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


 
   MAKING HEALTH CARE WORK FOR AMERICAN FAMILIES: THE ROLE OF PUBLIC 
                                 HEALTH 

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                    COMMITTEE ON ENERGY AND COMMERCE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                             MARCH 31, 2009

                               __________

                           Serial No. 111-24


      Printed for the use of the Committee on Energy and Commerce

                        energycommerce.house.gov

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                    COMMITTEE ON ENERGY AND COMMERCE

                 HENRY A. WAXMAN, California, Chairman

JOHN D. DINGELL, Michigan            JOE BARTON, Texas
  Chairman Emeritus                    Ranking Member
EDWARD J. MARKEY, Massachusetts      RALPH M. HALL, Texas
RICK BOUCHER, Virginia               FRED UPTON, Michigan
FRANK PALLONE, Jr., New Jersey       CLIFF STEARNS, Florida
BART GORDON, Tennessee               NATHAN DEAL, Georgia
BOBBY L. RUSH, Illinois              ED WHITFIELD, Kentucky
ANNA G. ESHOO, California            JOHN SHIMKUS, Illinois
BART STUPAK, Michigan                JOHN B. SHADEGG, Arizona
ELIOT L. ENGEL, New York             ROY BLUNT, Missouri
GENE GREEN, Texas                    STEVE BUYER, Indiana
DIANA DeGETTE, Colorado              GEORGE RADANOVICH, California
  Vice Chairman                      JOSEPH R. PITTS, Pennsylvania
LOIS CAPPS, California               MARY BONO MACK, California
MICHAEL F. DOYLE, Pennsylvania       GREG WALDEN, Oregon
JANE HARMAN, California              LEE TERRY, Nebraska
TOM ALLEN, Maine                     MIKE ROGERS, Michigan
JAN SCHAKOWSKY, Illinois             SUE WILKINS MYRICK, North Carolina
HILDA L. SOLIS, California           JOHN SULLIVAN, Oklahoma
CHARLES A. GONZALEZ, Texas           TIM MURPHY, Pennsylvania
JAY INSLEE, Washington               MICHAEL C. BURGESS, Texas
TAMMY BALDWIN, Wisconsin             MARSHA BLACKBURN, Tennessee
MIKE ROSS, Arkansas                  PHIL GINGREY, Georgia
ANTHONY D. WEINER, New York          STEVE SCALISE, Louisiana
JIM MATHESON, Utah                   PARKER GRIFFITH, Alabama
G.K. BUTTERFIELD, North Carolina     ROBERT E. LATTA, Ohio
CHARLIE MELANCON, Louisiana
JOHN BARROW, Georgia
BARON P. HILL, Indiana
DORIS O. MATSUI, California
DONNA M. CHRISTENSEN, Virgin 
Islands
KATHY CASTOR, Florida
JOHN P. SARBANES, Maryland
CHRISTOPHER MURPHY, Connecticut
ZACHARY T. SPACE, Ohio
JERRY McNERNEY, California
BETTY SUTTON, Ohio
BRUCE L. BRALEY, Iowa
PETER WELCH, Vermont

                                  (ii)
                         Subcommittee on Health

                FRANK PALLONE, Jr., New Jersey, Chairman
JOHN D. DINGELL, Michigan            NATHAN DEAL, Georgia,
BART GORDON, Tennessee                   Ranking Member
ANNA G. ESHOO, California            RALPH M. HALL, Texas
ELIOT L. ENGEL, New York             BARBARA CUBIN, Wyoming
GENE GREEN, Texas                    HEATHER WILSON, New Mexico
DIANA DeGETTE, Colorado              JOHN B. SHADEGG, Arizona
LOIS CAPPS, California               STEVE BUYER, Indiana
JAN SCHAKOWSKY, Illinois             JOSEPH R. PITTS, Pennsylvania
TAMMY BALDWIN, Wisconsin             MARY BONO MACK, California
MIKE ROSS, Arkansas                  MIKE FERGUSON, New Jersey
ANTHONY D. WEINER, New York          MIKE ROGERS, Michigan
JIM MATHESON, Utah                   SUE WILKINS MYRICK, North Carolina
JANE HARMAN, California              JOHN SULLIVAN, Oklahoma
CHARLES A. GONZALEZ, Texas           TIM MURPHY, Pennsylvania
JOHN BARROW, Georgia                 MICHAEL C. BURGESS, Texas
DONNA M. CHRISTENSEN, Virgin 
    Islands
KATHY CASTOR, Florida
JOHN P. SARBANES, Maryland
CHRISTOPHER S. MURPHY, Connecticut
ZACHARY T. SPACE, Ohio
BETTY SUTTON, Ohio
BRUCE L. BRALEY, Iowa
  






























                             C O N T E N T S

                              ----------                              
                                                                   Page
Hon. Frank Pallone, Jr., a Representative in Congress from the 
  State of New Jersey, opening statement.........................     1
Hon. Nathan Deal, a Representative in Congress from the State of 
  Georgia, opening statement.....................................     2
Hon. Henry A. Waxman, a Representative in Congress from the State 
  of California, opening statement...............................     4
    Prepared statement...........................................     5
Hon. Joseph R. Pitts, a Representative in Congress from the 
  Commonwealth of Pennsylvania, opening statement................     9
Hon. Gene Green, a Representative in Congress from the State of 
  Texas, opening statement.......................................     9
Hon. Anna G. Eshoo, a Representative in Congress from the State 
  of California, opening statement...............................    13
Hon. Janice D. Schakowsky, a Representative in Congress from the 
  State of Illinois, opening statement...........................    15
Hon. Michael C. Burgess, a Representative in Congress from the 
  State of Texas, opening statement..............................    15
    Prepared statement...........................................   160

                               Witnesses

Richard E. Besser, M.D., Acting Director, CDC, Acting 
  Administrator, Agency for Toxic Substances and Disease Registry    16
    Prepared statement...........................................    19
    Answers to submitted questions...............................   167
Jonathan E. Fielding, M.D., M.P.H., Chair, Task Force on 
  Community Preventive Services, Director and Health Officer, 
  L.A. County Department of Public Health........................    33
    Prepared statement...........................................    36
Heather Howard, J.D., Commissioner, New Jersey Department of 
  Health and Senior Services.....................................    89
    Prepared statement...........................................    93
David Satcher, M.D., Ph.D., Former U.S. Surgeon General, 
  Director, Satcher Health Leadership Institute, Morehouse School 
  of Medicine....................................................    99
    Prepared statement...........................................   101
Barbara Spivak, M.D., President, Mount Auburn Cambridge 
  Independent Physicians Association, Inc........................   114
    Prepared statement...........................................   116
Devon Herrick, Ph.D., Senior Fellow, National Center for Policy 
  Analysis.......................................................   124
    Prepared statement...........................................   126
Jeffrey Levi, Ph.D., Executive Director, Trust for America's 
  Health.........................................................   139
    Prepared statement...........................................   141

                           Submitted Material

Statement of the Human Rights Campaign, submitted by Ms. Baldwin.   162


   MAKING HEALTH CARE WORK FOR AMERICAN FAMILIES: THE ROLE OF PUBLIC 
                                 HEALTH

                              ----------                              


                        TUESDAY, MARCH 31, 2009

                  House of Representatives,
                            Subcommittee on Health,
                          Committee on Energy and Commerce,
                                                    Washington, DC.
    The subcommittee met, pursuant to call, at 10:06 a.m., in 
Room 2232 of the Rayburn House Office Building, Hon. Frank 
Pallone, Jr. (chairman) presiding.
    Members present: Representatives Pallone, Dingell, Eshoo, 
Engel, Green, DeGette, Capps, Schakowsky, Baldwin, Matheson, 
Harman, Gonzalez, Barrow, Christensen, Castor, Sarbanes, Murphy 
of Connecticut, Waxman (ex officio), Deal, Whitfield, Shimkus, 
Pitts, Burgess, Blackburn, Gingrey, and Barton (ex officio).
    Staff present: Andy Schneider, Chief Health Counsel; Sarah 
Despres, Counsel; Tim Westmoreland, Consulting Counsel; Naomi 
Seiler, Counsel; Anne Morris, Legislative Analyst; Virgil 
Miller, Legislative Assistant; Jon Donenberg, Fellow; Camille 
Sealy, Fellow; Alvin Banks, Special Assistant; Alli Corr, 
Special Assistant; Miriam Edelman, Special Assistant; Lindsay 
Vidal, Staff Assistant; Aarti Shah, Minority Counsel; Ryan 
Long, Minority Chief Health Counsel; and Chad Grant, Minority 
Legislative Analyst.

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE 
            IN CONGRESS FROM THE STATE OF NEW JERSEY

    Mr. Pallone. The hearing of the subcommittee is called to 
order. Today the subcommittee is meeting for the fourth hearing 
in the Making Health Care Work for American Families series. To 
date, we have heard about the failings of our current health 
care system, the need to increase access to care and improve 
our primary care work force, and the mechanisms that can make 
health care coverage affordable for all. In today's hearing, 
however, we are going to explore a less often discussed, yet 
extremely vital aspect of health reform and that is public 
health.
    Health reform isn't just about improving coverage and 
access. It is also about making our Nation healthier. We spend 
more than any other country on health care and still we have 
higher morbidity and mortality rates than any other 
industrialized Nation. More than half of our population suffers 
from at least one chronic condition, which not only increases 
our health care cost but also lowers our productivity, and this 
is simply not sustainable especially in these difficult 
economic times. What is frustrating is that these diseases for 
the most part are preventable. Too many people are dying of 
illnesses such as cardiovascular disease, respiratory diseases, 
and diabetes-related illnesses, and if the current obesity 
epidemic continues on the path it is on now, we will see even 
further increases in many of these diseases.
    In my home State of New Jersey, 14 percent of our children 
are clinically overweight and this epidemic is obvious 
nationwide. A report conducted by the Trust for America's 
Health in 2008 highlighted all potential problems these 
children will have to face during the course of their lifetime. 
Childhood obesity can lead to a myriad of health problems, 
including high blood pressure, Type II diabetes, joint 
problems, and depression, just to name a few. And this epidemic 
alone has the potential to cripple our health care system if we 
do not take measures to address it. Providing all Americans 
with health care coverage and improving access to care will 
address some of these issues. However, bolstering the public 
health system will be the vital component to making health care 
reform sustainable and to improving health outcomes.
    We must start investing in the prevention of these horrible 
diseases rather than just focusing on those who are already 
sick. This shift in our resource allocation could potentially 
save the system billions of dollars per year, not to mention 
the benefits to patients. Public health really means improving 
the quality of life for individual people, communities, and our 
society as a whole. Many of the federal, state, and local 
public health initiatives have already had huge impacts on out 
society's health. Diseases that once were life threatening are 
now all by extinct thanks to vaccination efforts, for example.
    Smoke-free environments have already had an impact on the 
rate of smoke-related illnesses, and the community-based 
prevention initiatives supported by the Centers for Disease 
Control have already shown great results and increasing healthy 
lifestyle awareness and adherence. It is our responsibility in 
Congress to ensure that they have the resources they need to 
continue and expand the work that they are doing. In short, if 
I could sum up, public health ensures that individuals in 
communities are able to lead healthier lives. We will hear from 
witnesses today who have dedicated their lives to this noble 
goal, and I want to welcome all of them. I know we have two 
panels today. I want to thank everyone for coming.
    I especially wanted to mention our New Jersey Department of 
Health and Human Services Commissioner Heather Howard. She has 
worked on the Hill previously with then Senator Corzine, now 
Governor Corzine. It is wonderful to see you again, Heather, 
and all that you do, and I am looking forward to your testimony 
and that of all the others today. And I will start now by 
recognizing Mr. Deal for an opening statement.

  OPENING STATEMENT OF HON. NATHAN DEAL, A REPRESENTATIVE IN 
               CONGRESS FROM THE STATE OF GEORGIA

    Mr. Deal. Thank you, Mr. Chairman. I too want to welcome 
both panels to our discussion here today, especially to thank 
Dr. Besser for being here and to congratulate him on his acting 
role as acting director of the CDC, a facility which all of 
Georgians and all of the people of this country, I think, can 
be very proud of. Thank you for being here. And, also, Dr. 
David Satcher, who is here representing the Morehouse School of 
Medicine, another facility in my great State of Georgia that we 
are very proud of, and thank him for the continuing 
contribution that they make to the delivery of health care in 
our Nation.
    Today we will focus on the role of public health and 
disease prevention which are critical components of our 
Nation's health care delivery system. From specialized research 
on infectious diseases, wellness, and prevention that is taking 
place at the CDE community outreach programs which promote 
health conscious behaviors, the role of the CDC in fulfilling 
the needs of the public is indeed substantial. As we move 
forward with health care reform this year, we must ensure that 
we continue to support those programs and activities which have 
proven to be successful. They provide a critical role, and we 
must ensure public health efforts are provided with the tools 
that they need to do the job well. In conjunction with these 
efforts, an equally important objective must be to incorporate 
incentives for individuals to make responsible choices about 
his or her health and thus adding value to prevention efforts 
in an avoidance of costly medical care in the future.
    The best way to ensure patients take proactive steps to 
improving their health, I think, is by taking their 
prescription medications as directed, by engaging in regular 
physical activity and by maintaining a healthy diet just to 
name a few. And it is well-placed incentives such as this that 
reward positive behavior and give individuals the opportunity 
to share in the savings generated by their prevention-minded 
efforts. The impact of establishing value-based incentives in 
the health care arena would take a significant positive step 
forward in maintaining healthy lives, not merely treating the 
sick once a condition presents itself.
    Another key component is coordination of patient care. All 
too often we hear of health care dollars being wasted by 
duplicative testing and unnecessary referrals, which are all a 
result of our silo system of health care delivery. Fortunately, 
with the incorporation of health information technology and 
patient electronic medical records and improved coordination 
among providers access to necessary information to administer 
the best care is vastly improved. Prevention efforts can be 
coordinated through the use of this technology. Home care can 
be assessed and patients can receive a continuum of care which 
our current system fails to support many times.
    Furthermore, as we continue to debate health care reform in 
the coming months, I hope we maintain focus on one of the most 
fundamental components of a well-performing health care 
delivery system, personal responsibility, giving patients and 
providers the freedom and responsibility to manage their care, 
not bureaucrats in Washington. It is critical to making 
improvements in our Nation's health care delivery system. 
Again, Mr. Pallone, I thank you for holding the hearing today, 
and thank all of our witnesses and look forward to your 
testimony. I yield back.
    Mr. Pallone. Thank you, Mr. Deal. Next is Chairman Waxman.

OPENING STATEMENT OF HON. HENRY A. WAXMAN, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Mr. Waxman. Thank you very much, Mr. Chairman. Over the 
past month, we have had several hearings on health insurance 
and how to get it to all Americans, but as valuable as it is 
health insurance can't do everything necessary to make our 
Nation healthy. Even if we make it possible for everyone to be 
insured, there will still be a major role for public health. 
Moreover, there will be an ongoing need for funding for these 
public health activities. I should begin by clarifying some 
basics. Public health includes many different things. It is 
working with groups and whole communities to improve health 
often more effectively than can be done between a provider and 
a patient.
    Fluoridation of water for a town is, for instance, vastly 
better than simply filling every citizen's cavities. Exercise 
programs to prevent obesity are better than having to treat 
diabetes among people who become obese. It is tailoring health 
insurance and health care to prevent and diagnose disease early 
rather than simply treating it in its later stages. 
Immunization is always better than outbreaks. Screening for 
hypertension is better than simply waiting for strokes. It is 
providing for safety net services where the insurance market 
alone fails to do so. Community health centers, HIV service 
providers, and family planning clinics provide care to people 
who might not otherwise be able to find a provider.
    Health profession's education programs can add to the 
primary care work force when the market might produce only 
specialists. And least glamorous, but critical, it is the 
infrastructure of daily disease control and health promotion. 
Closing down on sanitary restaurants is better than treating 
food poisoning. Compiling and studying epidemic trends can 
prevent major waves of disease. Public health is all of these 
things and more. It might be clear if I use an analogy. No 
community would be well served if all of its homeowners had 
fire insurance but there were no fire departments, 
firefighters, fire hydrants, or smoke detectors. That very 
well-insured town would still burn to the ground. Insurance is 
necessary but it is not sufficient.
    As we approach health reform, we must consider what aspects 
of the Nation's health are based on public health and make 
these investments at the same time as we invest in coverage. We 
need to provide as firm a funding and organizational base for 
these services as we do for insurance because they are 
essential in making insurance efficient and productive and in 
making the Nation healthier. We will continue to debate 
insurance plans, Medicare Advantage health savings account and 
acute care on other days, but today's hearing is about these 
public health activities that we seldom think about and we even 
more rarely provide for. I hope health reform will make us 
change that. Thank you very much, Mr. Chairman.
    [The prepared statement of Mr. Waxman follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Pallone. Thank you, Chairman Waxman. The gentleman from 
Pennsylvania, Mr. Pitts.

OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN 
         CONGRESS FROM THE COMMONWEALTH OF PENNSYLVANIA

    Mr. Pitts. Thank you, Mr. Chairman. I would like to thank 
you for convening this hearing. Within the larger context of 
health care reform, I think it is important for us to focus on 
two areas, chronic illnesses, which account for a major portion 
of health care expenditures, and prevention and wellness 
activities. There is a place for government programs and 
community services but if we are truly serious about reining in 
health care cost and transforming how we deliver health care in 
this country, I believe that we must focus on personal 
responsibility for lifestyle and health choices. We should 
empower citizens to change their behavior and incentivize 
responsible choices. There are great successes in the private 
sector such as the grocery chain, Safeway, which has cut its 
health care cost by covering all preventive care services 
appropriate for a patient's age group.
    It offers other benefits such as a 24-hour hot line staffed 
by registered nurses, services to help people manage chronic 
conditions, and incentives designed to promote healthier 
lifestyles. Where there are barriers to small group plans 
offering incentives such as these, we should re-evaluate 
current law and make necessary changes. Also, patients must be 
more involved in their own care and treatment. Health savings 
accounts can play a key role in active patient participation. 
We know that when people's own money is on the line they make 
wiser decisions. Mr. Chairman, I look forward to hearing the 
thoughts and testimony of our witnesses today, and I thank you 
and yield back my time.
    Mr. Pallone. Thank you. The gentleman from Texas, Mr. 
Green.

