[Senate Hearing 111-636]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 111-636

                         WHAT STATES ARE DOING 
                           TO KEEP US HEALTHY

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

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                                   ON

        EXAMINING WHAT STATES ARE DOING TO KEEP CITIZENS HEALTHY

                               __________

                            JANUARY 22, 2009

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions


  Available via the World Wide Web: http://www.gpoaccess.gov/congress/
                                 senate






                  U.S. GOVERNMENT PRINTING OFFICE
46-914 PDF                WASHINGTON : 2010
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing 
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC 
area (202) 512-1800 Fax: (202) 512-2104  Mail: Stop IDCC, Washington, DC 
20402-0001








          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

               EDWARD M. KENNEDY, Massachusetts, Chairman

CHRISTOPHER J. DODD, Connecticut     MICHAEL B. ENZI, Wyoming
TOM HARKIN, Iowa                     JUDD GREGG, New Hampshire
BARBARA A. MIKULSKI, Maryland        LAMAR ALEXANDER, Tennessee
JEFF BINGAMAN, New Mexico            RICHARD BURR, North Carolina
PATTY MURRAY, Washington             JOHNNY ISAKSON, Georgia
JACK REED, Rhode Island              JOHN McCAIN, Arizona
BERNARD SANDERS (I), Vermont         ORRIN G. HATCH, Utah
SHERROD BROWN, Ohio                  LISA MURKOWSKI, Alaska
ROBERT P. CASEY, JR., Pennsylvania   TOM COBURN, M.D., Oklahoma
KAY R. HAGAN, North Carolina         PAT ROBERTS, Kansas
JEFF MERKLEY, Oregon

           J. Michael Myers, Staff Director and Chief Counsel

     Frank Macchiarola, Republican Staff Director and Chief Counsel







                                  (ii)










                           C O N T E N T S

                               __________

                               STATEMENTS

                       THURSDAY, JANUARY 22, 2009

                                                                   Page
Harkin, Hon. Tom, a U.S. Senator from the State of Iowa, opening 
  statement......................................................     1
Burr, Hon. Richard, a U.S. Senator from the State of North 
  Carolina.......................................................     3
Fielding, Jonathan, M.D., M.P.H., Director and Health Officer, 
  County of Los Angeles Public Health, Los Angeles, CA...........     4
    Prepared statement...........................................     7
Emmet, Bill, Director, Campaign for Mental Health Reform, 
  Washington, DC.................................................    17
    Prepared statement...........................................    19
Hagan, Hon. Kay R., a U.S. Senator from the State of North 
  Carolina.......................................................    23
Dobson, Allen, Jr., M.D., FAAFP, Chairman, North Carolina Care 
  Networks, Inc., Assistant Secretary for Health Policy and 
  Medical Assistance, North Carolina Department of Health and 
  Human Services, Raleigh, NC....................................    24
    Prepared statement...........................................    26
Hatch, Hon. Jack, State Senator of Iowa, Des Moines, IA..........    28
    Prepared statement...........................................    30
Bigby, JudyAnn, M.D., Secretary, Health and Human Services, 
  Massachusetts, Boston, MA......................................    35
    Prepared statement...........................................    38
Sanders, Hon. Bernard, a U.S. Senator from the State of Vermont..    45
    Prepared statement...........................................    47
Casey, Hon. Robert P., Jr., a U.S. Senator from the State of 
  Pennsylvania...................................................    49
    Prepared statement...........................................    51
Merkley, Hon. Jeff, a U.S. Senator from the State of Oregon......    54

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Senator Kennedy..............................................    60
    Douglas McCarthy and Kimberly Mueller, Issues Research, 
      Inc.--Case Study...........................................    61

                                 (iii)

  

 
                         WHAT STATES ARE DOING 
                           TO KEEP US HEALTHY

                              ----------                              


                       THURSDAY, JANUARY 22, 2009

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:07 a.m. in 
Room SD-430, Dirksen Senate Office Building, Hon. Tom Harkin 
presiding.
    Present: Senators Harkin, Sanders, Casey, Hagan, Merkley, 
and Burr.

                  Opening Statement of Senator Harkin

    Senator Harkin. The Senate Health, Education, Labor, and 
Pensions Committee will come to order. Good morning, everyone. 
I'd like to thank everyone for coming this morning, the 
panelists and my fellow Senators and the public who are here, 
to discuss some of the creative ways that States are taking in 
promoting disease prevention and a broader culture of wellness.
    Of course, I want to state that I'm very glad that our 
committee chair, Senator Kennedy, is out of the hospital. He's 
doing very well and of course we wish him a speedy return to 
this seat.
    In December, looking ahead to the task of drafting historic 
health care reform legislation, Chairman Kennedy asked me to 
chair the Prevention, Wellness, and Public Health Working 
Group. I've said many times that this has to be the central 
part of health reform legislation, because we'll never get 
health care costs under control unless we place a major new 
emphasis on wellness and prevention and strengthening America's 
public health system.
    It's not enough to talk about how to extend insurance 
coverage and how to pay the bills. Indeed, I've laid down a 
marker for me here in the early days of our debate about 
national health care reform and it's just this: If we pass a 
bill that greatly extends health insurance coverage, but does 
nothing to create a dramatically stronger prevention and public 
health infrastructure and agenda, then we will have failed the 
American people.
    It simply makes no sense to legislate broader access to a 
health care system that costs too much, delivers too little, 
largely because it neglects prevention and public health. A 
robust emphasis on wellness is about saving lives, saving trips 
to the hospital, and saving money. I admit it's the only way 
that we're going to get a grip on skyrocketing health care 
costs.
    To that end, I look forward to hearing from our witnesses 
about the exciting, innovative things that States are doing in 
the field of public health and prevention. I have never been 
one to believe that all wisdom radiates from Washington. The 
fact is States are often more nimble and more creative when it 
comes to reform and public policy innovation. We look to the 
States as incubators and testing grounds for new ideas, and 
this is certainly true with respect to wellness, prevention, 
and public health.
    As we draft health reform legislation at the Federal level, 
it is important that we capture the excellent ideas and 
practices being pioneered by the States and to coordinate our 
initiatives. That is the purpose of this hearing.
    We have five distinguished witnesses this morning. I 
welcome my good friend Senator Jack Hatch, who played a leading 
role last year in passing Iowa's Comprehensive Health Care 
Reform Act. This legislation places a major emphasis on 
wellness. It ties preventative care to increased 
reimbursements. It creates new incentives to encourage primary 
care providers to offer preventative care and wellness 
treatments.
    I also welcome Dr. Jonathan Fielding, Director of the Los 
Angeles County Public Health, a professor at UCLA, and indeed 
one of America's foremost experts on public health. His 
testimony will focus on strategies for reducing tobacco use and 
obesity, especially among our young people. I especially 
appreciate Dr. Fielding's emphasis on the role that schools and 
communities can and must play in combating childhood obesity 
and preventing youth smoking.
    I welcome Bill Emmet, Director of the Campaign for Mental 
Health Reform. As Mr. Emmet knows very well, mental health is 
too often the neglected stepchild in our health reform agenda. 
It should be obvious that mental health is integral to physical 
health. In so many cases you can't have the latter without the 
former, and legislation drafted by this committee needs to 
reflect that reality.
    We have Dr. Alan Dobson, Assistant Secretary for Health 
Policy and Medical Assistance at the North Carolina Department 
of Health and Human Services. Again, North Carolina doing very 
exciting things. Dr. Dobson will discuss another aspect of 
health care reform that's important for controlling costs, the 
importance of getting entire communities involved in promoting 
wellness and prevention, something that's been done in North 
Carolina by emphasizing primary care and the medical home 
concept.
    Finally, we welcome Dr. JudyAnn Bigby, the Secretary of 
Health and Human Services for the Commonwealth of 
Massachusetts. Three years ago, Massachusetts enacted health 
care reform legislation designed to move the State to near 
universal health insurance coverage. But from the outset, 
leaders in Massachusetts insisted that health care reform is 
about much more than just health insurance. Their 2006 bill 
promotes wellness and prevention in many ways, and we have a 
lot to learn from the Massachusetts example.
    As I have said many times, prevention and public health 
have been the missing pieces in the national conversation about 
health care reform. It's time to make them the centerpiece of 
that conversation, not an asterisk, not a footnote, but the 
centerpiece of health care reform.
    With that in mind, I again welcome all of you to the 
committee. Your testimony will be valuable as we move forward 
with health care reform at the Federal level. I look forward to 
your ideas and your insights and all of your expertise.
    With that, I will yield to my friend and my colleague from 
North Carolina, Senator Burr.

                       Statement of Senator Burr

    Senator Burr. Thank you, Mr. Chairman. I apologize to the 
panel on behalf of the other colleagues, who are scattered 
around the Hill with activities on the Senate floor and 
confirmation hearings and meetings as we try to get an 
administration complete as quickly as we possibly can.
    Mr. Chairman, I join you in welcoming all of our guests and 
thank them for taking the time out of their busy schedule to 
travel to Washington to share with us examples of what States 
are doing to improve our Nation's public health. As you know, 
I'm a strong believer in the North Carolina community care 
model. Why? Because it's worked, because it's actually 
accomplished what it set out to do, and that's to provide a 
higher level of care to more people and, yes, for less money.
    I believe it's important to point out--and I don't think 
our panelists would disagree with me today, Mr. Chairman--that 
one of the fallacies to our inability to address prevention and 
wellness is the fact that inherently we don't pay for it, or we 
don't build it into the reimbursement schedule. If you look at 
Medicare and the number of years that some of us have fought to 
include prevention as a reimbursed item, and we've done it on 
only those things where there is 100 percent consensus, but not 
on the things that we had 99 percent agreement that might make 
a difference.
    Second, we have an antiquated scoring system in this town, 
and it can't look at a health care reform package with what it 
saves, only what it costs. If we attempt to modernize our 
health care system, hamstrung by how much we save and only 
altered by what it costs, we will either be unsuccessful at 
achieving reform or in fact we will construct something that 
doesn't accomplish our end goal, which is cover more people 
with a higher level of quality for a much less expensive cost.
    An important example of the trends that bring us here today 
to discuss prevention and wellness is the alarming increase in 
obesity in this country. According to the CDC, more than a 
third of adults, more than 72 million people, and 16 percent of 
America's children are obese--not just overweight, obese. In 
the last 20 years the obesity rates for adults have doubled and 
rates for children have tripled.
    We're headed in the wrong direction. We all know it. Not 
only is this trend costly, estimated at over $100 billion 
annually, it leads to numerous chronic diseases and lowers our 
quality of life. It is headed in an opposite direction than 
most of us know we need to go.
    I look forward to hearing from our witnesses today. I look 
forward to learning what we can from the experiences they've 
gone through, and it's my hope, Mr. Chairman, that we will all 
use what we learn today to put us down that path to a reformed 
system.
    I thank the chair.
    Senator Harkin. Thank you very much, Senator Burr.
    All statements of Senators will be made a part of the 
record, and we will now go to our witnesses. At the time of the 
questioning period we'll make sure we have enough time for 
Senators to make statements at that point in time.
    With that, again we welcome you all here. We'll just go 
from left to right, and we'll start with Dr. Fielding and then 
go to Mr. Emmet, Mr. Dobson, Senator Hatch, and Dr. Bigby. 
Again, we welcome you all. Your statements will be made a part 
of the record in their entirety. Try to sum up in 5 minutes, 
but we don't bang the gavel at 5 minutes. If you run a minute 
or so over, I don't mind. That's fine. If you could sum it up 
for us, we would certainly appreciate that.
    Dr. Fielding, Director of the Los Angeles County Department 
of Public Health, also professor at UCLA School of Medicine and 
Public Health at the University of California in Los Angeles; a 
founding member of the U.S. Preventative Health Task Force in 
the United States and also the chair of that at the present 
time; certainly one of the leading figures in prevention and 
wellness in America.
    Dr. Fielding, welcome and please proceed as you so desire.

  STATEMENT OF JONATHAN FIELDING, M.D., M.P.H., DIRECTOR AND 
   HEALTH OFFICER, COUNTY OF LOS ANGELES PUBLIC HEALTH, LOS 
                          ANGELES, CA

    Dr. Fielding. Thank you very much, Chairman Harkin, Senator 
Burr, and honorable members of the committee. I am here in my 
capacity as the Public Health Director for the Nation's largest 
local government, Los Angeles County, with a population 
exceeding 10 million.
    At a time when our Nation faces daunting economic 
challenges, a healthy population is an essential prerequisite 
for economic growth. Preventable chronic diseases sap our 
Nation's collective economic strength, reduce our international 
competitiveness, and increase medical care costs to the 
breaking point. Taking action now to reduce tobacco use and 
obesity rates can put us on the road back to economic 
prosperity and save tens of millions of Americans from 
preventable illness, disability, and premature death.
    It's estimated that perhaps one-third of all deaths in the 
United States are caused by smoking and the two primary risk 
factors for obesity, poor diet and lack of physical activity, 
and those cause a number of chronic diseases, including cancer, 
heart disease, chronic lung disease, and type 2 diabetes. 
Despite spending 16.5 percent of our GDP on health care or 
more, our results in terms of health are worse than almost 
every developing country and worse than every developed country 
and as bad as many developing countries. We have great 
opportunities.
    Of course we must make sure that our health care delivery 
system takes advantage of evidence-based recommendations. We 
also have to think about what are the changes we can make in 
communities and population--in things that can improve the 
health of populations.
    We know that core public health agencies are the only ones 
that are charged with worrying about the health of everybody, 
everybody, not just particular groups. We are leaders, we are 
science experts, we are conveners, facilitators, and advocators 
for evidence-based policy and practice. We have to work, not 
alone, but with schools, with the private sector, which has a 
very important role, faith-based organizations, and community 
advocates that share our resolve.
    Most importantly, we have to work outside what we normally 
consider as the realm of health care. We have to think about 
what goes on in other sectors. The approach of looking at other 
sectors has been articulated by the Federal Advisory Committee 
for Healthy People 2020, which I chair, and will guide the 
process of setting health objectives and priorities for the 
Nation, States, and localities.
    What's also important is that we all share in success. We 
know that we have to pay particular attention to the higher 
burden borne by minorities and those with low income and less 
formal education.
    Smoking remains the largest preventable cause of death, 
440,000 people a year dying in our country. Still, almost one 
in five American adults smoke and the average cost annually for 
health care costs and productivity is about $193 billion.
    Now, what do we need to do? One prong of what we need to do 
is prevention and that needs to be aimed at youth because 80 
percent of new smokers start before they reach their 18th 
birthday. What we know will work is raising the price of 
tobacco products through excise taxes to reduce initiation of 
new users, restricting minors' access to tobacco products, 
expanding and sustaining effective mass media campaigns 
targeting youth, particularly the National Truth Campaign, 
which has demonstrated high levels of effectiveness, 
eliminating tobacco marketing to minors, and reducing youth 
exposure to tobacco use in our popular culture, where movies 
have particular influence.
    We also know how to help current smokers quit. Again, 
raising the price makes a big difference. Mounting sustained 
mass media campaigns, like Become an EX, which is the campaign 
of the American Legacy Foundation, to encourage tobacco users 
to quit and give them information about resources to help them 
do that, to expand free tobacco cessation quit lines, to cover 
effective tobacco use treatments under all public and private 
insurance plans with no deductibles and no co-pays, and to 
ensure that all health IT systems include screening and 
treatment prompts, so that all tobacco users get counseling 
every time they touch the medical care system.
    To aid by prevention and cessation, we also need to 
increase regulation of tobacco products and their marketing. 
Finally, we have to protect every nonsmoker from the deadly 
effects of secondhand smoke by making sure all indoor 
environments are smoke-free across the Nation.
    Let me now turn to obesity. Senator Burr has done a 
wonderful job synthesizing the information on the terrible 
burden of obesity. It's tripled, the rate has tripled in our 
kids over the last 20 to 30 years. The majority of Americans 
are overweight, are obese, and the toll is huge, both 
economically and in terms of health, with heart disease, 
hypertension, diabetes, fatty liver, stroke, and other, and a 
number of forms of cancer.
    What is most disturbing is these costs will rise at an 
escalating rate over the next generation as the swelling ranks 
of obese children reach adulthood and begin developing obesity-
related diseases at progressively younger ages.
    Many social, economic, and environmental factors contribute 
to the obesity epidemic and therefore we need multiple 
approaches to deal with it. Health care reform can play an 
important part. Providers and health plans need to have 
evidence-based prevention techniques. They need to do body mass 
index monitoring as a vital sign just like blood pressure, 
nutrition counseling, breastfeeding promotion, advising parents 
to reduce the time they spend in front of screens, and physical 
activity promotion.
    However, we will not be successful with these efforts alone 
unless we change the environmental factors, so that the health 
choice becomes the easy choice. One policy imperative is the 
establishment of more rigorous nutrition standards for school 
meals and other foods sold on school campuses, including 
improvements in the Federal school meal program's nutrition 
requirements. Minimum nutrition requirements should also be in 
work and recreational settings.
    Removing barriers to participation in the underutilized 
Supplemental Nutrition Assistance Program can provide greater 
access to healthy foods for eligible families, as can 
increasing participation in the recently improved WIC program, 
which now offers more healthful food, including fruits and 
vegetables.
    Providing nutrition information at points of purchase 
through menu labeling or other efforts to better inform 
consumers is an important strategy. A recent health impact 
assessment conducted by my Department found that if menu 
labeling got patrons to as few as 10 percent of their meals 
that have 100 calories less than they normally would, we could 
reduce the percentage of increase in number of pounds per 
individual, by about 40 percent. We have 6.75 million pounds a 
year increasing in Los Angeles County. We could decrease that 
by 40 percent.
    Restricting food marketing to young children, establishing 
farm subsidies that support affordable healthy choices, 
creating other incentives for the food industry to lower the 
caloric content of products and have smaller serving sizes, and 
supporting programs and policies that eliminate food deserts 
need to be part of a comprehensive solution.
    Marketing of products high in calories, sugar, sodium, and 
fat to our youth remains the major challenge. The Federal Trade 
Commission has reported that the largest food and beverage 
companies in the country spent about $1.6 billion in the year 
2006 on marketing their products to children, including 
preschool children, school-aged children, and adolescents, and 
over 90 percent of those were for food and beverages high in 
sugar, fat, or sodium.
    Developing community, school, and workplace environments 
conducive to physical activity represents another vital 
approach to obesity prevention and control. Interventions shown 
to be effective in promoting physical activity include: 
community-wide campaigns, point of decision prompts to 
encourage stair usage, school-based physical education, and 
social support strategies such as in exercise buddy systems. 
These programs should be supported at the Federal level, both 
with targeted funding and economic incentives.
    Addressing land use and transportation practices and 
policies also offers significant opportunities for reversing 
the epidemic. For example, the upcoming authorization of the 
Federal transportation bill provides an excellent opportunity 
for prioritizing and funding projects and infrastructure that 
promote walking, bicycling, and other forms of physical 
activity.
    In addition, the Federal Government should support State 
and local efforts to institute land use and transportation 
policies that promote physical activity, including mixed use 
development, compact development, and expanded public 
transportation.
    For the vast majority of our preventable serious illness 
and injury, our success depends on knowing what works and then 
disseminating that and implementing it. Unfortunately, the two 
major bodies that are charged with this, the Preventive 
Services Task Force and the Community Preventive Services Task 
Force, are severely underfunded. In the case of the Community 
Preventive Services Task Force, we only are able to cover the 
minority of possibly effective community policies and programs 
and there is no funding for dissemination or evaluation of 
implementation. These need substantial increases and they are 
very small dollar amounts.
    Finally, we must recognize that there are common underlying 
causes for most of our chronic diseases and those reside in our 
socioeconomic environment and our physical environment. 
Poverty, poor educational attainment, and social isolation are 
important risk factors for virtually every chronic disease. To 
improve our Nation's health and competitiveness, it is vital 
that all congressional committees consider how their decisions 
affect health. Policies in agriculture, transportation, 
housing, environment, commerce and education all affect health 
and the health disparities between population groups.
    We possess the tools, including health impact assessment, 
to determine the likely health effects of these policies being 
considered in each of these sectors, and by routinely using 
these tools and considering the health implication of all 
Federal policies we can jump-start a national effort not only 
to make us a healthier Nation, but to make us the healthiest 
Nation.
    Thank you very much.
    [The prepared statement of Dr. Fielding follows:]
         Prepared Statement of Jonathan Fielding, M.D., M.P.H.
    Dear Chairman Kennedy, Senator Enzi, Senator Harkin, and Honorable 
Members of the Senate Health, Education, Labor and Pensions Committee, 
thank you for this opportunity to appear before you today.
    At a time when our Nation faces unprecedented economic challenges, 
a healthy population is an essential prerequisite for economic growth. 
Preventable chronic diseases sap our Nation's collective economic 
strength, reduce our international competitiveness, and increase 
medical care costs. Taking action now to reduce tobacco use and the 
obesity rate can help put our Nation back on the road to economic 
prosperity and save tens of millions of Americans from preventable 
illness, disability and premature death. Researchers estimate that a 
third of all deaths in the United States in 2000 were caused by tobacco 
use and the two most immediate risk factors for obesity (poor diet and 
a lack of physical activity), primarily by causing a wide range of 
chronic diseases (e.g., cancer, heart disease, chronic lung disease, 
diabetes).\5\ These diseases are the leading killers of Americans, are 
very costly to treat, and result in disability and death for many 
during what should be their most productive years. Researchers have 
also found that obesity and tobacco use are linked to decreased worker 
productivity.
    Our country currently spends more than any other nation on health 
care, 16.5 percent of our GDP in 2007, yet we still experience poorer 
health than most other developed nations and some developing countries. 
It is evident that the status quo approach is not working. Fortunately, 
many of the premature deaths and costs associated with obesity and 
tobacco use are preventable. However, in order to take full advantage 
of the opportunities for prevention, we must look beyond the borders of 
our health care system. To effectively reduce the rates of obesity and 
tobacco use, we also need to enhance the public health infrastructure 
of State and local public health departments with stronger, sustained 
support. Furthermore, we need policy changes in the other sectors that 
have large impacts on our Nation's health and on the serious health 
disparities among population groups. And we must work better with other 
partner agencies, in both the public and private sectors, that share 
our concerns about how to reduce the toll of these twin scourges.
                    reducing the toll of tobacco use
    Despite much success in reducing tobacco use over the past several 
decades, nearly one in five adults (43 million adults) continues to 
smoke.\1\ Among high school students, 20 percent report smoking, a rate 
that has remained unchanged since 2003.\2\ In addition, marked 
disparities in smoking rates exist, with the highest rates observed in 
lower income populations, African-Americans, American Indians, and 
those with mental health and substance abuse disorders.\3\
    Smoking is the leading cause of preventable death in the United 
States, with an estimated 440,000 people dying prematurely from smoking 
or exposure to secondhand smoke each year.\4\ Tobacco use causes eight 
different forms of cancer, chronic lung disease, cardiovascular 
disease, osteoporosis and a host of other serious diseases. Second-hand 
smoke causes cardiovascular disease and lung cancer in adults, lower 
birth weight and SIDS in infants, and chronic ear infections and 
respiratory problems in children. In total, more deaths are caused by 
tobacco use than by HIV, alcohol use, motor vehicle injuries, illegal 
drug use, suicides, and homicide combined.\5\ Additionally, an 
estimated 8.6 million people in the United States are living with one 
or more serious illnesses attributable to smoking, primarily heart 
disease and chronic obstructive lung disease.\6\ Perhaps most 
disturbing is the toll that smoking takes on our Nation's children. 
Approximately 80 percent of smokers begin before the age of 18.\7\ 
Research indicates that people who start smoking in their teens and 
continue throughout their lifetime will die 12-21 years earlier than 
people who never smoked. One in three youth smokers will eventually die 
of a smoking related disease.\8\
    In addition to the human toll, tobacco use also places an enormous 
economic burden on our society. During 2001-2004, average annual health 
care costs for smoking-related illness were an estimated $96 billion, 
with an additional $97 billion in productivity losses--making the total 
annual economic toll a staggering $193 billion.\4\
    Reducing tobacco use and exposure to secondhand smoke requires a 
four-pronged approach. First, we must prevent the initiation of new 
users by raising the price of tobacco products, effectively restricting 
minors' access to tobacco products, expanding and sustaining effective 
mass media campaigns, eliminating tobacco marketing to minors, and 
reducing the depiction of tobacco use in our popular culture, such as 
in movies. Second, we need to expand proven interventions that help 
tobacco users quit: increasing the price of tobacco products, sustained 
mass media campaigns to encourage tobacco users to quit and providing 
information about resources available to help them to do so, expanding 
tobacco cessation quitlines that can provide free help to tobacco users 
interested in quitting, covering effective tobacco-use treatments under 
all public and private insurance with no deductibles or co-pays, and 
ensuring that all health IT systems include screening and treatment 
prompts to ensure that all tobacco users receive treatment every time 
they are seen in the health care system. Third, we need to increase 
regulation of tobacco products and their marketing. Finally, we must 
protect all non-smokers from the deadly effects of secondhand smoke by 
ensuring that all indoor environments are smoke-free in every community 
in the country. The good news is that there is a strong evidence base 
demonstrating the effectiveness of these interventions.
Community Prevention Measures
    Based on the research evidence, the Task Force on Community 
Preventive Services has concluded that increasing the price of tobacco 
is effective in preventing the initiation of smoking and increasing the 
percentage of teen and adult smokers who successfully quit or reduce 
the amount they smoke.\9\ Price elasticity studies indicate that every 
10 percent increase in the price of a pack of cigarettes results in a 4 
percent decline in consumption (studies also show about 50 percent of 
this consumption decline is due to fewer smokers and 50 percent to 
fewer cigarettes consumed by continuing smokers).\10\ A cigarette tax 
resulting in a 50 percent increase in the price of cigarettes would 
decrease smoking prevalence by 10 percent, a net reduction of 4.3 
million adult smokers in the United States. Congress is currently 
considering raising Federal tobacco taxes, which include increasing the 
tax on cigarettes from 39 cents to $1 per pack to help pay for the 
State Children's Health Insurance Program (SCHIP).\11\ This important 
piece of legislation is a good start towards achieving the Centers for 
Disease Control and Prevention Healthy People's 2010 target of a $2 per 
pack tax increase. Increasing the Federal excise tax on cigarettes to 
the Healthy People 2010 goal offers an important opportunity to 
simultaneously reduce smoking rates and raise revenue that can be used 
to fund comprehensive tobacco prevention and control campaigns.
    Another effective community prevention strategy is the use of mass 
media in multi-faceted anti-smoking campaigns, similar to those in 
California, Massachusetts, and Florida, and the national American 
Legacy Foundation campaign. Media campaigns can be effective in both 
reducing youth smoking initiation and in increasing cessation rates. 
For example, the American Legacy's truth' campaign, the only 
national youth peer-to-peer smoking prevention intervention, was 
responsible for 22 percent of the overall decline in youth smoking in 
its first 2 years, resulting in 300,000 fewer youth smokers.\12\ 
Increasing support to expand these types of campaigns and assuring that 
the campaigns have national reach will help to counter the effects of 
the tobacco industry's substantial marketing efforts.
    Exposure to smoking in popular culture is another powerful pro-
tobacco influence on children that must be addressed. For example, 
studies indicate that Hollywood movies deliver billions of tobacco 
images to young audiences every year, and are responsible for 
recruiting one-third to one-half of young smokers in the United 
States.\13\ Additionally, the CDC has repeatedly linked smoking in 
films to the recent stall in the decline of youth smoking, and the 
National Cancer Institute has concluded that exposure to onscreen 
smoking causes adolescents to start smoking.\2\ \14\ Given these 
findings, it is crucial for the public health community to work with 
the entertainment industry to develop meaningful strategies to reduce 
the depiction of smoking in movies, and for the entertainment industry 
to implement a ratings policy for smoking that will reduce youth 
exposures and allow parents to make informed movie choices for their 
children.
    Other efforts to reduce youth initiation include reducing minors' 
access to tobacco products. These efforts require strong community 
support at the local level. Smoke-free policies have also been shown to 
reduce youth initiation and offer protection from the harms of 
secondhand smoke.
    Recommendations:

