
helps employees become better motivated about wellness. Can you 
explain why the holistic model of rehabilitation is viewed as 
the most effective method of creating a healthier lifestyle?
    Ms. Lommel. I'm not sure it's the most effective. It has 
been effective for us. I like Kim Russel's comments about 
culture. I'm sort of a culture fanatic, and I think that when 
you ask the question for what is the definition of that, I 
would say the definition of culture is the--some of the 
attitudes, beliefs and behaviors of a group of people, and the 
key there is a group of people. Every group of people has its 
own culture from a large university hospital setting to a 
smaller rehabilitation hospital to a school, down to a 
workplace.
    All of those cultures are different, and I think that 
wellness programs have to fit the culture of the group of 
people that are--that it is addressing. The reason that 
rehabilitation is a very successful model for wellness programs 
is that it is holistic. It does appeal to all of the dimensions 
of wellness that a person needs to address. The kinds of people 
who are not changing, the ones that are not participating in 
the company's wellness programs, are not doing so because 
they're afraid, and what they see out there is a goal of health 
and wellness that is unattainable to them because they already 
are overweight or diabetic or whatever.
    Rehabilitation meets people where they're at, and that 
could be a quadriplegic with a high spinal cord injury getting 
back to a very productive life, so it's an easy transition for 
us to see a person who is sedentary, overweight, diabetic, and 
has had three strokes to start with walking with the current on 
the water track, so it is an issue of culture, and it's also an 
issue of meeting people individually where they're at.
    The Chairman. Thank you. One of the things that you had 
mentioned is it's very embarrassing to many individuals 
sometimes. With rehab it's more a sense of comfort, and so that 
becomes very important. And then, of course, the idea that the 
person is afraid or if we can't afford it, or what the outcome 
will be. These are all important. But, what steps can the 
government take to incentivize employers to advocate a health 
and wellness program that goes the extra mile to make consumers 
feel comfortable and personally invested?
    Ms. Lommel. Again, I would go back to a group setting. You 
know, we all like sports. We all like competition; right? We 
all have competitions. Why do we like those things? You know, 
in a rehabilitation model everything has to be fun. I mean, we 
have a lot of fun in our various programs. We have dietitians, 
people on the night shift who roll carts of avocados.
    We have competitions between departments. We have 
competitions at ProActive. We have a big dance program at 
ProActive, ballroom dancing for older people.
    You know, it has to fit the situation, so when I think of a 
school, for example, what do kids like? You know, fit the 
wellness program to the situation that you're in. I think your 
question was what can the government do. None of this at 
ProActive is paid for by the government. I mean, there is no 
help for medical fitness centers or for--very few employers 
help subsidize fitness centers like this, even though we have 
many employees who change their entire lives here.
    The Chairman. Does anybody else want to tackle that? Mr. 
Sensor.
    Mr. Sensor. I certainly agree with that notion, but I would 
add maybe the elephant in the room, and that is the payment 
reform. I think about the 1,200 physicians that practice 
medicine under the umbrella of Alegent Health and what their 
day looks like on a daily basis and what their day could look 
like on a daily basis, and they, because of being driven by 
reimbursement as a reality, see patients largely in 15 minute 
blocks.
    They don't really have time to engage with that patient as 
to their health and health challenges, to encourage prevention, 
to help them evaluate assessments that have been performed, et 
cetera. So while I agree with all of you on the panel, there 
are things that we, as employers, and things that we, as 
providers, can do to drive prevention and wellness, and 
ultimately, as a country, we need to pay for it if we want it 
to happen even more broadly.
    The Chairman. Thank you.
    Mr. Fosdick. I think it goes back to accountability, and I 
really believe that the government has to hold employers more 
accountable, and the bottom line is the fact that I think we 
have to hold everybody accountable. I think some of the points 
brought out today are very specific, that a very specific 
amount of healthcare costs are held by a very small percentage, 
and some of those are, unfortunately, unstoppable.
    Some of things are things that could be corrected, and I 
think that we have to start holding a higher level of 
accountability to employers as well as the individual. I think 
that there are ways that could be done, and we have found that 
if we don't look at it seriously and keep people informed and 
hold people accountable that things don't change.