   OPENING STATEMENT OF HON. GENE GREEN, A REPRESENTATIVE IN 
                CONGRESS FROM THE STATE OF TEXAS

    Mr. Green. Thank you, Mr. Chairman, for holding this fourth 
hearing today on the health care reform and the role of public 
health. Disease prevention and good health promotion are 
important community issues we all support. Sadly, Congress has 
allowed the funding for disease prevention and community health 
programs to fall flat over the years, and we have not made much 
of an investment in prevention and wellness programs or disease 
prevention programs. The lack of funding for prevention and 
wellness and disease prevention programs is especially 
troubling in districts like mine where you rely on community-
based prevention programs because of our population.
    The Houston area is an international city and state where 
we have some of the highest rates of tuberculosis in the Nation 
and need a very strong disease prevention program. Houston has 
the third largest Hispanic population in the country, and I 
represent an area that is 65 percent Hispanic in a medically 
underserved district. Unfortunately, most minority populations 
have higher rates of disease like diabetes, cervical cancer, 
HIV AIDS, and heart disease in our community. In fact, Mexican 
Americans are twice as likely as Anglos to be diagnosed with 
diabetes. These diseases are mostly preventable but lack of 
access to care is still a barrier to the minority communities, 
and part of that probable cause to the many health problems for 
the Hispanic community as a whole. We rely on programs at the 
YMCA for our children who participate in sports to help reduce 
our obesity levels in children. We also rely on partnerships in 
our community health centers in the hospital district to 
monitor and help treat diabetes in our population.
    These programs are crucial in reducing our high diabetes 
and obesity rates. I am particularly pleased the American 
Recovery and Reinvestment Act included funding for prevention 
and wellness programs. These programs are key to reducing rates 
of chronic diseases in our communities. I would hope any health 
reform package we work on in this committee will take into 
account the importance of prevention, wellness, and data 
monitoring in disease prevention. Thank you, Mr. Chairman. I 
yield back my time.
    Mr. Pallone. Thank you, Mr. Green. The gentleman from 
Georgia, Mr. Gingrey.
    Mr. Gingrey. Mr. Chairman, I am going to waive my opening 
statement.
    Mr. Pallone. The gentleman from Kentucky, Mr. Whitfield.
    Mr. Whitfield. Mr. Chairman, thank you very much for 
holding this hearing, and we look forward to the testimony of 
the witnesses today. I would just point out that it is my 
understanding that less than 3 percent of all money spent by 
the federal government in health care is used for public health 
activities. And I know that in Kentucky for every 6 people 
admitted to the hospital in Kentucky last year one of them was 
admitted because of diabetes, so this whole issue of prevention 
has to be a vital part in our reform, and I look forward to 
working with the committee in addressing that issue. Thank you.
    Mr. Pallone. Thank you. Our subcommittee vice-chair, Mrs. 
Capps.
    Mrs. Capps. Thank you, Chairman Pallone. And I am so 
pleased that we are addressing public health needs in our 
hearing today as we endeavor to bring real health reform to 
Americans. It is in my DNA as a public health nurse that an 
ounce of prevention is worth a pound of cure. In my home State 
of California and throughout our country there needs to be a 
major shift in how we address health care. Instead of just 
talking about treating illnesses, we need to talk about 
preventing it as often as we can and educating and promoting 
healthy behaviors and decision making. We need to talk about 
the role that the public health community will play in 
achieving that goal, so I look forward to our witnesses. I 
welcome our first panel and know that we are going to have a 
lively discussion today. I yield back.
    Mr. Pallone. Thank you. The gentlewoman from Tennessee, 
Mrs. Blackburn.
    Mrs. Blackburn. Thank you, Mr. Chairman, and welcome to our 
witnesses. We are looking forward to the hearing today. And, 
Dr. Besser, I want to thank you for your testimony and point 
out one thing that I think is so important that we focus on. 
When you say we are not achieving an acceptable return for the 
investment we made on health care despite spending more than 
any other nation, and I think it does point out the importance 
of personal responsibility. We have some good pilot projects 
that have taken place in some of our states. Some of them have 
been successful. Some have not, but it does give us some good 
evaluated data and outcomes that we can look at, lessons that 
should have been learned, and I think it also points out how 
one size does not fit all in health care delivery. And I look 
forward to the testimony and the discussion today. Thank you, 
Mr. Chairman. I yield back.
    Mr. Pallone. Thank you. The gentleman from Utah, Mr. 
Matheson.
    Mr. Matheson. Well, thank you, Mr. Chairman. I concur with 
what our full committee chairman said that while access is an 
important issue, we also need to look for ways to reform our 
system to make it more efficient and preventive care and the 
public health system clearly create a venue where there are 
great opportunities to make more progress in this regard. If we 
don't find a way to make our system more effective for all the 
money we are putting into it, we are kidding ourselves. We have 
to find a way to be more efficient, find a better system than 
we have right now because we spend more than anyone in the 
world. We are not getting the best outcomes. And if we increase 
access for America into the current system it drives us off a 
financial cliff that much more quickly.
    This is a very important hearing today because this panel 
can give us some good ideas about where we can improve on 
important front end investments to have long-term benefit to 
our country. I yield back, Mr. Chairman.
    Mr. Pallone. Thank you. The gentlewoman from California, 
Ms. Harman.
    Ms. Harman. Thank you, Mr. Chairman, and thank you again 
for holding all of these thoughtful hearings. I want to 
recognize one of our witnesses this morning, Dr. Jonathan 
Fielding, who is the director of LA County's Department of 
Health, and who is a dear and valued advisor to me on health 
care issues. He oversees one of the Nation's largest public 
health departments and is charged with protecting LA County 
residents, especially in the realm of emergency preparedness, 
something always on the mind of this lawmaker. I just want to 
focus for 25 seconds on the need for developing surge capacity 
in our country as we consider health care reform.
    The only level 1 trauma center near LAX and the ports of LA 
and Long Beach, both top terror targets, which could be 
attacked simultaneously, is Harbor UCLA Hospital, a first class 
teaching hospital. Harbor's emergency room was cited for 
overcrowding and no terror attacks have even been contemplated 
yet. It has tried to address this problem but I worry that we 
are not ready and that should something like this happen in any 
city in America or near simultaneously in many cities in 
America, we won't be ready so this has to be part of health 
care reform. Level 1 trauma centers will have to take care of 
huge numbers of victims should we have near simultaneous terror 
attacks. And just as we think about the rising waters in Fargo, 
North Dakota, let us think about the rising numbers of people 
who will need health care and we are not ready. Thank you, Mr. 
Chairman.
    Mr. Pallone. Thank you. The gentlewoman from the Virgin 
Islands, Mrs. Christensen.
    Mrs. Christensen. Thank you, Mr. Chairman. Also coming from 
the Homeland Security Committee like Ms. Harman, we have been 
calling for more attention and funding to our public health 
system for the past 6 years, and also the issue is terrorism my 
interest is also in enabling the system to fulfill its 
responsibility to protect the public health every day and 
particularly in poor communities where it is most neglected and 
deficient. Homeland Security still has a role but the 
President's vision and determination provides us with an 
opportunity to ensure that the public health system in our 
country is strong and intact everywhere because it will only be 
as strong as its weakest link. As we approach reform 
strengthening public health in its broadest definition and 
eliminating health disparities must go hand in hand with 
expending coverage.
    And while prevention and individual care will produce some 
savings but mostly through a healthier, happier, and more 
productive and competitive populous as we heard at the last 
hearing it is primarily through community prevention 
approaches, public health approaches, that we will reap the 
most savings, reduce our Nation's soaring health care costs, 
and recapture our role of leadership as we improve our health 
standing among the nations of the world. So welcome to all of 
our panelists. Thank you for your leadership, and I look 
forward to the testimony.
    Mr. Pallone. Thank you. Our chairman emeritus, Mr. Dingell.
    Mr. Dingell. Thank you. I commend you for this hearing. I 
ask unanimous consent to put my entire statement into the 
record.
    Mr. Pallone. Without objection, so ordered.
    Mr. Dingell. It is an excellent one and it bears 
considerable attention, I hope everyone will understand. But 
your holding of this hearing is extremely important. There are 
significant benefits from public health investments and that 
includes investments in prevention. The American Recovery and 
Reinvestment Act of 2009 allocated a billion dollars for 
prevention and wellness, and even though the Congressional 
Budget Office has been hesitant on cost savings and prevention 
measures non-partisan studies have shown significant health 
cost savings from public health spending. According to the 
Trust for America's Health private insurers and individuals 
could save more than $9 billion annually within 5 years if we 
would just spend $10 per person on public health.
    I would urge, Mr. Chairman, that this hearing be used as a 
mechanism to enlighten the Congressional Budget Office and 
doubters about the need for the kind of prevention and wellness 
concerns that you are showing in having this hearing. With 
that, I yield back the balance of my time.
    Mr. Pallone. Thank you, Mr. Dingell. Thank you, Chairman 
Dingell. Next is the gentleman from Connecticut, Mr. Murphy.
    Mr. Murphy of Connecticut. Thank you very much, Mr. 
Chairman. I join my colleagues in looking forward to the 
testimony on this very important subject. I hope today that we 
explore a number of subjects but at the very least these two. 
First, as Mr. Pitts has pointed out, there are enormous 
opportunities to look at the private sector for the work that 
they have done in public health. In my district the company, 
Pitney Bowes, has been a leader in this respect. I hope that we 
talk about both the opportunities for public health within the 
private context but also the limitations. It works well if you 
are at a large employer but relying on the private sector 
certainly has limitations for those people who work for smaller 
employers or who have individual insurance.
    Second, I hope that we will be able to explore who is doing 
it right out there and who is doing it wrong. In Connecticut, 
we have done a wonderful job of using public funds to pay for 
breast cancer and cervical cancer screenings. And I think one 
of the things that we need to talk about is how we go out to 
different either political subdivisions or private employers 
who have done this right, get that information disseminated out 
to others so that we can standardize best preventive practices 
across this great country. Thank you, Mr. Chairman, for the 
hearing today, and I yield back my time.
    Mr. Pallone. Thank you, Mr. Murphy. The gentlewoman from 
California, Ms. Eshoo.

 OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN 
             CONGRESS FROM THE STATE OF CALIFORNIA

    Ms. Eshoo. Thank you, Mr. Chairman, for continuing on with 
a series of hearings relative to health care to help shape our 
thinking on I think one of the most long awaited bills by the 
American people, and that is to reshape our entire health care 
system. I am very pleased that we are focusing on public 
health. Public health has a long arm. It has a long reach. And 
I think it is one of the areas of health care that might be the 
most taken for granted in the entire system in the country. I 
came to understand and appreciate the role that public health 
plays before I came to Congress when I was in county government 
on the board of supervisors in San Mateo County in California, 
and whether it was on the prevention side for the county or on 
the side that had to react to say the removal of dangerous 
things off the shelves or markets, they moved very swiftly and 
in a very limber way to protect the public.
    I have often wondered why we have not progressed over the 
years to strengthen public health. And just as a physician 
would say to a patient, you can't starve yourself in order to 
lose weight, that is exactly what has happened to the public 
health system in our country. We have not funded it properly 
for it to go forward and do the magnificent work that it is 
capable of that it already has done and the role that we want 
it to play. So this is more than appropriate to have this 
hearing. I look forward to hearing from the very distinguished 
witnesses that are at the forefront of the public health system 
and our country, and I look forward to a bill that is going to 
strengthen the arm, that long arm that has a great reach to the 
American public to prevent bad things from happening, and when 
we do that we promote wellness at the same time.
    And what I hope we will also look at, Mr. Chairman, in 
terms of policy, and that is that I think in one fell swoop we 
could do so much in terms of obesity if we look at what food 
stamps will actually buy and pay for. If we continue to allow 
food stamps to buy junk and bad foods in the supermarkets or 
the small markets in the neighborhoods in the areas where poor 
people live then it is the federal government that really is 
promoting the worst. We can't just beat our chests about 
obesity in our country. We should just do something policy wise 
that really overnight could revolutionize what poor people 
ingest and what they buy with the food stamps that we provide. 
So thank you very much.
    Mr. Pallone. Thank you. The gentleman from Texas, Mr. 
Gonzalez.
    Mr. Gonzalez. I waive opening.
    Mr. Pallone. Thank you. Next is the gentlewoman from 
Florida, Ms. Castor.
    Ms. Castor. Thank you, Mr. Chairman. Bolstering our public 
health prevention and wellness initiative simply must be a 
lynch pin of our health care reform effort. Many community 
based prevention initiatives are working well already. We all 
have participated or know about them in childhood obesity or 
smoking cessation or diabetes screening. But I think it will 
take our renewed efforts in this health care reform effort, a 
modernization, additional resources that will ultimately help 
make Americans healthier. I want to thank all of the witnesses. 
Your testimony is very good. I trust that we will incorporate a 
lot of your recommendations into the health care reform effort 
that Americans are clamoring for. I yield back.
    Mr. Pallone. Thank you. The gentleman from Maryland, Mr. 
Sarbanes.
    Mr. Sarbanes. Thank you, Mr. Chairman, for holding the 
hearing. I am looking forward to the testimony today. Last year 
in the Ed and Labor Committee we had a hearing on the pension 
system in America, and a number of us questioned the premise of 
the hearing because we didn't believe there was actually a 
system in place but more of a patchwork arrangement. And I 
notice that this doesn't--the name of this hearing talks about 
the role of public health. It doesn't assert necessarily the 
public health system. And I would question whether we really 
have a system in place. I think we have strong public health 
advocates across the country and places where it is working 
very well. But to suggest that we have a system, I think, is a 
poor diagnosis, frankly.
    And one of the hopes I have for the health care reform 
effort that is under way is that we will emerge from this 
debate with a public health system in place. Many have 
critiqued the way we approach health in this country as having 
developed a sick care system rather than a health care system. 
Obviously, prevention is critical to changing that orientation, 
and public health is critical to that. So I look forward to 
your testimony. I am particularly interested in this notion of 
place-based initiatives. In other words, what do you do in 
schools, what do you do in clinics, what do you do in 
employment, in work places, and so forth, going to where people 
are to provide the kind of prevention, wellness, and fitness 
services that really will represent a true public health system 
is absolutely fundamental. So I look forward to your testimony. 
I thank you, Mr. Chairman. I yield back my time.
    Mr. Pallone. Thank you. Ms. Schakowsky.

       OPENING STATEMENT OF HON. JANICE D. SCHAKOWSKY, A 
     REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS

    Ms. Schakowsky. Thank you, Mr. Chairman. I do want to 
assert the centrality of a public health infrastructure but we 
certainly do need to do more to help bolster it and create it. 
I am going to soon reintroduce the Health Promotion First Act, 
which I first sponsored last Congress with bipartisan support 
including members from this committee. My bill recognizes that 
we need to improve research into health promotion, coordinate 
activities across agencies, and develop a strategy to improve 
public health. I want to mention two specific areas of concern 
to me. It has been mentioned before, but we need to reduce 
obesity among children and across all populations.
    A small example. There is an organization called Mainstay 
in Illinois where I am from, estimates that Illinois could save 
over $160 million a year by adjusting obesity in people with 
developmental disabilities who live in group homes, a setting 
really amenable to that kind of effort. STDs, we all were 
shocked, I think, or some anyway, earlier this month when the 
D.C. health department reported over 3 percent of the city's 
population, 7 percent of African American men, infected with 
HIV AIDS. Local experts put that number closer to 5 percent 
because of under reporting. And we have measures today that 
would help to stop STD transmission that need to be 
implemented.
    And, finally, it is hard to overstate the importance of 
increasing public health resources for research, public 
education, and treatment. Our public health work force is being 
stressed to its breaking point, and we have to do all that we 
can to repair that as well. So I thank you, Mr. Chairman, and I 
look forward to hearing from our witnesses. Yield back.
    Mr. Pallone. Thank you. The gentleman from Texas, Mr. 
Burgess.
    Mr. Burgess. Thank you, Mr. Chairman. In the interest of 
time, I have a statement that I will submit for the record. I 
am just very pleased to hear from our witnesses today. I am 
particularly looking forward to hearing from Dr. Satcher, and 
recognize his work that he has done on behalf of Alzheimer's 
patients in this country. Certainly, genomic medicine is a game 
changer. In medicine we are indeed on the threshold of a 
transformational time where it will be possible to identify 
individuals at risk, and now with newer monoclonal antibodies 
perhaps be able to offer some treatment options prior to the 
clinical manifestations of the disease, so this will become a 
much more long-term management problem and ultimately there are 
significant savings in our system that can be gathered by this 
type of activity. So, Dr. Satcher, we are grateful to you for 
your service and your work on that behalf. With that, Mr. 
Chairman, I will yield back the balance of my time.
    [The prepared statement of Mr. Burgess follows on p. 160.]
    Mr. Pallone. Thank you. The gentlewoman from Wisconsin, Ms. 
Baldwin.
    Ms. Baldwin. Thank you, Mr. Chairman, and before I begin, I 
would like to request unanimous consent to submit for the 
record testimony prepared by the Human Rights Campaign that 
addresses the issue of access to health care for LGBT 
Americans.
    Mr. Pallone. Without objection, so ordered.
    [The information appears at the conclusion of the hearing.]
    Ms. Baldwin. Thank you, Mr. Chairman. If we are going to 
meet the serious public health care challenges of today and 
tomorrow, we must help our states respond to these challenges. 
Many parts of our state and local public health system are 
fragmented and outdated. With my colleague on this committee, 
Congressman Terry, I sponsor the Strengthening America's Public 
Health Systems Act, a bill specifically that focuses on public 
health infrastructure. It invests in state labs of hygiene, 
improves surveillance and reporting systems and empowers the 
future public health work force. We also must rely on evidence-
based prevention efforts and fully fund our federal agencies so 
that they can conduct community-based interventions to prevent 
diseases like HIV.
    If we can more closely align federal funding with 
recommendations of the U.S. preventive services task force and 
the task force on community preventive services, I think we can 
see a real return on our investment in public health, a 
critical part of comprehensive health care reform. And, thank 
you, again, Mr. Chairman, and to our witnesses for this hearing 
and your testimony today.
    Mr. Pallone. Thank you. And I think that concludes the 
opening statements by the members of the subcommittee, so we 
will now turn to our first panel. First of all, welcome. We 
have with us today on my left Dr. Richard Besser, who is Acting 
Director of the CDC, and Acting Administrator of the Agency for 
Toxic Substances and Disease Registry. And we also have Dr. 
Jonathan Fielding, who is Chair of the Task Force on Community 
Preventive Services, Director and Health Office of the Los 
Angeles County Department of Public Health. And, again, thank 
you for being here. We have 5-minute opening statements. They 
become part of the hearing record. And I will start with Dr. 
Besser.

 STATEMENTS OF RICHARD E. BESSER, M.D., ACTING DIRECTOR, CDC, 
 ACTING ADMINISTRATOR, AGENCY FOR TOXIC SUBSTANCES AND DISEASE 
REGISTRY; JONATHAN E. FIELDING, M.D., M.P.H., CHAIR, TASK FORCE 
ON COMMUNITY PREVENTIVE SERVICES, DIRECTOR AND HEALTH OFFICER, 
            L.A. COUNTY DEPARTMENT OF PUBLIC HEALTH

              STATEMENT OF RICHARD E. BESSER, M.D.

    Dr. Besser. Good morning. I am Richard Besser, and I am 
honored to be serving as the Acting Director for the Centers 
for Disease Control and Prevention at the time our national 
focus turns to ways we can improve our health system. As a 
practicing pediatrician and leader of the Nation's principal 
prevention agency, I recognize both the urgency of solving the 
problems in our health system and the opportunities we have to 
improve the health of Americans as we do so. I would like to 
thank Chairman Pallone, Ranking Member Deal, Chairman Waxman, 
and members of the subcommittee for your support of prevention 
and public health, and for holding this important hearing today 
to turn the spotlight to the role of prevention and wellness in 
health reform.
    Today, it is evident that our health system is not fully 
achieving its primary goal, protecting and improving our 
health. If our vision for health reform is too narrow, we still 
won't achieve our ultimate goal of health for all Americans. 
For too long, in discussions of health reform, health care 
delivery and public health approaches have been treated 
separately, as if they were disconnected and mutually exclusive 
systems. With a discussion of health reform currently a focus 
for the Nation, it is time instead to start talking about 
solving our national health needs through a comprehensive 
system that seamlessly integrates health care delivery, 
prevention, and public health.
    CDC and our public health partners are already working to 
create these connections, connections between patients, 
providers, and public health officials. By creating more 
seamless integration between clinical care, which focuses on 
the health of a single person, and the public health system, 
which focuses on the health of an entire community or 
population, a truly reformed health system could increase 
access to needed health care services in the short term, and 
reduce demand for treatment services through prevention over 
time. For Americans to truly be healthier, we must not only 
have access to treatment when sick, but they should receive 
recommended screenings to detect the risk of disease early, 
have access to evidence-based interventions to prevent disease 
and injury before they occur, be supported by care systems that 
minimize progression of disease once it occurs, and live, work, 
and play in environments that promote healthy choices and 
behaviors.
    We move into a health reform discussion with strong 
evidence that prevention and public health interventions work, 
both in communities and health care settings, preventing 
illness, increasing years of healthy living, improving work or 
productivity, and often saving health care costs. While much 
remains to be done to improve our evidence base, we have clear 
documentation of the success of these approaches. My written 
statement draws example from immunization, tobacco prevention 
and cessation, community interventions to prevent and reduce 
obesity, and interventions that reduce health disparities, 
prevent the spread of HIV, reduce the impact of health care 
associated infections, and prevent costly and disruptive falls 
among older adults.
    We are pleased to be able to work closely with Dr. Fielding 
and the task force on community preventive services, which has 
conducted exacting reviews of the evidence and success to help 
guide our programmatic and policy interventions, something that 
will be particularly critical in a reformed health system. I am 
also happy that the committee will have the opportunity to hear 
from other public health leaders to help assess the value that 
can be delivered from these types of interventions. We are 
anxious to continue and accelerate this work with funding 
provided to HHS under the American Recovery and Reinvestment 
Act to address immunization, health-care associated infections, 
and prevention and wellness.
    Turning to what can be done to advance the public's health 
through reform of our Nation's health system, it is our goal 
that all Americans live in communities that create positive 
opportunities for health, including opportunities for physical 
activity and access to healthy food choices, live in 
communities that provide greater access to effective, evidence-
based clinical and community prevention interventions, provide 
effective support for management of health conditions, starting 
with costly chronic diseases, so that the consequences, both 
cost and health, are minimized, and protect citizens from harm, 
including from tobacco use, environmental hazards, contaminated 
food, hazardous work sites, risk of injury, and unsafe medical 
practices.
    We can put prevention to work across America. This can be 
accomplished through a broad, national prevention agenda 
through which we will need to provide tools and support the 
individuals to enable them to take responsibility for their own 
health, provide solid evidence upon which personal community, 
and policy decisions that promote prevention and wellness can 
be made, ensure rigorous tracking, monitoring, and evaluation 
so that we can measure performance and ensure accountability, 
more effectively support state and local health agencies with 
the tools and technical support to achieve positive health 
outcomes in communities across the United States, tailor 
interventions to reduce health disparities and improve health 
outcomes for populations most at risk, use policy levers to 
improve health, including those in areas not traditionally 
recognized as health-related policies, such as food, education, 
and transportation to create greater opportunities for physical 
activity and improved nutrition, address the health crisis 
caused by tobacco use through policy interventions, as well as 
comprehensive tobacco control programs, and reform the delivery 
system to promote a more seamless integration of individual, 
clinical, mental health, and community approaches that in 
combination can make us healthier.
    Mr. Chairman, and members of the committee, the problems in 
the health system remain a fundamental concern of families, 
communities, businesses, and policymakers. A deepening 
recession adds urgency to already recognized shortcomings in 
the current health system. I share the President's commitment 
to reform that makes health care affordable and accessible, and 
I look forward to working with the subcommittee to help make 
prevention a practical reality as part of this national health 
reform effort. Thank you very much.
    [The prepared statement of Dr. Besser follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Pallone. Thank you. Dr. Fielding.

            STATEMENT OF JONATHAN E. FIELDING, M.D.