     Increase the Federal excise tax on cigarettes.
     Increase support to expand multi-faceted anti-smoking mass 
media campaigns.
     Work with the film industry to reduce the depiction of 
smoking in movies and implement a movie ratings policy for smoking that 
will reduce youth exposures.
     Reduce minors' access to tobacco products.
Smoking Cessation Interventions
    A nationwide survey in 2000 found that 70 percent of smokers said 
they wanted to quit \15\ and a 2007 survey showed that nearly 40 
percent of current every day smokers had made a quit attempt in the 
past year.\1\ However, these rates are lower than in years past, and 
survey data show a long-term decline in the percentage of smokers who 
make quit attempts.\1\ In addition, the majority of smokers who attempt 
to quit do not use recommended cessation methods and most of these 
untreated smokers relapse within days of making a quit attempt.\15\ 
Moreover, only about 35 percent of smokers enrolled in commercial and 
Medicaid health plans received cessation services recommended by the 
U.S. Preventive Services Task Force.\16\
    It is clear that as part of health and health care reform we need 
to increase the number of smokers who try to quit as well as the 
percentage of smokers who are successful in their quit attempts. To 
achieve this we must implement community interventions that increase 
cessation attempts and cessation success, as well as expand access to 
cessation services that have proven to be effective--doubling, and in 
some cases, tripling the likelihood of successful quitting.\17\ One 
method for getting more smokers to make quit attempts, to contact quit 
lines, and avail themselves of smoking cessation aids, is to increase 
smokers' motivation to quit and knowledge of cessation resources via 
the mass media. The American Legacy Foundation partnership with States 
on the ``Become an EX'' campaign is an excellent example of how this 
type of community intervention can work.
    The Task Force on Community Preventive Services' recommendations 
include reducing out-of-pocket costs for treatment services and 
utilizing telephone cessation quitlines to increase both the number of 
tobacco users who use treatment and the number who successfully 
quit.\9\ Therefore, providing barrier-free coverage for counseling and 
FDA-approved medications should be part of the basic benefits package 
offered under all public and private insurance. In addition, telephone 
cessation quitlines or helplines are effective ways of providing 
intensive counseling services in ways that are easy for tobacco-users 
to access. Every State now has a cessation quitline, available through 
a single portal number that works nationwide: 1-800-QUIT NOW. However, 
these quitlines are under-funded, so the extent of services available 
varies by State and is largely insufficient to meet the demand for such 
treatments.
    Clinical recommendations for enhancing smoking cessation services 
include systems-level changes to encourage clinician screening and 
brief intervention every time a tobacco user is seen within the 
healthcare system, and increasing referrals to telephone quitlines.\17\ 
By employing evidence-based smoking cessation interventions, we will 
enable a greater number of Americans to live healthier, longer lives. 
For example, a study by the National Commission on Prevention 
Priorities found that increasing the delivery of tobacco-use screening 
and brief intervention is the single most cost-effective health 
insurance benefit for adults. In fact, it is more cost-effective than 
other commonly provided clinical preventive services, including 
mammography, colon cancer screening, PAP tests, treatment of mild to 
moderate hypertension, and treatment of high cholesterol.\16\
    Recommendations:

     Expand access to cessation services that have proven to be 
effective.
     Implement systems-level changes to encourage clinicians to 
screen their clients for tobacco use and offer brief interventions.
     Provide barrier-free coverage for counseling and 
pharmacotherapy as part of a basic health care benefits package.
     Provide funding for mass media efforts to get smokers to 
quit, and to seek help through telephone quitlines and the medical care 
system.
Regulation Efforts
    The tobacco industry's marketing expenditures have risen at 
unprecedented rates in the 10 years since the 1998 Master Settlement 
Agreement. According to the Federal Trade Commission's most recent 
report, tobacco marketing expenditures nearly doubled from 1998-2005, 
from $6.9 billion to $13.4 billion.\18\ Furthermore, the tobacco 
industry is using new marketing avenues, such as the internet, to pitch 
their products.
    To counteract these efforts, we have to consider stronger 
regulation of tobacco products, including their sales and marketing. 
Considering the toll of tobacco use on the Nation's health, legislators 
should consider measures that can halt tobacco marketing and sales to 
our youth, require tobacco companies to disclose the contents of 
tobacco products and remove harmful ingredients, and require more 
effective health warnings on tobacco products.
    Recommendations:

     Consider stronger regulation of tobacco products, 
including their sales and marketing.
     Halt tobacco marketing and sales to youth.
     Require tobacco companies to disclose the contents of 
tobacco products and remove harmful ingredients.
     Require more effective health warnings on tobacco 
products.
Reducing Secondhand Smoke Exposure
    At present, only 18 States have passed stringent indoor smoke-free 
ordinances that protect non-smokers from the deadly effects of 
secondhand smoke.\19\ Even fewer States have ordinances that restrict 
outdoor secondhand smoke exposure. This leaves most of the Nation 
without adequate protection against secondhand smoke. Federal 
legislation to make indoor and outdoor environments smoke-free, 
including restaurants, bars, workplaces, parks and public building 
entrances should be considered as a means to accelerate national 
progress in reducing non-smokers' exposure to secondhand smoke.
    Recommendation:

     Consider Federal legislation to make indoor environments 
smoke-free, including restaurants, bars, workplaces, and public 
buildings.
Roles of State and Local Health Departments
    State and local public health agencies have been on the forefront 
of the fight against tobacco for decades. They have been facilitators 
and conveners, advocates and educators. They have taken the lead in 
implementing many of the evidence-based community recommendations that 
have greatly contributed to our progress to date in reducing tobacco 
use. However, many of these agencies have no sustained funding, and 
almost none have sufficient funding to implement the recommendations of 
the Centers for Disease Control and Prevention. If we are going to have 
a consistent nationwide effort that further reduces the overall toll 
tobacco places on our society, as well as the disproportionate burden 
it places on minorities and low-income populations, then it is 
essential that we increase sustained core funding for public health 
agencies at the State and local levels.
    Recommendation:

     Enact legislation that identifies a specific source and a 
specific annual amount for the sustained funding of core public health 
activities at the State and local levels.
                      reducing the toll of obesity
    The obesity epidemic constitutes one of the most significant public 
health threats facing the Nation, with health and social consequences 
that reverberate across all sectors of our society and economy: to 
individuals, families, communities, employers, schools, and government 
at all levels.\20\ The obesity epidemic has resulted from the 
convergence of many changes in individual lifestyle behaviors, societal 
norms, community design, and economic trends.\21\ Eating outside of the 
home more often and the growth of super-sized meal portions; \22\ \23\ 
less time spent cooking at home; \24\ more time spent in front of 
televisions, computers, and playing video games; \21\ pressure to spend 
more time on academics rather than physical education in schools; \25\ 
\26\ easy access to unhealthy foods in elementary as well as secondary 
schools; \21\ urban design and transportation infrastructures that are 
automobile-centric; \27\ and work environments that are highly 
conducive to sedentary lifestyles \21\ are all factors that have 
contributed to the rapid escalation of this epidemic during the past 
three decades. Given the many social, environmental, and economic 
factors contributing to the obesity epidemic, multiple approaches will 
be required to stabilize and then reverse the obesity epidemic.
    Since the late 1970s, the prevalence of obesity among children--the 
segment of our population that is most vulnerable to this epidemic--has 
more than doubled among preschool (5.0 percent to 12.4 percent) and 
school aged (6.5 percent to 17.0 percent) children and tripled among 
adolescents (5.0 percent to 17.6 percent).\28\ In addition, the child 
obesity epidemic is much more severe in low income and minority 
populations. In Los Angeles County, for example, the prevalence of 
childhood obesity in 2006 ranged from a low of 4 percent in the 
affluent community of Manhattan Beach to a high of 37 percent in the 
city of Maywood, one of the lowest income communities in the 
county.\34\ Nationally, approximately 9,000,000 children over 6 years 
of age are considered obese.\29\ If this trend is not reversed, an 
estimated one in three babies born today will develop diabetes in their 
lifetimes, and the life expectancy of our children may, for the first 
time in modern history, actually be shorter than the life expectancy of 
their parents.\30\ \31\ \32\
    The obesity epidemic has not spared the adult population either. 
Among adults 20-74 years, the rate of obesity (defined as a body mass 
index of greater than 30) has more than doubled in the past three 
decades from 15.0 percent (1976-1980 NHANES) to 35.1 percent (2005-2006 
NHANES).\33\ In addition, another one-third of adults are overweight 
(defined as a body mass index of 25.0-29.9) and at risk of developing 
obesity and related medical complications. Significant disparities also 
exist in obesity rates among adults by age, gender, race-ethnicity, 
geography, and socio-economic status, with the highest rates seen among 
non-Hispanic black and Mexican-Americans. Non-Hispanic blacks and 
Mexican-American women aged 40-59 years, for example, continue to 
experience a higher rate of obesity than their non-Hispanic white 
counterparts (53 percent and 51 percent, respectively versus 39 
percent).\33\
    Research studies have established that obesity is a major risk 
factor for numerous chronic diseases, including coronary heart disease, 
type 2 diabetes, hypertension, certain types of cancers, fatty liver 
disease, and arthritis.\35\ Among obese middle-aged men, for example, 
moderate to severe obesity is associated with a 2- to 3-fold increase 
of developing coronary heart disease and having a heart attack.\36\ 
Among children, obesity at an early age predicts a greater risk for 
earlier onset of type 2 diabetes and heart disease in adulthood.\30\ 
\31\ \32\
    Between 1987 and 2001, the rising obesity rate and related medical 
conditions accounted for more than one-quarter of the growth in health 
care spending in the United States.\37\ Additionally, non-health care 
costs such as lost productivity attributable to obesity have been 
estimated to be even greater than health care spending, placing many of 
our businesses at a disadvantage in an increasingly competitive global 
marketplace.\27\ In 1995, lost productivity from obesity-related 
morbidity and mortality was approximately $47.6 billion nationwide.\38\ 
States are also hit hard by the productivity losses associated with 
obesity. In California, for example, lost productivity from obesity-
related morbidity and mortality was reported to be approximately $3.4 
billion in 2000.\39\ Together, these health care and non-health care 
costs are likely to grow at an escalating rate over the next 
generation, as the swelling ranks of obese children reach adulthood and 
begin developing obesity-related diseases at progressively younger 
ages.
    As a nation, we are faced with the daunting task of stabilizing and 
reversing this costly epidemic. Because there are many contributors to 
obesity, leaders at all levels of government and in the community must 
work together and take a multi-pronged approach to combating the 
obesity epidemic, implementing effective and sustainable interventions 
where Americans learn, work, and play. Many national leaders, including 
U.S. Senator Tom Harkin and Dr. Joseph Thompson,\20\ Surgeon General 
for the State of Arkansas, have echoed similar calls for action.
Roles of State and Local Health Departments
    We currently have the capability to successfully implement 
prevention measures which will yield results in both the short-term and 
long-term. Progress requires leveraging resources across multiple 
sectors of our society. We need to thoughtfully coordinate various 
community efforts designed to prevent obesity, create stronger linkages 
between our healthcare system and public health infrastructure, 
establish robust public-private partnerships with our business 
community, and demonstrate strong leadership from our Federal, State, 
and local government agencies. Local health departments, in particular, 
working with their State counterparts, can play a crucial role in 
spearheading efforts to address obesity and other chronic disease 
threats given their close working relationships with communities, 
schools, health care providers, and employers. Similar to their roles 
in tobacco control, local health departments are often the 
facilitators, advocates, and implementers of evidence-based prevention 
policies to combat the obesity epidemic, such as improved nutrition 
standards, school and worksite wellness policies, and land use policies 
that promote physical activity. However, as with tobacco control, their 
ability to do this vital work is compromised in the absence of a 
sustained source of funding that is not subject to the yearly 
appropriation process.
    Recommendation:

     Enact legislation that identifies a specific source and a 
specific annual amount for the sustained funding of core public health 
activities at the State and local levels.
Prevention Opportunities in the Healthcare System
    Health care reform can, and must, play an important role in obesity 
prevention. Today's health care environment presents many missed 
opportunities for reducing adverse lifestyle behaviors at the 
individual level. Incentives must be created for health care providers 
and health plans to incorporate evidence-based prevention techniques, 
including body mass index monitoring as a vital sign, nutrition 
counseling, breastfeeding promotion, providing advice to parents 
regarding reducing their child's screen watching, and physical activity 
promotion (including wider use of pedometers). When providers 
incorporate these techniques in their clinical practice or as part of 
an overall health benefits package, the patient experience is enhanced 
with a more equitable focus on both prevention and treatment.\21\ \26\
    Recommendations:

     Create incentives for health care providers and health 
plans to incorporate evidence-based prevention techniques in their 
clinical practice.
     Increase the utilization of proven clinical prevention 
techniques such as: body mass index monitoring as a vital sign, 
nutrition counseling, breastfeeding promotion, providing advice to 
parents regarding reducing their child's screen watching, and physical 
activity promotion (including wider use of pedometers).
Community Prevention Measures: Changing Our Environment
    Health care reform and efforts to appeal to individual 
responsibility have limited impact without broader community 
interventions and policy changes that create environments where the 
healthy choice becomes the easy choice. These types of efforts require 
investment and buy-in from different sectors of our society: schools, 
employers, cities, residential communities, local governments, 
community-based and faith-based organizations, etc.
    There are numerous opportunities to improve our food environments 
by increasing access to more nutritious foods and by providing 
consumers with nutritional information to help them make informed 
decisions regarding how they feed their families. One type of promising 
policy intervention designed to address child obesity is the 
establishment of more rigorous nutrition standards for school meal 
programs and other foods sold on school campuses.\21\ For example, 
California's passage and implementation of Senate Bills 677, 12 and 
965,\40\ \41\ \42\ which set and strengthen minimum school nutrition 
standards, is a step in the right direction. Minimum nutrition 
standards can also be instituted in other settings, including work and 
recreational settings.
    Federal programs can also play an important role in addressing 
child obesity by increasing opportunities for nutrition improvement, 
especially among low-income families--the segment of our population hit 
the hardest by the obesity epidemic. Updating and improving the 
nutrition standards and meal requirements for the National School Lunch 
Program and the School Breakfast Programs, for example, can make a 
great impact in promoting health and combating obesity. Together, these 
two programs provide a significant proportion of a participating 
student's daily nutrient and caloric intake on school days. The 
programs also serve as a safety net for children in need by providing 
meals at no or reduced cost.\43\ Likewise, removing barriers to 
participation for families eligible for the underutilized Supplemental 
Nutrition Assistance Program (SNAP) can provide greater access to 
healthful foods for these families. Another resource that low-income 
families can access to improve their nutrition is the recently improved 
Women, Infants, and Children (WIC) program food package, which now 
includes more healthful foods such as fruits and vegetables. WIC also 
promotes and supports breastfeeding, another important strategy for 
preventing child obesity.\20\
    Providing nutrition information at points of purchase (e.g., menu 
labeling) and other efforts to better inform consumers may also prove 
to be effective in combating the obesity epidemic. According to a 
recent health impact assessment (HIA) conducted by our public health 
department in Los Angeles County,\44\ if 10 percent of large chain 
restaurant patrons were to order an average of 100 calories less per 
meal as a result of menu labeling, then 38.9 percent of the 6.75 
million pound average annual weight gain in the county population aged 
5 years and older would be averted. Our county was also instrumental in 
gaining passage of a California law (SB 1420) that will require menu 
labeling (including calories on the order board) at all large chain 
fast food and full service restaurants.
    Restricting food marketing to young children, establishing farm 
subsidies that support affordable healthy food choices, creating other 
incentives for the food industry to produce lower calorie products and 
smaller serving sizes, and supporting programs and policies that 
eliminate ``food deserts'' are other food policy and environmental 
approaches that are required to stabilize and reverse the obesity 
epidemic.\20\ \21\ Oversight of food marketing of products high in 
calories, sugar, sodium and fat to our youth, for example, remains an 
important challenge. Youth (ages 8 to 18) spend an average of 6 hours 
per day using media, often using more than one medium at a time. In 
2006, an analysis by the Federal Trade Commission (FTC) indicates that 
the Nation's largest food and beverage companies spent $1.6 billion to 
market their products to children, including pre-school aged children, 
and adolescents. Of the advertisements viewed, nearly 98 percent of 
them by our children and 89 percent by our adolescents were for 
products that were high in fat, sugar or sodium.\45\
    The importance of engineering opportunities for physical activity 
in our communities, schools, and work places cannot be overstated. 
Developing environments which are conducive to physical activity 
represents a key, viable approach to obesity prevention.\26\ Various 
evidence-based physical activity interventions (e.g., communitywide 
campaigns promoting physical activity, point-of-decision prompts to 
encourage stair usage, school-based physical education, social support 
strategies such as setting up an exercise buddy system, and 
individually adapted health behavior change strategies) are available, 
and are potentially cost-effective for promoting physical activity in 
different settings, including at schools and in the workplace.\26\ \46\ 
Federal incentives to help States and local school districts improve 
physical education programs may promote wider adoptions of these 
effective, and potentially sustainable, physical activity 
interventions.
    Finally, addressing land use and transportation practices and 
policies offers important opportunities for reversing the obesity 
epidemic in America. For example, the upcoming reauthorization of the 
Federal transportation bill provides an excellent opportunity for 
prioritizing and funding projects and infrastructure that promote 
walking, bicycling, and other forms of physical activity. In addition, 
street- and community-scale urban design and land use policies, 
including zoning regulations, mixed-use and compact development, 
building codes, street lighting, roadway design standards, traffic 
calming approaches, and improvements to the continuity and connectivity 
of sidewalks and streets, are all promising built environment 
strategies for increasing physical activity.\25\ \27\ Increasing the 
utilization of emerging research tools such as health impact assessment 
can help us quantify the potential health benefits of these measures.
    Recommendations:

     Establish more rigorous nutrition standards for school 
meal programs and other foods sold on school campuses.
     Remove barriers to participation of families eligible for 
the Supplemental Nutrition Assistance Program (SNAP) and Women, 
Infants, and Children (WIC) program.
     Provide nutrition information at points of purchase (e.g., 
menu labeling).
     Examine food policy and environmental approaches that may 
prove effective for combating the obesity epidemic such as: restricting 
food marketing to young children, establishing farm subsidies that 
support affordable healthy food choices, creating other incentives for 
the food industry to produce lower calorie products and smaller serving 
sizes, and supporting programs and policies that eliminate ``food 
deserts.''
     Expand the implementation of evidence-based programs that 
increase physical activity such as: communitywide campaigns promoting 
physical activity, point-of-
decision prompts to encourage stair usage, school-based physical 
education, social support strategies such as setting up an exercise 
buddy system, and individually adapted health behavior change 
strategies. Provide Federal funding for a major national education 
campaign that uses a multi-media approach to encourage physical 
activity throughout the life course.
     Expand adoption of urban planning, land use, and 
transportation practices and policies that promote walking, bicycling, 
and other forms of physical activity.
     Increase the utilization of research tools such as health 
impact assessment (HIA) to quantify the potential health effects of 
policies and practices in sectors where health is not the primary 
interest but decisions have significant health effects.
Knowing and Using the Best Evidence to Improve Health and Prevent 
        Disease
    For the vast majority of our serious illnesses and injuries that 
are preventable, our success depends on knowing what works, both for 
individual patients and communities, and implementing these policies 
and practices. Unfortunately, the two national efforts to 
systematically review the research, make recommendations based on these 
findings, and assure that these best practices are disseminated to key 
user groups and then implemented, are severely underfunded. The U.S. 
(Clinical) Preventive Services Task Force has been more comprehensive 
because it has a clearly delineated domain (clinical medicine) and has 
had a sustained, although inadequate, funding base. In contrast, the 
Task Force on Community Preventive Services, supported by CDC staff, 
has had erratic and consistently insufficient funding. It has only been 
able to cover a minority of the possibly effective community policies 
and programs, and it has had virtually no funding to disseminate its 
findings. A much-needed increase in funding for both of these expert 
panels should be coupled with increased support to fill the priority 
research gaps they have identified.
    Recommendation:

     Increase and stabilize the funding for the U.S. (Clinical) 
Preventive Services Task Force and the Task Force on Community 
Preventive Services.