    Ms. Heinen. I just spoke a little about the Safeway 
example. There's been so much written about how Safeway is 
trying to do just that and hold its employees accountable for 
four things. It's not using tobacco, healthy weight, 
cholesterol, and blood pressure; and, of course, it's a 
voluntary program with the maximum incentive they do give 
employees who, if they meet the standard on those four health 
risks, they are paying 20 percent less for their health care 
so--if they can't keep it or fix it, and that's something that 
many companies are more and more interested in.
    It's a way of holding employees accountable. However, right 
now the incentives are limited and under HIPAA non-
discrimination, and it's a voluntary program.
    The Chairman. I know my time has run out. I'll turn it over 
to our Ranking Member Fortenberry. I know that we won't have 
time to come back around. I have to catch a flight back.
    Mr. Fortenberry. That's the Chairman's way of telling me 
politely to hurry up, so I'll try,
    Mr. Chairman, thank you. Let me, as I did for the previous 
panel, highlight some of the findings that I think jumped out 
from what you had to say today, and I'll come back and go 
through some specific questions.
    First of all, Mr. Sensor, you pointed out that you have 
half the premium of increases in your organization because of 
your wellness--or direct correlation to your wellness program 
compared to the national average.
    Dr. Williamson, you pointed out that five percent of 
patients account for 50 percent of healthcare expenditures. Ms. 
Lommel, I don't want to mis-state this, but your healthcare 
increases are less than 1.5 percent per year, 1.76 less than 
two percent a year. Extraordinary level compared to the 
national average.
    Mr. Fosdick, again, the Nebraska Medical Center, 27 percent 
in the last 5 years, nationally four percent, again 
attributable, directly correlatable, to what you've addressed 
in wellness programs that you've done for your employees.
    Ms. Heinen, this is particularly important to me. You're 
representing studies for 55 million Americans were represented 
for working for large companies. Diet and exercise, smoking 
cessation can result in 80 percent lower risk in the onset of 
heart disease and 40 percent lower risk in the onset of various 
type of cancers. You then also point out that, again, across a 
very large pool, which is confirmed by what we're finding here 
in smaller organizations in Nebraska and the region, there is a 
two to four percent cost reduction annually because of wellness 
and cost savings.
    Marsha, let's go back to the example you gave of the 67 
year old person who was now free from numerous medications that 
she was on previously. Why don't you--I think it's important to 
talk about that journey a little bit and the incentives that 
were in place there. Clearly, that's a natural will by that 
woman to take a turn and try something different, but were 
there other structures in place that affirmed those actions by 
the individual?
    Ms. Lommel. Well, that was just one example of a ProActive 
member who was retired who came to ProActive after having had 
several strokes and multiple health problems.
    Mr. Fortenberry. She joined ProActive as a citizen of 
Lincoln to try to get better?
    Ms. Lommel. Yes.
    Mr. Fortenberry. She's not a former employee. Just a 
member?
    Ms. Lommel. No. Right, right, right. Well, we have 3,800 
members. About, like I said, half of them come because they 
really need help in getting well. Some of them come as 
physicians' prescriptions written on a pad, ``Go to ProActive 
and get well.'' They write that on a pad.
    Mr. Fortenberry. But insurance is not paying for that?
    Ms. Lommel. No, no. Insurance is not paying for that. It's 
all private pay. Yes, they join as a member. She would start 
with a health risk assessment, and the ProActive wellness 
assessment that I talked about was just the adjunct to a health 
risk analysis. It is an individual session with a lifestyle 
coach to develop a program for her. If I don't know if she had 
arthritis, but a lot of the early stage people who have 
significant risks start with aquatic therapy, and our aqua 
track is the best thing going.
    It's a cross-current water track that we use for arthritis 
therapy, for MS, for a whole bunch of different diseases. We 
would get very involved with a social group. In this case, she 
wanted to dance, and we have all kinds of dancing programs or 
classes for members because it's fun, so she got very involved 
in tap dancing, started changing her eating habits, her 
lifestyle. It all balloons, you know, snowballs. You know, when 
you get into that wellness mentality, it snowballs and starts 
affecting everything.
    Mr. Fortenberry. So I think the larger question is for you, 
in the industry, as well as us, as lawmakers, is to how do you 
affirm undergird that will, an act to take on a mind-set or 
paradigm, as well as through the proper incentives, both at the 
employer level--and Ms. Heinen referred to this non-
discrimination clause issue that you raised--but also at the 
individual level? So, essentially, could you address it a 
little more precisely, the types of incentives, specific 
examples?
    You had talked about preventative care where you were able 
to actually pay to get well, and then we'll come back to your 
non-discrimination clause.