    Dr. Fielding. Chairman Waxman, Chairman Pallone, Ranking 
Member Deal, members of the committee, ladies and gentlemen, 
thank you very much for the opportunity to talk with you today. 
My name is Jonathan Fielding. I am Director of Public Health 
for Los Angeles County, and I chair the Community Preventive 
Service Task Force, and also chair the Secretary's Committee on 
2020 Objectives for the Nation. And I am here today to talk 
about a very well-developed tool and process that tells us what 
policies and what programs have been proven to improve the 
health of the U.S. population and how to assure this and that 
we use this information to increase our national productivity, 
particularly important in these economic times.
    As a background, health reform is very important to assure 
everybody has access to quality, affordable health care. 
However, the World Health Organization ranked the health system 
of the United States 37th in the world despite the fact that we 
spent 50 percent more of our GDP on health care than any other 
country. We need to pair health care reform with health reform, 
which requires changes in personal habits that relate to health 
and underlying causes of preventable health problems. The 
majority of the incredible, unprecedented 37-year gain in life 
expectancy during the 20th Century occurred because largely we 
had policies and programs urged by the public health community, 
including purer food and water, better environmental 
protection, occupational health laws, improved housing 
standards, better nutritional standards, and more sanitary 
waste disposal, as well as a general increase in the standard 
of living.
    But serious opportunities to improve health and reduce the 
terrible disparities in health among subgroups remain. Today, 
\1/3\ of all deaths in the United States are caused by tobacco 
use, physical inactivity, poor nutrition, and abuse of alcohol 
and other substances. In addition, we increasingly understand 
that poor education, low income, problems in our physical and 
social environments are the underlying causes of many diseases, 
and we have opportunities not only at the retail level, which 
is what we do in the health care system, but to work wholesale, 
which is working at the determinants of health in all of us 
where working on one can affect many diseases.
    Fortunately, we are learning what works to keep Americans 
healthy, to make improvements in their health behaviors, and to 
address the underlying causes of ill health in the physical and 
social environment. This progress is due to the work of great 
CDC staff with the independent external task force that I chair 
that develops the guide to community preventive services. We do 
systematic reviews and make recommendations that are based on 
the best evidence. Over 200 reviews and recommendations have 
been completed and we know that these recommendations make a 
difference. For example, our recommendation to reduce blood 
alcohol concentration limits for drivers to 0.8 helped to spur 
congressional legislation to limit access to transportation 
funds to states that permitted higher alcohol level. That 
contributed not only to safer roads but we saved many lives.
    The recommendation can also assist HHS in determining the 
best use of the Recovery Act funds. For example, to prevent 
smoking and increase cessation the guide has shown that social 
marketing campaigns are very effective. A public-private 
partnership could rapidly apply the Recovery Act resources to a 
national tobacco media campaign that could substantially reduce 
the one behavior, smoking, that causes the greatest number of 
preventable deaths. The guide also provides essential 
recommendations for how the health care system can increase its 
efficiency and effectiveness. Its companion clinical guides 
tells us what preventive services individuals should receive 
like mammography, while the community guide tells us how the 
health care system can most efficiently and effectively 
organize itself and deliver the services that maximize uptake 
continuity and health impact.
    Nonetheless, we face major challenges. First, because of 
insufficient core funding the 210 completed reviews and 
accompanying recommendations represent only a fraction of the 
highest priority opportunities and topics identified. Second, 
the recommendations are of little value if they are not used. 
The guide has been passively disseminated so awareness of its 
recommendation remains low and they have not become part of 
standard practice. Third, the guide often finds insufficient 
evidence to make a recommendation because the needed studies 
that could answer that question have not been done. One major 
gap is lack of information on how to reduce health disparities.
    Another priority opportunity is to quantify the health 
effects of decisions that are outside the health sector such as 
an education and transportation and criminal justice. Health 
impact assessment is an effective tool for such analyses that 
could basically help every congressional committee understand 
how the decisions they are considering would effect the health 
of all of their constituents. I have four recommendations for 
your consideration. First and foremost, the guide to community 
preventive services needs full, financial, and personnel 
support. A one-time infusion of $50 million would allow us to 
provide recommendations for all the high priority topics and 
intervention needed by communities within 3 years.
    These resources would also allow us to rapidly and 
efficiently expand and proactively disseminate the 
recommendations so they become standard practice for users in 
both the public and the private sector. The ongoing work of the 
task force will require $15 million annually on a continuing 
basis so that we can keep the recommendations current, assess 
the effectiveness of new policies and programs and continue 
active dissemination to assure that these recommendations are 
being followed and to evaluate to make sure. Second, the major 
gaps in evidence need to be filled with robust, targeted, 
funding for research with CDC as the lead agency. Third, we 
need support to use the best science to address the health 
effects where many disciplines need to interact.
    Global warming is one example and other policy issues 
through health impact assessment and other novel approaches. 
Fourth, the guide and these initiatives need evaluation to make 
sure recommendations are being implemented and determine if the 
expected health improvements are being realized. Finally, 
Healthy People 20-20 currently under development will provide 
health objectives for our Nation. These objectives need to be 
fully informed by the guide recommendation and results of the 
studies that we have looked at so that the objective set can be 
realistic and based on the best evidence. These two major 
initiatives need to be tightly linked to maximize the value of 
both. Thank you again for providing the opportunity for me to 
talk with you, and I look forward to discussing these issues 
and responding to your questions.
    [The prepared statement of Dr. Fielding follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Pallone. Thank you, both of you. We will start with our 
questions, and we generally have 5 minutes from each member, 
and I will start with myself. I tend, and I guess most people, 
tend to look at prevention sort of from two perspectives. One 
is what we call clinical preventive services delivered by 
physicians and other practitioners during a patient's visit, 
and that is why we emphasize, you know, in health care reform 
we want everybody to be able to see a doctor on a regular 
basis, and whether it is a school-based clinic covered in your 
insurance that that is an important part of prevention, that 
you can see somebody who can review your situation and give you 
care without having to get sicker and go to a hospital or 
emergency room.
    And the other thing is the community-based prevention like 
education campaigns, and these things are very important. I am 
going to use my kids as an example, and I hate to do that 
sometimes but it is the easiest thing for me. I do think that 
like education campaigns about, for example, not smoking are 
very effective. I mean I find that they see smoking as a very 
bad thing like almost socially unacceptable. And I think a lot 
of that has had to do with the campaigns. But I also question 
the limits of what we can do in these two categories because it 
just seems that so much of prevention is personal and 
individual. And, again, I will use my kids as an example. You 
know, they just want to watch TV. They want to play videos. In 
the old days, and I am really dating myself, you would be in 
the neighborhood and you would go out and play on the street or 
in the back yard. Today it is like watching the videos, 
watching TV, and, unfortunately, as members of Congress you are 
not with them every day so on the weekend I will try to get 
them out of the house but it is very tough.
    And the same thing is true with foods, you know, They want 
to go to McDonald's and the fast food places. Even if we are 
going out to eat, it is hard to get them to go to any place but 
fast foods and so my point is there is no question that these 
community-based prevention things like education with no 
smoking are effective, but it just seem to me we are losing the 
battle. And, I don't know, can we spend enough money on these 
educational campaigns, for example, to really make a 
difference? I mean, obviously, the smoking is a good example of 
that if I can use my own children, but it just seems like we 
are doing--we are spending some money on things like anti-
smoking initiatives and other things, but it is not anywhere 
near as effective as all the promotional and advertising 
activity that takes them in the other direction in terms of 
their lifestyle.
    So I just wanted to comment. You just think we need to just 
spend a lot more money or is there actually something we can do 
about personal life style? My question is very general, 
gentlemen.
    Dr. Besser. Thanks very much for that comment and question, 
Mr. Chairman. And you raise a very challenging question, how do 
you change behavior. When we are talking about things like 
smoking, you are talking about things like obesity, how do you 
work to help support an individual to make those changes. And 
educational campaign is part of that, but when you are looking 
at behavior change, we try and look at it in a more 
comprehensive way. Educating and informing is part of that. But 
what can you do to support that individual? I volunteer in a 
clinic in Atlanta, and I have just been astounded by the 
increasing number of children I see who are obese, and I talk 
to that child about activity and why aren't you going outside 
and playing and engaging in sports programs.
    Mr. Pallone. Doctor, not to interrupt you, but I am very 
active with Native American issues.
    Dr. Besser. Yes.
    Mr. Pallone. And the more I go to the different 
reservations and meet the tribes, the more I see younger and 
younger kids with the adult onset diabetes. I mean 20 years ago 
you would find somebody who was maybe 21. Now you find kids 
that are 10 or 11 years old.
    Dr. Besser. There is an epidemic of diabetes taking place 
in this country, and we are seeing it younger and younger. 
American Indian populations, Latino populations, it is 
absolutely out of control, and if we are going to handle the 
problem of ever increasing health care costs prevention has to 
be part of that. But the children I am seeing, when they go to 
school they don't have access to physical education programs. 
When they come home, they are not in communities that encourage 
physical activity. When they go to a fast food restaurant, 
there is no posting of nutritional information to allow 
families to make healthy choices.
    When we think about these problems, there are things that 
we can do on a policy level. There are things we can do on a 
community level. There are things we can do to help their 
clinician provide them with counseling, and there are things 
that we can do to help that individual make healthy choices. 
But it has to be a concerted effort not just focused on that 
individual. The public health solutions are the long-term 
solutions to many of these problems.
    Mr. Pallone. I just think we need to do so much more. I 
don't know if it is money or whatever it is to counteract the 
trend that we have no idea how much effort it is going to take 
and--go ahead.
    Dr. Besser. I think resources is part of it, evidence is 
part of it. As Dr. Fielding was saying, the more we know what 
works from various pilots in communities the more we can expand 
that to other communities. There is definitely a gap in 
research in many areas of the most effective ways to change 
behavior. We are very excited about the resources that are 
going into comparative effectiveness research on the clinical 
side, but we clearly feel that there needs to be more work done 
on comparing different interventions on the community level to 
see which ones give you the best bang for the buck.
    Dr. Fielding. Let me just mention a couple of things. With 
medicine, we are kind of taught that there is a single answer 
to a single problem. It is kind of one to one. When you take 
the issue as complex as obesity there isn't a magic bullet. You 
need to do a variety of things. Some of those are policies, as 
Dr. Besser said. Menu labeling, for example. I worked very hard 
with others in California to get menu labeling in the fast food 
restaurants right up on the order board. That is going to 
happen in the next 2 years. And so you and I as parents are 
going to look at that and say you want what? How many calories 
does that have? And, by the way, there is some confounding 
information. When you look at that, you wouldn't know that 
there is a yogurt shake that actually has over 1,000 calories. 
Oh, it is yogurt, you know, how bad can it be. So part of it is 
changing consumer information. Part of it is changing the 
opportunities in the school.
    We have worked with the school system in Los Angeles County 
to increase physical activity but again the funding is being 
cut so it is tough. Now we have changed the food in the vending 
machines there so there is not junk food available in the 
vending machines. But there is also an aggregation of fast food 
restaurants that are near high schools where kids go out from 
school and in fact buy that instead of eating the food that is 
available in school. So we have to take a variety of 
approaches. One thing is very clear that I as a physician 
talking to a patient is not the only answer. It is not going to 
be the whole problem solver for obesity. The same way with 
tobacco control. We know that physician very brief advice in a 
standardized way the research has shown that can be effective. 
That is not enough.
    You reference the truth campaign, which has been very 
effective by the American Legacy Foundation. But that requires 
tens of millions of dollars a year. Now one of the 
opportunities would be the federal government to say as part of 
the recovery act, we are going to put substantial dollars, 
match that with what is already available from the American 
Legacy Foundation, and do not only the prevention through truth 
but become an X like program which is the cessation program 
tied to quit lines. So there have to be a variety of 
mechanisms. No one is going to do it, and that is why it is 
confusing because it is not the medical paradigm. We need a 
very strong public health infrastructure with states and local 
public health agencies taking the lead in convening and letting 
people know the evidence and in working across the aisle.
    Mr. Pallone. Thank you. I know I went too long here. Mr. 
Deal.
    Mr. Deal. Thank you. Thank you both for your testimony. You 
know, there are categories that we can look at. One category is 
whether we know enough to know to do the right thing. For 
adults, most of us probably know what we ought to do. We just 
don't do it. But for children, they are in the formative 
stages, and I am concerned about the things that the government 
can and can't do, things government should or shouldn't do. And 
for adults pretty much there is a freedom of choice there that 
government has very little ability to change other than maybe 
to educate, but in children I think it is a different area.
    And I agree with what my colleague, Ms. Eshoo, brought up 
in her opening statement about the food stamp programs, and I 
want to enumerate a couple of things here and ask you if you 
all have looked at these things, and they primarily relate to 
children. Of course, I am a big proponent for recess. I have a 
theory that when recess went out obesity went up, but in 
Atlanta you mentioned, and my understanding is the school board 
in Atlanta has now made a decision to do away with the physical 
education classes because they had to use the time to meet the 
academic requirements that the state has imposed and maybe even 
we have imposed from the federal level down.
    Things like school nurse programs, things like putting 
restraints on what products can be used with food stamp 
purchases, which I understand we do have some restraints in the 
WIC program already, things like the school lunch program. Now 
I know most school lunch programs now have a salad bar. That is 
for the teachers primarily. It is not the students who are 
utilizing it. What are we doing, what can we do, what can we do 
in those environments because for children the majority of the 
time that anybody other than their parents have control over is 
in a school environment. Would you all address that as it 
relates to children and either what they eat in the school 
lunch program, what many of them eat as a result of food stamp 
purchases, et cetera?
    Dr. Besser. I think this relates to the concept of health 
in all policies, and how do we look to ensure that we are 
promoting health or not by implementing policies promoting un-
health through what takes place. Your comments about 
requirements, education requirements, and their impact is a 
really telling one. The reason that classes were increased was 
to try and improve the academic qualifications of students 
coming out of school. But we do know that students learn better 
when they are physically active, and the untoward consequences 
of some of those policies was squeezing physical education out 
of schools. We need to be able to look at that, and as public 
health practitioners we need to ensure that we have linkages, 
not just within the Department of Health and Human Services, 
but across government so that we are looking at how do you 
promote health in these other areas.
    The idea of a health impact assessment when policies are 
moving forward is very attractive because it would force us to 
say, OK, as we are looking to construction project, we are 
looking for new roads. Well, does that road project have 
sidewalks? Does it have bicycle lanes? Does it have things that 
actually could encourage people to be physically active or is 
that something that was not considered as part of that. The 
more creative we are and the more we are able to look at things 
that don't necessarily require new dollars the more effective 
we are going to be at building healthy communities that promote 
health for children and the entire population.
    Dr. Fielding. I think you are absolutely right. The WIC 
program has made important strides that can be emulated for the 
broader food stamp program, the SNAP program, but in the 
schools we changed the vending machines so they only have 
healthier snacks and taken out the soda, which has a lot of 
calories that kids----
    Mr. Deal. You have to be careful about that with Coca Cola 
in Atlanta as does Dr. Besser.
    Dr. Fielding. Well, my guess is Coca Cola probably makes 
more on the water they sell than on the Coke so maybe it 
helps----
    Mr. Deal. They have made a concerted effort as an 
organization to deal with that.
    Dr. Fielding. Exactly, so I think the large beverage 
manufacturers, they have a very broad range so whether it is A 
or B they certainly can do as well. But also the food that is 
served, a lot of that is bought through USDA so what percentage 
fat can that food be, what about portion size. You have people 
in the cafeteria who we have had to teach not to give huge 
amounts on a plate. There is also issues of plate waste. We can 
serve vegetables but what if kids don't eat them. So part of it 
is what we can do externally. Part of it is what has to be done 
in the family. In school, for example, physical activity needs 
to be real physical activity. As an example, playing softball 
or playing baseball, most people are sitting around. They are 
standing. Well, what if everybody ran around the bases every 
time somebody got a hit? That is the way to change the game, if 
you will.
    And the same way out of school. We have to make sure that 
kids have a safe environment in which to play. Are schools 
available after hours? What about those general after school 
programs? Is there lighting in neighborhoods? So you can't 
separate these. And then parents. For example, as Chairman 
Pallone said, you know, what about the kids watching 
television? Well, they are spending too much time in front of 
the screens. Well, some parents may say, you know, there is a 
limit on how much you can do or you can only do it after you 
have done some physical activity. Not easy for us as parents 
but we have to take charge of part of that ourselves.
    Mr. Deal. Thank you both.
    Mr. Pallone. Chairman Waxman.
    Mr. Waxman. I want to ask a question for both of you. In a 
little while, we are going to hear from Dr. Satcher, and he 
notes in his written testimony that racial and ethnic health 
disparities result in at least 83,500 excess deaths among 
African Americans each year. That is simply unacceptable. We 
have to address it in health reform. My question is what 
contribution can public health make to reducing racial and 
ethnic health disparities? Are there specific clinical 
preventive services that will reduce disparities if we cover 
them in health reform? Are there specific community-based 
preventive services that will reduce disparities if we fund 
them in health reform? Dr. Besser, why don't we start with you?
    Dr. Besser. Thank you, Mr. Chairman, for that question. I 
think that your comment that this is unacceptable is right on 
target. It is absolutely unacceptable the degree of disparities 
we see in health. CDC has undertaken a number of initiatives to 
try and address racial and ethnic disparities, but not on the 
scale that they need to be done. There is a program at CDC 
called REACH, which is racial and ethnic approaches to 
community health that has been done in a number of communities 
to specifically address within those communities the racial and 
ethnic disparities that occur.
    Where this program has been enacted, we have seen a removal 
of the disparity in rates of mammography among African American 
women. We have seen removal of disparity in the rates of blood 
pressure screening for African American men, an increase in the 
use of blood pressure medication. We have seen a decrease in 
smoking among Asian American men. We know how to address these 
disparities, and again it takes a community approach. It is not 
a one size fits all approach.
    And with appropriate scale up of these programs, I think 
that we can see the removal of a lot of these disparities. We 
have seen it in immunization programs where you have seen 
universal immunization. You have seen elimination or at least a 
closing of many of those disparities, and it is time for us to 
ensure that those programs are available to all of our 
communities.
    Dr. Fielding. Thank you very much. As your constituent, I 
am happy to add a couple of thoughts. First of all, we are not 
going to get to parity in terms of health unless we address 
some of the underlying determinants. I was asked the other day 
at a RAND conference, what is the single thing you would do to 
improve the health of the American people particularly focused 
on reducing disparities, and I said increase the graduation 
rate from high school for a number of minority groups. They are 
very poor in Los Angeles as in other parts of the country, and 
the differences in health that come along with that are 
substantial. The issues of transportation, the issues of access 
to nutritious foods, fruits and vegetables.
    Mr. Waxman. Well, how would you address this, in a 
community-based way or would you do it in a clinical way? I 
know that you can solve all the world's problems and it would 
change the disparities but if we are doing health reform, what 
do you recommend we do in health reform? Should we provide 
money for community programs? Should we provide certain 
clinical practices for those who are going to now be insured if 
we get a health reform bill through?
    Dr. Fielding. Yes, I think that, as you suggest, Mr. 
Chairman, at all levels in a health care reform system, you 
want to make sure that there are not only the ability but the 
incentives so that the providers have incentives to make sure 
that there are not disparities in terms of the access to 
services, but we also know that we have to use a lot of 
efforts. It is not simply that one has to have services 
accessible. They have to use them. And so one of the things we 
do in the community guide is to develop interventions which 
basically help people to use the services. And with different 
groups that may be different so for one group it may be that 
recall reminders make a difference. For another group it may be 
that you need to call their cell phones.
    For another group it may be that they have to have a case 
manager. It is trying to understand that that we are trying to 
do in the community guide working with the clinical guide, so I 
think the opportunity for all of those should be included in 
health system reform but we also, if we are going to reduce 
disparities, need to focus on the core of public health and the 
underlying problems. For example, in Los Angeles County African 
American men and women have a 25 percent smoking rate. The 
average rate in Los Angeles County is 14 percent. So we need 
programs, for example, social marketing programs that are 
particularly focused on the African American population there 
on tobacco.
    We need programs on obesity for Latinos as well as African 
Americans, so I think it needs to be a combination of what can 
go in the health care reform and the other parts of health 
reform that are outside the strict health care system.
    Dr. Besser. Chairman Waxman, if I could add to that. I 
think that it also ties into comments that were made by many 
members about the importance of a strong state and local public 
health system. In a community you need to have a public health 
infrastructure, epidemiologists and public health specialists, 
who can look at what are the risk factors in that particular 
community and address those. It is not a one size fits all, and 
those in the community, as Dr. Fielding is saying, in a 
community that got higher rates of smoking in one particular 
population, they have to look at what is driving that, who the 
community leaders are, and how you build a public health 
program that targets the drivers in that particular community, 
and to do that you need a strong, local public health system.
    Mr. Waxman. Thank you, Mr. Chairman.
    Mr. Pallone. Thank you. Our ranking member, Mr. Barton.
    Mr. Barton. Thank you, Mr. Chairman. One of the things that 
we can do to promote congressional health would be to stop 
scheduling simultaneous subcommittee hearings of this 
committee, which causes--but I guess it does promote de-obesity 
because it makes us run back and forth, up and down the stairs. 
I just have one question for this distinguished panel, and it 
is the idea of universal coverage. The President has said that 
every American should have health care insurance and you almost 
have to have--you don't have to but you almost have to have a 
mandate that every American has to have it, so my question is 
should that be an individual mandate or should it be some sort 
of a universal mandate that if you are not covered under a 
group plan there be a national kind of a backup fail safe plan 
for any individuals that don't have group coverage, so could 
you two gentlemen give us your ideas on how to get universal 
coverage for every American regardless of their employability 
and employment status?
    Dr. Besser. Thank you very much for that question. From a 
public health perspective, and that is the hat I wear and where 
my expertise lies, the critical factor is access to care and 
ensuring as a Nation that we move to a point where everyone has 
access to care and that care is not just being delivered in 
emergency rooms when people are sick. And I think there are 
many ways to get there. Which way we get there, I think is not 
one where CDC has the expertise. One thing that we hopefully 
over time will be able to bring more light to is the impact 
particular insurance or particular systems may have on an 
individual's health. We collect a lot of information on the 
health status of Americans through various surveys and one is 
the national health interview survey.
    And through that survey, we are now starting to collect 
information about type of insurance, type of insurance plan, 
whether it is a health savings plan or such so that over time 
we should be able to look at does that particular type of 
system have an impact on health drivers.
    Dr. Fielding. Sir, I don't know which is the best way to 
get there. I think what is important is that there be however 
you get there a core of services which is going to contribute 
to health because health then allows us to be more competitive, 
more productive as a Nation by reducing preventable problems. I 
think if we focus on that aspect there are probably a number of 
ways to get there but providing the emphasis on what we can do 
within that system and then working together with public health 
is probably our best opportunity to improve the health of every 
American and to reduce disparities at a time when unfortunately 
our health is not as good as that of our trading partners in 
many cases.
    Mr. Barton. Thank you, Mr. Chairman.
    Mr. Pallone. Mr. Dingell.
    Mr. Dingell. Thank you, Mr. Chairman. This question is to 
Dr. Fielding and Dr. Besser. Question, public health has a cost 
benefit to the society, does it not, yes or no?
    Dr. Fielding. Yes, it has a very substantial benefit to 
society, sir.
    Mr. Dingell. Dr. Besser.
    Dr. Besser. Yes, sir, I would agree with that.
    Mr. Dingell. All right. Now the reason for that question is 
the dealings in this committee with national health insurance 
or getting a program which will cover every American, that cost 
benefit may get dropped out of the equation because of the 
Congressional Budget Office which has a rather stingy attitude 
of quantifying things which they view as being unquantifiable. 
How do we then see to it that we get this question resolved in 
a way which is quantifiable so that we can get some 
discernable, visible, and calculable benefits to the society 
from public health so that we can get CBO to give us a proper 
estimate of savings and benefits that could be achieved by 
public health service, by CDC and other entities which work 
towards this end? Starting first with Dr. Fielding and then Dr. 
Besser.
    Dr. Fielding. Thank you very much. A very important 
question, Chairman. I think several things. First of all, you 
will hear from Jeff Levi from Trust for America's Health the 
kind of studies that they have done suggest a very good return 
on investment for some of the things we could do in public 
health. It is clear to me that we are not going to get where we 
need to with the national system of strong local public health 
and state public health unless the federal government is a 
partner with the states and localities, unless there is a 
sustainable amount of money that goes to make sure that the 
spine of public health is strong.
    With respect to the Congressional Budget Office with which 
I have had some discussions as well, I think that they tell me 
that the Congress is asking them to look very narrowly, and I 
don't think that looking narrowly answers the question. What 
they need to look at is the value. What is the relative value 
of different kinds of investments, and I think if you look at 
the relative value you get better.
    Mr. Dingell. That is an outfit, Doctor, that sometimes 
knows the cost of everything and the value of nothing and they 
have great difficulty in converting value to cost that is 
discernible and can then be included as justification in the 
legislation. I am asking your help about how do we get this 
quantification step done. And remember my time is running.
    Dr. Fielding. OK. What I am suggesting is that we look not 
only at the dollar savings in a very short period of time to 
the federal government, but we do two things----
    Mr. Dingell. Let me put it to you this way, Doctor. If we 
had Black Death there would be a--to spring back, we would all 
of a sudden have a very major cost to the society. AIDS has a 
very major cost to the society. If tuberculosis were to come 
back and break loose in the society, we would have a cost. How 
do we quantify these things and how do we request 
quantification from CBO so that they will give us something 
that will be useful in this discussion?
    Dr. Fielding. We can quantify the cost of epidemics in 
terms of health care costs, in terms of productivity loss, in 