    In conclusion, we have many opportunities to reduce chronic 
diseases, which together constitute over 80 percent of the burden of 
disease in the United States. Health care reform can play a vital role 
in these efforts. Changes in financing, health benefit structure, 
provider incentives, and practices can be very helpful in reducing the 
toll of these diseases. However, if we are to reach our health 
potential as a nation, we must devote equal energy to prevention at the 
community level. There are policy and programmatic changes at the 
community level that have been clearly shown to be effective in 
reducing tobacco use and the rate of obesity. Too often they are 
ignored.
    Finally, we must recognize that there are common underlying causes 
for most of our chronic diseases, and these causes reside in our social 
environment and our physical environment. Poverty, poor educational 
attainment, and social isolation are important risk factors for 
virtually all chronic diseases. To improve our Nation's health and 
competitiveness, it is vital that all congressional committees consider 
how their decisions affect health. Policies in agriculture, 
transportation, housing, environment, commerce, and education all 
affect health and disparities in health among groups. We possess the 
tools, including health impact assessment, to determine likely health 
effects of policies being considered in each of these, and other, 
sectors. By routinely using these tools and considering the health 
implications of all Federal policies, we can jump-start a national 
effort to be not just a healthy nation, but the healthiest Nation.
    Thank you again for this opportunity to address this important 
committee and discuss how we can bring a full dose of prevention to the 
diseases caused by these problems.
                               References
    1. Centers for Disease Control and Prevention. Cigarette smoking 
among adults--United States, 2007, MMWR 2008: 57(45).
    2. Centers for Disease Control and Prevention. Cigarette use among 
high school students--United States, 1991-2007. MMWR 57(25).
    3. Centers for Disease Control and Prevention. Cigarette smoking 
among adults--United States, 2006, MMWR 2007: 56(44).
    4. Centers for Disease Control and Prevention. Smoking-attributable 
mortality, years of potential life lost, and productivity losses--
United States 2000-2004. MMWR 2008: 57(45).
    5. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of 
death in the United States, 2000. JAMA 2004:10;291:1238-45.
    6. Centers for Disease Control and Prevention. Cigarette smoking-
attributable morbidity--United States, 2000. MMWR 2003; 52:842-844.
    7. Mowery PD, Brick PD, Farrelly MC. Legacy First Look Report 3. 
Pathways to Established Smoking: Results from the 1999 National Youth 
Tobacco Survey. Washington DC: American Legacy Foundation. October 
2000.
    8. Centers for Disease Control and Prevention. Projected smoking-
related deaths among youth--United States. MMWR 1996: 45(44).
    9. Tobacco. Guide to Community Preventive Services Website. Centers 
for Disease Control and Prevention. (Available at 
www.thecommunityguide.org/tobacco/).
    10. Hopkins DP, Briss PA, Ricard CJ, Husten CG, et al. Reviews of 
evidence regarding interventions to reduce tobacco use and exposure to 
environmental tobacco smoke. The Task Force on Community Preventive 
Services. Am J Prev Med 2001;20(2S):16-66.
    11. Linbblom E. State Cigarette Excise Tax Rates and Rankings, 
Campaign for Tobacco Free Kids, October 2008 (Available at http://
tobaccofreekids.org/reports/prices).
    12. Farrelly MC, Davis KC, Haviland ML, Messeri P, Healton CG. 
Evidence of a dose-response relationship between ``truth'' antismoking 
ads and youth smoking prevalence. Am J Public Health 2005:95;425-31.
    13. Dalton M, Sargent J, Beach M, Titus-Ernstoff L, Gibson J, 
Ahrens M, Tickle J, Heatherton T. Effect of viewing smoking in movies 
on adolescent smoking initiation: a cohort study. Lancet 2003:362;281-
85.
    14. National Cancer Institute. The Role of Media in Promoting and 
Reducing Tobacco Use. Smoking and Tobacco Control Monograph No. 19 
Bethesda, MD: U.S. Department of Health and Human Services, National 
Institutes of Health, National Cancer Institute, NIH Pub. No. 07-6242, 
June 2008.
    15. Centers for Disease Control and Prevention. Cigarette smoking 
among adults--United States 2000. MMWR 2002: 51(29).
    16. Maciosek MV, Coffield AB, Edwards NM, et al. Priorities among 
effective clinical preventive services: results of a systematic review 
and analysis. Am J Prev Med 2006:31;52-61.
    17. Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and 
Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD: 
U.S. Department of Health and Human Services. Public Health Service. 
May 2008.
    18. Federal Trade Commission Cigarette Report for 2004 and 2005. 
Available online at http://www.ftc.gov/reports/tobacco/
2007cigarette2004-2005.pdf (accessed 1/18/09).
    19. Americans Nonsmokers Rights Foundation Report. Available online 
at http://www.no-smoke.org/pdf/WRBLawsMap.pdf (accessed 1/19/09).
    20. Thompson JW. Children's Health Reform Agenda. Opportunities for 
Impact: Preventing Tobacco Use & Childhood Obesity. A Prevention Policy 
Paper Commissioned by Partnership for Prevention. Partnership for 
Prevention, December 2008.
    21. Kumanyika SK. Minisymposium on obesity: overview and some 
strategic considerations. Annu Rev Public Health 2001;22:293-308.
    22. Nielsen SJ, Popkin BM. Patterns and trends in food portion 
sizes, 1977-1998. JAMA 2003;289:450-453.
    23. Nielsen SJ, Siega-Riz AM, Popkin BM. Trends in energy intake in 
U.S. between 1977 and 1996: similar shifts seen across age groups. Obes 
Res 2002;10:370-378.
    24. Kent A, Graubard B. Eating out in America, 1987-2000: trends 
and nutritional correlates. Prev Med 2004;38:243-249.
    25. Increasing Physical Activity. Guide to Community Preventive 
Services Website. Centers for Disease Control and Prevention. http://
www.thecommunity 
guide.org/pa/. Accessed on: 1/17/2009.
    26. Kahn EB, Ramsey LT, Brownson RC, et al. The effectiveness of 
interventions to increase physical activity. A systematic review. Am J 
Prev Med 2002;22(4S):73-107.
    27. Handy SL, Boarnet MG, Ewing R, Killingsworth RE. How the built 
environment affects physical activity. Views from urban planning. Am J 
Prev Med 2002;
23(2S):64-73.
    28. NHANES data on the Prevalence of Overweight Among Children and 
Adolescents: United States, 2003-2006. CDC National Center for Health 
Statistics, Health E-Stat. (http://www.cdc.gov/nchs/products/pubs/pubd/
hestats/overweight/over
wght_child_03.htm)
    29. Childhood obesity in the United States: facts and figures. Fact 
Sheet. Institute of Medicine of the National Academies, September 2004.
    30. Freedman DS, Khan LK, Dietz WH, Srinivasan SR, Berenson GS. 
Relationship of childhood overweight to coronary heart disease risk 
factors in adulthood: The Bogalusa Heart Study. Pediatrics 
2001;108:712-718.
    31. Freedman DS, Mei Z, Srinivasan SR, Berenson GS, Dietz WH. 
Cardiovascular risk factors and excess adiposity among overweight 
children and adolescents: the Bogalusa Heart Study. J Pediatr. 2007 
Jan;150(1):12-17.e2.
    32. Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. 
Predicting obesity in young adulthood from childhood and parental 
obesity. N Engl J Med 1997; 37(13):869-873.
    33. Ogden CL, Carroll MD, McDowell MA, Flegal KM. Obesity among 
adults in the United States--no statistically significant change since 
2003-2004. NCHS data brief no. 1. Hyattsville, MD: National Center for 
Health Statistics, 2007.
    34. Los Angeles County Department of Public Health, Office of 
Health Assessment and Epidemiology. Preventing childhood obesity: the 
need to create healthy places. A cities and communities health report. 
October 2007.
    35. Thompson D, Edelsberg J, Colditz GA, Bird AP, Oster G. Lifetime 
health and economic consequences of obesity. Arch Intern Med 
1999;159:2177-2183.
    36. Rimm EB, Stampfer MJ, Giovannucci E, et al. Body size and fat 
distribution as predictors of coronary heart disease among middle-aged 
and older U.S. men. Am J Epidemiol 1995;141:1117-1127.
    37. Thorpe KE, Florence CS, Howard DH, Joski P. The impact of 
obesity on rising medical spending. Health Affairs Web Exclusive: DOI: 
10.1377/hlthaff.w4.480.
    38. Wolf AM, Colditz GA. Current estimates of the economic cost of 
obesity in the United States. Obes Res 1998;6:97-106.
    39. The Economics of Obesity and Physical Inactivity Center for 
Weight and Health, University of California, Berkeley, 
www.cnr.berkeley.edu/cwh.
    40. California SB 677--Summary of provisions. The California 
Childhood Obesity Prevention Act of 2003--Deborah Ortiz. Source: http:/
/www.publichealthadvocacy.
org/PDFs/SB677_Summary.pdf downloaded 2/4/2008.
    41. SB 12 School Nutrition Standards. ``It's the right thing to 
do.'' Fact sheet from the California Center for Public Health Advocacy. 
Source: http://www.publichealthadvocacy.org.
    42. SB 965 Healthy Beverage Bill. ``Assuring Nutritious Drinks in 
California Schools.'' Fact sheet from the California Center for Public 
Health Advocacy. Source: http://www.publichealthadvocacy.org.
    43. Stallings VA, Taylor CL (Eds.). Nutrition Standards and Meal 
Requirements for National School Lunch and Breakfast Programs: Phase I. 
Proposed Approach for Recommending Revisions. Committee on Nutrition 
Standards for National School Lunch and Breakfast Programs, National 
Research Council, 2008.
    44. Simon P, Jarosz CJ, Kuo T, Fielding JE. Menu Labeling as a 
Potential Strategy for Combating the Obesity Epidemic: A Health Impact 
Assessment. Los Angeles County Department of Public Health, 2008.
    45. Food and Beverage Marketing to Children and Adolescents. What 
Changes are Needed to Promote Healthy Eating Habits? A Research Brief. 
Robert Wood Johnson Foundation, October 2008.
    46. Roux L, Pratt M, Tengs TO, et al. Cost effectiveness of 
community-based physical activity interventions. Am J Prev Med 
2008;35(6):578-588.

    Senator Harkin. Thank you very much, Dr. Fielding.
    Now we go to Mr. William Emmet, the Director of the 
Campaign for Mental Health Reform. In this role he coordinates 
the efforts of over 18 national organizations to make mental 
health services a national priority. He previously worked for 
the National Association of State Mental Health Program 
Directors and the National Alliance on Mental Illness.
    Again, as I said, all your statements will be made a part 
of the record. Please proceed.