    Mr. Sensor. Thank you, Mr. Fortenberry. Absolutely, and 
both of those are complimentary of one another. Like you've 
heard from several panelists already today, our employees and 
their dependents are encouraged to annually participate in 
health appraisals and an on-line tool. They're given $100 
simply to do it. It identifies electronically and immediately 
what the risk factors are. Sometimes those are small risk 
factors.
    I recently did mine, and I have seen my doctor. My 
cholesterol was slightly elevated, and it gave me some 
suggestions as to how to lower my cholesterol. Sometimes there 
are significant issues, for example, smoking or perhaps alcohol 
use, in which case the individual can voluntarily choose to 
participate in a program, or they'll get a call from a personal 
health coach, all free. That individual will encourage them to 
enroll in a program and become their new best friend in their 
achieving the goals of that program.
    If they complete that program, they'll then be remunerated 
on top of the $100, depending on what risk factor they 
addressed, $200, $300, or $400 additional. You can see the 
construct. The same thing. I'm going to pay you $500 a day to 
get you to quit smoking will oftentimes cause people to walk 
across the line. They already knew they should quit. Now 
they've been incentivized to quit, and I won't take our 
precious time today, but the stories are really incredible of 
people approaching me from the grocery stores and gas stations 
and the halls of our hospitals talking about how their employer 
has finally helped them to address their risk factors, how 
they've gotten off their blood pressure medicine, how much 
better they feel, how much more energy and how less sick they 
are. But, it's really the concert of the preventative programs 
and the wellness and lifestyle programs working together to 
change their health.
    Thank you.
    Mr. Fortenberry. Thank you. Ms. Heinen, again, you pointed 
out that some of the interplays of legal restrictions here 
actually may be interfering with such types of incentives. Now, 
it's put under the label of non-discrimination, but I wonder if 
that's an unfortunate word, because you're not talking 
necessarily about discriminating, but not being allowed to 
incentivize, and that's another way to put it at a higher 
level.
    So let's talk about the interplay of Federal laws that 
might unintentionally, while trying to project the individual 
patient rights, interfere with innovative opportunities that we 
may have here to partner with patients for their own wellness.
    Ms. Heinen. Well, exactly, and as the other panelists have 
testified that, you know, financial incentives can make a 
difference, and not all will make a difference. They don't work 
for everyone, but they can be very important, and in just 
getting these programs on the radar screen, incentives in the 
workplace to participate, a 20 percent limit, you know, is a 
little bit of a barrier.
    We understand and acknowledge that certainly there are 
risks that aren't preventable by the individual, and we need 
appropriate protection, but employers do feel that given the 
magnitude of the savings, in the Safeway example, they say they 
have held their trend constant for the years that they've been 
doing this program, 4 years now.
    That's a big impact financially on the company and does 
also benefit the employees who also, let's not forget, pay for 
health care.
    Mr. Fortenberry. Do you think this rule like 20 percent is 
artificially low?
    Ms. Heinen. I would say that, yes.
    Mr. Fortenberry. Dr. Williamson, Mr. Fosdick, would you 
care to elaborate again on anything that you've done that is--
you've both provided us some examples of the protectiveness of 
your own wellness programs, but how that could be expanded in 
an interplay with a Federal law.
    Dr. Williamson. We've had a chance to work with over 100 
employers on this particular program and tried many incentives 
on the particular culture in their company they want to--that 
fits what they want to do, so the one that seems to create the 
most participation for us is actually the personal contribution 
to premium differential, so even at $10 a month difference in 
what that family is contributing or that person is contributing 
on their insurance premium will make a difference in how they 
participate.
    You know, the way we have structured this is that it's 
generally a phased approach, so when an employer initially gets 
involved, they might just want to incentivize participation in 
the health care and completing the health risk assessment and 
maybe talking to a lifestyle coach about particular issues. 
But, over time I think it needs to progress if this is going to 
continue, if their improvement continues, so if they have a 
risk, they have a chronic disease or they have some other risk, 
then the next step ought to be that they address that. I think 
the final step probably is something along the lines of what 
we've heard from Ms. Heinen, which is more of a standard base.
    You know, if you had--if you smoke, you need to quit. If 
you're overweight, you need to get your BMI down below a 
certain level, or if your cholesterol is high, it should come 
down, and that's where you get into this 20 percent concern. 