terms of cost to the Social Security system and the like. That 
is easy. What is hard to know is what exactly it takes to 
prevent those because it comes from a number of different 
places. I think if we ask the CBO to look at what is the health 
benefit for a dollar invested in alternative ways, that is what 
I mean by value. Instead of just saying what is the dollar 
back, what is the health value? We are spending right now $1 
out of every $6 in this country on health care. We don't know 
in many cases what the value of those dollars is. We need to 
compare that with the value of public health.
    Mr. Dingell. If you give preventive care, you could shrink 
those numbers. Let me get to Dr. Besser.
    Dr. Besser. Thank you, Mr. Chairman. I think that you raise 
a critical question and a critical problem. When we look at 
many of the interventions and programs in public health the 
return on investment is long term. When we are talking about 
promoting physical activity and appropriate nutrition in 
children, that will have major payoffs to those individuals but 
also to our economy over the lifetime of that individual.
    Mr. Dingell. Or alcohol or smoking.
    Dr. Besser. Exactly. Alcohol or smoking. Those behaviors, 
if presented early, will have lifetime benefits and will have 
lifetime impacts on our economy.
    Mr. Dingell. How do we insist CBO assist us in quantifying 
those benefits?
    Dr. Besser. Well, I think that that is a real challenge. It 
is very promising, some of the data, Trust for America's 
Health, and Jeff Levi is going to be talking about short-term 
return on the investment. And that is promising, but I do think 
that for the broader consideration of public health that can't 
be the only part of the conversation because even if we were 
not seeing the return on investment that Trust for America's 
Health was seeing, we are seeing a very good value on the 
investment over the lifetime of individuals and over the 
lifetime of the economic return over the lifetime of those 
individuals. So the issue of time frame, cost to whom, who is 
paying the cost and who is the benefit being accrued by are 
very important parts of that discussion and one that we have to 
find a way around if we are going to see a long-term commitment 
to supporting public health.
    Mr. Dingell. Thank you, Mr. Chairman. My time has expired.
    Mr. Pallone. Thank you, Chairman Dingell. Mrs. Blackburn.
    Mrs. Blackburn. Thank you, Mr. Chairman, and thank you all 
for your testimony. Listening to you, it seems like we could--
and listening to the questions, we are coming back to three 
things, which are lack of education, lack of physical activity, 
and then tobacco as three things that are really detrimental to 
health and good healthy lifestyles. Dr. Besser, you mentioned 
linkages with other resources and other agencies, and I just 
wanted to ask a couple of quick questions. Number one on the 
tobacco issue, we know that the Sinar amendment, the Sinar 
program, has been effective in helping states reduce their 
tobacco usage, their underage tobacco usage, but we also know 
that after the master settlement agreement that very little of 
that money is being used on tobacco.
    I was in the state Senate in Tennessee when that was 
passed, and of course like so many states it went to fund a 
program, a health care delivery program, and the general fund 
and things of that nature that really weren't dealing with 
tobacco education. And some of us, myself included, who had 
been active with smoking cessation education, and as chairman 
of a former lung association, were disappointed in that. So 
would you all support a proposal that would require states to 
use a certain percentage or an expanded percentage of that 
master settlement money for tobacco education? Just a quick yes 
or no from you all.
    Dr. Besser. Congresswoman, I have to confess that I am not 
familiar with the Sinar legislation and so I need some 
information around that. What I can say is that tobacco control 
is one of those areas where we have seen major public health 
successes both in terms of reduction in rates of smoking in 
adults, children who decide not to start smoking, decrease in 
second hand smoke, and I also know that if we don't keep up 
those efforts around tobacco control, we are going to see those 
benefits go away. It is not something where you do it and you 
are done.
    Mrs. Blackburn. Dr. Fielding.
    Dr. Fielding. I don't know legally what can be done. It 
really is disappointing that the attorney general settlement 
did not specify that some of that money be used for tobacco 
control because a lot of states have not--tobacco control is an 
area we know a lot. We know a lot what can make a difference, 
and it is very disappointing that in many states unfortunately 
we are not putting the resources in that we need in order to 
reduce the rate. How that could be achieved, I am not sure 
legally, but it would be very important to have money 
consecrated to that problem because we know how to use it well.
    Mrs. Blackburn. OK. On the linkages, coming back to that, I 
am one of those that believe that when you took physical 
education classes and consumer science or life skill classes 
out of the high schools that you started seeing lack of 
education with people, individuals, that did not understand, 
Dr. Fielding, as you were saying, what calories exist in food 
and what those choices should be. But along that line, have 
either of you worked with the U.S. Department of Agriculture 
and the Agricultural Extension Service, their FSC program or 4H 
club programs, anything like that on education because they 
have staff and they have materials that are developed to 
address that, either of you?
    Dr. Besser. I have not personally but let me get back to 
you about any collaboration CDC would have with USDA in that 
area.
    Mrs. Blackburn. OK. That would be great. Dr. Fielding.
    Dr. Fielding. We have worked with WIC programs which we 
think are moving in the right direction and we have tried to 
change what is served in the schools and that works with USDA 
but we have not had direct contact.
    Mrs. Blackburn. Well, and the WIC program for many of us 
that come from state governments when we did welfare reform, 
what we did was to require some of that education, and then in 
Tennessee one of the things we did was to move some of that 
education back out to our local county extension services 
because they do have the individuals there that not only can 
provide the education but can mentor, which is a critical 
component of changing the habits and the behavior. And I know 
when Dr. Satcher does his testimony, he is going to speak a 
little bit to the influence of lifestyle and behavior. Thank 
you. I yield back. Thank you, Mr. Chairman.
    Mr. Pallone. Thank you. Mr. Matheson.
    Mr. Matheson. Thank you, Mr. Chairman. Dr. Besser, I was 
going to mention to you, have a discussion with you about 
issues about MRSA, if I could. Last year, a study was reported 
that caught a lot of our eyes about the effect that MRSA is 
having. Specifically, the study estimates that in 2005 more 
than 94,000 invasive MRSA infections occurred in the United 
States and over 18,000 of these infections resulted in death 
which was many more than had previously been thought. But there 
are many infections and other resistant bugs that aren't 
receiving as much attention and certainly should be adequately 
monitored as we discuss prevention and public health.
    You may be familiar with legislation I introduced last year 
and plan to reintroduce that is called the STAR Act. It would 
establish a network of 10 sites across the country which could 
be part of existing surveillance sites or health departments. 
These sites would provide an early warning system to monitor 
anti-microbial resistance. I look forward to working with you 
as we try to develop that legislation as a way to strengthen 
this country's ability to respond to what I see as an emerging 
public health problem. I wonder if you could just discuss with 
me any gaps you see in our current surveillance capabilities. 
Specifically, I would ask do we have an early warning 
surveillance system to monitor anti-microbial use and the 
emergence and spread of resistance?
    I would also like to ask you if you think our current 
systems are reactionary or are they geared at preventing 
outbreaks. And, third, I would ask your sense of how we compare 
with other countries in this set of issues.
    Dr. Besser. Thank you, Mr. Matheson, for these questions 
about a very important public health problem. MRSA is one type 
of resistant infection and it is one that has gained a lot of 
national attention. One of my areas of focus early in my career 
at CDC was around appropriate antibiotic use, and I started 
CDC's program, Get Smart, Know When Antibiotics Work, so that 
is directed around trying to prevent the increasing rise or the 
academic of antibiotic resistant strains. We are absolutely 
thrilled that the ERA funds that have come down have $50 
million in there to look at health care acquired infections 
because when you look at a site where resistance is likely to 
occur and develop health care settings are one of those places 
where you are seeing a lot of bad bacteria and a lot of 
antibiotics. You put those together and you are going to 
promote resistance.
    There are major gaps in our ability to detect infectious 
diseases and detect resistant infections, and those ERA funds 
are going to help with that to some extent. Our ability to look 
at antibiotic use and behaviors around that, we have some 
surveys in the NCHS, National Center for Health Statistics, 
that allow us to get a window on how antibiotics are being used 
in clinical practice. As we move toward electronic health 
records, that is going to improve our ability to look at 
practices across providers and for providers to look at their 
own practice and see how are they complying with 
recommendations, how is their use of antibiotics.
    When we look across different countries, there are some 
countries that we have higher rates of resistance in and some 
that we have lower rates of resistance, and it is important 
that we work with other countries to see what strategies and 
solutions have been effective at reducing infections and 
resistance. We do know how to reduce infections in health care 
settings. We have programs that have been very effective that 
we have developed jointly with the Agency for Health Care 
Research and Quality. These demonstrated in southwestern 
Pennsylvania, implementation of these reduced bloodstream 
infections by 70 percent. And so for many states and 
localities, it is how do we help them go to scale and how do we 
provide the assistance and resources to make that happen.
    Mr. Matheson. Well, I appreciate that response, and again I 
look forward to continuing to work on this issue.
    Dr. Besser. Likewise.
    Mr. Matheson. I yield back, Mr. Chairman.
    Mr. Pallone. Thank you, Mr. Matheson. Next is Mr. Burgess.
    Mr. Burgess. Thank you, Mr. Chairman. I got a number of 
things I want to get through. Of course, Mr. Pitts and Mr. 
Shimkus said before they left that they would yield me their 
time as well. Dr. Besser, let us stay on the subject of 
infection for just a moment, and you reference it in your 
written testimony but can you talk just a little bit about your 
approach to this or perhaps delineate what would be a preferred 
approach to controlling particularly central line infections 
and do so in a way that so that we don't inhibit reporting if 
we come at it. And I worry about this because we do this over 
and over and over again in Congress and CMS. We come at things 
punitively and then we tend to drive reporting underground so 
can you address that?
    Dr. Besser. Thank you, sir, for that question. It is a 
challenge. There is an inherent difficulty when reporting of an 
infectious disease could have negative consequences to the 
individual that is reporting that. The national health care 
safety network that CDC supports and is in place in many states 
allows for confidential reporting and provides to health care 
institutions an ability for them to look at their own rates of 
infection and develop strategies to reduce rates of infection.
    Mr. Burgess. Now under HIPA at CDC can you accept that data 
at CDC if someone wants to compile that data on a state level? 
Can they export it to you?
    Dr. Besser. CDC is able to receive anonymzed data from many 
sources and when we work with states around this area there are 
provisions that protect those data that come to CDC. What we 
found is that when hospitals start to do the surveillance 
around line infections and implement what have been shown to be 
effective control strategies that they see a dramatic decline 
in those infections. They are entirely preventable, and that is 
something that where we think there could be major 
improvements.
    Mr. Burgess. Sure. That is the epidemiologist mantra. To 
measure is to control. I guess I am concerned because our 
tendency is to be punitive on this and I know certainly from 
the physician community we are so goal directed. If you are not 
going to pay me if I diagnose a surgical site infection, I will 
never diagnose another surgical site infection through my 
professional career because after all I want to get paid. So we 
contend to obscure the data by how we focus on things. I want 
to touch on something else because you have got in your 
testimony about HIV prevention, and nowhere in there do I see--
I will just tell you the problem that I have in my community in 
southeast Fort Worth is that we have individuals who are 
arrested for one thing or another, incarcerated and returned to 
the community and now with an HIV infection and it then spreads 
outward from that exposure. Are we doing anything to look at 
our exposure to our prison population and then their subsequent 
re-integration into society?
    Dr. Besser. Mr. Burgess, I will need to get back to you on 
that in terms of specific programs in that setting. I think 
that when it comes to HIV prevention and control as with other 
infectious diseases understanding where transmission is 
occurring and ensuring that we have programs to address that 
route of transmission is absolutely essential. Earlier we heard 
someone mention the 3 percent HIV prevalence in African 
American males in the district. That is unacceptable. We need 
to understand what is driving transmission and put in place 
control efforts so that that will not be the case. But let me 
get back to you in terms of--I know we do a lot of work with 
health care--with infectious disease transmission in prison 
settings but I want to make sure I get back to you with 
accurate information.
    Mr. Burgess. OK. Very good. And I appreciate that, and of 
course we know that if we are seeing that high a rate in 
African American men it will just be a very short period of 
time before we see a similarly high rate in African American 
women, and part of our job is to prevent that from happening in 
the first place through educational activities. One last thing 
that I will just mention and I have heard access mentioned 
several points this morning. I have an area that I represent. 
Two or three of my zip codes have some of the highest infant 
mortality rates in the Nation, and it is in Tarrant County, 
which of course has a robust county hospital district, county 
tax supported facility and literally within the shadow of these 
facilities are some of these neighborhoods where infant 
mortality is so high and the problem therein is utilization and 
not access because access is clearly available but we don't 
have clinics where the people are, and trying to work through 
the cumbersome bureaucracy that exists in HERSA and HHS has 
made it all but impossible to get a community health center, a 
federally qualified health center, developed in those areas.
    And one of the most meaningful things we can do as we go 
forward is to try to unravel some of that so that we don't put 
these barriers up to getting the care were it is actually 
needed. I hear testimony from other members on both sides of 
the dais where they talk about 10, 12, or 14 federally 
qualified health centers they have in their districts. I have 
zero in my district, and I have got infant mortality rates that 
are third world, and it is unconscionable that we will continue 
this program where--it is not just a racial disparity. It is a 
geographic disparity that is of startling proportions and I 
really hope that going forward this committee will spend some 
effort in looking at that, and certainly where CDC can give us 
some help, I hope they will do so. So I thank you, Mr. 
Chairman, and I will yield back.
    Mr. Pallone. Thank you. Next is Mrs. Capps.
    Mrs. Capps. Thank you, Mr. Chairman, and, boy, what an 
excellent panel. This could go all day. And I have a question 
for each of you and I have tried to make it narrow but it is 
impossible. Dr. Besser, you discussed examples that make it 
clear that accurate information about key public health 
indicators such as infant maternal health is essential to 
improving the overall health of the public. Maybe this is what 
Chairman Dingell was kind of getting at as well. There are 
currently barriers to surveillance that make it difficult to 
gather public health data. We have to have the data in order to 
make the case for more access and better ways of implementing 
public health. Can you describe briefly some of those barriers, 
what we could do to help accomplish the positive health 
outcomes that comprehensive surveillance data could give us?
    Dr. Besser. Thank you very much for that question. There 
are a number of things that I can think about that would 
improve our ability to understand the health status of 
Americans. Right now there is so much discussion around 
electronic health records and what these are going to provide 
to improve clinical care by providing to that clinician 
information about screenings that need to take place. Well, 
this also is a potentially very powerful tool for population 
health and insuring that as this moves forward there are fields 
that are in there that represent the important components that 
we need to look at for public health, and that the clinics are 
not just connecting to each other but they are connecting to 
public health departments.
    That is one thing that would be extremely effective. We at 
CDC have seen over time a decline in support for our National 
Center for Health Statistics. The National Center for Health 
Statistics is critically important to measuring health of 
people around this country. It is important for us in terms of 
measuring the impact of programs that we put in place and 
ensuring that we are spending our resources appropriately. It 
is important for identifying disparities and issues that need 
to be addressed in particular communities. And we have had to 
make tough choices over time in terms of decreasing the 
frequency of surveys or decreasing the size of a population 
under a survey, and it is very difficult when we are doing that 
to really get a measure of the health status of all Americans.
    Mrs. Capps. Even though I know you could talk more about 
this topic, I just want to from that as we look for a 
comprehensive health legislation, we do need to be cognizant 
that data collection is an integral part of doing that. Dr. 
Fielding, you have done so much for the metropolitan Los 
Angeles area. Thank you. As we work to reform the health care 
system public hospitals and community health centers are 
essential to ensuring that rising numbers of uninsured and 
underinsured patients can access health care during a recession 
which we are seeing right before our eyes. In the future, 
safety net health systems must remain intact to provide the 
services that newly insured patients will need to effectively 
access care if we are really going to implement an increased 
number of people getting care.
    We have got to find a place for that to happen, including 
language translation and social work services. Safety net 
providers will also continue to provide money losing services 
such as trauma and burn care that many other hospitals choose 
not to offer. So what kind of policy questions should we be 
addressing in our health reform dialogue to insure that the 
safety net stays viable for the future and that kind of topic 
particularly now if we transition into a broader based health 
delivery system?
    Dr. Fielding. Thank you very much. You are absolutely 
right. We need to maintain a safety net. These are providers 
who are very sensitive to the population for whom language is 
not a barrier who understand the morays, the culture, the 
beliefs, and that has been lacking is sufficient funding to try 
and knit all the pieces together so that, for example, 
community health centers might have the same record as the 
hospital or primary care and secondary care might have the same 
ability and to transport things back and forth easily 
electronically. That is one need. Another need, of course, is 
simply to give people the tools so that they can maintain the 
infrastructure necessary.
    In some cases, public systems have not done as well in 
trying to maintain themselves just physically as others have. 
But I also think that we have to look over time in the local 
situation to see what impacts a broader mandate will have and 
in some cases it may transform systems. In other cases, it may 
not change them very much. To what degree are there going to be 
competitive opportunities or not, so I think it is going to be 
a situation by situation issue. I would add one point to answer 
your last question. We do a local health survey. We have the LA 
health survey, and we do over 8,000 people every other year in 
Los Angeles County of over 10 million people. And we get a lot 
of interesting and important information on issues as diverse 
as breast feeding and what are the barriers to that, one of our 
most important opportunities, or emergency preparedness. What 
percentage of our population are prepared for emergencies and 
have a family communication plan, have the 10 essential items 
that they need?
    We have more than our share of natural disasters and we 
worry, of course, about others so I think having local data 
collection is also important to supplement the very important 
role that NCHS plays. And I just want to echo that the National 
Center for Health Statistics has not had the funding they need, 
and if we are doing to coalesce our Nation around the 2020 
objectives for the Nation, then we have to have the data on 
which to base that, and we have to know if we are tracking in 
the right direction or not and not just nationally but at the 
local level, so robust funding for that effort is going to be 
essential.
    Mrs. Capps. Thank you both.
    Mr. Pallone. Thank you. Mr. Gingrey.
    Mr. Gingrey. Mr. Chairman, thank you. And I wanted to ask 
both Dr. Besser and Dr. Fielding, all Americans of course 
should have quality health care regardless of income, race or 
age. Dr. Besser, let me start with you. I believe, of course, 
that any disparity should be a major part of health care 
reform, and I know we have talked about this this morning and 
several of my colleagues on both sides of the aisle touched on 
that issue. And, Dr. Fielding, I think in your testimony you 
talked about a lot of things, situations, education, but I 
guess really what I want to find out is if either one of you 
think that there are other reasons for racial disparity in 
regard to receiving the kind of high quality health care.
    An example, in the Medicaid program, there might be a 
tendency, might, I would hope not but I think likely there is 
for health care providers to be a little bit prejudice towards 
people who come in the door who obviously are not taking care 
of themselves. Maybe they are obese, maybe they are unkempt, 
maybe they are smoking cigarettes, whatever. But I really am 
concerned there could also be that same sort of attitude 
towards different minority groups. And so this is a little 
touchy subject but I think it is hugely important that we talk 
about it, so I would like for you to address that.
    Dr. Besser. Thank you, Mr. Gingrey. Dr. Fielding, in his 
discussion earlier was talking on issues around social 
determinants of health, and I do think those are critically 
important. Where you live, whether your parents graduated from 
school, what type of occupation they may have and what type of 
occupation you have are things that do impact on your health. 
We know that children who live in the inner city have rates of 
asthma that are far greater than individuals who don't live in 
an urban environment. We know that children who are born to a 
single parent have a lower likelihood of graduating from 
school, and if you don't graduate from high school then your 
health future is more bleak.
    And so there are a lot of factors that go into issues of 
health, some having to do with access to care. In the clinic I 
work in in Atlanta, I would say that it is a fraction of the 
children I see there have any health insurance at all. Those 
who do, the state pays Medicaid, and whenever I have one of 
those children it is like a blessing because I know that I can 
refer them to the dentist down the hall to get their teeth 
taken care of, and I can refer them to other services. So I 
think access to care is part of the issue when we look at 
promoting health, but it is important to look in each community 
to see what are the barriers for the entire population to get 
the health services and the health that they deserve.
    Mr. Gingrey. Dr. Fielding.
    Dr. Fielding. Yes. I think one of the needs is to develop a 
work force which is reflective of the population and I think 
there are a lot of efforts, and Dr. Satcher has been a real 
leader and can talk about both his leadership training and 
other efforts. I think that is a very important initiative. I 
think it is also important to realize that a lot of the health 
disparities are really inequities. They arise from social and 
economic disadvantage, and we have some responsibility to try 
and overcome those. We are not always entirely successful but 
we need to do that and sometimes it will take some extra 
effort.
    The third point though is that we have a very heterogeneous 
population. In Los Angeles County, for example, there are no 
minorities because there is no majority currently. Now there 
will be a majority within 10 years and that will be Latino in 
this largest county in the country, so the whole issue of 
minorities is an interesting one in terms of definition. But I 
think there is real opportunities, and we have to marry what we 
do at the individual level with what we do at the community 
level. That is why having core public health is so essential to 
helping to reduce disparities, and we need a lot more research 
on that.
    When we in the community guide look at each of these 
policies and programs we find often times that there isn't data 
on which programs have reduced disparities, and we need a very 
focused research effort to do that, realizing of course that 
not all disparities are ones that come from social or economic 
disadvantage, sickle cell among African Americans, Tay-Sach's 
among Jews and northern Europe origin, et cetera, et cetera, so 
there are some differences that are not real disparities in the 
same sense.
    Mr. Gingrey. And thank you, Dr. Fielding, as well. As I 
read my book and material, and I think I noticed the figure of 
58,000 or so deaths per year in a minority population, all 
these things considered, which both you and Dr. Besser 
discussed, over and above that there are still this many deaths 
over what it should be for minority groups, and I look forward 
to the second panel. I will bring up this same issue with Dr. 
Satcher because I think it is very important. I would like to 
know is there any evidence that providers of health care 
whether they are in Los Angeles County or in Atlanta, Georgia 
that for reasons of maybe unrecognized prejudice within 
themselves are not ordering the necessary tests or not taking 
the necessary amount of time with certain populations, and if 
that is the case obviously that is something that we need to 
stop whether it is through educating our young people in 
medical school or what, but I thank you for your response. I 
know my time has expired. And, as I say, I look forward to the 
next panel as well. I appreciate that. I yield back, Mr. 
Chairman.
    Mr. Pallone. Thank you, Mr. Gingrey. Mrs. Christensen.
    Mrs. Christensen. Thank you, Mr. Chairman. I am tempted to 
answer Dr. Gingrey's question, but I am going to leave it to 
Dr. Satcher in the interest of time. But I am glad that just 
about every one of the panelists speak to the importance of the 
social determinants, and I am particularly interested in the 
health impact assessment, something that I have been advocating 
for as well. I have two questions. I am going to try to get two 
questions in. Dr. Besser, all of us are very pleased with the 
$1 billion for prevention and you have outlined broadly how CDC 
plans to use that money, but in the $650 million for prevention 
and wellness, how much of that is going to be used to target 
health disparities, maybe expand on reach programs, for 
example, and we also within the three minority caucuses are 
working on a bill to create health empowerment zones, which 
would allow health communities to have the resources and 
develop the plans, address the health disparities, and then 
give them priority for funding from any one of the agencies in 
the federal government to not only address the disease entities 
but also the social determinants. What do you think about that 
program? How are you using the money?
    Dr. Besser. Thank you, Mrs. Christensen. In terms of the 
prevention and wellness funds, we are absolutely thrilled to 
have $650 million to work on that. Those funds were appropriate 
to the department, and I chair the group, the subgroup within 
the department that is looking at how best to utilize those 
funds. We have put together a working group from across the 
department and it has been an incredible process because when 
we look at the areas that CDC has control over, we see what we 
know, but when we sit down in the same room with people from 
the Agency on Aging, folks from SAMSA, folks from HERSA, we get 
additional ideas, and so we are in the process of formulating 
this signature initiative. Disparities is going to be one of 
those factors that is looked at here because in everything we 
do in public health, we need to ensure that we are addressing 
disparities. At this point, I can't tell you what the entire 
program will look like but disparities will be part of that.
    Mrs. Christensen. Thank you. And I am going to ask the 
other question about the health empowerment zones on the next 
panel as well. So, Dr. Fielding, I am interested to know how 
the task force over 200 proven methods relates to communities 
of color and if they go far enough to help eliminate health 
disparities. A lot of people have made reference to diabetes so 
let me just focus on that. ADA recommends, for example, 
screening for pre-diabetes if one is a racial or ethnic 
minority or over 45. The task force really as best as I 
understand it doesn't recommend pre-diabetic screening. And in 
terms of diabetes screening, Medicare covers screening for if 
one has two out of seven risk factors the task force recommends 
if there is hypertension present, but do you think that CMS 
recommendations or the task force recommendations are adequate 
to address the issues of people of color when, as we have 
heard, Mexican Americans have twice as much--twice as more 
likely to have diabetes, African Americans and Native Americans 
as well.
    And you, yourself, have said in your testimony that there 
is this major gap in information on health disparities that 
needs to be closed. What can be done to close that gap and to 
make sure that the solutions that we recommend address all 
Americans?
    Dr. Fielding. Well, thank you. A very well crafted and 
complicated set of questions that I hope I can answer easily, 
but it is not so easy because, first of all, we have to make 
sure that if we screen for something that we have the ability 
to change the course of the disease based on screening. 
Fortunately, for diabetes the evidence growing for Type II 
diabetes that we can, that there are programs that can help 
people, particularly through nutrition and physical activity 
can, in fact, reduce the likelihood that they are going to get 
frank diabetes, so that is very important.
    There are huge differences with Latinos and African 
Americans having much higher rates associated with higher rates 
of overweight and obesity. There has not been enough research 
on what the differences are, and are there any specific ways 
that we should be treating people based on genetic differences, 
cultural differences, and the like. One of the opportunities, I 
think, is to take some of the money that is being allocated for 
comparative effectiveness and to look at not only comparative 
effect of different methods but look at them with respect to 
different populations.
    Mrs. Christensen. We had a big major battle in trying to 
make that happen, but I think we were successful.
    Mr. Pallone. Thank you. Mr. Murphy.
    Mr. Murphy of Connecticut. Thank you, Mr. Chairman. I think 
one of the most exciting things about the more broader 
comprehensive health care debate that is happening right now is 
that we are focusing not just on the financing piece of the 
equation but also trying to challenge Congress to step up and 
look at the way we deliver health care. And one of the, I 