   STATEMENT OF WILLIAM EMMET, DIRECTOR, CAMPAIGN FOR MENTAL 
                 HEALTH REFORM, WASHINGTON, DC

    Mr. Emmet. Well, thank you very much, Mr. Chairman and 
Senator Burr and members of the committee. It's a wonderful 
opportunity to be here, and I will do my best in the brief time 
available to demonstrate that it is impossible in fact to 
consider a comprehensive approach to health reform in this 
country without understanding the many ways in which addiction, 
substance use, and a range of mental health disorders 
contribute to the overall picture of chronic disease.
    Mental health and substance abuse have been overlooked too 
frequently, as you mentioned, Senator, and I appreciate your 
commitment to seeing that that doesn't happen in health reform 
efforts under way now.
    The costs associated with the failure to appropriately 
treat mental health and substance use disorders are high. 
According to the National Institute on Drug Abuse, the economic 
cost of drug, alcohol, and tobacco use in the United States is 
more than $500 billion. In 2002 mental illnesses and substance 
use disorders led to $193 billion in lost productivity, which 
happens to be more than the revenue of 499 of the Fortune 500 
companies. By 2013 this figure is estimated to rise to more 
than $300 billion.
    The World Health Organization has found that depression 
alone was the fourth leading cause of disease burden in 1990 
and by 2020 predicts that it will be the single leading cause. 
Indeed, right now mental illness is the leading cause of 
disability for people between the ages of 15 and 44 in the 
United States and Canada. As we all know too well, suicide 
accounts for over 32,000 deaths annually, or at least in 2005, 
the last year for which we have figures, many of them 
preventable through timely intervention.
    Mental health and substance use disorders frequently co-
occur. It is in part for this reason that the mental health and 
addictions field, still largely separate in terms of funding 
and organization, now recognize the need for greater 
collaboration in practice and in health care policy. They are 
treating many of the same people with too little coordination 
and costly consequences.
    Yet mental illness and substance abuse do not exist in a 
vacuum. We can now appreciate that mental health and substance 
use disorders are also interwoven with other chronic disorders, 
including obesity and tobacco consumption, heart disease, 
pulmonary disorders, hypertension, and the list goes on. There 
is a developing awareness that failure to address the co-
occurrence of mental health disorders, substance use disorders, 
and other chronic conditions leads to worse outcomes overall 
and more costs across the Nation's health care system.
    Many people with mental health and substance use disorders 
suffer from chronic conditions simply because they are not 
receiving appropriate health care. People with mental illnesses 
are uninsured at twice the rate of the general population. 
Thirty-four percent of people with mental illness have no 
health coverage at this point. In other words, many people with 
mental illnesses are excluded from our Nation's porous health 
care system right from the start.
    Mr. Chairman, people with mental illness in the public 
mental health system die on average 25 years earlier than the 
general population. This is a stunning revelation that has come 
to light in recent years. The vast majority die because they 
suffer from a host of chronic conditions that are largely 
preventable: respiratory ailments, complications associated 
with obesity and poor nutrition, diabetes, et cetera. People 
with mental illness may constitute in fact the most unhealthy 
segment of our Nation's population. As best we can tell, no 
other identified group of Americans lives with so many chronic 
medical conditions or as a consequence die so young.
    The excessive morbidity and mortality they experience is 
certainly a public health crisis. People with schizophrenia die 
from diabetes at 2.7 times the rate of the general population. 
They die from cardiovascular disease at 2.3 times the rate of 
the general population, 3.2 times the rate from respiratory 
disease, and 3.4 times the rate from infectious diseases.
    We are also learning more about the interplay of depression 
and other conditions. The likelihood of heart attack is four 
times greater for persons with depression than in the general 
population. The likelihood of stroke is 2.6 times greater. 
Depressed men are 2.3 times as likely to develop diabetes as 
the rest of the population.
    This all adds up to more outpatient visits and hospital 
days for patients in whom depression accompanies a chronic 
condition than for those without depression. Medical-surgical 
costs are in fact 1.4 times higher for people who are also 
suffering depression.
    Now, any discussion of prevention and modifiable risk 
factors should include a look at tobacco consumption among 
people with mental health diagnoses. Persons with mental 
illness smoke approximately half of all cigarettes produced in 
this country and are only half as likely to quit as smokers 
without mental illness. Approximately 50 percent of those with 
a serious mental illness are smokers, compared with 23 percent 
for society at large. Evidence also points to people with 
mental illness consuming more of each cigarette they smoke and 
inhaling the smoke from them more deeply.
    We've seen that the mortality rates for people with mental 
illness are much higher than those for others in society. 
Roughly half of those deaths are due to smoking-related 
illnesses.
    Looking at other ways we can look at prevention, we should 
give considerable thought to how the bad outcomes we are now 
seeing can be avoided through preventive efforts. We in the 
field look forward very much to the March release of an 
Institute of Medicine report on the prevention of mental 
disorders, produced in part with support from the Substance and 
Mental Health Services Administration.
    Prevention comes in many packages, as the members of this 
committee know so well. In this instance it seems evident that 
a baseline preventive approach has to start with public 
education about the fact that mental illnesses are, in fact, 
illnesses like any other.
    I'd love to talk more about preventive efforts, but I see 
that the time is seeping away. I just want to say that we must 
develop a better understanding of many of the factors, as Dr. 
Fielding has mentioned, that lead to the experience of mental 
illness and chronic illness, including trauma, maternal 
depression, and many other community factors.
    There is much to be done, Senator, and the effort now under 
way to reform our Nation's approach to health provides an 
unparalleled opportunity to address these issues. Thank you 
once again for the opportunity to discuss the ways in which 
substance abuse and mental health disorders contribute to the 
picture of chronic disease in our Nation. There is much to be 
learned about it. My hope is that by beginning this examination 
we are able to move toward a general improvement of the health 
status of millions of Americans and a reduction in unnecessary 
costs and unnecessary lives lost in this country.
    Thank you, Senator.
    [The prepared statement of Mr. Emmet follows:]
                  Prepared Statement of William Emmet
    Mr. Chairman, members of the committee, thank you for inviting me 
to speak with you today about mental health and substance use disorders 
in the context of chronic disease. I am honored to have this 
opportunity and will do my best in the time available to demonstrate 
that it is impossible to consider a comprehensive approach to health 
reform in this country without understanding the many ways in which 
addiction, substance use, and a range of mental health disorders 
contribute to the overall picture of chronic disease.
    I serve as Director of the Campaign for Mental Health Reform, a 
coalition of 18 organizations working together on Federal policy. All 
18 organizations agree that ``mental health is integral to health'' and 
collaborate on development of policy informed by this verity. I also 
have had the privilege of working closely with colleagues in the 
substance abuse community through the mechanism of the Whole Health 
Campaign, which was formed to promote the idea that health policy 
cannot be addressed without incorporating an understanding of both 
mental health and substance abuse. I am indebted to a large number of 
my colleagues for the help they have provided in the preparation of 
this testimony.
    This hearing's focus on chronic disease and prevention and the 
pairing of substance abuse and mental health with tobacco-use and 
obesity on this panel are propitious in several ways, and I applaud the 
decision to present these topics in this manner. It is important from 
the outset to understand that mental illnesses and substance use 
disorders are chronic conditions that are also intertwined with other 
chronic conditions, creating a complex web in which many lives are 
snared and much money is wasted.
    Perhaps the first point to make about mental illnesses and 
substance use disorders is that they frequently travel together, 
wreaking havoc on individuals' lives with repeated cycles of 
dispiriting and destructive behavior and leaving a trail of pain and 
suffering that swallows whole families. In many people, it is 
impossible to separate one condition from the other. It is in part for 
this reason that the mental health and addictions fields, still largely 
separate in terms of funding and organization, are now recognizing the 
need for greater collaboration in practice and healthcare policy. They 
are treating many of the same people. Your invitation to discuss these 
issues together augurs well for the direction in which future health 
policy must head.
    While we often use the term ``co-occurring disorders'' to describe 
concurrent mental health and substance use conditions, we are 
increasingly using the term to describe the overlay of mental disorders 
and a broader range of chronic disorders. It is important to note, 
also, that mental disorders themselves frequently co-occur. For 
example, according to the Multimodal Treatment Study of Children with 
Attention Deficit/Hyperactivity Disorders (MTA) conducted by the 
National Institute of Mental Health, 79 percent of children with AD/HD 
have at least one co-occurring mental disorder and according to the 
Centers for Disease Control and Prevention (CDC), 50 percent of 
children with AD/HD have a co-occurring learning disability. New data 
is beginning to show significant co-occurrence between AD/HD and 
autism.
    Measures from different sources all point to the conclusion that 
the costs associated with the failure to appropriately treat mental 
health and substance use disorders are high. According to the National 
Institute on Drug Abuse, the economic cost of drug, alcohol and tobacco 
abuse in the United States is more than $500 billion. Drug, alcohol and 
tobacco use currently cost schools throughout the country an extra $41 
billion per year in truancy, violence, disciplinary programs, school 
security and other expenses.
    In 2002, mental illnesses and substance use disorders led to $193 
billion in lost productivity--more than the revenue of 499 of the 
Fortune 500 companies--and by 2013, this figure is estimated to rise to 
more than $300 billion.
    Using a measure called Disability Adjusted Life Years (DALYs) in 
its study of the Global Burden of Disease, the World Health 
Organization has found that depression was the fourth leading cause of 
disease-burden in 1990 and by 2020 will be the single leading cause. 
Indeed, mental illness is already the leading cause of disability for 
people between 15 and 44 in the United States and Canada.
    When we examine mental health, substance use, and other chronic 
disorders, however, it is only by seeing how deeply interwoven they are 
that we truly appreciate the costs of failing to address them in an 
integrated approach. Mental health and substance use disorders are 
interwoven with other chronic disorders, including obesity, tobacco 
consumption, heart disease, pulmonary disorders, and hypertension. 
Failure to consider the co-occurrence of mental health disorders, 
substance use disorders, and other chronic conditions leads to worse 
outcomes and more costly treatment.
    Many suffer from these conditions simply because they are not 
receiving appropriate healthcare. As Joseph Parks, M.D., director of 
the Missouri Department of Mental Health, points out, this is an issue 
for all people with limited income, which certainly includes those who 
utilize the public mental health system. Preventive care is all but 
unknown in this population. As a result, they overuse emergency rooms, 
get less primary care, and go for routine screens and tests at 
significantly lower rates. They also have very low rates of dental 
care, which is often not paid for by public programs. Finally, it would 
be a mistake to think that people receiving services in the mental 
health system have a direct link to general medical care; there is 
little integration of primary care and psychiatry.
    People with mental illnesses are uninsured at twice the rate of the 
general population: 34 percent of people with mental illness have no 
health coverage at this point. In other words, many people with mental 
illnesses are excluded from our Nation's porous healthcare system right 
form the start. In addition, it is possible to identify ``patient 
factors'' (amotivation, fearfulness, homelessness, victimization/
trauma, resources, advocacy, unemployment, incarceration, social 
instability, IV drug use, etc.), ``provider factors'' (comfort level 
and attitude of healthcare providers, coordination between mental 
health and general health care, stigma), and ``system factors'' 
(funding, fragmentation) as reasons people with mental illnesses are 
receiving poor overall healthcare.
    The result? As documented by the Substance Abuse and Mental Health 
Services Administration (SAMHSA) and the National Association of State 
Mental Health Program Directors (NASMHPD), people with mental illness 
in the public mental health system die on average 25 years earlier than 
the general population. They die because they suffer from a host of 
chronic conditions that are largely preventable: respiratory ailments, 
complications associated with obesity and poor nutrition, diabetes, 
etc. Indeed, as alarming as this data about premature death is, we 
should not let it obscure the fact that people with mental illness may 
constitute the most unhealthy segment of our Nation's population. As 
best we can tell, no other identified group of Americans live with so 
many chronic medical conditions or, as a consequence, dies so young. It 
is estimated that as much as 8 percent of adult Americans--17.5 million 
people--have a serious mental illness; the excessive morbidity and 
mortality they experience is certainly a public health crisis.
    It is only relatively recently that researchers have begun to 
collect reliable data on this issue, but the scope of the problem has 
become clear. While suicide and injury account for about 30-40 percent 
of premature deaths in persons with schizophrenia, about 60 percent are 
due to ``natural causes.'' According to a 2000 study reported in 
Schizophrenia Research, people with schizophrenia die at 2.7 times the 
rate of the general population from diabetes, 2.3 times the rate from 
cardiovascular disease, 3.2 times the rate from respiratory disease, 
and 3.4 times the rate from infectious diseases.
    Some very revealing work has been done using data from the 
Behavioral Risk Factor Surveillance System (BRFSS), the State-based 
surveys conducted by the CDC. It shows that persons with high health 
risks are highly likely to have a co-morbid mental illness. It also 
shows that persons with mental illness constitute a significant portion 
of the target population of major public health programs. And the study 
leads to the conclusion that persons with mental illness appear to 
qualify as a Health Disparities Population.
    A number of studies have looked at depression's link to various 
illnesses. Depression is a risk factor for stroke and coronary artery 
disease. The likelihood of developing myocardial infarction is four 
times greater for persons with depression than in general population; 
the likelihood of stroke is 2.6 times greater, according to two 
studies. Depressed men are 2.3 times as likely to develop diabetes, 
according to another. Other studies note the high impact of depression 
on outcomes of cardiovascular illness. This all adds up to more 
outpatient visits and hospital days for patients in whom depression 
accompanies a chronic condition than for those without depression. 
Medical/surgical costs for people also suffering depression were 1.4 
times higher than for those who were not in one HMO. Myocardial 
infarction plus depression yielded 41 percent higher costs in another 
study.
    A study of Medicaid patients in Maine had implications for policy 
on several levels. It revealed the importance of screening tools for 
depression in primary care and for health issues in mental health 
settings, the need for reimbursement for mental health interventions in 
primary care and health interventions in mental health settings, the 
benefits of integrated mental health/health care management for 
individuals with complex needs, and the need for integrated analysis of 
utilization and cost across both mental health and health care.
    A new study of Medicaid patients in six States published in this 
month's issue of Psychiatric Services indicates that substance abuse 
also has an extreme impact on general medical costs. It shows that as 
patients with substance abuse disorders got older, their medical care 
costs increased at a far higher rate than behavioral health costs. For 
people with substance abuse disorders--on average, 29 percent of the 
Medicaid population--the six States paid $104 million more for medical 
care than for those patients who did not have an alcohol or drug abuse 
diagnosis.
    I earlier discussed the co-occurrence of mental health disorders 
and substance abuse. Given the scope of today's hearing, it may also be 
instructive to look more closely at the intersection of tobacco use 
with mental disorders. According to the Smoking Cessation Leadership 
Center, based at the University of California at San Francisco and 
funded largely by the Robert Wood Johnson Foundation, persons with 
mental illness smoke half of all cigarettes produced and are only half 
as likely to quit as smokers without mental illness. Approximately 50 
percent of those with serious mental illness are smokers, compared with 
23 percent for society at-large. Evidence also points to people with 
mental illnesses consuming more of each cigarette they smoke and 
inhaling the smoke from them more deeply. We have already seen that 
mortality rates for persons with mental illness are much higher than 
those for others in society; half of these deaths are due to smoking 
related illnesses. There is evidence, too, that smoking is also 
associated with increased insulin resistance, which clearly holds 
implications for the high rates of diabetes in people with mental 
illnesses.
    Where does this lead us?
    It should be apparent from this summary of data that mental health 
and addictions treatment must be fully integrated into a coordinated 
health reform agenda. As the Nation's health policy is reshaped, we 
must not overlook the interaction of mental health and addictions 
disorders with each other and with a range of chronic conditions. The 
committee's outreach to the substance abuse and mental health 
communities clearly indicates that you have no intention of crafting 
such an incomplete policy approach, so I am greatly encouraged and 
pledge the assistance of our communities in your ongoing work.
    A number of models and approaches that have entered the health 
reform debate in recent months hold promise for improvement in the 
Nation's ability to address chronic conditions and prevention, but 
their implications for mental health and substance abuse have not, as 
yet, been fully explored. For example, most descriptions of the 
coordinated care models known as ``medical homes'' (or ``clinical 
homes'') make little reference to mental health or substance abuse. We 
have seen that the lack of coordination in medical care may, in fact, 
be most pronounced when it comes to mental health and substance abuse 
disorders, so it is extremely important that the place of these 
disorders in the medical home receive more attention.
    Similarly, much hope for the improvement of our Nation's healthcare 
delivery system has been placed in expansion of health information 
technology. While we feel it very important to achieve appropriate 
standards for privacy and security in HIT systems, we would not want 
such standards to somehow exclude or separate mental health and 
substance abuse treatments from the rest of the medical community. 
Properly implemented, in fact, HIT can be an instrument of consumer 
empowerment, leading to much greater awareness of one's health status 
and providing the opportunity for improved self-management strategies.
    The emphasis on quality and effectiveness characterizing much 
healthcare discussion these days must also be cast in terms that 
accommodate mental health, substance abuse, and their interaction with 
other conditions. Approaches to the care and treatment of people with 
the chronic conditions discussed earlier--diabetes, heart disease, 
respiratory illnesses--should always include mental health and 
substance use screening. By the same token, mental health and substance 
abuse service providers should ensure their clients and patients are 
receiving primary medical attention. As in much of medicine, the trend 
should be towards payment for outcomes.
    We also should give considerable thought to how the bad outcomes we 
are now seeing can be avoided through preventive efforts. As members of 
this committee know so well, prevention comes in a variety of packages. 
In this instance, it seems evident that a baseline preventive approach 
must be public education promoting the understanding that ``mental 
health is essential to overall health.'' Widespread acceptance of this 
concept would begin to enable individuals and systems to overcome the 
barriers to effective care I have tried to identify in this testimony.
    We must also approach prevention across the lifespan and work to 
provide the appropriate screens, starting with well-child visits, that 
can identify the co-occurrence of mental health, substance abuse, and 
chronic conditions. It has long been a popular belief that mental 
illnesses and addictions begin in late adolescence or early adulthood. 
In fact, this is a misconception. The average age of onset for mental 
disorders is 14. Addictions to alcohol, marijuana, and tobacco also 
start in adolescence or childhood, and studies are clear that when use 
of these substances is started at an early age, the consequences later 
in life are much more pronounced than they otherwise would be. For 
example, youth who first smoke marijuana under the age of 14 are more 
than five times as likely to abuse drugs in adulthood.
    We must develop a better understanding of the role trauma plays in 
mental health conditions and substance abuse and then employ approaches 
that mitigate trauma's effect. We must understand and address maternal 
depression, the consequences it can have on a young child's physical 
and emotional development, and the ways it can play out over the span 
of that young child's life.
    With respect to the contributions of mental health and substance 
abuse disorders to the range of chronic conditions, work can be done to 
address modifiable risk factors, including: smoking, alcohol 
consumption, nutrition, exercise, intravenous drug use, unsafe sexual 
activity, time spent in group care facilities (leading to TB and 
infectious diseases). It is in our failure to pay attention to these 
factors that we can begin to identify the roots of many chronic 
conditions afflicting people with mental health and substance use 
disorders.
    Indeed, such prominent practitioners as members of NASMHPD's 
Medical Directors Council point out that established monitoring and 
treatment guidelines to lower risk are underutilized in the population 
of people with serious mental illnesses. This is true both in the case 
of practitioners in mental health and addictions treatment facilities 
and practitioners in the larger medical arena who see people with 
mental health or substance abuse disorders. The failure to treat 
metabolic syndrome in patients with schizophrenia is an unfortunate but 
common example of the sort of missed opportunities common today. If 
mental health professionals, who often spend much of their energy 
making sure their clients are taking their prescribed psychotropic 
medications, could monitor their follow-up with other medical 
interventions and lifestyle modifications, the lives of many people 
with mental illnesses would be extended.
    We need to know more about the interplay of mental health, 
substance abuse, and chronic diseases. Surveillance tools that analyze 
both physical health and mental health and their interaction will be a 
boon to our growing understanding of their complex relationships. With 
that information, we can begin to develop public health programs aimed 
at risk reduction or chronic disease prevention that address mental 
health issues in program design, implementation and assessment. We need 
also to encourage collaboration between public behavioral health and 
public health authorities and remove financial disincentives to their 
coordination.
    There is much to be done, and the effort now underway to reform our 
Nation's approach to health provides an unparalleled opportunity to 
address these issues. Thank you once again for the opportunity to 
discuss the ways in which substance abuse and mental health disorders 
contribute to the picture of chronic diseases in our Nation. My hope is 
that by beginning this examination, we are able to move towards a 
general improvement of the health status of millions of Americans and a 
reduction in unnecessary costs in our health system.

    Senator Harkin. Thank you very much, Mr. Emmet.
    Now to introduce our next witness I will turn to my good 
friend from North Carolina, Senator Burr.
    Senator Burr. Thank you, Mr. Chairman. Thank you for the 
opportunity to formally welcome and introduce Dr. Allen Dobson. 
Dr. Dobson was the Assistant Secretary of Health Policy and 
Medical Assistance in the North Carolina Department of Health 
and Human Services from 2005 to 2007. In addition to those 
duties as Assistant Secretary, he also served as North 
Carolina's medical director.
    In 2007 Dr. Dobson stepped down from his State appointment 
to become the Vice President for Clinical Practice Development 
for North Carolina's health care system and returned to his 
position as President of Caberas Family Medicine.
    Dr. Dobson is a native of North Carolina, received his 
undergraduate degree from North Carolina State University, his 
medical degree from Wake Forest University--who we were very 
proud of until they lost last night and lost the No. 1 spot in 
the national basketball rankings--and completed his residency 
in family medicine at East Carolina. He certainly has a 
biography that would lead him to run for statewide office. I am 
hopeful that's not in his plans.
    Mr. Chairman, Dr. Dobson has been actively involved in 
health care policy on a State and national level for a long 
time. He was an early leader and developer of the nationally 
recognized community care program of North Carolina. It's 
primary care based on Medicaid managed care programs. The 
program received the Annie E. Casey Award for Innovations in 
Government, presented by the Harvard Kennedy School of 
Government in October 2007.
    It's particularly an honor for me to introduce him, but 
more importantly I think a special treat for those of us on 
this panel to hear from somebody who has proven successes at 
reforming the health care system. I welcome Dr. Dobson.
    Senator Harkin. Thank you, Senator Burr.
    This committee is now blessed to have two Senators from the 
great State of North Carolina on this committee. I would ask if 
our new Senator, Senator Hagan, would like to add anything to 
what Senator Burr said about Dr. Dobson.

                       Statement of Senator Hagan

    Senator Hagan. Thank you, Mr. Chairman.
    Senator Burr certainly gave an overview of Senator Dobson's 
great resume and record, but I personally had the opportunity 
to work very closely with him for a number of years when I was 
the chairman of the budget in North Carolina as a State 
senator. We were very lucky to have you working so hard on our 
behalf, and I think the Community Care program which we'll be 
hearing about is a model that I'm hoping that the rest of the 
country will take serious note of. It helps from a primary care 
physician's standpoint. It's funded in a different way, and I 
think that there's a lot of good things that he'll share with 
us today.
    It's definitely working and I think it's something that we 
need to be looking closely at from a Federal level and 
hopefully replicating in other areas.
    Thank you.
    Senator Harkin. Thank you very much, Senator Hagan.
    Dr. Dobson, it looks like you've got good support from your 
two Senators here. Welcome. Please proceed.

 STATEMENT OF ALLEN DOBSON, JR., M.D., FAAFP, CHAIRMAN, NORTH 
CAROLINA COMMUNITY CARE NETWORKS, INC., ASSISTANT SECRETARY FOR 
HEALTH POLICY AND MEDICAL ASSISTANCE, NORTH CAROLINA DEPARTMENT 
           OF HEALTH AND HUMAN SERVICES, RALEIGH, NC

    Dr. Dobson. Thank you. You might think I was from North 
Carolina.
    [Laughter.]
    Thank you, Senator Harkin, Senator Burr, for your kind 
introductions, and Senator Hagan. Distinguished members of the 
committee, thanks for the invitation to come here today and 
share with you Community Care of North Carolina.
    I'm going to talk about the delivery system. It's about how 
do you put this together and do what we know is right for the 
citizens. Community Care of North Carolina is a public-private 
partnership between the State of North Carolina and 14 not-for-
profit networks that are comprised of the majority of local 
health care providers, mainly primary care physicians, 
hospitals, health departments, social service agencies, and the 
safety net organizations.
    Some of our networks include mental health and schools. It 
is about putting together the pieces. Together this partnership 
delivers the key components of the medical home and a 
community-based management system for Medicaid, our SCHIP 
recipients, and other low-income adults and children in our 
State. It now includes over 3,500 primary care physicians, 
1,200 medical homes, covers all 100 counties of North Carolina, 
and manages 875,000 recipients.
    Community Care delivers quality and cost savings to our 
State through basically three critical elements. First, primary 
care physicians serve as a medical home, where patients are 
known, care is coordinated, and quality is kind of the first 
priority.
    Second, these local networks serve as a virtual integrated 
health care system in the community that link the medical home 
and patients to the rest of the providers and support agencies 
in the community. Health care is like politics; it is local, 
and they're all different. These networks leverage existing 
community resources and relationships and provide the needed 
physician leadership locally and local collaboration to create 
creative solutions in improving care and quality to meet our 
statewide goals. These networks provide a flexible structure 
that has been adaptable to rural as well as urban areas of our 
State.
    Third, the State funds these medical homes and networks 
differently. As we've heard, rather than fee for service, we 
provide a monthly fee to the medical home; but we also provide 
a monthly fee to the network to provide those additional 
resources that binds the system together, such as case 
managers, care coordinators, clinical pharmacists, and part-
time medical directors to work with practices, and a local 
quality improvement infrastructure to help support these 
medical homes. This assures that optimum supports are provided 
to patients and improvement goals are achieved.
    Community Care has clearly identified and demonstrated 
quality improvement, cost savings, and growth, because we 
started as a pilot and it grew into a statewide program--not 
mandated, but by grassroots. Community Care physicians, both 
locally and statewide, meet as a medical directors group and 
they develop and agree upon quality measures, desired outcomes, 
and whether these are local or statewide initiatives. The 
results are monitored and reported back.
    We have seen improvement in asthma care, resulting in a 35 
percent decrease in hospitalizations and improvement in 
diabetes care. We've seen improvement in preventable dental 
caries in small children because we decided that we didn't have 
dental access, so we would train primary care physicians to do 
screenings and fluoride varnish, and we've seen decreased 
caries. Other networks have seen increased Medicaid preventive 
visits.
    The network medical directors meet with State officials 
regularly to plan and implement initiatives to meet State 
goals.
    We've also seen significant cost savings through reduction 
of costs. The Sheps Center at UNC as well as Mercer have done 
statistically reliable cost comparisons to show that we've 
saved in excess of $100 million a year in the State Medicaid 
program from reducing costs.
    In short, we've successfully managed the North Carolina 
Medicaid program through this clinical management strategy, 
rather than just payment reduction or regulatory controls. I 
would add, in this particular economic environment that our 
State and the Federal Government is faced with, Community Care 
was built for just such times. Medicaid is countercyclical. 
It's needed when the economy is bad. At the same time, when 
budget pressures are hard having a local network and a way to 
reach into the community and make changes is valuable and 
important. We look forward to our Community Care network 
stepping up and helping the State through this tough economic 
time.
    Community Care is now the centerpiece strategy for North 
Carolina in health care. It is enthusiastically accepted by 
both patients and providers. We have been mandated to expand 
into SCHIP and into the aged, blind, and disabled. We now have 
a Medicare demonstration waiver that we hope will be approved 
very shortly to allow Community Care to serve those duly 
eligible for Medicare and Medicaid and our at-risk Medicare 
population, because this is a clinical program, not a payment 
program.
    The Community Care program is also the platform for a 
multipayer public and private quality improvement effort, which 
is physician-led, around five key diseases in our State, and is 
also helping as the platform for addressing important health 
care issues such as health disparities, prevention, mental 
health integration, the uninsured, childhood obesity, and child 
development.
    We believe that Community Care is an important national 
model for health care reform. It is local. Its local 
infrastructure can work both with rural and urban, as well as 
public and private settings. We've built this on Medicaid, but 
this is a clinical program and it can work in any particular 
area.
    The path forward for our system can clearly be informed by 
a lot of our important work that's done by our most and best 
integrated health care systems. I will tell you that the 
majority of our Nation's health care is still provided in 
communities where there's no system at all--rural, fragmented, 
multiple providers. The lessons learned in Community Care of 
how you put a health care system together in a virtual sense 
for a common cause can provide a road map of how we organize 
our local systems, regardless of size, to focus on quality, 
cost, improvement in the health of citizens.
    In summary, while health IT, payment reform, and expansion 
of health care insurance are extremely important, I think it is 
essential that we have a sustained effort in organizing the 
health care delivery system to really achieve access, quality, 
and efficiency goals and achieve sustainable goals. Community 
Care thus I think provides an important example of what States 
can do and how it can provide leadership and new models to 
possibly provide an alternative for Congress to consider as we 
talk about health care reform for our Nation.
    Thank you for the opportunity to be here, Senators.
    [The prepared statement of Dr. Dobson follows:]
        Prepared Statement of L. Allen Dobson, Jr., M.D., FAAFP
    Senator Kennedy, Senator Enzi and other distinguished members of 
the committee; thank you for the invitation to be here today and to 
share with you the work of Community Care of North Carolina. I am Dr. 
Allen Dobson, Chairman of the Board of Directors for North Carolina 
Community Care Networks, Inc., the statewide umbrella organization 
representing all our local Community Care networks, and former 
Assistant Secretary and Medicaid Director for the North Carolina 
Department of Health and Human Services.
    Community Care of North Carolina (Community Care) is a public-
private partnership between the State of North Carolina and 14 not-for-
profit networks that are comprised of the majority of local healthcare 
providers; primary care physicians, hospitals, health departments, 
social service agencies and safety net organizations. Together this 
partnership delivers the key components of a medical home and 
community-based care management to Medicaid and SCHIP recipients and to 
other low-income adults and children of our State. Our Community Care 
networks now include over 3,500 primary care physicians in 1,200 
medical homes covering all 100 counties of North Carolina and manage 
over 875,000 patients.
    Community Care delivers improved quality and cost savings to our 
State through three critical elements. First, primary care physicians 
serve as ``true medical homes'' for patients--where the patients are 
known, care is coordinated and quality care is the first priority. 
Second, local networks serve as ``virtual'' integrated healthcare 
systems that link the medical home and patients to the rest of the 
local providers and support agencies. These networks, by leveraging 
existing community resources and relationships, provide the needed 
physician leadership and local collaboration to create local solutions 
for improving care management and quality to meet statewide goals. This 
network system provides a flexible structure that is adaptable to rural 
as well as to urban areas of our State. Third, the State funds the 
medical home through an additional monthly fee and also funds the 
network to provide additional local resources such as case managers/
care coordinators, clinical pharmacists, part-time medical directors 
and the local quality improvement infrastructure to work with and 
support the local medical homes. This assures optimal supports are 
provided to patients and that improvement goals are achieved.
    Community Care has demonstrated quality improvement, cost saving 
and phenomenal growth. Community Care physicians, both locally and 
through a statewide medical directors group, develop and agree upon 
quality measures and desired outcomes whether for local initiatives or 
statewide projects. The results are monitored and reported to networks 
and practices. Many networks have shown significant improvements in 
asthma care that have resulted in a 35 percent decrease in 
hospitalizations, as well as improvement in diabetes care. North 
Carolina has seen improvement in preventable dental caries in small 
children by training primary care doctors to screen for dental disease 
and apply fluoride varnish. Other networks have seen a marked increase 
in preventive visits for Medicaid children. Network medical directors 
meet regularly with State officials to plan and pilot care improvement 
strategies. Significant cost savings have also been documented by both 
the Sheps Center at University of North Carolina at Chapel Hill and 
Mercer Human Resources Consulting Group. Statistically reliable cost 
comparisons have shown savings exceeding $100 million per year since 
2003. In short, North Carolina has successfully managed the cost of its 
Medicaid program through this clinical management strategy rather than 
just payment reduction and regulatory controls.
    Community Care is now the centerpiece healthcare strategy in North 
Carolina. It is enthusiastically accepted by both patients and 
providers. The legislature has mandated the expansion into SCHIP and 
also the aged blind and disabled. Community Care is now seeking a 
Medicare demonstration waiver to serve citizens eligible for both 
Medicare and Medicaid as well as at risk Medicare recipients. Community 
care is also the platform for a major State initiative that will unite 
public and private payors in adopting and measuring physician-led 
quality care for 5 key diseases and is helping North Carolina address 
such important health issues as health disparities, prevention, the 
uninsured, childhood obesity and child development.
    We believe Community Care can serve as an important national model 
for healthcare reform. Community Care's local infrastructure will work 
in both urban and rural as well as public and private settings. The 
path forward for the U.S. healthcare system can clearly be informed by 
the important work of some of our best and most integrated healthcare 
systems. However the majority of the Nations healthcare is still 
provided in communities where there is no ``system'' at all. Lessons 
learned in Community Care can provide a road map to organizing all 
local communities regardless of size in order to focus on quality, 
costs and improvement in the health of its citizens.
    There are a number of lessons from Community Care I would like to 
re-state. These are: (1) primary care physicians and the medical home 
are essential to providing improved access to care and prevention; (2) 
public-private partnerships that develop and strengthen local 
healthcare systems are important; (3) providers are best motivated when 
the focus is on quality, population health and how care is delivered 
locally; (4) a shared responsibility and shared incentives are 
important; (5) the program must have flexibility that allows 
communities to organize themselves based on their unique 
characteristics and resources; (6) strong physician leadership is 
needed; (7) to create meaningful and lasting improvement you have to 
engage the physicians and other community providers who care for our 
patients; and (8) a portion of the saving must be reinvested to further 
develop local systems and programs.
    In summary, while improving Health IT, payment reform, and 
expansion of health insurance coverage, are important, what is 
essential is a sustained effort in organizing the healthcare delivery 
system to achieve needed access, quality and efficiency goals. 
Community Care thus provides an important example of how States can 
provide leadership and new models that may provide a valuable 
alternative for Congress to consider.
          Appendix 1.--Examples of Community Care Initiatives
    Asthma; Diabetes; Pharmacy Management (PAL, Nursing Home 
Polypharmacy); Dental Screening and Fluoride Varnish; Emergency 
Department Utilization Management; Case Management of High Cost-High 
Risk; Congestive Heart Failure (CHF); Assuring Better Child Development 
(ABCD); ADD/ADHD; NC HealthNet/Coordinated care for the uninsured; 
Gastroenteritis (GE); Otitis Media (OM); Projects with Public Health 
(Low Birth Weight, open access & diabetes self management); Diabetes 
Disparities; Medical Home/ED Communications; Aged, Blind and Disabled 
(ABD) care management; Depression Screening and Treatment; Mental 
Health Integration; Mental Health Provider Co-Location; E-Rx; Partner 
with AHEC to support Improving Performance in Practice Initiative; 
Medical Group Visits; and Dually Eligible Recipients.