You know, there's a point where you build up these incentives, 
and at 20 percent you're running against this issue here, and 
you're kind of stuck.
    Mr. Fortenberry. All right. Thank you.
    Mr. Fosdick. And I think it goes back to education. The 
bottom line is the fact that there are still many, many 
corporations in this country who've resisted every year and 
have their HR person or managements implying that our 
healthcare costs will go up four or six or eight percent and 
inflate the sheet that much, and they kind of resist it every 
time.
    They'd rather take it, and the bottom line is I think there 
can be some way that maybe--you know, maybe leadership in 
Congress can send information to CEOs saying, Here's some 
examples, here are best practices, and I would be very 
uncomfortable if I was an HR person who went in every year and 
say, Good news, our costs are going up, and I don't have a clue 
on how to fix it.
    I think that may be very uncomfortable for me, so I think 
sharing the best practices, but I wouldn't do it--I would make 
sure they go directly to the CEOs, because obviously HR people 
aren't willing to take the initiatives do the things they've 
got to do.
    Mr. Fortenberry. We're somewhat confined.
    Well, thank you all for your insights. Clearly, this is 
very helpful. Now, of course, we haven't had time to impact the 
issue of limited participation by smaller employers where a 
majority of Americans are working and the cost factors there 
for the small employer in terms of incentive wellness, but 
clearly large employers, large health systems that are doing 
this are showing these three to one returns on investments, so 
hopefully there's a trickle down effect there and an 
educational effect to show that this is a true cost saving 
measure.
    Of course, we're not talking about people who are having to 
buy their own individual policy or who are priced out of the 
market because of unaffordability issues there, but if we can 
lower our overall healthcare costs, that should lower premiums 
in the general market and improve outcomes. I think what you're 
saying is pretty helpful to me, important in that regard, so 
thank you very much. The Chairman is about to conclude.
    Before he does, I hope you all will bear with me, but 
because we are anticipating a potential national championship 
year this year, I thought I'd give our Chairman a Nebraska 
football jersey and thank him for his generosity in coming to 
us.
    The Chairman. Thank you very much. I'm going mention 
something from the earlier panel about participating earlier in 
education because the research needs to be done, especially if 
we look at the subject matter that we've addressed today. I 
really do appreciate our Ranking Member for bringing this to 
our attention on a national basis, and for having a hearing 
here in Lincoln, Nebraska. One of the things that needs to be 
done from an education perspective is for employers who run a 
small business.
    Large employers hand out materials on health benefits that 
are there, but you really don't have an actual orientation of 
what it actually means, and maybe we should have some form of 
an orientation on a voluntary basis. That would save tons of 
dollars and people would begin to understand the real value not 
only to their life, but also the impact it has on the cost 
factors of health. I appreciate you making your statements.
    We need to do more on a voluntary basis in local and 
private and public systems, having a way for people to really 
begin to understand, to change their attitudes and behaviors, 
and what it means to them in their life. It's very difficult 
for us to participate in the lives of our kids and others and 
grandchildren as we mature in age, and we want to assist with 
our grand kids, and that's why it's important we have this kind 
of orientation.
    We don't have a teacher orientation; we don't have anything 
that covers health.
    What is it that we need to cover in that area? We need to 
do a little bit more on a voluntary basis. With that I'd just 
like to again thank all of the panelists for being here. Before 
I make my final closing statement, I would turn it over to our 
Ranking Member Fortenberry to make his closing remarks, and 
then I will make my closing remarks and then officially do what 
I have to do to adjourn this official meeting.
    Mr. Fortenberry. Well, again, thank you, Mr. Chairman, for 
the generosity you have shown in taking time away from your 
constituents in California to be with us here. We appreciate 
your sincere leadership on these important essential questions 
affecting our nation and are honored to have you. I'd like to 
conclude by picking up on one comment that Marsha Lommel gave 
as well. We talked quite a bit in our earlier panel about the 
relationship between nutrition and wellness and health and how 
it's showing the experience that you all have had in making 
wellness programs, how it actually does reduce costs and 
improve healthcare outcomes, and we all feel better.