think, emerging consensus points is the role of primary care 
providers in that equation, and our lack of focus on trying to 
give those primary care doctors the space with which to really 
engage in good preventive medicine.
    One concept that has been talked a lot about is the medical 
home model which would give primary care doctors a much greater 
role in coordinating care. And it strikes me that to the extent 
that we are going to return to a much more primary care based 
model it is an opportunity for public health as well. And so my 
question to both of you is simply this. What is the space in 
which a greater focus on primary care intersects with public 
health and what are the things that we need to do as a Congress 
to try to create a greater role for primary care physicians to 
be able to do real coordination with public health systems that 
surround them? I will ask Dr. Besser first and then Dr. 
Fielding.
    Dr. Besser. Thank you, Mr. Murphy. I spent 5 years as a 
pediatric residency director in California and served on a 
commission that was trying to see what we could do to encourage 
more people to go into primary care. Clearly, there are major 
gaps in the number of primary care physicians in this country 
and in particular in isolated areas that contribute to 
disparities. I think to make primary care more attractive in 
addition to the balance on reimbursement being different than 
what it currently is, we need to have community services 
available that primary care physicians can tie into, so that 
when they see an adult with pre-diabetes they can connect to 
something in the community that will help address that issue.
    I visited Vermont a couple weeks ago and was exposed to the 
Vermont blueprint for health, and what they are experimenting 
with is just that, how do they--they have a system where if 
they have a patient who has a medical condition that has 
partially a community solution, they can connect to a team in 
the community to address that. And it is profound what that 
does in terms of your ability as a primary care physician to 
impact on the health of your patients.
    Mr. Murphy of Connecticut. Dr. Fielding.
    Dr. Fielding. Yes, I would agree entirely. We need to have 
ways of interfacing between those in primary care and those in 
public health who are doing community services. When I say 
public health, it is not just governmental public health, it is 
all the voluntary agencies and the other supporting and social 
agencies that are equally important and that aren't always well 
coordinated. There is a real problem in getting those in 
training to go into primary care. And I think the reimbursement 
issue is probably going to have to be addressed if we are going 
to redress some of that balance between those who want to go 
into specialty care and those who want to do primary care.
    But I also feel it is important to point out that even if 
we have good primary care and good linkages unless we are 
addressing the other determinants of health, we are not going 
to become the healthiest Nation. We are going to be still 
pretty low on that list despite spending $1 out of $6 on health 
care. So the question is, and one of the things that would be 
helpful would be to have the physicians who are more 
understanding and knowledgeable about public health, I think 
the amount of training that a physician has, for example, in 
public health as part of their residency, as part of their 
medical school, varies tremendously, and in some cases not very 
much, so they don't have an understanding of how there can be a 
better fit between what goes on in the office and what goes on 
in the community.
    Mr. Murphy of Connecticut. Thank you for those responses. 
Dr. Fielding, I want to take a right turn and just move to a 
different subject and ask your quick thoughts. About the 
structure of health care delivery through the public sector, in 
Connecticut we have a very disjointed system where we have some 
municipal offices of health, we have some regional offices of 
health, and in more rural areas we have part-time offices of 
health where there is just a doctor, a physician in the 
community, who is that local health director. And it is of 
great worry to me that if something big and terrible was to 
happen that we might not have the sort of aligned and 
consistent infrastructure to respond. I would ask very quickly 
if that is a concern of yours and to Dr. Besser as well.
    Dr. Fielding. It is a real concern. There is great 
diversity in the capacities. One of the things that I think has 
to happen is there has to be some coalesce. There need to be 
networks. Whether you want to do that structurally or simply 
through memos of agreement and joint training or whatever, but 
we have too many. In some cases we have departments with very, 
very limited. The accreditation process will help that that 
will coalesce, will push people to try and come together but 
there needs to be statewide and even regional systems around 
metropolitan areas where people can respond as one.
    Mr. Murphy of Connecticut. Thank you very much. I yield 
back, Mr. Chairman.
    Mr. Pallone. Thank you. Ms. Eshoo.
    Ms. Eshoo. Thank you, Mr. Chairman. I guess the benefit of 
staying for a long time in a hearing is that you get to hear a 
lot, and I appreciate what you have said, both in terms of your 
testimony, and I respect the work that you do. It seems to me 
that we already know a lot. It doesn't mean that we shouldn't 
continue to comply to do the research that is necessary, to 
drill down, to understand better the composition of a 
community, what the various factors are that contribute to the 
bad outcomes that we know that we have, and so I support all of 
that. I am looking forward to a really great surgeon general of 
the United States because I think we need someone that is going 
to really market public health and what we can do.
    Now I think that we have a lot of structure. I am not 
saying that we shouldn't add to it and make sure that we target 
our investments very well, but we also know what the tremendous 
contributors are to very poor public health. I mean is there 
any community in the country, rich or poor, black, white, 
green, purple, yellow that benefits from smoking? I mean we 
just know that it is bad. It is worse in some communities 
because they are targeted. They are targeted because they may 
be uneducated, because they are poorer, because they are that 
much more vulnerable. What community is it terrific to be 
overweight? I mean we know what obesity does. We know what it 
does in children. We know what it does in adults. Everything 
from heart attacks to juvenile onset of diabetes and on and on. 
I think that the public health system in the country really 
needs to concentrate or take a fresh look at how you can do 
better marketing.
    Don't you think it would be powerful to do even ads that 
show maybe a bag of sugar, a 10-pound bag of sugar? I mean 
where is it--children are sweet by nature but they don't need 
to consume 40 to 60 pounds of sugar, refined sugar, a year, in 
order to be sweeter or better or healthier. So I think that 
there are some things that we may be overlooking that are very, 
very powerful messages, and I don't know, there must be a 
national association of public health directors in the country. 
Why not look at some of this outreach money from the stimulus 
package that will really target those communities that are 
being mauled by these terrible things.
    It is more of a statement than a question. I was very taken 
with the public health service did in Japan. They required 
adults, men and women, to come in and have their waist 
measurements taken, and if they were over a certain number of 
inches for males, over a certain number of inches for females, 
they had to go back in 3 months to have that taken again. Why? 
They made a pointed effort to bring it to every person that if 
they are overweight that they are subject to that we may not be 
able to do that in our country that way. But the whole issue of 
food stamps. Why don't you all come out with a great campaign 
and come here and advocate the hell out of the Congress and say 
let us link obesity and food stamps and do something about that 
together?
    So while my colleagues have come up with a hundred good 
items today, I think that we need to look at just marketing the 
heck out of the country on some of these things that we know 
are bad, awful, that are killers, that are contributors to the 
heavy, heavy costs in our system and to the agony and tragedy 
that takes place in families and also to give kids a chance, 
give kids a break. So, I don't know, you may not want to 
respond to that. I got 20 seconds left. I think that you have 
some power that you may be overlooking to tell you the truth, 
and I want you to have the maximum amount of dollars to do what 
needs to be done. I am not going to go into that. But do you 
have anything to say about this? Do you have anything that you 
can tell us that you are going to be marketing as kind of the 
marketing directors for public health across the country?
    Dr. Besser. Two comments. Thank you for that statement. One 
is that I think you are on target that for many things we know 
what works, and we need to implement it. And what we are 
working on with the stimulus dollars is implementing evidence-
based programs.
    Ms. Eshoo. Yes, I don't want any wild marketing that can't 
keep a promise or isn't based in sound science, but it seems to 
me we got a pile of science about some of these things already.
    Dr. Besser. The other comment I want to make is that there 
is a $20 million pilot in the Farm Bill to look at what you can 
do to promote healthy food in food stamps. And we have seen 
improvements in WIC and hopefully there will be evidence that 
doing that with food stamps will also be effective.
    Ms. Eshoo. Well, you know, see, I kind of disagree with 
that. I think that that has got to be the slow man's approach 
in order not to go anywhere. We know that food stamps purchase 
junk in plain English and it seems to me that the public health 
directors in the country would be a great antidote to the 
lobbyists that come here and say really this junk is OK, but 
let us do a study in a slow walk. So you can tell where I am 
headed. I have a legislative impatience, but I think outside of 
legislation but advocacy in some of these areas here that we 
could really make some headway. Thank you, Mr. Chairman.
    Mr. Pallone. Thank you. Mr. Gonzalez.
    Mr. Gonzalez. Thank you very much, Mr. Chairman. And to the 
witnesses, thank you for your testimony. We are having 
hearings, multiple hearings, just about every week in 
preparation for what will be landmark legislation, health care 
reform, so in the context of that, first, a general proposition 
is what is the role of public health, but specifically and in 
the context of what we are contemplating doing here in 
Congress, which I know that you have been following because 
there is impact to you, but I guess not everyone agrees that we 
should have this reform and surely not everyone--we will have 
witnesses that will follow you that don't agree even about your 
particular role. There are some that believe that for 
contagious diseases public health has an appropriate role but 
when it comes to treatment and prevention of chronic diseases 
that public health does not.
    And I believe that one of the witnesses will testify 
specifically to that. I could be incorrect about that, but that 
is the first question. What is the role when it comes to 
contagious versus chronic? It really kind of sets the stage for 
what is the appropriate role for public health. And, secondly, 
there are those that are saying, well, if we do revolutionize 
the availability of access to health insurance with a public 
option that has tremendous impact, and so I want to know what 
you bring to the table. What does public health bring to the 
table in this greater equation when it comes to expanding where 
we were talking about accessibility, affordability, and quality 
health care as we attempt to fashion legislation?
    Dr. Besser. Thank you very much for that question, and I 
think it is a fundamental question that we are dealing with 
today, and that is what is the relative roles between access to 
care and providing health care services and public health which 
focuses on prevention and health promotion. I think that if we 
solely look at access to care, and don't get me wrong, access 
to care is critically important, but if we only look at access 
to care, we are not going to see an improvement in the health 
status of our Nation in the long run. We need programs that are 
looking at what is driving the diabetes epidemic, what is 
driving the rise in heart disease, what is driving these 
issues. And that is where public health comes in.
    If our entire country has access to care, we still have a 
critical role for public health setting aside the health 
protection issues of emerging infectious diseases and 
responding to public health emergencies. Public health is 
responsible for ensuring that the environment we live in is 
healthy and looking to ensure that there aren't toxins in the 
environment that are putting people at risk. Public health 
looks at addressing disparities. Even with access to care, 
there will be disparities that need to be addressed by the 
public health community. Public health is critical for 
occupational safety and health and ensuring that the work 
environments in our community are safe.
    And we know through so many programs that public health can 
have a dramatic impact by promoting health, by addressing those 
issues of physical exercise, nutrition, and smoking. We keep 
hearing those three. Those are the big three. There are also 
additional ones, alcohol use, substance abuse, but public 
health and what public health does within the community setting 
is fundamental to ensuring that in the long run we are spending 
less on health care and that our population is healthy.
    Mr. Gonzalez. Thank you.
    Dr. Fielding. I think Dr. Besser said it extremely well. 
Our job is to provide conditions in which people can be 
healthy, and we are going to get there just by increasing 
access as important as that is. We also need to be clear what 
we are talking about when we talk about public health. I think 
we have been using it here in different ways. One way is 
governmental public health, very important. The state and local 
public health agencies, that is the core infrastructure. But 
public health also means working with non-profits, working with 
businesses, working with voluntary organizations at the 
community and state and national level.
    And we need that broader conception of public health to be 
effective, but we are not going to solve a tobacco problem or 
unintentional injuries or substance abuse problems just by 
providing more medical care. We have to focus on the prevention 
side. We have to focus on the community support side and that 
can't all be done through the health care system. We have 
already medicalized perhaps too much and it is time perhaps to 
redress that balance.
    Mr. Gonzalez. Thank you. Mr. Chairman, I have a minute 
left, and I just really want to make a statement in 
appreciation for some of the things that you have said. You 
have eluded though to health information technology or 
electronic medical records. I can think of no greater 
beneficiary than public health in making sure that we have wide 
acceptance and adoption of HIT. It is called information 
gathering, analysis and dissemination which is basically the 
essentials in what you all do, so I commend you, thank you for 
your comments, and I hope that you will be pushing hard every 
initiative that we have regarding the adoption of HIT. I yield 
back.
    Mr. Pallone. Thank you. The gentlewoman from Florida, Ms. 
Castor.
    Ms. Castor. Thank you very much. Yesterday morning I 
visited a community health center in my district in Tampa and 
we were announcing additional recovery funds, grants, under 
President Obama's recovery plan. The Tampa Bay area community 
health center has received a little more than $3\1/2\ million. 
The center I visited, they are going to hire doctors and 
physician assistants and nurses, and they are very 
appreciative, and they will be able to see more patients. And 
they took me on a tour afterwards, and I was not aware that all 
of the community health centers in most of the urban areas in 
Florida have already converted to electronic medical records. 
And they raved about it. They said we really are able to 
provide better patient care.
    They also said we are able to cut down on fraud because 
there is a picture of each patient. If they have someone come 
in and ask for certain pharmaceuticals and the picture doesn't 
match that they call security. But following up on some of the 
discussions there are requirements in place right now for 
health centers and other providers to collect data and to 
transmit it, whether it is a community level, a state health 
level or to the National Center for Health Statistics that you 
mentioned, are there requirements in place now?
    Dr. Besser. No. Within particular states and localities, 
there may be individual requirements but at a federal level 
there is not a requirement for reporting of that information. 
When I was talking earlier about the National Health Safety 
Network that is looking at infections in health care settings, 
that is a voluntary system of collaboration between states or 
health care facilities and the CDC. I look forward to a day 
when all of our health care settings are connected 
electronically and that information is flowing to public health 
at all levels because that can really have a dramatic impact on 
improving health.
    Dr. Fielding. There is one exception though and that is 
reportable diseases through the states and to the Centers for 
Disease Control, and one of the real advantages of having 
electronic systems that work through laboratories is that we 
get much faster reporting and much more complete reporting 
because it is one thing if you have to ask a busy doctor to 
fill out this report and send it in, and maybe it comes in and 
maybe it doesn't and maybe it is timely and maybe it isn't. 
When you are getting direct feeds from the laboratory as we are 
in Los Angeles County from a lot of the large laboratories, we 
know about identification of problems of reportable diseases 
much more quickly and are able to get a jump on them. And from 
the standpoint of controlling outbreaks and potential 
epidemics, that is a crucial advantage.
    Ms. Castor. So as we build this infrastructure, there needs 
to be data collection points. What is the logical location? Is 
it community based, state based? Is it reporting to this 
National Center for Health Statistics? How do we build that 
infrastructure? What is your recommendation?
    Dr. Besser. There are a number of different models that 
look at this and there are several critical pieces. As Dr. 
Fielding was saying, being able to transmit laboratory data 
that way is essential to early detection and control of 
outbreaks. But creating a health information community so that 
the data can be viewed at different levels. It can be viewed 
within a health system. It can be viewed at the local or state 
public health level. It can be viewed at the federal level. 
Clearly, there have to be protections within those systems that 
protect the identity of individuals but having that kind of 
common space for looking at data would have enormous benefits.
    Ms. Castor. OK. In my 1 minute that I have left, Dr. 
Besser, you have experienced environmental justice issues. Can 
you provide your priority recommendations for health care 
reform and public health relating to environmental justice in 1 
minute or less?
    Dr. Besser. Thank you. Clearly, health is not something 
that takes place in a doctor's office. It takes place in all 
settings, and we have to ensure that our population is living 
in healthy environments. So looking at schools, work places, 
where you reside is critically important, and that is an 
essential protective value of public health. Public health is 
there to look to ensure that our communities are safe. From an 
environmental perspective, we need to make sure that we are not 
being exposed to chemicals and toxins that could impact on our 
health, and the resources need to be there for public health at 
all levels to fulfill that function.
    Ms. Castor. Thank you very much.
    Mr. Pallone. Thank you. Mr. Sarbanes.
    Mr. Sarbanes. Thank you, Mr. Chairman. Thanks for your 
testimony today. I am fighting the same battle you are, Mr. 
Chairman, with my kids and getting them outside, and so I 
wanted to pick up on that theme and develop it a little bit 
more because there is such huge benefits to getting our kids 
outdoors. I have authored something called the No Child Left 
Inside Act, which I invite you to learn more about. It began 
with a coalition of 12 organizations in Maryland. We now have 
1,200 organizations across the country that represent 40 
million members among them, and this coalition is comprised of 
educators who understand that when you get kids outdoors and 
have a chance to apply what they are learning outside, thy 
learn better. It consists of environmentalists, of course, who 
want the next generation to have a heightened awareness of the 
environment typically when we are facing issues of climate 
change.
    But it is also comprised of many, many public health 
advocates who recognize that getting kids outdoors and engaging 
them, not just saying go outside, but giving them a reason to 
be there and excited about being outside is fundamental to 
improving their health, health of the next generation. And so I 
would for starters invite you to join the coalition and be a 
supporter of that. But the information that underpins the 
effort is showing, for example, that the average child today 
spends 4 to 5 hours indoors on television, the Internet, the 
video games, and notwithstanding the arrival of Wii and its 
contribution to physical exercise in a virtual world, there are 
still reasons to get kids outdoors.
    The data also shows that kid spend an average of about 4 
minutes a day outdoors in unstructured play and recreation. We 
have predictable consequences for their health, both in terms 
of attention span and their physical health and so forth. So I 
am very excited about the potential to link our efforts with No 
Child Left Inside, which is to try to create a federal source 
of funding, grant funding, to promote environmental education 
to really integrate it in the instructional program across our 
public school system to get kids outdoors to link that effort 
to the public health effort.
    And what I would love to hear you speak about for just a 
few moments is the extent to which you think environment 
education efforts of that kind can represent kind of a leading 
edge of public health effort with respect to the next 
generation in particular although I will add that when you talk 
to these kids who have gotten so jazzed and engaged by being 
outdoors, they are telling you that they are going back to 
their families insisting that their parents and their siblings 
go for hikes on the weekends and get outdoors. So they are 
dragging the rest of their family into the light at a time when 
we need that for so many reasons.
    So I wonder if you have brought this lens in thinking about 
public health and maybe a revolution of public health, this 
lens on education and environmental education in particular to 
the effort. And I invite either one to address it.
    Dr. Besser. Thank you, Mr. Sarbanes. First, I love the 
title No Child Left Inside and look forward to reading more 
about that particular legislation. I think that this fits in 
very well with our view of how public health can contribute to 
health and the idea that health occurs in all settings. Schools 
that foster a culture that values the environment, that values 
getting out into the environment will create adults who do the 
same and that will be a more active society and a healthier 
society. The Academy of Pediatrics has standard recommendations 
on how much time should be allowed in front of a television or 
a computer screen but your point is very well taken that there 
have to be alternatives to that.
    When I talk to a parent about getting their child outside 
to play either on structured play or on team play if those 
options aren't available there is not a lot of value in my 
spending that time with that parent going through that 
counseling, so I look forward to reading about your 
legislation. I think the intent of it is right on target in 
terms of promoting health in all areas.
    Mr. Sarbanes. We will make sure it is on your desk when you 
get back to your office. Mr. Chairman, I won't name the 
particular video game that does this, but it is not atypical, 
and there is one game in particular where I think after about 
an hour of playing on it, it invites the child to blink their 
eyes, close their eyes and open them 10 times before they 
embark on the next level of the game and so this is meant to 
represent the compensation for the fact that they are not 
getting exercise or need a break from that virtual engagement, 
so we have got a lot--and I just want to say obviously the next 
generation has to be well versed in technology. That is not 
what I am talking about. We are trying to achieve a balance at 
a time when things are way out of whack. I yield back my time.
    Mr. Pallone. Thank you. You are right. Ms. Baldwin.
    Mrs. Baldwin. Thank you, Mr. Chairman. As you have heard, 
our committee has had a lot of focus on addressing health care 
disparities especially based on race and ethnicity, and you 
have already been questioned a lot about those issues. I 
believe that there are serious health disparities that exist 
based on sexual orientation and gender identity and that belief 
is based on much input from and discussion with leaders of 
community-based organizations that provide direct services to 
lesbian, gay, bisexual, and transgender youth and adults, and 
also based on some of the few local survey tools that actually 
ask questions. But it is really quite frustrating to get a 
clear understanding of the scope of these disparities because 
most of the data collection tools at the national level don't 
ask questions about sexual orientation or gender identity.
    Dr. Besser, you have noted that you have learned about the 
importance of tracking health data and monitoring changes in 
health. I am wondering if you are aware that the national 
health interview survey, the federal government's most 
comprehensive and influential survey, does not include a 
question on either sexual orientation or gender identity.
    Dr. Besser. That is not something that I was aware of but 
something that I think I need to learn more about. Clearly, if 
we are going to address a particular health issue, we need data 
to be able to look at that clearly.
    Mrs. Baldwin. Would you support adding such a question to 
that survey tool if you find that it indeed doesn't exist?
    Dr. Besser. What I would like to do is understand first 
whether it is there and, if not, why it is here, whether there 
are any legal restrictions to collecting any particular data. I 
think that in order to make informed health decisions, we have 
to know. In addition, I think we need to do work on the health 
care delivery side to improve the core competencies of health 
care providers to address issues of gender and sexual 
orientation. My experience coming through medical school and 
even as a residency director, it is not something where there 
is a lot of education in how to address those issues.
    Mrs. Baldwin. I think that is a very important companion 
inquiry. I want to share that it is my understanding that none 
of the surveys that are conducted through the National Center 
for Health Statistics inquire about issues of sexual 
orientation or gender identity, and it is my understanding that 
the only mention of such issues in the 2020 objectives is that 
there is a statement basically that we need more data on LGBT 
populations because we cannot currently understand the depth of 
the problem. So I think we have a very serious issue that it is 
really hard to make evidence-based recommendations when you are 
not collecting any evidence. Can you tell me in any way right 
now how does the CDC currently track and monitor the health of 
the LGBT population?
    Dr. Besser. I can't answer that question, but I will get 
back to you on that. I think that is an important area for us 
to be pursuing.
    Mrs. Baldwin. I have some time left, and I want to ask some 
really broad questions about the public health infrastructure. 
I wonder if you could each give me an assessment of the current 
local, state, and federal public health surveillance system, 
what you think the infrastructure status is right now. As I 
noted in my opening statement, I author a bill with my 
colleague, Congressman Terry, to make some infrastructure 
investments there. And the second quick comment I would like 
you to make is whether epidemiology struggles with the same 
work force shortage issues that we are seeing in the medical 
system generally.
    Dr. Besser. Addressing your second question first, since it 
is an easy one, there are major gaps in our public health work 
force and a number of organizations have developed estimates of 
how great those gaps are. Of great concern is with the current 
state of our governments at all levels, we are seeing a loss of 
the work force at the state and local level, tens of thousands 
of state and local public health employees who will be let go 
and so that is a gap. Your question about surveillance, I will 
answer briefly and would be happy to follow up in more detail 
but there is great variability in our ability to detect 
laboratory capacity is extremely variable. Some states have 
wonderful systems. Others are much more rudimentary, and we 
need a system that protects our entire country.
    Dr. Fielding. Let me just add a couple of things to that. 
We also have pipeline issues, not just those that are being 
laid off because of the economic climate but in epidemiology, 
laboratorians and those that can do the analysis work as those 
techniques become more and more sophisticated there is serious 
gaps in that. With respect to surveillance, I think that we 
need to be very broad in what we look at. Increasingly, we need 
to look at the environment and a lot of aspects of the 
environment. Some of that is the physical environment, some of 
that is the social environment, and we need to have good core 
indicators to look at those. With respect to the LGBT 
community, we have done some--we have, in fact, in Los Angeles 
asked those questions in our survey and find that there are 
serious gaps in the delivery system, found, for example, that 
the highest rate of tobacco use was among the LGBT community, 
and have, in fact, devoted specific programs to some of the 
problems that we found.
    Certainly, with respect to HIV, you know, in Los Angeles 
County a very disproportionate burden is on men who have sex 
with men. So I think that information is very important 
information and we can't develop effective programming without 
that.
    Mr. Pallone. Thank you. I think that concludes our 
questions and thanks for bearing with us. I know we have a lot 
of members of the subcommittee now. When they all show up it 
goes on a for a while. But this is very helpful, and I don't 
think that we stress public health enough but it is also 
difficult to get a handle on what exactly we should do. But I 
think you gave us some very good ideas so thank you very much.
    Dr. Fielding. Thank you very much. Mr. Chairman, if you can 
indulge me just 30 seconds. I just want to make the point that 
if we do the things that we already know work in terms of 
things from the community guide and the clinical guide, we can 
save very many lives today with what we know, not that we don't 
have to know more, but we need to make sure we put in place 
what we know. And that has not been fully done and I think we 
need more work to get that out to everybody who can work on it. 
Secondly, I would like to suggest that the Partnership for 
Prevention, which is a good non-profit here has suggested some 
model legislative language for health reform in the areas of 
public health and prevention. If you don't mind, I would submit 
that for the record so that others can----
    Mr. Pallone. We would certainly appreciate that. Without 
objection, so ordered.
    Dr. Fielding. Thank you so much.
    Mr. Pallone. And thank you both.
    Dr. Besser. Thank you, Mr. Chairman.
    Mr. Pallone. I appreciate it. Let me welcome all of you, 
and I will just basically introduce each of you. From my left 
certainly no stranger to this process is Commissioner Heather 
Howard, who is the Commissioner of the New Jersey Department of 
Health and Senior Services. Thanks for being here today, 
Heather. And then we have Dr. David Satcher, who is the former 
U.S. Surgeon General, and now Director of the Satcher Health 
Leadership Institute at Morehouse School of Medicine. And then 
we have Dr. Barbara Spivak, who is President of Mount Auburn 
Cambridge Independent Physician's Association, and Dr. Devon 
Herrick, who is Senior Fellow at the National Center for Policy 
Analysis, and, finally, Dr. Jeffrey Levi, who is Executive 
Director of the Trust for America's Health.
    And, as I said before to the previous panel, we ask you to 
basically make a presentation for about 5 minutes and then we 
will have questions from the panel. And I will start with my 
New Jersey Commissioner Heather Howard.