    Senator Harkin. Thank you very much, Dr. Dobson.
    Now it's my privilege to introduce my fellow Iowan, Senator 
Jack Hatch; who has had a long and distinguished career in the 
legislature as a State Representative and as a State Senator. 
He is now the Assistant Majority Leader of the Iowa Senate. He 
is chair of the Health and Human Services Budget Committee. In 
2007 Senator Hatch led the legislature's comprehensive health 
care reform effort, in which they committed to covering all 
Iowa children by 2011.
    Senator Hatch created both the Community Health Center 
Incubator Program and the Iowa Collaborative Safety Net 
Provider Network. He has been recognized by a broad variety of 
groups for his health care initiatives in our State. The Iowa-
Nebraska Primary Care Association gave him their Underserved 
Champion of the Year Award in 2005. The Polk County Medical 
Society gave him their Outstanding Medical Leadership Award. 
The Iowa Academy of Family Physicians recognized him also.
    He has just been recognized by all of the providers 
throughout the State, and Nebraska too, I might add, for his 
great leadership.
    He's here with his daughter. I remember--just a little 
tidbit--a long time ago there was a picture in the paper, the 
front page. I remember that, Jack, when you were a State 
Representative at that time. It was a wonderful picture of the 
State legislature meeting, and there was a photo of Senator, 
then Representative, Hatch on the floor holding this little 
baby, and with a little bassinet next to him, taking care of a 
baby because his wife was working. It was just a very wonderful 
picture. Of course now that daughter's grown and very pretty 
and she's here. She's here with him today.
    Thank you again for all your great leadership in the State 
of Iowa. We're very proud of you, and your statement will be 
made a part of the record and please proceed, Jack.

   STATEMENT OF HON. JACK HATCH, STATE SENATOR OF IOWA, DES 
                           MOINES, IA

    Mr. Hatch. Thank you, Senator Harkin, Senator Burr, and 
other members of the Senate. I appreciate being asked to come 
here. I come as a representative of the entire legislature. 
This was not done by a single person or a group of people. It 
was done by all of us. As a result, the enacting bill was 
passed by the legislature by a margin of 92 to 4 in the House 
and 44 to 4 in the Senate.
    Some people would think that when you reach a consensus 
like that it is a bill that is not worth much. As I will 
hopefully demonstrate, Iowa extended itself and became a State 
that is committed to universal health care for its children and 
its adults.
    I must say also that it wasn't done by us doing it by 
ourselves. We took people and we interviewed a number of people 
from other States--Massachusetts, Vermont, Pennsylvania, North 
Carolina, Wisconsin, Pennsylvania, Washington State. All of 
these States and others have created a part of what is needed 
for a universal care system. We created a commission, as a 
result of our preliminary discussions, of all stakeholders.
    I have to tell you, though, that people thought it would 
fail, when you get the insurance industry, the labor unions, 
big, small businesses, consumer groups, that it would end up in 
a free-for-all. This commission traveled throughout Iowa, went 
to six cities, 10 monthly meetings, dozens and dozens of 
subcommittee meetings, and presented a proposal to the 
legislature a year ago.
    The legislature embraced that proposal and, unlike most 
blue ribbon commissions, enacted most all of the 
recommendations. As a result, we passed the Comprehensive 
Reform Act of 2008. In it we focused on extending health 
insurance coverage to all children by 2011, expanding coverage 
to some adults, but with a goal of all adults later on.
    We created medical homes, statewide electronic health 
records, preventive and chronic care management, quality 
control. We dealt with the workforce shortage issue, discussed 
and developed programs for long-term care, and created wellness 
programs with the Governor's Council on Physical Fitness.
    It was done in a bipartisan way. During the commission 
meetings we asked the two former governors, Governor Terry 
Brandsted, a Republican, and former Governor Tom Vilsack, now 
your U.S. Secretary of Agriculture, to conduct three public 
hearings. Senator, the first public hearing was in Council 
Bluffs. If I had closed my eyes and listened to Governor 
Brandsted, I would have thought that I was listening to you, 
because what he opened up with was that in America we have a 
sick care system. Those of you that know Senator Harkin, he has 
said that often, but it's rarely that a Republican governor 
would have said that. And when a Republican governor and a 
liberal Senator say it, we think maybe we're on the right 
track.
    We proceeded with concerning ourselves with, here's an 
opportunity. Everybody understands that we have a system that 
is broken. What Iowa did was dig in and look at some of the 
main elements. All of those elements are of concern and have an 
element of prevention and wellness to it.
    Specifically, with our proposal for creating medical homes 
it is understood that we have a coordination of care when you 
have one provider coordinating all of your care, and that 
provider could be assisted with counselors, social workers, 
nurses, then we're looking at how to keep a person healthy and 
not treating somebody only when they're sick.
    The legislation specifically required a council that we 
created to look at how to reimburse providers on preventing 
sickness and reimbursing them at a rate that would incentivize 
them to be a medical home. There are some models now, hospital 
models, but we're very interested in the North Carolina model 
of Community Care and how they're integrating all of those 
functions together.
    We also have a great opportunity in Iowa where we have 
developed a statewide fiber optics system. Along with a private 
hospital, we now have the opportunity to connect all the 
hospitals in Iowa, all 117 of them, into an electronic health 
records system. We have set up a commission to foster that, to 
lead that, and to identify additional dollars to finance it. 
Hopefully that will be completed within 2 years, where every 
hospital in the State will be connected to a fiber optic 
system.
    We also are developing our public health programs. We've 
established an Iowa Healthy Communities Initiative--The 
Governors Council on Physical Fitness small business qualifying 
wellness program, where we'll give tax credits to small 
businesses. We've also passed the Healthy School Initiative so 
that school children will be able to have nutritious lunches at 
schools and systems to work with their families outside of 
school.
    We have provided also mental health initiatives, as Mr. 
Emmet has so clearly established is necessary if we are going 
to really provide a universal system.
    In summary, we're not finished yet. We have a second bill 
that will be coming and introduced next week that will create 
an insurance exchange similar to Massachusetts', that will be 
established as a nonprofit corporation separate, that will be 
directed to develop plans, affordable plans for adults and 
children above the 300 percent mark of poverty, so that they 
can buy into affordable products.
    Second, we are going to follow the lead of Connecticut, 
where last year Connecticut passed a bill that provided small 
businesses, municipalities and nonprofits to buy into the State 
employee plan. Unfortunately, that was vetoed by the governor. 
We hope to have better success in Iowa.
    We're going to also allow pharmacists to have greater 
flexibility. They're so much a part of the universal system 
that we forget that pharmacists have a consumer orientation and 
a patient-centered orientation that we want to be able to 
corral. We, of course, are going to expand transparency. There 
is nothing better in a free system than to have consumers have 
the ability to guide their own health care practices. We're 
going to put more responsibility on the patient. When the 
patient has responsibility, when they know what their health 
care is, when they can help participate in paying for it, then 
they will be better patients and healthier Americans.
    With that, Senator, I thank you very much for this honor, 
for the opportunity to speak in front of you and your 
colleagues.
    [The prepared statement of Mr. Hatch follows:]
             Prepared Statement of State Senator Jack Hatch
    Chairman Harkin, members of the Senate HELP Committee and 
distinguished panel members, today, I am presenting Iowa's response to 
the health care crises our Nation is experiencing. On May 21, 2008, 
after 12 months of study by a bipartisan blue ribbon commission and 
thorough and vigorous debate by the legislature, Governor Culver signed 
HF 2539, the Health Care Reform Act into law. By overwhelming support 
(94-4 in the Iowa House and 42-4 in the Iowa Senate) this legislation 
placed Iowa at the forefront of the health care reform movement in 
America (See summary in Appendix A).
    Iowa is in the first year of implementing this legislation, which 
is comprehensive in its scope, cooperative in its breadth and long-term 
in its goal-setting. Iowa is not alone in enacting plans to reform our 
health care system. Massachusetts, Vermont, Illinois, North Carolina, 
Pennsylvania, Maine, Washington State, Hawaii and Wisconsin, among 
others, have decided not to wait for Federal action and enacted into 
their State law some innovative initiatives on how to reach universal 
coverage. States are collaborating with each other through associations 
like the National Conference of State Legislatures, Milbank Memorial 
Fund, the Robert Wood Johnson Foundation and the Progressive States 
Network in order to remedy their health care problems.
    Iowans are not getting healthier. The cost of coverage and the cost 
of care are becoming too expensive for average everyday Iowans. Each 
day we wait, Iowans are becoming more at risk of losing their coverage. 
Our health care system is heading for a catastrophic implosion.
    However, there is light at the end of the tunnel and it may not be 
the light of an oncoming train. The work being done in our State and 
other States truly fulfills the ``laboratories of democracy'' role 
States have traditionally played.
    If the Obama administration and the new Congress act now, and 
includes the successful experiments of many States in your design and 
implementation of a new system, Iowans and all Americans may be able to 
find health care security.
                           iowa did not wait
    Our reform is comprehensive and provides a solid foundation for our 
next series of legislative initiatives but Iowa and the States can not 
do it without a national policy.
    Now, Congress is poised to act. Senators Kennedy and Baucus have 
submitted legislation or announced drafts of proposals to reach 
universal health care. Senator Harkin, your subcommittee is focused on 
prevention and wellness as one of several toe-holds on Congress' 
proposals.
    I was asked to present on the topic of how Prevention played a role 
in Iowa's reform. It was the centerpiece of our efforts.
    Preceding the enactment of the bill, the 2007 General Assembly 
created the Commission on Affordable Health Care Plans for Small 
Businesses and Families.\1\ This commission was composed of 29 Iowans 
representing all the healthcare stakeholders. It reported the 
following:
---------------------------------------------------------------------------
    \1\ Commission on Affordable Health Care Plans for Small Businesses 
and Families, State of Iowa-Legislative Service Agency, December, 2007.
---------------------------------------------------------------------------
Poor Health Status, Unhealthy Behaviors, and Chronic Disease
          Even though Iowa ranks second in health system performance, 
        the State has fallen in health status among the States 
        declining from sixth in 1990 to eleventh in 2007.\2\
---------------------------------------------------------------------------
    \2\ Americas' Health Rankings, A Call to Action for People & Their 
Communities, Findings, 2007 Results, Table 1--2007 Overall Rankings, 
http://www.unitedhealthfoundation.org/ahr2007/results.html as reported 
in Health Promotion in Health Care, presented by Dr. James A. Merchant, 
December 19, 2007.
---------------------------------------------------------------------------
          The United States Centers for Disease Control and Prevention 
        report that the four factors influencing health are personal 
        behavior, the environment (elements in the air, water, homes, 
        communities, workplaces, and food that cause disease), and 
        access to health care and genetic makeup. Of these, personal 
        behavior is the most pertinent, while access to health care is 
        the least. However, 88 percent of health resources are spent on 
        treatment and only 4 percent on changing personal behavior.\3\ 
        Fifty to seventy percent of all health care costs and premature 
        deaths, illnesses, and disabilities are related to behaviors. 
        Two specific behaviors in point, tobacco use and obesity, add 
        increased financial and social costs. An average of 10 percent 
        of total claims costs is directly attributable to tobacco use. 
        Annually, smokers cost $1,623 in excess medical expenditures 
        and $1,760 in lost productivity compared to nonsmokers. Smoking 
        is the leading risk factor for asthma, cancer, diabetes, heart 
        disease, and chronic obstructive pulmonary disease.
---------------------------------------------------------------------------
    \3\ David Osborne and Peter Hutchinson, The Public Strategies 
Group, Transforming Health Care So We Can Keep Our Promises, 
www.legis.state.ia.us/lsadocs/IntComHand/2008/IHPAF157.PDF.
---------------------------------------------------------------------------
          An average of 10 percent of total claims costs is directly 
        attributable to obesity. Annual medical expenses for persons 
        with a body mass index (BMI) of between 30 and 34 cost $1,400 
        (or 25 percent) more than for persons with a BMI of less than 
        25; for those with a BMI greater than 35, the cost is $2,267 
        (or 44 percent) more than persons with a BMI of 25; and sick 
        days of those who are overweight are two to three times those 
        of persons with normal weight, costing employers $1,500-$2,000 
        annually in excess sick pay. A person with a BMI of 25 or 
        greater is subject to increased incidence of diabetes, heart 
        disease, strokes, joint replacements, and back problems.\4\
---------------------------------------------------------------------------
    \4\ Michael Parkinson, M.D., American College of Preventive 
Medicine, as reported in Health Promotion in Health Care, Presented to 
the Commission by Dr. James A Merchant, December 19, 2007.
---------------------------------------------------------------------------
          As noted above, unhealthy behaviors often lead to chronic 
        disease, and the increased incidence of chronic disease among 
        Iowans has greatly contributed to the State's decline in health 
        status. Chronic diseases are among the most prevalent, costly, 
        and preventable of health problems. Chronic diseases are 
        ongoing, generally incurable illnesses or conditions such as 
        cardiovascular disease, asthma, cancer, and diabetes, but many 
        are preventable through elimination of health-damaging 
        behaviors and generally are manageable if diagnosed early and 
        treated appropriately. More than 1 million Iowans suffer from 
        at least one chronic disease. Chronic diseases are the leading 
        cause of death and disability in the State. Approximately 23 
        percent of Iowans are affected by cardiovascular disease, 10 
        percent by asthma, 8 percent by depression, 5 percent by 
        diabetes, and 5 percent by cancer. The percent of Iowans 
        considered obese (a BMI of 30 or more) increased from 13 
        percent in 1990 to 25 percent in 2005. The estimated cost of 
        chronic diseases to Iowa including direct and indirect costs, 
        such as lost productivity, is $7.6 billion. Additionally, Iowa 
        spends an estimated $783 million in obesity-related medical 
        expenditures each year.\5\
---------------------------------------------------------------------------
    \5\ Partnership to Fight Chronic Disease, The Growing Crisis of 
Chronic Disease in Iowa, http://fightchronicdisease.net/dpfs/
PFCD_IowaFacts.pdf.

    Iowa's experience is not isolated to one State. These statistics of 
deteriorating health conditions ripple through every State of our 
country. Our approach to health care reform is comprehensive, but 
preventive care, how our providers deliver it and how patients use it 
are central to our reform.
    In Iowa, as throughout America, our health care system is treating 
people ONLY when they get sick and NOT treating them to remain healthy. 
We spend most of our resources responding to illness, rather than 
preventing it.\6\ Preventive Care has to be elevated to a more 
integrated level of care in our new system.
---------------------------------------------------------------------------
    \6\ David Osborne, Reinventing Health Care--The Role of the States, 
Memo to the New President, 2009, p. 197.

          Iowa is a leader in the quality of health care provided to 
        its citizens. However, patient safety and the provision of 
        high-quality care still can be improved. Ensuring that all Iowa 
        health care providers understand and utilize evidence-based 
        practice guidelines will improve patient outcomes and slow 
        escalating health care costs. Special focus should center on 
        effective interventions to treat chronic illnesses such as 
        diabetes, pulmonary disease, and cardiovascular disease that 
        affect many Iowans. Chronic disease management programs that 
        provide easy access to health care providers, regular 
        monitoring, and patient incentives to follow treatment plans 
        can improve Iowans' quality of life and reduce health care 
        costs.
          Iowa should be a leader in wellness, prevention, early 
        diagnosis, and management of chronic disease by ensuring all 
        health care providers understand and utilize best practices and 
        utilize established protocols for treating chronic diseases to 
        provide best results and make the best use of different health 
        care professionals.
          As health care costs continue to escalate, incentives and 
        education need to drive individual responsibility for use of 
        health care services and lifestyle choices that improve health 
        while containing costs.\7\
---------------------------------------------------------------------------
    \7\ Commission on Affordable Health Care Plans for Small Businesses 
and Families, State of Iowa--Legislative Service Agency, December 2007.
---------------------------------------------------------------------------
             preventive care in key areas of iowa's reform
1. We Expanded Coverage to all Kids
    Iowa's comprehensive bill accepted a bold goal that by 2011, every 
eligible child (32,000) will have health care coverage with an 
appropriation of $25 million over 3 years to ensure success. (We 
increased eligibility to 300 percent of FPL knowing that Iowa would 
have to fund most of these kids with State funds only. Hopefully, 
Congress will pass the extension of the SCHIP and share in this 
expansion).
    The legislation also requires all parents of children eligible for 
Medicaid and our SCHIP program to acknowledge whether their child or 
children are covered by insurance on the State income tax form. Besides 
Medicaid and SCHIP programs, Iowa has initiated specific prevention 
strategies for kids. This included the continuation of a model program 
Iowa developed 2 years ago:

    1st Five, a program to detect a child's developmental concerns in 
the first 5 years by preventing the need for more intensive and 
expensive care later. This program recruits primary providers to 
enhance their well-child exams to include:

    a. social and emotional development,
    b. autism, and
    c. family risk factors like depression and stress.
2. We Created Medical Homes
    This is an evidence-based practice that provides superior and more 
cost-effective, patient-centered care that can be affordable and 
sustainable (American Academy of Family Physicians model). We required 
incentives to encourage providers to offer preventive care and wellness 
treatments through primary care providers. Coordinating medical care in 
a timely manner assumes that the patient will be seen regularly. We 
tied preventive care to increased reimbursements to allow the provider 
and the patient to practice preventive care. Providers apply to become 
medical homes with emphasis on primary care as well as hospitals like 
Iowa Methodist and Mercy Hospitals in Des Moines. Private medical 
practices are now pilots for developing and implementing medical homes. 
A Medical Home Advisory Council was created to develop and implement 
standards for the establishment and operation of medical homes in Iowa.
    The Iowa legislature also created I-Smile \8\; a statewide 
prevention program for low-income children that requires a ``Dental 
Home.'' More children, including those under age 5, are receiving 
preventive services, primarily through the title V child health 
network. There has also been a significant increase in the number of 
physicians providing screenings and fluoride applications.
---------------------------------------------------------------------------
    \8\ Inside I-Smile: A Look at Iowa's Dental Home Initiative for 
Children, Iowa Department of Public Health, December 2008.
---------------------------------------------------------------------------
3. We Developed a Statewide Electronic Health System
    When it comes to fiber optics, Iowa is unique. In 1987, Iowa 
created a state-owned and statewide fiber optics system. Originally, it 
was developed for education purposes and it was connected to every 
college, university, public library and middle and high school in the 
State. Today, Iowa has approved utilizing the state-owned and statewide 
fiber-optic system, in conjunction with the private Iowa Health System 
fiber-optic system, to connect all of Iowa's 117 hospitals to this 
system. This allows Iowa to have the only statewide electronic health 
care system in America before 2010.
    The importance of electronic health records to preventive care is 
undeniable:

    a. prevents medical errors and duplicative testing,
    b. provides the consumer with direct access to their health history 
and encourages patient responsibility,
    c. encourages coordination of care between providers, and
    d. allows for medication therapy by Pharmacist.

    As most experts will profess, the establishment of the 
infrastructure will not correct the difficulty in utilizing a competent 
electronic health system. We received two grants from the FCC to 
promote the development of electronic health systems in rural Iowa. As 
a result, we established the Health Information Technology Council to 
direct the competitive approaches into a single statewide system. To 
ensure purposeful and forceful implementation of this initiative, the 
legislature mandated the establishment of a single patient 
identification number and a coordination of care document. However, 
States will need the Federal Government to provide leadership in 
privacy standards and requisite financing to implement the system.
4. We Strengthen Our Public Health and Prevention Programs
    The legislation also focused on developing partnerships with the 
private sector and local governments. The following initiatives 
continue to build a strong foundation of preventive care throughout our 
health care system:

    a. Healthy Communities Initiative.--Building on the Harkin Wellness 
grants of the past few years, Iowa has created a Healthy Communities 
initiative which funds projects as diverse as walking trails and 
pathways to better nutritional options in cafeterias.
    b. Small Business Qualified Wellness Program Tax Credit.--The 
Department of Public Health is to develop a plan, to be delivered to 
the legislature, on providing a State tax credit to small businesses 
that provide qualified wellness programs to their employees.
    c. Governor's Council on Physical Fitness and Nutrition.--The 
Governor's Council on Physical Fitness will assist in developing a 
strategy for the implementation of the statewide initiative to increase 
physical activity, improve physical fitness, improve nutrition, and 
promote healthy behaviors.
    d. Healthy Kids Act.--This act, SF 2425, with an effective date of 
July 1, 2009, establishes physical activity requirements for students 
in grades K-12. It sets out nutritional content standards for food and 
beverages sold on school grounds during the school day other than food 
provided under the school lunch program. The act also includes a 
requirement that students take first aid and CPR classes in order to 
graduate. In other legislation, we required dental and lead screenings 
prior to enrollment into kindergarten for all students.
    e. Preventive and Wellness Demonstration Programs.--Blank 
Children's hospital in Des Moines is one of 27 sites for the National 
Children's study, which is the largest ever study conducted on 
children's long-term health, with a focus on obesity. Also, the 
Medicaid population has provided useful data in a project initiated in 
2000 by former Governor Tom Vilsack that made use of pharmaceutical 
case management for patients with multiple drugs for chronic 
conditions.
    f. Improvement of Our Mental Health System.--We improved our mental 
health system by initiating emergency mental health crisis units 
throughout the State. This is the start of a comprehensive mental 
health system redesign that was initiated in 2007 and continues today. 
Steps to improve mental health and substance abuse diagnosis are 
included in this effort.
5. Prevention and Chronic Care Management
    In our reform legislation,\9\ Iowa was very specific on the role of 
prevention. We created the ``Prevention and Chronic Care Management 
Advisory Council'' to develop a State initiative for prevention and 
chronic care management and to report to the legislature by July 2009. 
The report is to provide the following:
---------------------------------------------------------------------------
    \9\ HF 2539, passed and signed into law on May 21, 2008, Division 
IX, section 51, p. 43.