    But you made a very good point, Marsha, in sensitizing this 
to the fact that wellness programs, in and of themselves, can 
attract healthy people, and there are certain barriers to those 
who are facing more challenges that make it difficult for them 
to participate. I think that was very insightful as well, 
because clearly this is a direction that we must embrace as a 
nation. Better nutrition, better lifestyle, better incentives, 
understanding of the legal interplay for those incentives, but 
also having an impact by creating a facility with a real caring 
heart and a progressive, holistic approach to the various 
dynamics of health care, so with that said, again, thank you 
for hosting us today. I thank all of the witnesses who 
graciously joined us, and again, thank you, Mr. Chairman, for 
leading us today.
    The Chairman. Thank you very much, and again I want to 
thank each of the panelists for your knowledge and your 
expertise and your participation. We hope that the best 
policies meet the challenges of our economy and our nation, 
especially as it pertains to health; not only the importance of 
preventive measures, but the cost to society and its taxpayers. 
I think we began to address the impact it has on us as we 
address national issues of health, and nutrition. Nutrition 
becomes very important for a lot of us, the appropriate 
nutrition not only for our children, but for adults, in making 
changes.
    With that I want to again thank Congressman Fortenberry for 
having the leadership in bringing this panel together and 
taking on this topic. It was his choice to raise this topic, 
and he said, ``I want to have it in Lincoln, Nebraska, not back 
in Washington, D.C. I want to bring it to our area and address 
this on a national level.'' And I'm glad we were able to work 
out a schedule with him out here.
    Again, I look forward to hearing from you in the future, 
and you're all welcome to come to my district anytime to 
beautiful San Bernardino. Fog is there. It's really pretty, but 
the smog is there in that area. With that I'd like to state 
that under the rules of the Committee our record of today's 
hearing will remain open for 30 calendar days to receive 
additional materials, supplemental witness responses from the 
witnesses, and any questions posed by Members.
    The hearing on the Subcommittee on Department Operations, 
Oversight, Nutrition, and Forestry is now adjourned.
    [Whereupon, at 12:48 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]
      
                Submitted Material by Dr. David H. Janda
    A Prevention & Consumer Driven Approach
    Achieving Health Care Emancipation & Freedom
    By David H. Janda, M.D.
    On September 22, 1862 President Abraham Lincoln issued The 
Emancipation Proclamation:

    ``That on the 1st day of January, in the year of our Lord 1863, all 
        persons held as slaves within any state or designated part of a 
        state, the people whereof shall then be in rebellion against 
        the United States, shall be then, thenceforward, and forever 
        free; and the executive government of the United States, 
        including the military and naval authority thereof, will 
        recognize and maintain the freedom of such persons and will do 
        no act or acts to repress such persons, or any of them, in any 
        efforts they may make for their actual freedom . . . And upon 
        this act, sincerely believed to be an act of justice, warranted 
        by the Constitution upon military necessity, I invoke the 
        considerate judgment of mankind and the gracious favor of 
        Almighty God.''

    With these words President Lincoln ended slavery, which was a 
flagrant violation of the institutions of America--``a government of, 
by and for all the people.''
    The institution of slavery denied freedom to fellow Americans. In 
2009, freedom is being denied to every man, woman and child--freedom of 
health care. Some in the HMO industry, many in the insurance industry, 
and many Federal ``Big Government'' bureaucrats are denying Americans 
their freedom of health care. The Obama Health Care Plan is the 
instruction manual and play book for this approach. The ``Masters'' of 
Health Care are trying to deny individuals their freedom to choose what 
doctor you can see, what medicine you can take, what hospital you can 
go to, and how your spend your health care dollars. They even take it a 
step further in the Obama Health Care Plan--IF--yes, IF you can be 
treated. These ``Masters'' of Health Care are driving us to unnecessary 
pain, suffering, and, in some cases, death. The health care system 
needs drastic reform, in this country and around the world. Most 
importantly, this reform must be based on the bedrock of providing each 
person, each family and business their healthcare freedom.
    As I wrote in my book, The Awakening of a Surgeon, I believe health 
care reform has become ``A Domestic Vietnam.'' One of the tragic 
lessons from the Vietnam War was that if the policy makers and decision 
makers do NOT listen to the grunts on the front line we will lose the 
war. If we lose the battle to implement ethical and humane health care 
reform, this time we can NOT get in our helicopters and planes and fly 
away. Every American citizen, family and business will become a 
casualty. The message from the front line is: Stop empowering Big 
Government bureaucrats, the HMO industry and the insurance industry. 
The key to reform is to EMPOWER each American citizen, family and 
business. We should fight to give people, families and businesses 
control over their health care finances and the right to chose who they 
see, where they go for treatment and what treatment they can receive. 