 STATEMENTS OF HEATHER HOWARD, J.D., COMMISSIONER, NEW JERSEY 
DEPARTMENT OF HEALTH AND SENIOR SERVICES; DAVID SATCHER, M.D., 
 PH.D., FORMER U.S. SURGEON GENERAL, DIRECTOR, SATCHER HEALTH 
  LEADERSHIP INSTITUTE, MOREHOUSE SCHOOL OF MEDICINE; BARBARA 
  SPIVAK, M.D., PRESIDENT, MOUNT AUBURN CAMBRIDGE INDEPENDENT 
  PHYSICIANS ASSOCIATION, INC.; DEVON HERRICK, PH.D., SENIOR 
FELLOW, NATIONAL CENTER FOR POLICY ANALYSIS; AND JEFFREY LEVI, 
     PH.D., EXECUTIVE DIRECTOR, TRUST FOR AMERICA'S HEALTH

                  STATEMENT OF HEATHER HOWARD

    Ms. Howard. Good afternoon. Thank you, Chairman Pallone, 
Ranking Member Deal. New Jersey is very, I have said it before 
but it bears repeating, we are very lucky to have your 
leadership, Chairman Pallone. I am pleased to be here today as 
the Commissioner of the New Jersey Department of Health and 
Senior Services, and also as a representative of the 
Association of State and Territorial Health Officers. I 
represent more than 50 public health officers today. We know 
that public health has been the cornerstone for most of the 
health achievements of the 20th Century. Advances in maternal 
and child health, sanitation and clean water, immunizations, 
infectious disease control, food safety, declines in death from 
heart disease and stroke and environmental health protection, 
these were all spearheaded through public health initiatives.
    During the 20th Century, the health and life expectancy of 
people living in the U.S. improved dramatically. According to 
the CDC, 85 percent of that increase, fully 25 of the 30 years 
gained in life expectancy is attributable to public health. So 
I am optimistic today that we are talking about the importance 
of public health, and I am optimistic that significant health 
reform is going to happen this year and it is long overdue. 
Part of that health reform package together with universal 
health insurance coverage and health systems reforms must be a 
strengthening of our capacity to protect public health, to 
encourage wellness and to prevent illness.
    Too often when we talk about health policy in the United 
States, we talk primarily about the financing of health care 
and we don't focus as much on improving health and preventing 
disease. That is why today's hearing is so important. We know 
that nearly 80 percent of our health care dollars are spent on 
chronic illness, and until we do what we need to do to improve 
the health of all Americans, we will never be able to get those 
costs under control. We need to take a system approach to 
prevention. Everyone should have access to essential preventive 
services and screenings, and we need a public health work force 
to deliver that basic package. These investments in public 
health and prevention are essential elements in transformation 
of health reform.
    In fact, a focus on public health is what will make health 
care reform sustainable, both as finances and improving 
people's well being. As we enhance prevention by preventing and 
managing chronic diseases better and reducing obesity rates, we 
will reduce skyrocketing health costs and achieve significant 
cost savings over the long run. Simply put, public health both 
improves lives and saves money, and health care reform cannot 
be successful without a strong public health foundation. It is 
clear that President Obama and the Congress understand this 
critical link because of the $1 billion investment in the 
Recovery Act and the creation of a prevention and wellness 
trust. I want to thank the members here for that achievement.
    As the President has said, investing in prevention will 
lower health care costs, improve care, and lower the incidents 
of heart disease, cancer, asthma, and diabetes, which are among 
New Jersey's leading killers just as they are around the 
Nation. Public health is the responsibility of all levels of 
government starting at local and county level through the state 
and to the federal government, but the role of a state public 
health agency is distinct. We must work to ensure a clean and 
healthy environment for the entire community. The state public 
health system ensures that the water along the Jersey shore is 
safe to swim in and that the beaches are clean, something I 
know is very important to the chairman. The state public health 
system ensures that the water we drink is safe and that our 
children play in day care centers that are free of hazardous 
contaminants.
    One of the ways that state public health agencies work to 
reduce health disparities is by promoting healthy lifestyles, 
providing services like services like tobacco quit lines for 
those who want to kick the habit and obesity prevention 
programs. Recently, I visited several WIC clinics, that is the 
Women, Infant and Children program, as part of a public 
education campaign to promote healthy mothers and healthy 
babies, and I saw first hand the valuable work that peer 
counselors do to promote breastfeeding and provide new mothers 
with the support and education they need to successfully breast 
feed their babies.
    In addition, thousands of women at these clinics learn the 
importance of feeding their family nutritious meals. Just this 
year, WIC will soon be introducing fruits and vegetables as 
part of the basic food package. That is a reform that is long 
overdue, and I am sorry Congresswoman Eshoo is not here. She 
was talking about the importance of improving what we do with 
food stamp dollars, but we are doing that already with our WIC 
dollars. This healthy mothers equals healthy babies campaign 
was a key recommendation of a prenatal care task force I 
created to improve access to early prenatal care for women 
across New Jersey.
    We know that public health has been responsible for a 90 
percent reduction in infant mortality over the last 100 years 
but as a public health leader, I recognize there is more to be 
done until all children are born with a healthy start in life, 
and when we know that in New Jersey a black infant is more than 
3 times as likely to die in its first year of life than a white 
infant, we have more work to be done. In addition to educating 
the public about public health the New Jersey Department of 
Health is responsible for testing 
chemical and biological agents in its lab and coordinating the 
state's response to a flu pandemic that would immobilize 
business, cripple the food supply, and sicken millions.
    The state public health agency is also responsible for 
licensing, regulating, and inspecting nursing homes and 
hospitals, insuring access to quality health care for everyone, 
reducing the incidents of adverse medical events and supporting 
our safety net providers. In short, the state public health 
agency is where the rubber hits the road in terms of protecting 
and promoting the health status of New Jersians and all across 
the country. Let me give you a few key examples. Mr. Chairman, 
I know that food safety is one of your top priorities and you 
have worked with your colleagues to introduce a comprehensive 
bill to reform the FDA. We need to look no further than the 
recent salmonella outbreak to know how important our work is in 
this area.
    When New Jersey was at the center of the anthrax attacks in 
the fall of 2002 the state's health department lab functioned 
as New Jersey's only CDC approved facility in the quest to 
identify anthrax. During this national crisis, the state lab 
rotated teams of trained scientists working 15-hour shifts for 
2 months processing more than 3,000 specimens and positively 
identifying 106 samples for the presence of anthrax. Since 
then, New Jersey has developed a national reputation as a 
leader in emergency preparedness. We are developing and 
implementing a statewide response to public health emergencies 
and with critical federal financial support we built a health 
command center, the first and only facility of its kind in the 
Nation which coordinates situational updates, medical assets, 
and resources to provide a timely and efficient response to an 
emergency.
    Coordination among federal, state, and local agencies is 
also key in addressing environmental conditions that can 
threaten the public health of our residents. New Jersey is the 
most densely populated state in the Nation and many of our 
residents live in an urban environment where the potential for 
exposures to hazardous chemicals and contaminants is a very 
real threat. We have an estimated 20,000 contaminated sites and 
more superfund sites than any state in the Nation. Because of 
this, the work of the department is so important to coordinate 
with the federal, county, and local partners to protect the 
public health by preventing potential exposures to harmful 
environmental substances. Just 2 years ago after high levels of 
mercury were discovered in a day care center on the site of a 
former thermometer factory the public health system responded 
by closing the center.
    Then Governor Corzine quickly enacted legislation requiring 
the department to establish evaluation and assessment 
procedures for the interior buildings used as day care 
centers----
    Mr. Pallone. I am going to have to ask you to summarize a 
little bit.
    Ms. Howard. Wrap it up?
    Mr. Pallone. Yes.
    Ms. Howard. Well, thank you. There are many other examples 
of how we are working together, many other great examples of 
New Jersey, but in sum, as I said earlier, I am extremely 
hopeful that transformation of health reform will happen this 
year and that will include a strengthening of our capacity to 
protect the public health, to encourage wellness, and prevent 
illness. I look forward to working with you.
    [The prepared statement of Ms. Howard follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Pallone. Thanks a lot. Dr. Satcher.