    1. Recommend organizational structure for integrating prevention 
and chronic care management into the private and public health care 
systems.
    2. Coordinate care among health care professionals.
    3. Prioritize chronic conditions that have a fiscal impact to the 
State's health care programs.
    4. Involve health care professionals in identifying patients that 
could receive preventive services.
    5. Increase communication between providers and patients.
    6. Develop educational, wellness and clinical management protocols 
to be used by providers.
    7. Coordinate national standards on outcomes with best practices.
    8. Develop methodologies to align reimbursements and create 
financial incentives and rewards for providers to utilize preventive 
services.
    9. Involve all stakeholders including consumers, providers, 
insurers and other entities to sustain this initiative.
    10. Coordinate with health care technology initiatives.
    11. Involve public health researchers to develop and implement a 
sound basis for collecting data.
                               next step
    Iowa, like many other States, is proceeding with our separate 
health care reform initiatives. We know we can not do it without 
Congress and President Obama plowing the field ahead of us; but it is 
critical that both State and Federal Governments act in union with each 
other.
    While we watch your progress we ask that you watch the State's 
progress as well. During this year, legislation will be introduced to 
continue to build on our existing reforms:

    1. Create an Insurance Exchange to develop more affordable 
insurance plans for children and adults ensuring greater access to 
health care coverage.
    2. Expand the coverage for Iowa's SCHIP program to include more 
children.
    3. Allow small businesses, non-profits and cities and counties to 
join the State's health insurance pool.
    4. Allow pharmacies greater flexibility in providing information 
and medication to their patients.
    5. Increase workforce by creating a partnership with hospitals to 
expand physician residencies and nurse education services throughout 
the State, especially in rural Iowa.
    6. Expand the transparency initiatives to improve quality at 
hospitals and allow greater consumer choice.

    We are eager to be partners in any long-term solution for health 
care in this country; however, we are realistic, the final push for 
reform must come from the Federal Government.
    We are very grateful to Senator Harkin for his leadership and 
foresight in working to change the focus of our system from ``a sick 
care system to a health care system.'' All States will wait in 
anticipation of your deliberations in hopes that 2009 is the year we 
deliver on our promises to provide all Americans with universal health 
care.
                                 ______
                                 
    Appendix A.--Iowa's Historic Health Care Coverage Legislature--
                              HF2539-2008
    After more than a year of traveling the State convening meetings 
with insurance executives, labor leaders, doctors, nurses, dentists, 
pharmacists, consumers, legislators and dozens of representatives from 
industry, hospitals, clinic, and interested citizens, the Iowa 
legislature passed a historic health care program to cover all kids. It 
is life changing for 53,000 kids.
    That's the number of uninsured children in Iowa. That's the number 
of Iowa boys and girls who don't automatically go to a doctor when they 
are sick. Now, we have created new publicly subsidized programs for 
34,000 of the poorest kids, and new ``affordable'' plans for the 
remaining 19,000 kids from families who are middle income and no 
insurance. By 2011, it is our plan that all kids will have access to 
affordable health insurance.

     We appropriated $25 million over the next 3 years to 
enroll all the kids into a health coverage plan. Included with this 
financial commitment is the establishment of a council that includes 
the two former Governors. They are to design a plan to cover all kids 
and report back to the legislature for us to enact. The money is 
reserved for the kids; it is our guarantee that the money will be there 
and that health care coverage will be affordable.
     We built preventive care and chronic care management 
practices for all kids through the creation of medical homes as a way 
to deliver quality health care.
     We created a statewide electronic medical records system 
funded by hospitals, Federal assistance and State funds. This will do 
more than just process medical records electronically; we will be able 
to connect rural hospital doctors with specialist in Des Moines or the 
University of Iowa Hospitals and Clinics for immediate prognosis.
     We developed health care coverage for working adults with 
low wages; too low to participate in the company's health care plan. 
This ``premium assistance'' program will be a pilot project with the 
``direct day care workers'' who work in the nursing home industry.
     We allowed persons leaving group insurance to protect 
their coverage if they go to individual policy from being excluded due 
to pre-existing conditions. This is a small step forward.
     We created a new stakeholder's workgroup to develop cost 
containment strategies and recommend new consumer transparency 
procedures to ensure greater navigating of the consumer through the 
maze of medical costs and procedures.
     We created a consumer advocate bureau in the Insurance 
Commissioner's office to allow everyday Iowans a central point of 
contact to find answers on insurance company's policies.
     Allow individuals working for small businesses to deduct 
their health care expenses on their Federal income tax obligations. 
This will require the small business to enroll in the Federal income 
tax section 125.

    It is hard to underestimate the importance of health care reform to 
our economy and to the well-being of our kids and families. Our 
accomplishment this year is only the beginning. We have more to do; we 
have to insure low-income adults, create more small business 
initiatives, enact cost reduction strategies and develop greater 
consumer protection.

    Senator Harkin. Thank you very much, Senator Hatch, and 
thank you again for your great leadership in my home State.
    Finally, we will hear from Dr. JudyAnn Bigby, currently the 
Secretary of Health and Human Services for the State of 
Massachusetts, where she oversees 17 State agencies. In 
addition, Dr. Bigby chairs the Health Care Quality and Cost 
Council, which was created in Massachusetts in the 2006 health 
care reform law.
    Dr. Bigby received her medical degree from Harvard Medical 
School. Dr. Bigby, in no small part because the chairman of 
this full committee is from Massachusetts, we hear a lot about 
Massachusetts health care systems. Welcome and please proceed.

STATEMENT OF JUDYANN BIGBY, M.D., SECRETARY OF HEALTH AND HUMAN 
              SERVICES, MASSACHUSETTS, BOSTON, MA

    Dr. Bigby. Thank you very much, Senator Harkin. I'm very 
pleased to be here today representing Massachusetts and 
Governor Deval Patrick, and I hope I have some additional 
information to share with you about what we've done in 
Massachusetts.
    I want to thank you for your leadership on acknowledging 
the importance of prevention and the fact that we can save 
health care dollars if we focus more on that. I want to thank 
the other distinguished committee members for being here today 
and your commitment to this important topic.
    As you've mentioned, in 2006 Massachusetts enacted a health 
care reform bill that was designed to get the State toward 
near-universal coverage. Our most recent survey, which we 
announced about 6 weeks ago, demonstrates that we have 97.4 
percent of our Massachusetts residents covered, including 99 
percent of our children. With that, what we've seen is that now 
more than 90 percent of people report that they have a regular 
health care provider, and they also report that they're 
receiving preventive care at a higher rate than they were 
before health care reform.
    Health care reform in Massachusetts, though, is more than 
just a health insurance bill. The bill also includes several 
important initiatives that promote wellness and prevention and 
acknowledges the need to eliminate health disparities. In 
addition, Massachusetts has a significant history of adopting 
successful public health approaches to reduce costly risk 
factors and to promote wellness, and I'll spend some time 
talking about those as well.
    One requirement in chapter 58 was that our Mass Health 
Program, which is our State Medicaid program, collaborate with 
the Department of Public Health to implement a wellness program 
for Mass Health members. In phase I of this program, Mass 
Health developed training programs and forums to promote 
culturally appropriate communication with members about the 
importance of regular preventive care, and we've seen an 
increase in the number who are participating in prevention.
    In phase II we will implement an incentive program for Mass 
Health members, who will receive coupons for fruits and 
vegetables that they can redeem at participating grocery stores 
and farmers markets. They will also receive information on 
nutrition through these vendors and also through our WIC 
program.
    We also implemented a program within our Mass Health 
Medicaid program to promote smoking cessation by extending a 
benefit that covers individual and group counseling, nicotine 
patches, and other nicotine replacements. Since we implemented 
that program in July 2006, more than 60,000 Mass Health 
subscribers have used the benefit. In over 2 years, 15,000 
people have stopped smoking.
    Within 1 year after they stopped smoking, cardiovascular 
incidents and asthma emergency room visits declined 
significantly among the former smokers. This decrease resulted 
in a dramatic reduction of health care costs in the first year 
alone, representing direct savings to the Commonwealth.
    Beyond the initiatives directly related to health care 
reform, we restored funding for our tobacco control program and 
we've seen Massachusetts has now the lowest rate of smoking in 
its history at 16.4 percent. All the initiatives, many 
acknowledged by Dr. Fielding, we know are successful and we 
continue to implement them.
    Using the success of the tobacco control program as a 
model, the Commonwealth last month announced a new 
comprehensive approach to tackling obesity. This is the Mass in 
Motion program, which will promote healthy eating and regular 
physical activity. It includes regulatory changes to require 
that schools measure the body mass index of students in grades 
1, 4, 7, and 10 and provide parents with information about the 
significance of those measurements; and will pass regulations 
that would require fast food chain restaurants to display 
calorie information on their menus.
    The governor signed an executive order requiring agencies 
responsible for large food purchasing to follow strict 
nutritional guidelines. We've also given grants to communities 
to establish wellness initiatives at the local level, and we 
provide a workplace wellness program for public and private 
employers with a toolkit that was designed and tested by our 
Department of Public Health, and we will provide support to 
employers who want to initiate these programs.
    I'm going to move on now to talk a little bit about what 
we're doing to address racial and ethnic health disparities. 
These are widespread nationwide. In Massachusetts, while we 
generally are known for our healthy indicators, we have 
documented disparities across the Commonwealth in health 
outcomes, health care quality, and in access to care.
    In 2004 the legislature established a special commission to 
study racial and ethnic health disparities. The commission made 
recommendations in four areas: access to health care, health 
care quality and delivery, work force development and 
diversity, and also social determinants. The Patrick 
administration and the newly created Disparities Council are 
working together to model racial and ethnic disparity solutions 
that follow the recommendations put forward by the commission.
    We know that addressing health disparities requires actions 
and initiatives both inside and outside of the health care 
system, because disparities result from a variety of 
intersecting factors that range from public policy to 
individual behaviors to the design of the health care system.
    One of the things that we did, to try to get a better 
handle on what is happening within the health care system, was 
pass regulations that requires all hospitals to collect and 
uniformly report self-reported race-ethnicity of all patients. 
Beginning in July 2009, health plans will also be required to 
collect race and ethnicity data in a uniform standard. The 
State will monitor the quality of care delivered to racial and 
ethnic minorities on particular quality indicators, including 
serious reportable events, hospital-acquired infections, and 
overall hospital mortality, and expect providers to respond to 
any disparities that are demonstrated.
    We also established the Office of Health Equity within the 
Executive Office of Health and Services. This office will 
ensure that health, economic, education, environmental, 
transportation, and other policies promote health equity and 
will examine the potential impact on disparities of any new 
policies.
    Within our Medicaid program, we implemented a pay for 
performance program in acute care hospitals. This first of its 
kind in its country rewards positive outcomes based on 
established clinical measures in maternity and newborn care, 
respiratory care, surgical care, and health disparities. 
Hospitals are required to report to us how they are 
implementing established culturally and linguistically 
appropriate services, on how to operationalize practices 
designed to address the needs of racial and ethnic and 
linguistic population groups.
    This year the program will continue to assess the 
structural standards and also expand the rewards to hospitals 
who have demonstrated that they have been able to decrease 
disparities in the clinical indicators I have mentioned.
    This is just one example of a program that needs to be 
built into any of the quality monitoring initiatives that we 
are implementing at the State or Federal level.
    I want to conclude by saying we have other initiatives that 
I could talk about. They are described in my written testimony. 
I just want to underscore the importance of getting toward 
universal coverage for everyone. We've been able to demonstrate 
that it has had an impact on people's access to prevention 
services and should be the foundation for moving forward on 
this topic.
    Thank you.
    [The prepared statement of Dr. Bigby follows:]
               Prepared Statement of JudyAnn Bigby, M.D.
    My name is Dr. JudyAnn Bigby, and I am the Secretary of Health and 
Human Services for the Commonwealth of Massachusetts. I am honored to 
be here with you today to represent Massachusetts and Governor Deval 
Patrick in offering testimony before the Health, Education, Labor, and 
Pensions Committee about Massachusetts' initiatives related to wellness 
and prevention and health disparities.
    I particularly want to thank Chairman Kennedy of Massachusetts for 
inviting me to testify today and for holding a hearing on States' 
public health efforts. I also want to thank Senator Michael Enzi and 
the other distinguished committee members for their interest in and 
commitment to this important topic. I look forward to hearing your 
insights and perspectives and answering any questions you may have.
    As you know, in April 2006, Massachusetts enacted a health care 
reform bill designed to move the State to near-universal coverage. 
Thanks to Governor Deval Patrick, the Legislature and the commitment of 
a coalition of advocates, providers, business leaders, and committed 
officials in Washington like Chairman Kennedy, Massachusetts recently 
reported that 97.4 percent of our State's residents, including, as far 
as we can measure, 100 percent of children, have health insurance. We 
also know that more than 90 percent of people report that they have a 
regular health care provider and more report receiving preventive care.
    Health Care Reform, Chapter 58, was more than just a health 
insurance bill. Chapter 58 dealt with wellness and prevention, as well 
as health care disparities--all issues that the Patrick administration 
is focusing on through the design and implementation of several 
policies. Promoting wellness and prevention has begun with our Medicaid 
program, MassHealth, through a wellness incentive program and the 
coverage of tobacco replacement drugs. While health care disparities 
are addressed through a first-in-the-Nation pay-for-performance program 
for acute hospitals.
    In addition to these relatively new policies, Massachusetts has had 
significant success using public health approaches to reduce high-cost 
risk factors. The Patrick administration believes that these 
approaches, combined with our efforts to expand health care access 
throughout the State, can form a powerful model for national efforts 
towards universal health care.
Wellness and Prevention Initiatives--Health Care Reform: More Than Just 
                            Health Insurance
                      masshealth wellness program
    Section 54 of Chapter 58 requires that MassHealth collaborate with 
the Massachusetts Department of Public Health (DPH) to implement a 
wellness program for MassHealth members. It specifies five clinical 
domains: diabetes and cancer screening for early detection, stroke 
education, smoking cessation, and teen pregnancy prevention. The law 
mandates co-payment and premium reduction for members who meet wellness 
goals. However, since members do not pay significant co-payments or 
premiums, we have recommended alternative incentives.
    The MassHealth Wellness Program works with providers to design 
training programs and forums to promote culturally appropriate 
communication with members about the importance of regular preventive 
health care and health risk factors. It also provides members with 
printed materials to help them learn about healthy lifestyle choices 
and the benefits of those choices.
    The MassHealth Wellness Program, in collaboration with the 
Department of Public Health, is exploring the feasibility of developing 
an incentive program for MassHealth members participating in wellness-
related activities. The reward would consist of coupons for fruits and 
vegetables that would be used in participating grocery stores and at 
farmers' markets. Distribution of reward information and nutrition 
education would occur through the existing provider (grocery stores and 
farmers' markets) and staff networks for the WIC program.
Tobacco Control
    On the prevention front, the Mass Tobacco Control Program partnered 
with MassHealth to design, promote, and evaluate the MassHealth smoking 
cessation benefit implemented on July 1, 2006 as part of Health Care 
Reform. The benefit includes group or individual counseling by smoking 
cessation counselors and covers nicotine lozenges, patches and other 
cessation medication. Utilization data indicates that over 60,000 
MassHealth subscribers have used the benefit over the first 2 years, 
representing one in three smokers. Behavioral Risk Factor Social Survey 
(BRFSS) data indicate that between 2006 and 2007, the smoking rate in 
the MassHealth population decreased from 36.1 percent to 33.2 percent, 
an 8 percent reduction in the number of smokers. Over 15,000 MassHealth 
members quit smoking during this period.
    Preliminary data also indicate that within 1 year after quitting 
smoking, cardio-vascular incidents and asthma emergency room visits 
declined significantly for former smokers. This decrease resulted in a 
dramatic reduction in health care costs in the first year alone, 
representing direct savings to the Commonwealth.
    The latest BRFSS analysis (2006) on the correlation between health 
insurance and smoking prevalence indicates that those with private 
health insurance are half as likely to smoke as those with no insurance 
or MassHealth. There was no significant difference between MassHealth 
members and the uninsured in terms of smoking prevalence, but this data 
predates the addition of a smoking cessation benefit to MassHealth.
    It was imperative for our State to implement effective tobacco 
control. Tobacco use is the leading cause of preventable death and 
illness in Massachusetts. More than 8,000 Massachusetts residents die 
each year from the effects of smoking. And though they are not smokers 
themselves, an estimated 1,000 or more Massachusetts adults and 
children die each year from the effects of secondhand smoke. In our 
State, tobacco kills more people each year than car accidents, AIDS, 
homicides, suicides and poisonings combined.
    In addition to the price paid in lives lost, tobacco imposes a 
heavy financial burden on the Commonwealth. Smoking costs Massachusetts 
an estimated $4.3 billion each year due to excess direct health care 
costs.\1\ Each pack of cigarettes sold in Massachusetts costs the State 
an estimated $14.22 in direct health care costs.
---------------------------------------------------------------------------
    \1\ Massachusetts Department of Public Health. Smoking-Attributable 
Mortality, Morbidity, and Economic Costs (SAMMEC): Massachusetts 2006.
---------------------------------------------------------------------------
    Beyond the initiatives directly related to Health Care Reform, the 
Massachusetts Tobacco Control Program works to improve public health in 
the Commonwealth by reducing death and disability from tobacco use.
    The program has:

     a community-based smoke-free families initiative,
     a web-based youth-targeted initiative called the84.org to 
spread the message that non-smoking is actually the norm among 
teenagers,
     community smoking cessation demonstration projects 
targeting high-risk groups such as veterans and people in recovery,
     increased monitoring of youth sales--we have seen a 
decrease in the number of violations,
     produced a video targeting youth,
     initiated public information campaigns advertising our 
Quit Line and the dangers of secondhand smoke, and
     implemented a statewide ban on smoking in workplaces.

    I am happy to report there have only been a few violations.
Reversing the Rise in Obesity
    The Commonwealth has adopted a similarly comprehensive approach to 
tackle obesity through the Mass in Motion program, which promotes 
healthy eating and regular physical activity.
    More than half of the Massachusetts Adult population is overweight 
as are a third of middle and high school students. The percentage of 
the population that is overweight has been increasing steadily over the 
last three decades. It disproportionately affects low-income 
populations and residents of color. In fact, almost two-thirds of adult 
African-Americans in Massachusetts are overweight. This 
disproportionate impact is a result of a variety of policies and 
practices, which have meant that for lower income residents the most 
affordable and accessible foods are often the least healthful ones.
    Mass In Motion is a multi-faceted program that includes:

     Regulatory changes to promote healthy eating, such as Body 
Mass Index testing of Massachusetts students in public schools in 
grades 1, 4, 7 and 10, as well as menu labeling for fast food chain 
restaurants;
     An Executive order by Governor Patrick requiring Health 
and Human Services Agencies responsible for large food purchasing to 
follow strict nutritional guidelines in their food service operations. 
State purchases of food by these agencies runs into the tens of 
millions of dollars per year;
     Grants to communities to establish wellness initiatives at 
the local level;
     Workplace Wellness programs throughout the State and 
supported by a tool kit designed and tested by the Department of Public 
Health to help employees stay healthy, and businesses to be more 
productive;
     The launch of a State-sponsored Website that promotes 
healthy eating and physical activity at home, at work, and in the 
community. The objective of the Website is to provide simple, 
practical, cost-effective ways for Massachusetts' residents to:

          Improve eating habits;
          Increase physical activity;
          Ask experts questions about improving their diet and 
        physical exercise routine; and
          Get involved in helping to build healthy communities.
                    mental health prevention efforts
    The State is also exploring public health and preventative 
interventions to promote mental health and to address disparities in 
health outcomes among individuals with mental illness.
    People with mental illness experience significant health 
disparities with substantially increased risk of early death and 
significant disabling illness. Individuals with mental illness die 25 
years earlier than the general population from potentially preventable 
and high-cost diseases such as diabetes, cardiovascular disease, 
respiratory illness, and lung cancer. Other high-cost risk factors 
among individuals with mental illness include homelessness, poverty, 
unemployment, incarceration, and co-occurring substance use issues.
    The Commonwealth's Department of Mental Health is committed to 
developing comprehensive and integrated physical and behavioral health 
care. Enhanced integration of both physical and behavioral health 
results in improved health outcomes.
    As a result, the Department has an extensive community provider 
network that coordinates medical care for mental health consumers. 
Benefits include improved communications for consumers through 
coordinators attending medical appointments and having portable 
medication lists.
    The Department also has a strong partnership with MassHealth in the 
re-procurement and management of its managed care entities, which have 
clear requirements to coordinate physical and behavioral health care.
    The Department has led a 2-year demonstration pilot with Community 
Mental Health Centers and Community Health Centers at six sites across 
Massachusetts to enhance this integration. This effort has resulted in:

     the co-location of behavioral health and primary care 
services,
     a centralized intake,
     a streamlined referral process,
     on-site clinicians, and
     care managers focused on assessment and treatment of 
mental health disorders.

    The Department of Mental Health recognizes that trauma often plays 
a central role in the development of mental health and substance abuse 
problems. The Department has coupled this with recovery-focused models 
of care to ensure a more complete prevention model of treatment for 
behavioral health and substance use issues.
    The Department is recognized as a national leader in trauma-
informed care, having been the first State in the country to:

     implement trauma treatment guidelines (1998),
     develop and implement a trauma assessment to be used in 
all State facilities (1998),
     require trauma assessment for every consumer in 
psychiatric care in the Commonwealth (2006), and
     continuously develop specialized tools for youth and 
people with intellectual and developmental challenges (2001-2008).