Above all, focus on PREVENTION. Prevention is the key to the most 
efficient, humane and ethical health care cost containment policy.
    The issues of health care reform and the proposed ``solutions'' are 
very frustrating for those of us on the frontline of health care 
delivery. Health care reforms often are presented as a politically 
Right/Left/Liberal/Conservative issues. On the contrary, this is an 
issue that transcends political parties and affects every man, woman, 
child, business and community in our country. I do not see health care 
on a political Left/Right Axis; I see it on an Up/Down Axis. Up 
represents individual freedom, freedoms of health care for every 
person. Down represents oppression of people and businesses and their 
health care freedom. I believe Americans' health care freedoms are 
currently being oppressed by a number of different entities. Many 
individuals at the Federal Government level and their proposed reform/
plans are hindering health care freedom. Certain corporate entities in 
the HMO and the Insurance Industry also are limiting freedom. They are 
dictating what type and how much health care is to be delivered. They 
have decimated the doctor/patient relationship and I believe they are 
putting people and businesses in harms way. When I became a physician I 
took an oath to ``Do No Harm.'' This current structure inflicts harm.
    There is one solution that unlocks the shackles that HMO's, some 
insurance companies and Big Government Bureaucrats have placed on every 
person, family and business. That solution is Health Savings Accounts. 
Competition reduces costs in health care, just as in other 
``industries.'' Personal Health Savings Accounts (HSAs) already 
demonstrate an ability to change the system for the better. Putting 
people back in charge of their own health care gives them incentives 
like nothing else can. People make healthier choices about how they 
live when they ``have a dog in this fight.''
    Personal HSAs are coupled with higher deductible, Catastrophic 
Insurance coverage, so no one falls through the net by an unexpected 
major need. Such coverage is much less expensive. An employer can put 
the cost savings into the HSA, before taxes. Both immediate and long-
term savings ensue. HSAs earn investment income, and can be used for 
all medical expenses, covering the deductible, as well as medications 
and incidentals. Unspent, it grows yearly. An HSA is fully portable, if 
you change jobs, as many now do. It is also inheritable by a spouse. 
For those now on Medicaid, patients would be provided an HSA at a 
fraction of the current cost paid by state and Federal governments.
    A recent analysis of Health Savings Accounts by The United States 
Department Treasury revealed 33% of small businesses now with HSA's 
previously did NOT offer coverage. In addition, 31% of those signing up 
were previously uninsured. Forty-two percent of HSA purchasers had 
family incomes below $50,000. The benefits of the HSAs are many, 
reducing health care costs by an average of 35% and extending coverage 
in the process.
    Health Savings Accounts, coupled with prevention-related 
interventions are the keys to reducing health care costs for every 
person, family and business. Prevention of health care need is the most 
efficient and ethical means of cutting health care costs. It is a far 
more effective and compassionate way of reducing costs than 
manipulating health care ``need'' by reducing access and availability 
of care through rationing as promoted by the Obama Health Care Plan, 
the Federal Government, and the HMO and insurance industries. By way of 
example, according to the Federal Government, one of our studies at The 
Institute For Preventative Sports Medicine revealed how to prevent 1.7 
Million people from being injured every year and how to save $2 Billion 
in health care costs per year. Of note is that we spent $1,000 on that 
series of studies. When it comes to Prevention, this financial benefit 
is not the exception, it is the rule. Health Savings Accounts are the 
vehicle to drive health care costs down, and Prevention is the key that 
ignites the engine to the HSA vehicle.
    The goal is to make health care available and affordable. When I 
became a physician, I took an oath to ``Do No Harm.'' I decided to add 
to that oath to ``Prevent Harm.'' Through Prevention initiatives and 
Health Savings Accounts, we have an opportunity to bring health care 
freedom to every person, family and business. If we do not act now, we 
will never be free of the ``Masters''--the HMO and Insurance 
Industries, and Big Government bureaucrats.
    Victor Hugo stated, ``There is nothing more powerful than an idea 
whose time has come.'' The time has come for Health Savings Account 
driven by Prevention and Wellness initiatives.
  Supplemental Material Submitted by Blake J. Williamson, M.D., M.S., 
Vice President and Senior Medical Director, Blue Cross and Blue Shield 
                             of Kansas City

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 Supplemental Material Submitted by Marsha Lommel, President and CEO, 
                    Madonna Rehabilitation Hospital

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