                   STATEMENT OF DAVID SATCHER

    Dr. Satcher. Thank you, Chairman Pallone, Ranking Member 
Deal, and members of the committee for this opportunity. I 
appreciate the discussion that has taken place this morning 
around the public health approach to health system reform. I 
want to just say a word about my background because I think it 
may be the basis for some of the discussion. I had the 
opportunity to direct the Centers for Disease Control and 
Prevention from 1993 to 1998, served as Surgeon General from 
1998 to 2002. Three of those years, I also served as assistant 
secretary for health which made me responsible for leading the 
development of health to 2010. As Surgeon General, I had the 
opportunity to release the first ever report from a Surgeon 
General on mental health but also to release the first report 
on sexual health, and finally in 2001 the report on overweight 
and obesity.
    Since leaving government, I have had the opportunity to 
serve as founding chair of Action for Healthy Kids which 
focuses on programs in the schools to create the kind of 
environment that help children develop habits of healthy 
living. I have also served on WHO's Commission on Social 
Determinants of Health, and more recently on the Alzheimer's 
study group, co-chaired by Speaker Newt Gingrich and Senator 
Bob Kerrey.
    I want to make four quick points. Today, I think based on 
our discussion the health care system is the patient, and the 
patient is clearly sick. You have talked about the problems of 
runaway cost, restricted access, questionable quality of care, 
and disparities in health, not just among racial and ethnic 
groups but different socio-economic groups, rural versus urban, 
and certainly disparities in the way we approach mental health 
when compared to physical health. I think in order to respond 
to these health systems problems we must revisit the major 
determinants of health. And again I think the four major 
determinants, access to quality health care, which according to 
our data, accounts for about 10 to 15 percent of the variation 
in health outcome, biological/genetics, which accounts for 15 
to 20 percent, environment, both physical and social, 
accounting for 25 to 30 percent, and then human behavior or 
lifestyle, which accounts for 40 to 50 percent of the 
variation.
    I point this out because any health system that is going to 
be effective must respond to all of these determinants, not 
just access to health care. Public health is the only approach 
that will allow us to respond to all of these determinants of 
health. Only a health system that is balanced at the community 
level that balances health promotion, disease prevention, early 
detection, and universal access to care including mental health 
parity. Finally, in order to implement such a system, I would 
make points of the following recommendation.
    Clearly, we need the appropriate incentives in place. As 
you have heard, most of the incentives today are for the 
provision of medical care. That is very costly. We pay for 
procedures. We do not encourage students to go into primary 
care because primary care does not pay the way specialty care 
does if we are going to encourage people to go into primary 
care. We need to really reimburse appropriately. I heard a 
recent example which is very interesting, and that is if we had 
a building that we were trying to improve, and it had, say, 12 
to 15 stories, and we focus all of our attention on the 10th 
floor and not on the foundation, then that building would be 
very weak. Primary care, which coordinates public health and 
medicine, is in fact the foundation. A population database is 
critical and I strongly support the electronic health records 
system.
    After Hurricane Katrina, one of the major problems we had 
was that most of the people who left New Orleans not only 
didn't know their diagnosis, not only did not know what 
medications they were taking, they didn't know the diagnosis, 
so we need an electronic health record, but it will also 
significantly improve data management for improving our system. 
We need a community-based collaboration for health care, and we 
need a work force that is balanced, balanced in terms of the 
different levels of health care and not just physicians but 
nurse practitioners, physician assistants, community health 
workers, a balanced work force. And that work force needs to 
represent a diversity of cultures and language, race and 
ethnicity. So, Mr. Chairman, I strongly recommend that we pay 
much more attention to public health as we move forward in this 
system, that we incentivize prevention and health promotion, as 
many businesses, by the way, are doing right now, and they are 
answering some of those questions about the cost benefits. So I 
again appreciate the opportunity. I look forward to the 
question and answer period.
    [The prepared statement of Dr. Satcher follows:]

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
    Mr. Pallone. Thank you, Dr. Satcher. Dr. Spivak.

                  STATEMENT OF BARBARA SPIVAK

    Dr. Spivak. Thank you. My name is Barbara Spivak. I am a 
practicing physician in Watertown, Massachusetts, and President 
of the Mount Auburn Cambridge Independent Physician 
Association, which is a member organization of approximately 
500 physicians affiliated with Mount Auburn Hospital and 
Cambridge Health Alliance, the public hospital in Cambridge. I 
appreciate this opportunity to testify about the important role 
coordinated care plans play in helping us both align as 
incentives and give us the resources to create a comprehensive 
program to deliver higher quality care at a reasonable cost. I 
would like to share with you today the--give you some flavor of 
the infrastructure that we have in our organization that 
provides care coordination, case management, pharmacy 
management, referral management, utilization management, and 
does quality programs that encourages prevention strategies as 
well as improvement in chronic disease outcomes.
    Our arrangement with our hospital and Tufts Health Plan 
through the Tufts Medicare Preferred HMO product allows us to 
provide different levels of care for patients depending on 
their health status, their social status, and their frailty. 
For example, in patients who are severely ill who are at home, 
we have programs that send nurse practitioners into the home. 
When people are in rehab facilities, we have nurse 
practitioners and physicians who go in not once a month like in 
traditional fee for service but go in up to four or five times 
a week to keep them in the facility.
    Our lowest level of care was where a case manager may just 
call the patient on a monthly basis, make sure they are taking 
their medicines properly and help them arrange rides for their 
doctor's appointments. In some cases, nurse practitioners 
actually go with patients to physician's appointments because 
the patients themselves may not be able to hear everything that 
the physician says and organize all the med changes that 
happen. We use case managers who follow patients through the 
continuum of care so that when a patient is in the hospital in 
a rehab and then goes home that case manager knows their family 
and social situation and can help set them up with the most 
appropriate services to keep them at the lowest level of care 
possible.
    We have a pharmacist who works with us full time who works 
with patients who are on eight or more medicines to simplify 
their regime, encourage the use of generics, and when patients 
with chronic diseases are out of control in terms of 
cholesterol management, for example, or diabetic control, they 
work with specialists to make recommendations to the primary 
care doctor for better medical management. We have utilization 
management programs that do not deny care but work with 
physicians to make sure that they are ordering the right test 
for the right patient for the right disease or referring to the 
right doctor the first time. This avoids both duplication of 
testing and unnecessary testing.
    We work with a health plan in doing disease management 
programs in CHF and COPD, and the help plan provides us with a 
care alert program that takes claims data and runs it against 
1,500 rules based on evidence-based medicine that provides us 
with gaps in care that our physicians can then address. Our 
hospital works aggressively on decreasing med errors, improving 
quality so that we have not had a ventilation assisted 
pneumonia in over a year. Many of these programs are not funded 
in traditional fee for service medicine. Traditional fee for 
service medicine leaves the doctor alone in the room with the 
patient and when the patient walks out, they are on their own.
    In our system, we have multiple levels of support for the 
physician, the patient, and their families. We use education as 
a prime method of improving care. We just try to help 
physicians do a better job. We help to keep patients at the 
lowest level of care possible, mainly trying to keep them at 
home when we can. Traditional medicine really does not allow 
for the infrastructure that we have had to do that, and I would 
encourage the committee as they look forward to funding plans 
that continue to allow us to have the networks and the support 
and the infrastructure. I also would like in my testimony, I 
made reference to some quality data because I think it is 
important for people to see that we actually do what we say we 
do.
    So if you look at our mammogram rates, they are 14-percent 
higher than in fee for service medicine. Diabetic eye exams are 
21-percent higher. Colon cancer screening rates are 18-percent 
higher. Diabetic patients go to the hospital 35-percent less 
often. Our readmission rates are 58-percent fee for service 
Medicare, and our ER utilization is over 20-percent lower. Our 
diabetic patients have heart disease that is 23-percent lower 
than Medicare patients and have strokes that are 46-percent 
less often. So I think the statistics show that what we are 
doing actually works. Part of what this does is it really 
aligns the incentives so that the health plans, the hospitals, 
and the physicians all work together in a collaborative way to 
do the right thing.
    [The prepared statement of Dr. Spivak follows:]

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    Mr. Pallone. Thank you, Dr. Spivak. Dr. Herrick.

                   STATEMENT OF DEVON HERRICK

    Mr. Herrick. Mr. Chairman and members of the committee, I 
am Devon Herrick, a Senior Fellow at the National Center for 
Policy Analysis, a nonprofit, nonpartisan research institute. 
We strive to solve problems by relying on the strength of the 
competitive entrepreneurial private sector. I welcome the 
opportunity to share my views, and I look forward to your 
questions. Community-based public health has a very important 
role in our society in our health care system, and it has 
achieved some very significant results over the past century. I 
mean, for example, like I mentioned before, vaccination, safe 
foods, fluoridation. The London cholera epidemics in the late 
1800's are a classic example of a public health initiative that 
was very successful as are controlling contagious diseases.
    Yet, over the past few decades public health has struggled 
to tackle many of the problems through community-based 
initiatives that don't particularly lend themselves to 
community-based solutions. Most Americans who suffer from 
chronic ailments don't really consider their problems to be 
public health problems. Rather, people who suffer from 
diabetes, from asthma, from hypertension, to them their 
problems are very real and very personal. That is to improve 
public health. We also need to free the doctors and free the 
patients to find innovative solutions that meet their 
individual needs. America is unlikely to mitigate the 
increasing problem of chronic diseases unless patients 
themselves become more involved, and moreover patients are not 
likely to become more involved unless they have a financial 
incentive for doing so and control more of their own health 
care dollars.
    For example, approximately 125 million Americans have a 
chronic ailment and many of these are not receiving the 
appropriate care from their physicians. One reason for this 
poor compliance is because the physicians often lack the 
integrated systems to care for their patients but a bigger 
reason is they often lack the financial incentives to provide 
appropriate care. For example, consider diabetes. Nearly 24 
million Americans have diabetes, about a third of which don't 
even know they have it. This constitutes around 8 percent of 
the population arising to nearly one in four seniors the 
leading cause of death. We spend several billion dollars a year 
for diabetes complications that could have been averted through 
appropriate care.
    But, yet, numerous studies have shown that considerable 
benefit from self management training for Type II diabetes, 
patients can be trained to inject insulin, monitor and maintain 
a log of blood glucose levels, and use the results to 
appropriately adjust dietary intake, activity levels, and 
medical doses. I recently came across a firm that helps 
patients manage diabetes remotely using tele-medicine. For 
example, an enrollee is given a wireless blood glucose monitor. 
They are instructed to test their blood glucose or blood sugar 
at selected times a day. They can send the results wirelessly 
to their physician's office. If they fail to test on schedule, 
they are given an e-mail or a phone call to prompt them to 
repeat the test or take the test. A particularly high reading 
might prompt a phone call from a diabetes nurse inspecting 
them, inquiring what have I just eaten, and don't do it again.
    This all becomes part of their electronic medical record, 
the result of which can be used and shared with their health 
coach to help them maintain better compliance. A great example 
of what is often times considered a community-based approach 
was the Ashville project in North Carolina, which helped 
enrollees and self-insured health plans better control their 
diabetes, but yet on closer inspection what it really was, was 
individual pharmacists being compensated and being paid to help 
individual patients manage their diabetes. Another area I want 
to talk about is asthma self management. Nearly 20 million 
Americans suffer from asthma, around 2.5 million school kids 
miss around 15 million school days per year because of asthma.
    A Dutch study comparing self management to usual care found 
that those that were trying to monitor their own conditions 
received a savings of about 28 percent in their second year 
compared to additional physician care alone. They can also use 
software packages just to track and monitor their conditions 
and their readings. These become part of their electronic 
medical records, the data which can be shared with their 
physicians. A recent study of asthma patients trained to 
perform in-home asthma self-monitoring found that their 
readings were consistent to establish guidelines. Another study 
of bleeding and clotting disorders by the VA and the home self-
monitoring of clotting of those taking Warfarin therapy was 
superior to standard monitoring alone. Tele-medicine holds 
significant promise to allow patients with chronic ailments who 
are motivated to better manage their conditions and interact 
with physicians in ways not possible just a few years ago. I 
think this is critical to better self-management of chronic 
conditions.
    In conclusion, community-based health care has a place in 
our health care system. However, disease is very personal. The 
solution to the public health problems associated with 
increasing chronic disease is to allow patients to control more 
of their own health care dollars and to allow patients and 
providers to benefit from new arrangements that produce higher 
quality and lower cost. For example, government insurers, 
Medicare and Medicaid should also allow doctors and hospitals 
to repackage and re-price their services under government 
health care payment systems allowing them to gain financially 
from providing better care. The most important lesson is 
entrepreneurs can solve many of the problems that plague our 
health care system. Public policy should encourage these 
efforts, not discourage these efforts. Thank you.
    [The prepared statement of Mr. Herrick follows:]

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    Mr. Pallone. Thank you, Dr. Herrick. Dr. Levi.

                   STATEMENT OF JEFFREY LEVI

    Mr. Levi. Thank you, Mr. Chairman. Good afternoon. My name 
is Jeffrey Levi and I am the Executive Director of Trust for 
America's Health, a nonpartisan, nonprofit organization 
dedicated to saving lives by protecting the health of every 
community, and working to make disease prevention a national 
priority. I would like to thank the members of the subcommittee 
for the opportunity to testify on the role of prevention and 
public health as a component of the health reform debate. This 
afternoon I would like to make 2 major points. First, the 
critical importance of public health programs, in particular, 
population and community-based prevention in improving the 
health of Americans and making a reformed health care system 
more effective.
    Second, the need to create a reliable, stable funding 
stream for public health programs and services as part of 
health reform. Otherwise, the potential benefits of public 
health to the health care system will be lost. My written 
testimony also addresses the need to build the evidenced-based 
prevention programs and invest in public health systems and 
services research, to improve the quality of public health that 
is delivered in the U.S. Much of what is said there has been 
covered in Dr. Fielding's testimony. Health care in the United 
States has become an expensive burden on our economy. High 
rates of chronic disease are among the biggest drivers of the 
American health care costs. What this means in real terms is 
that Americans are not as healthy as they could be or should be 
and that is translating into huge growth in our health care 
costs.
    The country will never be able to contain health care costs 
until we do a better job of preventing people from getting sick 
in the first place. That is where public health comes in. The 
Nation's public health system is responsible for keeping 
Americans healthy and safe by preventing disease and promoting 
healthy lifestyles including those that prevent or mitigate 
chronic disease, diseases that are driving up health care 
costs. The goal is to prevent disease, prevent people from 
having to enter the clinic and need disease management, which 
is really what Dr. Herrick was talking about. He was talking 
about disease management rather than primary prevention. Yet, 
there are proven community-based programs that actually prevent 
disease that promote healthy environments and behavior making 
it easier for people to make healthy choices.
    Shifting community norms about tobacco use, the social 
marketing campaigns, changing the physical and social 
environment in which people live by making communities more 
walkable through better street lighting and sidewalks, creating 
group walking or exercise programs to encourage physical 
activity or improving access to healthy foods are all examples 
of community interventions that work to prevent or mitigate 
chronic diseases; and we know that investing in prevention, 
especially community-based programs, can have a big payoff. A 
study, Trust for America's Health, issued last summer found 
that an investment of $10 per person per year in improving 
community-based programs to increase physical activity, improve 
nutrition and prevent smoking and other tobacco use, with that 
the country could save more than $16 billion annually within 5 
years.
    This is a return of investment of $5.60 for every dollar 
spent, based on an economic model developed by Urban Institute 
and an extensive review of evidence-based studies by the New 
York Academy of Medicine. Out of that $16 billion in savings 
Medicare could save more than $5 billion, Medicaid $1.9 
billion, and private payers could save more than $9 billion. 
That is the good news. We have proven community-based public 
health interventions work; but to fully realize this potential 
return on investment and keeping Americans healthy requires a 
larger and sustained investment in public health. The bad news 
is right now the public health system is structurally weak in 
nearly every area and that is the system which ranges from 
federal agencies such as the CDC from whom you heard earlier to 
the nearly 3,000 state and local public health agencies to 
countless non-governmental organizations.
    That system does not have enough resources to adequately 
carry out core disease prevention functions. In collaboration 
with the New York Academy of Medicine, Trust for America's 
Health convened a panel of experts to analyze how much is 
currently spent on public health in the United States and how 
much more would be needed to support core public health 
services at a sufficient level. The panel's professional 
judgment was that there is currently a shortfall of $20 billion 
per year in spending on public health. Therefore, we believe 
that a reformed health care financing system must include 
stable and dedicated funding for core public health functions 
and community-based prevention. We recommend the establishment 
of a public health and wellness trust fund through a mandatory 
appropriation or set aside of a portion of new revenues 
generated from the financing of health reform. Resources from 
the trust fund would be allocated to specific public health 
programs or activities as directed by the relevant 
appropriations committees those public health functions and 
services that surround, support, and strengthen the health.
    The trust fund would fund core governmental public health 
functions. It would also fund population level non-clinical 
prevention and wellness programs which can be delivered both 
through governmental and non-governmental agencies. It would 
support clinical preventive services such as screening and 
immunizations that are not covered by third party payers, and 
it would also support work force training and development, as 
well as public health research. The trust fund could help make 
up for the country's current $20 billion annual shortfall in 
public health spending. Based on the current distribution of 
responsibility along with federal, state, and local 
governments, $10 to $12 billion of that amount should be a 
federal responsibility. In short, Trust for America's Health 
believes that prevention and public health must be at the 
center of any effort to reform our health system. Public health 
programs are a critical and underfunded component of the 
Nation's health system. We encourage Congress to establish a 
public health and wellness trust fund to make our country 
healthier, our health system more cost effective and our 
economy more competitive. Thank you, Mr. Chairman.
    [The prepared statement of Mr. Levi follows:]