    Many of the prevention initiatives taken at the Department of 
Mental Health have been quite successful and have the potential for 
replication on a national level.
                  racial and ethnic health disparities
    Racial and ethnic health disparities exist Nationwide. In 
Massachusetts, disparities exist throughout the Commonwealth, not just 
in urban areas. Massachusetts has disparities in health outcomes, 
health care quality, and in access to care:

     The black, non-Hispanic Infant Mortality Rate is twice as 
high as the white non-Hispanic IMR (9.4 vs. 4.3 deaths per 1,000 live 
births).
     The teen birth rate for Hispanic women is almost 6 times 
higher than for white non-Hispanics (73.2 vs. 12.9 per 1,000 women ages 
15-19 years old).
     Cambodian, Central American and African mothers are less 
likely to receive prenatal care in their first trimester compared with 
mothers in other ethnic groups. (Massachusetts Department of Public 
Health, Birth Outcomes 2007)
     Blacks have a 35 percent higher age-adjusted mortality 
rate compared to whites and nearly twice the rate of Hispanics and 
Asians.
     Blacks have higher age-adjusted death rates for heart 
disease, cancer, stroke, diabetes, HIV/AIDS, homicide, MVAs and other 
injuries. (2001 Massachusetts Department of Public Health report 
Massachusetts Health Status indicators by Race and Hispanic Ethnicity)
     Blacks have higher hospital discharge rates for 
hypertension, stroke, and cardiovascular disease.
     Blacks and Hispanics have three to four times higher rates 
for asthma discharges compared to whites. (2001 Massachusetts 
Department of Public Health report Massachusetts Health Status 
indicators by Race and Hispanic Ethnicity) In one health care setting, 
insured Blacks with diabetes were less likely than whites to be 
prescribed cholesterol lowering drugs when indicated and were less 
likely to have their diabetes well controlled (Sequist TD et al. Arch 
Intern Med 2006;166:675-81)
     In 2007, 5.7 percent of all Massachusetts residents did 
not have health insurance. However, Hispanics and Black Non-Hispanic 
residents have higher rates of uninsurance when compared to other races 
and ethnicities.
       commonwealth's approach to eliminating health disparities
    In 2004, the Legislature established a special commission to study 
racial and ethnic health disparities. The Commission issued its report 
in the summer of 2006 and aligned their recommendations into four 
categories:

    1. access to health care,
    2. health care quality and delivery,
    3. workforce development and diversity, and
    4. social determinants.

    The Patrick Administration and the Disparities Council, a council 
created as part of Health Care Reform, are working together to model 
racial and ethnic disparities solutions on the recommendation put 
forward by the Commission. We are undertaking a number of initiatives.
    We know that addressing health disparities requires actions and 
initiatives inside and outside of the health care system. Disparities 
result from a variety of intersecting factors that range from public 
policy to individual behaviors to design of the health care system. We 
must address all factors to achieve health equity.



    To address these disparities, the Patrick administration has taken 
a number of pro-active and innovative steps, including:

     Distributing $1 million in new funding to support a wide 
variety of community-based efforts to eliminate disparities. More than 
30 grants were awarded to local agencies to establish culturally and 
linguistically appropriate health care services, training programs for 
health care workers, and support systems for residents of color who 
face challenges in navigating the health care system.
     Implementing a regulation that requires all hospitals in 
the State to gather and report accurate and consistent information on 
the race and ethnicity of all patients. This first-in-the-country 
regulation is producing information that will soon be published in a 
Department of Public Health report highlighting patterns of access to 
care and identifying facilities where additional efforts are needed.
     The publication of several reports that highlight 
disparities in particular health areas--such as HIV.
     The formation of an Office of Health Equity at both the 
Department of Public Health and the Executive Office of Health and 
Human Services to insure that multiple programs and agencies adopt 
policies that target disparities.
                activities implemented under chapter 58
Pay-for Performance Program to Promote Health Care Equity
    Beginning in October 2007, MassHealth implemented a pay-for-
performance program in acute care hospitals. One of the first of its 
kind in the country, the program rewards positive outcomes based on 
established clinical measures in maternity and newborn care, 
respiratory care (including pediatric asthma control), surgical care, 
and health disparities.
    In the first year of the program, health disparities were addressed 
structurally, using established Culturally and Linguistically 
Appropriate Services (CLAS) standards to assess how widely institutions 
have operationalized practices designed to address the needs of racial, 
ethnic and linguistic population groups that experience unequal access 
to health services. This year, the program will continue to assess 
structural CLAS standards and will expand to reward hospitals that 
reduce or eliminate identifiable disparities on the clinical indicators 
by race and ethnicity.
    This promising program is only one example of how we can use 
quality-based purchasing strategies to address health disparities. I 
urge the committee to remember, as more sophisticated quality 
initiatives and pay-for-performance programs expand, that the 
elimination of health care disparities remain an essential element of 
quality in our health care system.&

    Senator Harkin. Thank you very much, Dr. Bigby. Thank you 
all for just excellent testimonies.
    We have a vote at 11:35. I'm just going to ask one question 
and we'll move on. We'll do 5-minute questions back and forth.
    Dr. Fielding, you're the chair of the U.S. Preventive 
Services Task Force and the Community Preventive Services Task 
Force. As I listened to all these people, a lot of States--of 
course some of these I know about because you're here this 
morning and I've read about what you're doing. There may be 
other States out there and localities doing interesting things 
that we don't know about.
    Does your Preventive Services Task Force have the ability 
to go out to all these different States and get input as to 
what they're doing, so you can kind of look at maybe some 
innovative things that are going on, things that are working, 
so we can get evidence-based programs for both workplace, but 
school-based and community-based kinds of programs? Do you know 
about all these things?
    Dr. Fielding. No, not about all these things. There are a 
lot of exciting things going on. What our charge is in the 
Community Preventive Services Task Force is to look at what's 
been published, primarily in peer reviewed journals, because 
that's then gone through a vetting process, and based on that 
make recommendations, what we know works or areas where there 
is insufficient evidence, or what we know does not work.
    Unfortunately, the funding has been very, very small and 
we've not covered most of the areas we would like to cover. 
We've covered a lot of them, but it's still a minority. One of 
the opportunities is to really look more carefully at the 
evidence that comes from practice, but that is not currently 
part of what we're able to do with the resources that we have. 
We're also not able to publish or disseminate the information 
in ways that are essential.
    Senator Harkin. There's no central kind of a clearinghouse 
anywhere where States could send their information, send things 
in where they have done things, where they have evidence that 
they've actually prevented illnesses or saved costs, like North 
Carolina, like Massachusetts, like Iowa?
    Dr. Fielding. I'm not aware of one place. Certainly the 
State health officers--ASTHO has a newsletter. There are things 
like that in the reports that are done from time to time. I'm 
not aware that there is a clearinghouse, but Dr. Bigby might be 
able to enlighten us on that.
    Senator Harkin. Dr. Bigby, do you know of any?
    Dr. Bigby. I'm not aware of any type of clearinghouse that 
has this information.
    Senator Harkin. It seems to me that that's something we 
ought to be looking at CDCP to be doing. We'll take a look at 
that. I'm just curious.
    Senator Burr.
    Senator Burr. Allen, if you will, you did a great job of 
describing this integration of a network and the different 
providers that fit into that network. Could you clarify for the 
committee how much per member per month does Medicaid pay those 
providers to be part of that network? I think it's a shocking 
number and I think they need to hear it.
    Dr. Dobson. Thank you, Senator, yes. We have two different 
payments. Besides the Medicare-Medicaid fee schedule, which 
North Carolina pays pretty close to Medicare for our providers, 
which helps with access, we pay the primary care doctors $2.50 
per member per month for children and $5 for the adults 
disabled.
    The more important part is that we fund to the communities 
the cost of the medical home infrastructure. We send it to the 
network. For instance, the networks get paid $3 for children 
and then up to $8 or $9 PMPM now for our aged, blind and 
disabled. It goes to discretely pay for the service, like case 
managers and infrastructure, clinical pharmacists, the wrap-
around services that put this together.
    I think the lessons we've learned, it's hard sometimes to 
just say we're going to pay physicians more or we're going to 
pay for certain services more. Having an organization who's 
accountable at the local level, as we add functions to and 
request those networks to do more, we increase those payments. 
It becomes a very accountable exchange. It's not a lot right 
now. Again, we can do more, but we've been building this 
gradually from the ground up. So we've been very, very 
conservative with the amount of money we're putting in there.
    Senator Burr. The point I wanted my colleagues to hear is 
we're all faced with a physician network, a provider network, 
that increasingly does not want to handle Medicare patients. 
Yet when they see a successful network, when they see a 
structure that works for $2.50 a month, they're willing to be 
part of it. I dare say if you increase their reimbursement by 
$2.50 a month you wouldn't get that type of a response. In its 
totality the network suggests to them here's something that 
actually accomplishes what our mission is as providers.
    Let me move to Dr. Fielding just real quick. Last Congress, 
Senator Coburn and I introduced a comprehensive health care 
bill. It was S. 1019. Included in that legislation was language 
that instructed the USDA to develop a list of foods that were 
not nutritionally sound and would not be available for purchase 
under the food stamp program.
    Now, given the extensive emphasis on obesity prevention, 
would you be supportive of a policy like that where USDA 
produced a list of items that were not nutritionally sound and 
we did not include those in the food stamp program?
    Dr. Fielding. Well, Senator, you're absolutely right that 
the food stamp program has not always helped with the solution 
to the problem of overweight and obesity. It may have 
contributed to it in some ways. I think the difficulty is that 
it's hard to look at any one particular purchase, because it 
depends on what else you're eating.
    I think it works with respect to, for example, vending 
machines in schools to say, here are the criteria for what can 
be in vending machines. I think there are certain items that 
probably might fit on that list. In many cases it's a question 
of how much, it's a question of how often. What's really 
critical is to have much more education built into the food 
stamp program and to provide incentives for those recipients to 
eat foods that are healthful and to have access to those.
    Senator Burr. Well, I heard your testimony on obesity and 
some or all touched on it to some degree. I think in all the 
testimony it was a very comprehensive approach to how we solve 
obesity. I think what I got out of it, we've got to quit 
sending a mixed signal. We've got to attack this like it's an 
epidemic. If we find it offensive that we would take a program 
that provides an individual their ability to purchase food and 
we include in that everything that we say for kids or whoever 
selectively that this is bad, then I have to ask, why would we 
do it that way?
    That overcomes every educational piece that you could go 
out and try to reinforce, because you're telling them it's bad, 
but over here you're saying, ``but we'll allow you to have the 
money to go purchase it.'' You know, if we're going to solve 
this problem we're going to have to make sure that we're 
reinforcing all of these at every aspect, and it means we're 
going to have to rethink the way we do certain programs that 
are certainly compassionate and beneficial, but let's make sure 
that they're compassionate and beneficial and healthy.
    I thank the chair.
    Senator Harkin. Senator Burr, I look forward to working 
with you on it. We have to reauthorize the child nutrition 
bill--that's the school lunch, the school breakfast, the WIC 
program--this year in the Agriculture Committee. I look forward 
to working with you on it. I feel much akin to what you're 
saying on this, that we have to rethink how we're doing some of 
these things and what we're allowing.
    We have a new ability now, as you know, under the SNAP 
program, as we call it now--it's not called food stamps because 
we don't have stamps any more. It's a credit card. With that 
stripe on the back, you can encode a lot of information. With 
those UPC codes and stuff like that, you can encode a lot of 
information. I'd like to work with you on that. We never talked 
about that.
    Senator Sanders.

                      Statement of Senator Sanders

    Senator Sanders. Thank you very much, Senator Harkin, and 
thank you for your continued efforts in the fight for disease 
prevention. Thank you all for this panel. It's been a wonderful 
panel.
    As I think we have heard today, we spend more money by far 
per capita on health care than any other Nation on Earth, and 
yet our health care outcomes are way behind many other 
countries. I think one of the reasons, Mr. Chairman, is, as Tom 
Daschle told us, who testified here just a few weeks ago, we 
have an inverted pyramid. We spend huge amounts of money on 
specialty care and yet we underfund, grotesquely in my view, 
primary health care.
    Right now, in my view we need a revolution in terms of 
primary health care in this country. Right now, among other 
things, we do not even produce and educate enough doctors, 
enough dentists, enough nurses, to get out into the rural and 
urban areas for primary care. We are entirely dependent upon 
importing people from other countries, often third world 
countries, and depleting their health care supply of 
professionals as well.
    I'm going to make a few statements that I would like folks 
to comment on, and perhaps we could start with Dr. Dobson. One 
of the things I am trying to do, and it has widespread 
bipartisan support--it started with Senator Kennedy, Senator 
Harkin's a strong supporter, President Bush a supporter--if we 
can quadruple the number of federally qualified community 
health centers, which provide good quality health care, dental 
care, low-cost prescription drugs, mental health counseling, we 
can provide community-based health care in every underserved 
area in America for all of $8 billion a year, and many of the 
studies that we read tell us that we will save substantial sums 
of money by keeping people away from emergency rooms and out of 
the hospital. We keep people healthy rather than allow them to 
go to the hospital at great expense.
    Also, what we know about these community health centers is 
you have doctors who can talk to people and educate people 
about obesity, about alcohol, about tobacco. We understand that 
one to one relationship works very, very well.
    I would like, starting with Dr. Dobson, perhaps your 
comment on what it would mean in terms of disease prevention 
and keeping our people healthy if we had a community health 
center, if we greatly expanded the National Health Service 
Corps, so we educated, we provided the opportunity for people 
to go be doctors and nurses and dentists, serve in underserved 
areas? What impact would that have on the health of the Nation?
    Dr. Dobson. Thank you, Senator. Yes--well, let me just make 
a couple comments. No. 1, I think we should look at the 
community health centers and what they do right, because we 
have funded health centers to provide the functions that the 
entire health system should be providing regardless. If you 
look at it, we fund them such that they're made whole for 
providing uninsured care. We fund them such that, and they 
actually provide those key elements of the medical home concept 
that we're talking about.
    It really is about investing in the primary care system. If 
you look at other industrialized countries, the difference is 
not necessarily how they pay for it. It's that they actually 
have a developed primary care system. I would say to you that 
to really get where we need to go we need to spend money on 
primary care and prevention, we need to train primary care 
physicians and providers differently than we do now and how we 
fund them, and we need to pay them adequately.
    So where does that money come from? Part of it is an 
investment, but another part of it is that we have to get some 
efficiencies out of our system, where we're spending money that 
we don't need to be spending and reapply it.
    Senator Sanders. Dr. Dobson, would you feel comfortable 
making the argument that investing in community health centers, 
investing in primary care, actually saves money at the end of 
the day?
    Dr. Dobson. Yes, I do. But, I don't think the community 
health system structure is the only structure for which you 
could do that. My only fear of applying a single approach to 
solving the Nation's health care systems is that we'll end up 
with a two-tiered system, because unless everyone gets their 
care through community health systems how are we going to 
assure the same quality for the rest of the population?
    I would assert to you those same functions that we need to 
put in community health centers and expanding needs to be 
funded throughout the health care system.
    Senator Sanders. Right, I would certainly agree.
    Yes, doctor--Senator Hatch?
    Mr. Hatch. Senator Sanders, thank you. I don't think we 
realize, when we talk about the safety net providers, that we 
think of our county hospitals. You've identified the community 
health centers as the safety net as well. Not only should they 
be expanded, but we have as well as the community health 
centers free clinics. In Iowa we have over 37 free clinics that 
receive and see over 150,000 patients a year. These are Iowans 
that can't and don't go anywhere else. Not only are there free 
clinics involved in our collaborative safety net provider 
network, but we have rural clinics too that are operating 
independently, most of the type with physician assistants as 
their major provider.
    On top of that, we have visiting nurses that are the only 
access that Iowans have--and I'm sure in your States, too--to 
the people who are in their homes and can't go anywhere else.
    This safety net that we're talking about is not just the 
community health centers. They are the most established and 
they are functionally the best. They provide extraordinary care 
to people who wouldn't or couldn't go to anybody else. Even 
though we should have that extended to everyone, until we have 
a true universal system we are going to be patchworking our 
health care system with these kinds of providers, and they have 
to be supported and we have to extend their opportunities.
    Senator Sanders. I certainly agree. I think we have to end 
the national, international disgrace that we are the only major 
country on Earth without a national health care program, and I 
think we have to revolutionize primary health care, keep people 
healthy, and save money. I think that's essentially what 
everyone here has been saying.
    Thank you very much, Mr. Chairman.
    [The prepared statement of Senator Sanders follows:]

                 Prepared Statement of Senator Sanders

    Thank you very much, Mr. Chairman. I want to commend you 
for holding this hearing today. Vermont is the healthiest State 
in the union, but even in Vermont, this is a relative term. 
Obesity and tobacco are the top two causes of death in Vermont 
as well as the rest of the country and is responsible for many 
preventable chronic diseases. Substance abuse and mental 
illness are chronic diseases we too often sweep under the rug 
and are often intertwined with other chronic diseases. We are 
simply falling down on the job of keeping our citizens healthy 
and clearly can't afford to wait to tackle these problems in 
the United States. Individual States are making great strides, 
but we need to ensure that all Americans have the same basic 
access to prevention and care no matter what State they live 
in. But I am optimistic that we are entering a new age, a time 
to ``remake America,'' as our new president just said.

                                OBESITY

    Obesity does not just affect the obese, it affects everyone 
because of the impact it has on the health care system, health 
care costs, and the economy. The reality is that poor and 
working-class families often live in communities where healthy 
choices for nutrition and physical activity are limited. 
Vermont is one of the leanest States with among the lowest 
obesity rates in the Nation. Of course, that still isn't saying 
much when one out of eight of our Vermont high school kids is 
obese. Several States, including Vermont, had a small amount of 
Federal funding to fight obesity, but Vermont and some other 
States just lost those programs to Federal funding cuts. 
Childhood obesity is a national epidemic, tripling in the last 
30 years and we need to reverse this trend. This is a big issue 
with many agencies from health to education to transportation 
to labor to commerce that have a role to play to solve it.

                                TOBACCO

    Vermont's network of 20 coalitions has successful 
prevention programs that reach out to youth ages 10-18, through 
TV and radio media campaigns that has reduced tobacco use from 
one in three Vermont youth to 18 percent. Investment has been 
small, but results have been substantial. And yet in Vermont 
nearly one in five adults and more than one in six of our youth 
still use tobacco.

                        COMMUNITY HEALTH CENTERS

    President Obama said the question is not whether our 
government is too big or too small but whether it works. 
Community based programs and Community Health Centers must be 
in the forefront of the new healthcare debate because they 
work. Vermont and the Nation have seen success improve health 
results with Community Health Centers, but those results are 
tenuous because funding is not strong or stable. As I've said 
before in previous hearings, it's been proven that people who 
go to Community Health Centers do better than those seen in 
other settings. We must change the healthcare debate from how 
to pay for treatment to how to prevent disease.
    One quick example: we know that a key to changing behaviors 
is to first talk about it with a health care professional. And 
we know that Community Health Centers do a much better job 
talking to people about tobacco use than private providers. 
Four out of every five Medicaid patients in health care centers 
and nearly three quarters of all patients going to health care 
centers have had their tobacco use discussed with them, 
compared to only about half of insured adults who don't use 
health centers.

                             MENTAL HEALTH

    Since the economic crisis has rapidly unfolded through the 
fall and winter of 2008, health facilities report a substantial 
spike in the number of individuals seeking mental care while 
there has been simultaneous funding cutbacks of mental health 
agencies in 32 States, including Vermont. Vermont has been a 
leader in this country on the issue of mental health parity; 
other States have looked to Vermont as a model for where they 
want to go. We understand that to be successful mental health 
work must be at the grassroots, community level.
    The health of our upcoming generation is worse than their 
parents. We need to make sure that the next generation has a 
healthy start as they head into adulthood.
    I thank you all for being here this morning.

    Senator Harkin. Thank you, Senator Sanders.
    Senator Casey.

