[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
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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
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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
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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:]
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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:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
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.]
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