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    Mr. Pallone. Thank you, Dr. Levi. Those bells mean that we 
have votes. We have three, 15 minutes, a 5 and a 5, so figure I 
guess about a half an hour. So what we are going to do is have 
questions when we come back in about a half hour or so. I hope 
no one has to leave. OK. So the committee stands in recess.
    [Recess.]
    Mr. Pallone. The subcommittee will reconvene if the panel 
could take their seats. I realize I think I said half an hour 
but it was more like an hour unfortunately. So we will start 
with questions, and I will begin and yield to myself 5 minutes. 
Basically, on the disparities issue, I guess I would ask Dr. 
Satcher and Commissioner Howard this questions. I don't know if 
you were here when the first panel was here, but I basically 
said that a lot of these decisions that lead to healthy 
lifestyles are very personal and so you wonder to what extent 
public health agencies can really influence them, but I know 
that they can because I think the anti-smoking efforts on the 
part of public agencies were very successful, and I used my 
kids as an example.
    But when we hear about disparities, you know, I go back to 
the same thing again. To what extent are some of these 
disparities things that we can change, and of course I think, 
Dr. Satcher, of the fact that often times in the inner city, 
you know, you don't have as many parks or open spaces so it is 
more difficult for people maybe to get exercise. I don't know 
if that is necessarily true but sometimes it is true. And other 
members have made the argument that sometimes in certain urban 
areas you don't even have a supermarket where you can get fresh 
foods or vegetables.
    But I could just as well make that argument, I use the 
example of some of the American Indians. I am very familiar, 
for example, with some of the Pema tribes in Arizona, and they 
have some of the highest incidents of diabetes, you know, that 
comes from a lot of it from obesity, and yet they have plenty 
of open space although they do have a problem in that their 
traditional diet ranching, farming, has sort of disappeared in 
the last few years. So I mean do you think that there are 
things that we can do that make a difference in terms of these 
disparities, you know, like creating more open space or 
providing more fresh vehicles or whatever you think is the 
case?
    Dr. Satcher. Well, I think it is a very important question, 
and the answer is, yes, I do. Beginning with our children, I 
think again it gets back to providing incentives and some of 
those incentives are being with parents out walking and 
enjoying, you know, that association. But I really think there 
are a lot of ways that we can incentivize our children to 
engage in health efforts. Now one of the reason I spent so much 
time with the schools since I left office with the Action for 
Healthy Kids program that is now in all 50 states and the 
District of Columbia is that schools are the great equalizers.
    Some of the kids come from homes with single parents and 
the parent may only have time to get up and get the kids off to 
school and try to be there when they get back, but the children 
spend over 1,000 hours in school every year. We pay for that, 
and we ought to be committed to an environment that helps 
habituate children to health lifestyles because children become 
habituated to unhealthy lifestyles and that is foods that are 
high in fat, foods that are high in salt, foods that are high 
in sugar are really addicting and children become habituated so 
the time that they spend in school and the resources that we 
use at school ought to be devoted to helping to habituate 
children to healthy lifestyles. We can do that. We provide the 
resources.
    And I think what Congress did in 2004 with the WIC 
reauthorization basically requiring every school district that 
received funds for free meals to have in place a wellness 
policy within 2 years has worked well. According to our 
studies, over 90 percent of the school districts have those. 
Now the problem is how do we get them to implement them?
    Mr. Pallone. But, you know, and I want to move on to ask 
Commissioner Howard a question, you know there is a 
proliferation now in a lot of urban areas and all over like 
charter schools and smaller public schools. A lot of times they 
don't have the buildings or the playgrounds and to some extent 
as we have emphasized, you know, studies and I think of the 
charter schools, a lot of them started for high tech or math or 
science or whatever, and then they don't necessarily have the 
facilities, you know, or the playgrounds or whatever. But, 
anyway, I have to ask Commissioner Howard this question.
    Ms. Howard. Just on that point.
    Mr. Pallone. Yes, sure.
    Ms. Howard. I think that is a great point for you to raise 
because even when we control for health insurance, we see 
troubling disparities based on race, so we know that just 
universal access to health insurance is not the only answer to 
get----
    Mr. Pallone. That is what I was going to ask you actually, 
so why don't you just get into it.
    Ms. Howard. Well, I think it is clear, and I think that is 
where public health plays a role where we can focus on 
evidence-based community interventions. And I will just give 
you one example. In your own district, I visited the FUEC in 
Long Branch and they are doing an interesting project with 
pregnant women called the health start model.
    Mr. Pallone. The health center, yes.
    Ms. Howard. The FUEC that is run by the VNA there. Every 
pregnant woman who comes in is assigned a nutritionist and a 
social worker. So I toured, and I said this is better care than 
I got when I was pregnant. It was amazing the follow-ups she 
got, so she got nutritional counseling throughout her pregnancy 
and so her risks were detected early. Then she got the social 
supports that she needed, and those are the kind of programs 
that we know are evidence-based that we know work to reduce 
infant mortality, so I think public health really does play a 
critical role in reducing disparities since we can't there just 
on expanding coverage.
    Mr. Pallone. I am going to try to get in my second question 
to you which was I think the notion that if we do health care 
reform and somehow we manage to cover everyone that a lot of 
these public health concerns are going to go away but I don't 
think that is true, and I wanted you to comment on that. What 
happens in this post-Nirvana environment when we pass 
comprehensive health insurance and everyone has health 
insurance, are you still going to have a major public health 
role here and how do we build that into it?
    Ms. Howard. I think that is a great question to discuss 
today. I think absolutely public health has a role for two 
reasons. One, I think public health is critical to the 
sustainability of the health reform that you all will enact. 
Public health, as we have talked about today, and you heard 
from your first panel of the critical role we can play in 
managing chronic diseases and containing cost will be critical 
to making health reform work, so I think it is part of health 
reform. I think we also can't ignore the fact that health 
reform will probably leave some people behind. We have seen in 
Massachusetts, for example, that none everyone has been 
covered.
    And actually we have seen, I was looking this up last 
night, that federally qualified health centers, the community 
clinics, have seen an increase in the number of visits since 
they have had their universal health care. So safety net 
providers like federally qualified health clinics will still 
play a role because they know how to reach perhaps hard to 
reach populations in culturally competent ways. They are 
critical to reducing disparities. So, one, it is critical to 
the sustainability from a financial perspective, but also we 
know that coverage is not the only answer to improving the 
health of Americans, and so public health will still be vital 
whether it is dealing with making sure that kids go to a day 
care center that has clean air, whether it is making sure that 
we don't have food safety problems. All those things we are 
still getting in public health.
    Mr. Pallone. OK. Thank you. Mr. Deal.
    Mr. Deal. Thank you. Dr. Spivak, I was intrigued by your 
testimony as to what your group is doing. It is apparently very 
impressive results that you are achieving. And I notice that 
you mentioned the Tufts Health Plan Medicare Preferred. I 
assume that is a Medicare Advantage program, is that correct?
    Dr. Spivak. That is correct. It is a Medicare Advantage HMO 
product, so it is different than the Medicare Advantage fee for 
service products in that the patients choose a primary care 
physician and choose a network, so it allows us to get 
information about them because we know who their primary care 
doctor is and who is responsible for their care, so it give us 
access to claims data about their pharmacy utilization, what 
prescriptions they are really filling, and gives us easier 
access to if they go out of our network getting information 
about their care as well.
    Mr. Deal. Obviously, you are aware that much of the 
movement about Medicare Advantage is to do away with those kind 
of programs. If Medicare Advantage is basically abolished then 
your network that you have established would virtually 
disappear because--and you wouldn't have the flexibility that 
you have described in the way you outreach now, is that right?
    Dr. Spivak. That is correct. And it is one of the problems 
that we see if Medicare Advantage goes away that the fee for 
service medicine just doesn't allow us to give the 
infrastructure and the support that we need to do this kind of 
care. The medical home concept that people are talking about 
goes a little bit towards it but it really doesn't go far 
enough in the current models to provide the extensive programs 
that we have today.
    Mr. Deal. Dr. Herrick, following on that same line of 
questioning from your printed testimony excerpts you say 
government insurers should also allow doctors and hospitals to 
repackage and re-price their services under government health 
care payment systems allowing them to gain financially 
providing better care. You go on to say entrepreneurs can solve 
many of the health care problems that critics condemn. One of 
the concerns I have is that if we move into a system that is as 
rigid as our current systems are in basically a fee for service 
format, I think we bill rigidity into the system and we don't 
allow any room for entrepreneur or even for those providers who 
want to do things in a little different way. Is that the point 
you were trying to make?
    Mr. Herrick. Well, the point I was trying to make is under 
the current system it is a very rigid system. Basically 
Medicare and Medicaid tend to pay by task. We are not paid for 
results, we are not paid for outcomes. In a sense, if you have 
pay for performance often times it is the payers of health care 
trying to tell the purveyors of health care, the providers of 
health care, how to practice medicine. It is the doctors and 
hospitals that know the most about how to practice medicine. 
Let them propose novel solutions. Let them experiment. And if 
they can find a way that has higher quality and lower cost let 
them suggest ways of getting paid.
    For example, I gave some anecdotes about how the chronic 
disease management firms talk to you on the phone. They might 
e-mail you to tell you, you forgot to take a certain blood 
glucose test, but Medicare will not pay for those, will not 
reimburse for that type of advice, neither will Medicare, but 
yet these are very innovative type of arrangements. Tele-
medicine is a very efficient way to prod people into 
compliance. We need to have ways of reimbursing physicians for 
doing those very novel ideas.
    Mr. Deal. Dr. Satcher, once again, I compliment you for all 
the good work you are doing and for things that you are 
continuing to promote. The Alzheimer's research is particularly 
important. But I think as we look at children, which has I 
think been one of your focuses as well in your testimony here 
today as Georgia has its peach care component of our S-Chip 
program isn't it important that we give some flexibility to the 
way that program works so that, for example, there can be 
coordination between community health centers that may be 
providing part of the care between primary physicians that may 
become a medical home and then the traditional providers of 
health care. I have a sense that we don't have that kind of 
coordination of care that is allowed under our current silos in 
which we deliver health care. Do you agree or disagree?
    Dr. Satcher. Oh, I agree. This was about Alzheimer's. One 
of our major recommendations, in fact, a second recommendation 
is for enhancing community collaborative care using electronic 
health records but tying people together all the way from 
family members who take care of relatives when they are ill 
with Alzheimer's, tying them together with physicians and other 
health care providers so the community collaborative system of 
care is one that I think is very important at every level.
    Mr. Deal. I have to keep shielding my eyes to see the clock 
up there. I think I am over and exhausted my time. Thank you 
all for being here.
    Mr. Pallone. Mrs. Christensen.
    Mrs. Christensen. Thank you, Mr. Chairman. And I want to 
thank the panelists for their patience. I know you have had a 
long week. Dr. Howard, you say in your testimony that we need a 
public health work force to deliver the basic package. Would 
you elaborate on the components and the characteristics that 
you see being needed in that work force?
    Ms. Howard. Thank you. That is a great question. I think 
one thing we haven't talked about today is the nursing public 
health work force. We haven't talked enough about nurses, and 
nurses are a critical component of our public health system, 
and we are facing a very dire shortage of nurses in New Jersey 
but nationally. So that is just one example of where we are 
facing a shortage. We are also facing in New Jersey, and I know 
this is true nationally and in our urban areas, a shortage of 
other practitioners as well. And access to dental care is 
restricted, so we have a number of practice areas where there 
is a real shortage. I am pleased that in the recovery act there 
was funding for development of the work force, and I think that 
will go a long way.
    But I encourage you all as you think about reforms to think 
about that, and I think one of the lessons learned from 
Massachusetts was that even having universal health insurance 
was not good enough. People can't see a provider. And then from 
my own perspective also states are unfortunately having to make 
lots of cuts in programs, and we are cutting staff in vital 
programs because of the economy, so it is hitting us on all 
fronts.
    Mrs. Christensen. Thank you. Dr. Satcher, references have 
been made to 2010 and I guess it is now 2020 goals. I think we 
started at 2000 goals, then to 2010, and now to 2020. Why do 
you think we have not been doing better achieving our 2010 
goals, and if you could also in your answer comment on the 
importance of diversity in the work force?
    Dr. Satcher. Healthy People started, as you know, in 1980 
with Healthy People 90, and then we had Healthy People 2000, so 
you are right. It has been around. And we have had goals for 
each decade, and the idea is that we maintain those goals until 
we achieve them. I think there are several issues related to 
the achievement of 2010 goals, and one, of course, is we did 
not anticipate that we would have 8 million more people 
uninsured than we had in the year 2000. We also, as you know, 
have not put in place the kind of system we have been 
discussing here this morning that are going to really be 
critical for the elimination of disparities in health, and they 
have got to be programs that target all of the determinants of 
health, which is why I took time to mention those determinants 
again.
    So I think a real commitment to eliminating disparities in 
health is a commitment to a public health approach to health 
care delivery in this country. I also think that the whole 
issue of cultural diversity is critical. The Institute of 
Medicine in its 2003 report 
following our having set the goal of eliminating disparities 
pointed out that the absence of cultural diversity in health 
care was a very dangerous situation. They gave examples from 
several areas including mental health. When the people 
providing the care don't understand the language or the culture 
of the people they are taking care of, and I know that 
Congressman Gingrey mentioned that this morning.
    But it was very clear from that report that it did, in 
fact, damage health care when the providers didn't understand 
the culture, not just the language, but the culture of the 
patients they were taking care of, so I have seen some good 
examples of programs now where they try to integrate the 
community into the system of care. We don't have enough African 
American physicians or Hispanic physicians or Native American 
physicians to do that or nurses. That is what I was getting to 
that we have to look beyond just the physicians if we are going 
to have that kind of diversity. And we can make progress down 
the line with community health workers, nurses, and others, and 
that is what some programs are now doing, programs that take 
care of southeast Asians, Native Americans, African Americans.
    Mrs. Christensen. Dr. Levi, I was going to ask you how much 
the public health trust fund--what was your estimate, but you 
gave me that. We also have been talking about a health 
disparity elimination trust fund or a health equity trust fund, 
so I was really interested in that. I wonder if you would want 
to comment on community health centers and their role. One easy 
area to get funding for in the Congress has always been 
community health centers, but I find that we only think about 
the community health centers and not all of the things that 
community health centers need. Do you understand my question? 
Can you speak to that?
    Mr. Levi. I think I do, and I think it is partly again to 
be thinking about what needs to surround the primary care 
system in order for it to be effective. And the kinds of 
community prevention programs that we were talking about really 
the things that can make a difference to--a community health 
center doctor can write a prescription, so to speak, for a 
person to go out and get more exercise.
    Mrs. Christensen. If you have the staff.
    Mr. Levi. Assuming you have the staff. Making certain 
assumptions. If you have the staff and someone needs--the 
prescription is get more exercise and eat healthier, but you 
live in a community where it is not safe to walk, where there 
aren't sidewalks, there aren't opportunities to exercise, and 
where healthy food isn't accessible, then you are not going to 
have a successful intervention there. So for the community 
health center to be effective the people who are served by that 
health center need to live in a healthier community, and that 
has to be built into what we think about in health reform, and 
find a way to bring these together.
    The return on investment that I spoke about in my testimony 
was thinking about doing these interventions truly on a 
population level, the entire country. Is we target it to high 
risk communities where there is a high prevalence of these 
conditions the return on investment would be even greater. And 
we are talking about flexibility in the Medicaid program and 
the Medicare program. Some flexibility, we would love to see as 
an opportunity for Medicare and Medicaid dollars to do work in 
a community. So we know people who are on Medicare and obese 
have much higher costs than people who are not. So let us 
target people 55 to 64 in their communities with proven 
evidence based interventions, spend some Medicare dollars up 
front to get them healthier as they are entering the Medicare 
program.
    As I was going around the country talking about this 
report, I met with some Medicaid plans, some Medicaid managed-
care plans, and they were frustrated that they didn't have the 
flexibility, for example, to go into their catchment area and 
give everyone a pedometer. They were absolutely convinced that 
if they did that, they would save money but that was not an 
allowable cost because they would also be reaching non-Medicaid 
beneficiaries which only emphasizes the point that we have to 
surround whatever is this reformed health care system with true 
community level interventions.
    Mrs. Christensen. Mr. Chairman, I plan to introduce a 
health empowerment zone bill that I hope will do that, and we 
invite you to look at it when we do.
    Mr. Levi. Great. Thank you.
    Mr. Pallone. Thank you. Mr. Gingrey.
    Mr. Gingrey. Mr. Chairman, I want to remind that I waived 
my opening statement so hopefully I will have time to ask two 
questions. Dr. Spivak, I think Ranking Member Deal may have 
addressed this a little bit a moment ago in regard to this 
independent physician association that you run in Massachusetts 
and the success rate that you think it has. It is a Medicare 
Advantage plan as I understand your testimony, is that correct?
    Dr. Spivak. We also do the similar management for 
commercial products with Tufts Health Plan, Blue Cross and 
Harford Pilgrim, so we have about 50,000 commercial lives as 
well.
    Mr. Gingrey. Right, but this plan that you have with Tufts 
Medical Center is a Medicare Advantage, and as you described 
it, and that was always--has always been my understanding of 
what a Medicare Plus Choice and not Medicare Advantage Plan 
does in contrast to the Medicare fee for service where it is 
just kind of episodic care, in fact, until we made some recent 
changes in the law even a routine physical examination was not 
covered and now it is only covered at the entry into Medicare 
exam, and yet what the Administration is proposing in the 2010 
budget is to really cut significantly the funding to Medicare 
Advantage, I would say almost to the bone, and take some of 
that money at least to create this escrow account to help pay 
for health care reform which would then go toward creating more 
payment to primary care physicians to man a medical home, to 
incentivize them by additional payments for wellness.
    It seems like it is the very same thing that Medicare 
Advantage was designed to do, and I realize that maybe we are 
paying a little bit too much, 115 percent or whatever it is, 
and maybe some cuts could and should be made, but it is like 
just scoring in esthetic way and saying, well, this compared to 
Medicare fee for service is too expensive, but if you look at 
it over a 10 or 20 or a lifetime period of those Medicare 
patients who receive their care through that type with an 
emphasis on prevention and wellness, at the end of the day if 
you score esthetically or dynamic then the savings, I think, 
would be there. If you would quickly comment on that for us, 
then I will go to Dr. Satcher.
    Dr. Spivak. I think that one of the things that was not 
talked about today is that the public health crisis that we 
face is also the aging population, and as our population ages 
they are going to need more and more help with their health 
care. I think that the Medicare Advantage programs allow 
physicians to work with health plans and with hospitals in a 
way that forms a network that will give much more support to 
the elderly than any type of traditional fee for service 
medicine can, and in the long run will keep costs down. I think 
we have looked at alternative methods of paying doctors. Paper 
performance does not seem to--it may improve quality a little 
bit but it doesn't seem to cut costs down.
    All of the programs in public health that we have talked 
about are critical but at the end of the day when patients are 
sick, they need a model of health care that will support them. 
I really believe groups like mine provide the model.
    Mr. Gingrey. Reclaiming my time, I believe that too, and I 
hope we are not about to throw the baby out with the bath 
water, as they expression goes. I really feel that if we had 
continued in a cost effective way to let Medicare Advantage 
provide care for right now 10 million Medicare recipients have 
chosen that over fee for service, and then to incentivize 
people through the tax code maybe or through ha reduction in 
Medicare Part B premium, if they executed a living will advance 
directive that is actually on line as we get this fully 
integrated electronic medical system to cut down on those costs 
and let them say what they want at the end of life. But thank 
you so much for that.
    Dr. Satcher, I want to thank you again for your service to 
our country and the time you have spent in government and 
outside government and what you are doing now at Morehouse 
School of Medicine. It is great to see you again. You stated in 
your testimony that half of health outcomes come as the result 
of human behavior and that we must provide incentives and 
rewards for healthy lifestyles. I agree completely. Do you 
think that businesses that have implemented programs that let 
us say reward smoking cessation, a healthy diet, regular 
exercise are an effective way to better the public health and 
what kind of benefits come from these types of programs and 
cost savings associated with this type of program. I would 
imagine it is pretty significant.
    Dr. Satcher. Yes, I do think that businesses that invest 
in, for example, work site wellness programs, we have been 
working with the Technology Association of Georgia, and we have 
been looking at data from many of those businesses. And it is 
clear that they can show that for every dollar invested in 
wellness, in some cases they save $4, in mental health I think 
it is a little bit more than that. They save by investing. Now 
they save it by preventing illness in the population that they 
would have to pay for but they also save it by preventing 
absenteeism from work and they save it by enhanced 
productivity.
    I would be happy to submit to you data from several of 
those companies as opposed to naming them because I am on the 
board of one of those companies, so it wouldn't be fair. But 
clearly there is data showing that investment in work site 
wellness programs saves money in terms of how much we pay for 
care and how much we pay for absenteeism and lost productivity 
when people become sick.
    Mr. Pallone. I am going to try to wrap up because----
    Mr. Gingrey. Dr. Satcher, thank you, Dr. Spivak, thank you, 
and thank you, Mr. Chairman, for your indulgence. I yield back.
    Mr. Pallone. And we are going to end with Mr. Engel because 
otherwise you would have to wait another half hour or an hour 
for us to come back again because there are more votes. Mr. 
Engel.
    Mr. Engel. Thank you, Mr. Chairman. I am going to try to 
give the abbreviated version of questions. Let me ask Dr. Levi 
about HIV prevalence in the United States. We found out last 
year it was higher than we had thought much to our dismay and 
that the global HIV prevention working group which is comprised 
of 50 leading public health experts and others released a study 
last summer called behavioral change in HIV prevention, and in 
the study essentially what they came to conclusion is they said 
prevention efforts to be successful will be unsustainable 
unless there is a comprehensive evidence-based approach 
employed that targets behavior social norms and other 
underlying drivers in the HIV AIDS epidemic.
    So, Dr. Levi, could you please discuss the contributions 
the guide to community preventive services has made with 
regards to reviewing HIV behavioral and social interventions at 
the community level and where is our research lacking and how 
much do you believe that increased funding would enable the 
guide to better assist HIV prevention efforts?
    Mr. Levi. Overall, the guide has been chronically 
underfunded and so it is unfair to judge the guide on what it 
has covered and not covered. But one of the things I think we 
need to be careful about is that there are actually within CDC 
several efforts, for example, in addition to the community 
guide in identifying successful interventions. And within the 
HIV AIDS division of the CDC, they have developed a compendium 
of what they consider to be approved community-based 
interventions and successful prevention program from which 
grantees can choose as they decide to spend federal dollars, so 
there are multiple ways of approaching it.
    I think the real challenge that we have around HIV 
prevention in this country, and this is something I have been 
working on since the beginning of the epidemic, is that we 
haven't fully committed the resources to the kinds of community 
change that is necessary to implement the policies that we know 
work so we have had restrictions, frankly, on use of needle 
exchange, use of federal funds for needle exchange programs. 
That is an evidence-based approach and countries that adopted 
it early on in the epidemic, they have not had the same kind of 
epidemic as they did, you know, among injection drug users, not 
just for HIV but also for transmission of hepatitis which has 
resulted in tremendous cost savings in those countries.
    We have not had that benefit of that because we failed to 
adopt evidence-based practices. In terms of community change, I 
think it really does again come back to community level 
interventions that reach the multiple communities that are 
affected by the epidemic. It is not a one size fits all effort. 
It is not just going to be promoting use of commons or 
promoting safe sex or promoting abstinence. It is going to be 
what works in a particular community and what brings people 
together to feel empowered to adopt the norm changes that need 
to happen. That is much more complex than the programs we have 
been willing to talk about until now, but that is what it is 
going to take in the same way, as we have been talking about 
earlier, there isn't a one size fits all for obesity. There 
isn't a one size fits all for physical activity. There isn't 
going to be one size fits all for HIV. And I don't think that 
we have been willing to invest in those affected communities 
enough to empower them and give them the resources.
    Mr. Engel. Let me ask you one final question on another 
topic. Health insurance pays for many clinical preventive 
services like immunizations and screening tests such as 
mammograms but important community level prevention services 
such as fluoridation of water or lead abatement in buildings 
are not reimbursed by health insurance, so it means that 
federal, state, and local agencies that provide these services 
rely on our annual appropriations process to fund these 
important activities. I would like you to explain what kind of 
challenges that poses and in your testimony you mentioned there 
was a need for reliable funding source for public health 
activities. What would that funding stream look like?
    Mr. Levi. Well, you are absolutely right. The dependence on 
the fluctuations in the annual appropriations cycle has meant, 
and Commissioner Howard could probably speak to this better, 
meant that there isn't a reliable source of revenue and 
therefore not a predictable source of funding and it is very 
hard to plan to build programs and to build capacity, and so 
what we have been seeing, we have seen it in many areas, we 
have seen it in chronic diseases. We have seen it most 
evidently, I think, on the preparedness side where there is an 
initial major investment state staff up using those dollars and 
then the dollars start withering away literally, I mean 25 
percent cut since the peak.
    And so it is hard to keep staff. It is hard to retain 
staff. And, in fact, you know, at a time when we are seeing 
whole generation of public health workers retiring and we need 
to fill back fill, we don't have the resources and the 
stability of resources to make sure that we have a new work 
force coming in and that this is a viable occupation for people 
to enter. To resolve that, we think there ought to be the 
equivalent of a trust fund. If we are going to guarantee 
funding for health care, we should also be guaranteeing funding 
for public health. So there is a reliable mechanism that states 
can depend on, the CDC can depend on, and we can make the 
investments that over time will indeed pay off.
    Mr. Pallone. We are going to have to--I think we only got a 
couple minutes.
    Mr. Engel. OK. I was going to ask the commissioner if she 
agreed.
    Ms. Howard. I do.
    Mr. Engel. Thank you.
    Mr. Pallone. Thank you, Eliot. I hate to rush, but I don't 
want you to have to wait another hour for us to come back 
because we have another series of votes. So thank you very 
much. This has been very helpful. We want to stress the public 
component of this health care reform. You may get additional 
questions in writing within the next 10 days from some of us to 
respond to, and hopefully you will respond to them. But, again, 
thank you for all your input and what you do. And without 
further adieu, the subcommittee hearing is adjourned.
    [Whereupon, at 2:35 p.m., the subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]

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