                       Statement of Senator Casey

    Senator Casey. Mr. Chairman, thank you very much. I want to 
say first of all that I'm honored to be part of this committee 
now. This is my first hearing as a member of this committee and 
I'm grateful for that opportunity, and grateful for your 
leadership on these issues over the course of many years.
    This is an especially significant time in our Nation's 
history, not only because we're starting a new administration, 
but because I think on the issue of health care we've finally 
arrived at a point where there is a consensus. Where that 
consensus will take us we don't know yet, but we have a real 
opportunity now to confront this issue and maybe actually vote 
on a bill, a significant bill on health care.
    So we're grateful. We're thinking today, of course, of 
Chairman Kennedy and his own health, but also grateful for his 
leadership over many years and the bipartisan way that this 
committee has conducted its business, Senator Kennedy and 
Senator Enzi being good examples of that, and we're seeing that 
as well today.
    We're grateful for the testimony and witness provided today 
by those who are providing the benefit of your experience as 
public policymakers or analysts and what's happening in our 
States.
    In Pennsylvania we've had good success on a number of 
fronts. One is on, as many of you know in the States and from 
the perspective you come from, children's health insurance, a 
tremendously successful effort that started at the State level 
and then made its way to become a national program. Today in 
Pennsylvania, for example, the Cover All Kids Initiative, a 
rather new initiative within--under the umbrella, I should say, 
of children's health insurance, has shown a dramatic 
improvement in health care for children.
    As of 2008, only 4.6 percent of Pennsylvania children ages 
0 to 18 were without health insurance. We're at the top echelon 
of States in terms of coverage. We now have enrollment as of 
January of 183,891 children. That number will go up--it's high, 
it's a great number, but it will go up exponentially if the 
Senate and the House pass the children's health insurance 
legislation which will be before the Senate--actually, is 
before the Senate after work in the House. That's a great 
opportunity for our State and I think for the country.
    We have an adultBasic program which provides health care 
coverage, but the problem with that is we have a tremendously 
growing waiting list.
    With that as background, let me just get to some basic 
questions for the panel and for individuals. One concern that I 
have--there are a number of people on this panel; you can chime 
in as you see fit--about this local versus the national 
challenge we have. Many of the proposals and experiences that 
have been related today have been successes at the local and 
State level. You have a lot to be proud of and a lot to brag 
about. The problem we have here is that there's a tremendous 
need for national legislation.
    I guess I'd ask Dr. Dobson and Senator Hatch about this in 
particular. How do you see that conflict being resolved, where 
you have success at the local level--and our State is a State 
where we value local control, local control of education, local 
control of a lot of other things. We have more municipalities 
than any other State. We're going to be wrestling with this. 
How do you see that playing out when there's such a fervor and 
a consensus, I think, on taking action at the national level?
    Dr. Dobson. I think if you take the example that we've 
tried to create in North Carolina, where you establish a 
framework which then allows communities to innovate within the 
basic framework of community care and meet their needs, so it 
becomes more function-based versus regulatory controlled, and 
there becomes that shared accountability. I think the Federal 
Government has similar abilities to deal with States in a 
shared accountability, particularly in public programs, of 
saying, ``Here is what we would like to accomplish, here is how 
we would like to fund it,'' and give some shared accountability 
between the States and the Federal Government to help build 
this delivery system and get the accountability we need to save 
the money and move the system forward, because again if you 
become--it becomes like some of our demonstration projects and 
some of our--within CMS.
    By the time we have got them constructed to study them, 
they become almost unsuccessful because you're not able to 
adapt to the local conditions and changing environment for when 
you start something. I think there has to be some flexibility 
between the Federal Government and the States in this shared 
ownership.
    We almost provided too much flexibility in the Medicaid 
program. We have programs operating so, so differently. I think 
that, at least for Medicare and some of the public programs, 
there can be this shared accountability of the Federal 
Government and the States to move the system forward.
    Senator Casey. Senator Hatch.
    Mr. Hatch. Senator Casey, thank you. I'm going to answer 
this as an elected official. Like yourself and the other 
members here, I ran on the basis that I was going to provide 
universal coverage to my constituents. I've been doing that for 
20 years, and I suspect that most of you have been doing that 
for your entire life as well.
    There may be a fervor to do something nationally, but there 
is an absolute recognition on the States that we don't and 
can't wait any longer, and that States have to move on their 
own. It was Massachusetts that opened the door, literally 
allowed us to believe that we could do that. As Massachusetts 
so boldly entered the universal coverage politics, we then said 
we could do it, and you see an array of opportunities.
    I've had the privilege over the last couple of months to go 
to three or four national conferences, talk about it with 
people from Hawaii, Wyoming, North Carolina, Florida, Texas, 
New Mexico, every State, and they all are anxious to do 
something.
    I'm going to give you four areas of reform that my 
colleagues nationally have kind of put together in an informal 
way. The first kind of guiding principle is that we have to 
stabilize the financing through a payment reform. We have to 
reform the payment structure--not change it, not tinker it, but 
it's got to be a revolutionary reform in how our providers are 
paid, what they're paid for.
    Second, we have to increase cost containment policies. 
States are trying to save money in containing costs, but it's 
difficult in the politics to ask your hospitals to save money, 
who are trying to get their providers to save money when they 
aren't getting reimbursed enough, and we're trying to force 
mandates on them because we know our constituents need it.
    We have to have a completely new sense of cost containment 
initiatives. Part of that is the national medical records 
standards, a patient identifier number, and a document of 
coordination. It also needs to share data across State lines.
    The third area is absolutely increase access and affordable 
insurance coverage. We have to commit that everybody in this 
country deserves health coverage and health care, and it's not 
for some; it's for everybody. We have to have a complete system 
that does it. That's why universal coverage in my State and 
Massachusetts and other States have focused, not on the single 
payer system, but on the fact that everybody deserves it. It is 
not a privilege any more. It is a right, just like public 
education.
    That means we have to have flexible laws with ERISA and we 
have to negotiate with insurance companies on pre-existing 
condition exemptions and on the guarantee issues.
    Then last, something your State is well known for is 
increasing quality. The transparency of our health care system 
has to be open. Hospitals, doctors, government, and patients 
have to have a better standard for where we operate and we have 
to have complete access to that transparency.
    If we do those kinds of things, if we have shared 
decisionmaking between the provider and the patient, then the 
patient has more shared responsibility. They are now required 
to participate, and if they don't participate, if they think 
they can go only when they get sick, then we haven't done our 
job.
    Those are the four kind of general areas that States and 
the Federal Government have to proceed with.
    Senator Casey. Thank you very much.
    [The prepared statement of Senator Casey follows:]

                  Prepared Statement of Senator Casey

    Thank you Mr. Chairman and I'd like to say at the outset 
what an honor it is to be here today as a new member of the 
HELP Committee. I have a profound commitment to the issues that 
fall within this committee's jurisdiction and I look forward to 
working together with my colleagues on issues of vital 
importance to the American people. So I thank Chairman Kennedy 
for his unparalleled leadership over these many years and you, 
Mr. Chairman, and Senator Enzi for setting a standard of 
effective collaboration. I am proud to be a member of this 
team. I also thank you, Mr. Chairman, for calling this hearing 
and bringing together such a distinguished panel of State and 
national experts regarding what we can learn from ongoing State 
initiatives.
    We all know we are in a time of change--significant and 
challenging change. We've all heard the statistics--the U.S. 
currently spends nearly 18 percent of its GDP on health care, 
more than any other nation, and yet for all that money, we 
still have poorer health than most developed countries and even 
some developing countries. As we embark on a new era of hope 
and change and responsibility, our health care system tops the 
list of priorities.
    I know this committee, and the Finance Committee, have been 
hard at work on putting together a comprehensive health care 
reform initiative. But as today's witnesses will testify, many 
States--rightfully--have not been able to wait for the Federal 
Government in order to begin moving forward on their own health 
care reform initiatives. The lessons we can learn from States 
that have pushed forward on these initiatives are invaluable. 
It is encouraging to hear that States like Iowa, Massachusetts, 
and many others, including Pennsylvania, are all coming to 
similar conclusions about what is truly necessary and what 
works for genuine health care reform.
    In Pennsylvania, the Cover All Kids initiative has shown 
dramatic improvement in health care for children. As of 2008, 
only 4.6 percent of Pennsylvania children age 0 to 18 were 
without health insurance, which puts Pennsylvania near the best 
in this respect among the States.
    Pennsylvania's CHIP enrollment increased to 183,891 in 
January. This was more than a 10 percent increase since January 
2008. Also, there were 10,774 children enrolled in CHIP in 
January who would not have been eligible before the Cover All 
Kids expansion.
    The economic situation in Pennsylvania and nationwide has 
deteriorated in the last six months and this is reflected in 
the recent acceleration of monthly increases in Pennsylvania 
CHIP enrollment. Fortunately, no limitations have been imposed 
upon CHIP enrollment in Pennsylvania to date.
    The increase in demand for Pennsylvania's adultBasic 
program has been even more dramatic. AdultBasic provides 
coverage to adults who cannot obtain health insurance and is 
currently 100 percent State funded; adultBasic enrollment has 
been limited due to available funds, and efforts are being made 
to bring this Pennsylvania program under a Medicaid waiver to 
allow coverage for more adults who do not have health 
insurance. The adultBasic waiting list is now growing at 10 
percent per month.
    While there are unique aspects to many of the State 
initiatives, there is a clear and emerging consensus around the 
value of prevention for issues such as tobacco use and obesity, 
the importance of addressing chronic conditions including 
mental illness and substance use disorders, the significance of 
wellness programs, the importance of coordination of care 
through medical homes and of course, the necessity of providing 
health care coverage for all our citizens, especially our 
children.
    But as I know the experts will tell us, and as we are 
learning in PA and elsewhere across this country, increased 
health care coverage must go hand in hand with prevention, 
wellness and cost savings measures.
    One of the things I know we will hear a lot about this 
morning--and probably already have--is that our health care 
system is focused upon treating people after they are sick, not 
focused on preventive care that keeps people healthy. I know 
there has been great progress in many States to change this 
focus--to truly focus upon the health and wellness of our 
citizens--and I believe that is the only way we will truly 
transform our health care system into what it can and must 
become in the 21st century.
    So thank you again Mr. Chairman, thank you to our 
distinguished witnesses, and I look forward to hearing more 
this morning.
    Senator Harkin. Senator Hagan.
    Senator Hagan. Thank you, Mr. Chairman.
    Since this is a prevention meeting, talking about 
prevention health care, my question is relating to educational 
programs for children in school, whether there are any programs 
that are currently ongoing that have a curriculum-based 
nutrition education format. I know there are some piecemeal, 
but whether any school system actually has a K-12 curriculum-
based nutritional education program.
    I think if we can educate our youth on this issue, years 
from now we'll be a lot better off from an obesity standpoint.
    Dr. Fielding, I know you commented some on that issue to 
start with, and I was just curious.
    Dr. Fielding. I'm not aware that there is a comprehensive 
integrated K-12 curriculum. In general, our findings in the 
Community Prevention Services Task Force in most areas is that 
education alone probably doesn't do it. Education can be very 
useful, but only as part of a more comprehensive approach.
    For example, in Los Angeles County we've worked with the 
local school board, a very large one with 700,000 students, to 
change what's in the vending machines and to change the 
standards for what is in the school nutrition. If you do that 
and then at the same time try and make sure that kids are 
really getting good physical education, physical activity, and 
after-school programs and the like, I think that can work. I'm 
not sure that the education alone is sufficient.
    The other point is that we realize that we have to think of 
the life course trajectory. We need to really start almost in 
the prenatal period. We know now that some of the things that 
happen prenatally affect adult diseases. We have to have it all 
the way through there, through breastfeeding, through what goes 
on in the preschools. Preschools, for example; we haven't 
really focused a lot on the meals that they serve and the 
nutrition, what they consider, ``nutrition.''
    It requires that, and it does require, I think, looking at 
the incentives. What are the incentives in agriculture? What 
are the incentives? What kind of marketing can be done to 
children? As I said, $1.6 billion is spent marketing to 
children from different foods, most of which are high in things 
that we wouldn't like them to be high in.
    I think it takes that broad approach, because there's not a 
magic bullet here, unfortunately. Everything is interconnected. 
Senator Casey made the point about SCHIP. Well, it's being 
funded by a 61-cent increase in tobacco excise tax. That's 
going to help our tobacco problem. That's going to reduce 
initiation among youth and that's going to increase cessation 
among smokers. There are ways of marrying what can be good 
policy in one area to what can be good policy in another.
    Senator Hagan. Mr. Chairman, I personally feel that's 
hitting one area a little bit too hard for this program, but 
that's a different day.
    One of the issues that we've done in North Carolina is to 
take the transfat out of the school lunches. We also passed 
legislation having to do with what's available in vending 
machines during the school day in elementary, lower and middle 
school, and especially not having soft drinks and things like 
that.
    Mr. Chairman, if I might ask one more question.
    Dr. Dobson, the electronic medical records. I know that in 
some of the community health centers in North Carolina that 
they have very extensive electronic medical records, especially 
from the standpoint of disease management. I was just wondering 
if you had any suggestions on how that's helping from keeping 
people out of the emergency rooms, helping with their care. 
Ultimately, I know it's an expense in getting it together and 
putting it together, but I think long-term it will help with 
care and cost savings. Can you elaborate on any of that, 
please?
    Dr. Dobson. Yes. I think that my personal perspective on 
electronic records, we absolutely have to have them. It will 
require State and national leadership because having the 
records alone doesn't accomplish the goal. You have to actually 
share the information. It really is about saying what do we 
need to do, how do we get our practices at the local level to 
change from just dealing with the person as I see them to 
thinking about all my diabetics, all my asthma patients, what 
are our patients and our community needing, and sharing that 
data between the local providers.
    There are some issues around when we're trying to integrate 
mental health services with medical services. We have 
significant barriers for the right kind of exchange. It's going 
to take Federal and State leadership to do more than just put 
electronic records out there. It's really dictating how we use 
them.
    Senator Harkin. Thank you very much, Senator Hagan.
    Senator Hagan. Thank you, Mr. Chairman.
    Senator Harkin. A vote has started, but we have 15 minutes. 
We have plenty of time for the distinguished Senator from 
Oregon, Senator Merkley.

                      Statement of Senator Merkley

    Senator Merkley. I thank you very much, Mr. Chair. I really 
appreciate this hearing. I think that it's widely understood 
that the best dollar we have in health care is a dollar spent 
on prevention, on disease management, and therefore we need to 
do a whole lot more in that area.
    Also, I think your testimony as a panel reflects that the 
States have been the laboratory in this area, and that we have 
a lot of ideas to share between the States and also to provide 
input to national health care efforts, which this is a very 
exciting time right now, and I look forward to working under 
Senator Kennedy's leadership this year that we might achieve 
that goal of universal coverage.
    Oregon, like many States, has been experimenting. School 
nutrition, as in North Carolina, has been a big factor. School 
exercise; establishing smoke-free buildings, commercial 
buildings and public buildings throughout the State; having 
very strong tobacco prevention programs.
    I thought I'd mention that we have a real choice housing 
program, designed to stabilize the mentally ill because if 
they're homeless it's very hard to address health care issues. 
Some of your testimony goes to that.
    I wanted to ask a couple questions and I'll ask for very 
quick responses within the time so we can get to this vote. The 
first is, there's a new product being marketed in Oregon called 
``Snus,'' and it is designed largely to appeal to the young. 
We're very concerned about tobacco addiction through this 
product. It comes in different flavors, candied flavors and so 
forth.
    Do you have any comment on this or any familiarity with it?
    Dr. Fielding. I'm not familiar with that product, but I 
think it raises the issue that there are a number of products 
that have been focused on youth and there's been a lot of 
marketing of those products, and that's why I and others feel 
that there needs to be an increased form of regulation so that 
we don't have these other products that try and slide in and 
that can unfortunately get kids hooked.
    Senator Merkley. Yes, please?
    Mr. Emmet. I think you can also extend that to alcohol use. 
There are any number of products that are intended to appeal to 
younger drinkers, and we know that starting substance use at an 
early age often leads to much greater problems later on in 
life, to alcohol abuse and substance abuse. Again, appealing to 
people at a young age is certainly detrimental to their health.
    Senator Merkley. Anyone else familiar with this ``Snus'' 
issue?
    [No response.]
    Well, I certainly would draw it to your attention as 
something that merits--I'm sure what's coming to Oregon may be 
coming to your State soon. In part, it's a response to the 
success we've had in changing the culture on smoking. This is 
more of a chew type product.
    Something I wanted to ask about is breastfeeding. In Oregon 
we passed what I think was really a national model bill about 
having hospitable workplaces for women to continue to return to 
work and to be able to continue breastfeeding. All the 
nutritional experts that we had testify said that this is 
really one of the best things, that we have this miracle drug 
for children called breast milk and shouldn't we be working a 
lot harder.
    Is this something that you have paid attention to and are 
interested in?
    Dr. Fielding. Yes. In my testimony I did suggest, but went 
over very quickly, that promotion of breastfeeding is one of 
the things we know can be very effective as part of an effort 
not only to improve nutrition overall, but to help control over 
time the high rates of overweight and obesity. There are many 
benefits, and there are also mental health benefits of having a 
breastfeeding program.
    We have done quite a bit in Los Angeles County and Los 
Angeles City to try and promote this, and also trying to reduce 
the impact of the give-away of formula and asking hospitals not 
to do that and to really promote breastfeeding. We have been 
pushing that with hospitals, because that's really where a lot 
of decisions get made.
    I really applaud what's occurred in Oregon.
    Dr. Bigby. Senator Merkley, I also appreciate your raising 
this issue. It's a great example of how the intersection of 
health care policy and other outside of the health arena 
intersect. The biggest barrier to women breastfeeding and 
continuing to breastfeed for the recommended amount of time is 
actually their returning to work----
    Senator Harkin. That's right.
    Dr. Bigby [continuing]. And the lack of leave, paid leave, 
for pregnancy and postpartum. If we want to promote 
breastfeeding we also have to look at the types of policies 
that promote women being able to take a reasonable leave after 
birth.
    Mr. Hatch. Senator, the University of Iowa's hospital and 
clinic has a program of a breast milk bank, which the 
legislature also provides financing for, to store breast milk 
for women and for children--for children that will need it when 
their mothers can't provide it.
    Senator Merkley. I will provide to you all a copy of what 
we did in Oregon. We worked closely with the business community 
for businesses with 25 or more employees to be able to 
establish standards for an area and a strategy in which women 
would find it much easier to express milk at work and be able 
to continue breastfeeding.
    With that, my time has expired. Thank you, Mr. Chair.
    Senator Harkin. Thank you very much, Senator Merkley. Also, 
I thought maybe you were going to talk a little bit about the 
great work that Portland has done in providing the kind of bike 
paths and walking paths for people to get to work and places 
where you put your bicycle. I have not seen it; I've just read 
about it, and my brother, who lives out there, says it's one of 
the best things he's ever seen, what Portland has done.
    Senator Merkley. I invite you to come to Oregon. I'd love 
to show you that first-hand.
    Senator Harkin. I'd like to see it.
    Senator Burr.
    Senator Burr. Mr. Chairman, Dr. Dobson referenced in his 
opening statement that the State of North Carolina had filed 
for a 646 waiver with Medicare to begin to include dual 
eligibles and high-risk Medicare beneficiaries in Community 
Care. That program was approved last week by CMS, the waiver 
was approved.
    I want to point out for the committee members--and it gets 
at the heart of what I think all our panelists have said--that 
when we start to get ahead, all of a sudden we get knocked 
back. There's a likelihood that that approval of that waiver 
will get held up with the Administration's new order for all 
waivers that were granted in the last several weeks to stop.
    I hope my colleagues, after hearing this, will work with me 
to distinguish for the Administration. This waiver when granted 
offers an opportunity for North Carolina to save $1.4 billion 
over the next 5 years, and a lot of that money comes out of the 
Federal share of what goes into the delivery of health care to 
those targeted individuals.
    I thank the chair.
    Senator Harkin. I'm sure our former colleague Senator 
Daschle, who is about to take over--he's been away because of 
an illness in his family, but I'm sure this is something that 
he would like to work with us on. Let me know and I'll be glad 
to work with you on it, Richard.
    Well, we have a vote in progress now and we're going to 
have to leave. I have a lot more questions and just dialogue 
that I could engage with all of you on, but I think if I just 
might say in closing, I thank you all for your great 
leadership.
    The record will stay open for 10 days for questions from 
committee members that may be submitted to you in writing. 
Again, just to pick up I think where Dr. Fielding started, and 
that is that we have to think about prevention and wellness as 
a lifetime type of thing. It's not one point in time that you 
do it. Prevention starts before birth, to make sure that every 
expectant mother has the proper nutrition, and cutting down on 
smoking and alcohol and making sure that every baby that is 
born has the ability to get nutritious mother's milk one way or 
the other, whether it's directly or through a food bank, 
working with workplaces to make sure that people who go back to 
work--my daughter lives in your county and just had her second 
child not too long ago, and her workplace provides 
breastfeeding places and places where they can pump. It's just 
wonderful. But not everybody does that, and we have to figure 
out how we do this nationally.
    Then school-based programs. We haven't even talked about 
school-based programs really. I mentioned briefly with Senator 
Burr about the reauthorization of the child nutrition bill this 
year, getting better foods in our kids for kids in school.
    One of you mentioned exercise programs. Who was it that 
mentioned exercise at school? Did you do that, Jack, in Iowa?
    Mr. Hatch. Yes.
    Senator Harkin. The legislature passed a mandate that you 
have to have physical exercise programs K through 12. That's 
probably not been implemented yet. I don't know.
    Mr. Hatch. It starts July.
    Senator Harkin. Of this year?
    Mr. Hatch. Yes.
    Senator Harkin. I'll look forward to that. We've got to 
start thinking about that also; and fruits and vegetables in 
schools, which I've been pushing. School-based programs; 
workplace-based programs for small employers, how they can do 
that along with the big ones. We've got to put the incentives 
in. If there are tax breaks, there are tax incentives, we've 
got to think about how we do those things for workplaces and 
community-based programs.
    I look around, there's a lot of communities in this country 
that are doing interesting things. I mentioned Portland being 
one that I just happen to know about because I have family 
members that live out there. Other cities and places are doing 
things. I'm familiar with some of the things we've done in 
Iowa, Senator Hatch, with community-based programs and things 
like that, simple things.
    One community worked with the grocery store in their 
community and with the medical community and they got the 
grocery store to put little arrows, a heart, and it's ``Heart 
Healthy,'' along every aisle, so that a shopper going through 
would look at it and say: ``Oh, this is heart healthy.'' Of 
course, you go down the candy and the potato chip aisle and the 
like and you don't see any of that. I mean, it's a subtle way 
of letting people know that this is good for you. From my talks 
with people there, it has really changed some of the buying 
habits of the people as they go through the grocery stores.
    Some of these things, you think of them and you say, 
``Well, that just makes sense.'' But not everyone's doing it, 
and we have to think about this comprehensively.
    Community wellness programs, providing--and transportation. 
I tried in the last transportation bill, I offered an amendment 
that said that any entity that gets Federal money through 
transportation for streets and roads and things like that had 
to incorporate in their planning and architecture bike paths 
and walking paths. Now, I didn't say they had to do it. I just 
said they had to put it in their planning.
    I lost that amendment. We're up in 2010 and I'm not going 
to lose it this time. Just things like that. You mentioned 
that, Dr. Fielding, about transportation and how sidewalks to 
schools, sidewalks in neighborhoods, lights, things like that, 
that encourage people.
    I don't mean to go on about this, but a lot of times when I 
talk about prevention and wellness people say: ``Well, that's a 
personal responsibility; people have got to take care of 
themselves.'' Well, I believe that. That is true. So much of 
our society is set up to inhibit you from doing the things that 
you know should be done, whether it's taking walks in the 
neighborhood or climbing stairs that are hidden and dark and 
you can't find them anywhere, healthy foods.
    Nothing is more frustrating than to travel and you go 
through an airport and the only thing you can find are fatty, 
high sodium. Once in a while you can find salads, but most of 
it is junk food in the airport. Everything is against you 
trying to be healthy. Kids in schools now, the vending 
machines, soda pop, high fat, high sodium foods in our schools 
for kids.
    No matter how hard you try--you really have to try hard to 
be healthy in this country. You shouldn't have to do that. It 
ought to be easy. It ought to be one of the easiest things you 
do--to eat healthy, work healthy, play healthy, be healthy. It 
ought to be something that we just engender. That's how I see 
this whole health care debate unfolding, that we just have to 
incentivize it, provide the incentives in there. Sometimes 
that's money, sometimes it's support, sometimes it's changing 
laws, partnerships, State, local, Federal Government. It can be 
tax laws, changing tax provisions.
    I sit here and I see this moment in time when we can do 
this. We can really make prevention and wellness the 
centerpiece of our health care reform, so people in America 
start thinking about it. If you talk about health care reform 
to the average American out there, they think of one thing: How 
am I going to pay the bills? Am I going to get insurance 
coverage so I can pay the bills if I get sick? We've got to 
start having people think anew about, how am I going to be 
healthy, how am I going to maintain my health, how are my kids 
going to be healthy, and start getting that paradigm shift--
that's a well-worn word around here, ``paradigm shift''--get 
that shift in thinking in this country, in the supportive 
things that we need to go along with it.
    We have this moment in time to do this right now. People 
are ready. We know it saves money. We have good documentation 
from a lot of States on the money that you're saving out there, 
North Carolina, Massachusetts, Iowa, and we can take these 
examples.
    Last, I just want to say one thing, Mr. Emmet. You know, so 
many of our physical ailments start with mental illness. We 
know that. It's been well-documented. The biggest single factor 
in young women dropping out of college are eating disorders, 
which start with mental health problems. A lot of these mental 
health problems we know start early in life. They start in 
grade school and in high school. And we're not paying attention 
to it.
    Some of these kids come from tough homes, tough 
neighborhoods, and they don't get the kind of supportive 
environment that higher income kids, for example, might get at 
home. We have to think about the mental health of our kids. It 
may start with something very small when they're a child and 
then it eats away and it eats away and it eats away through 
grade school, through high school. It then relates to substance 
abuse, tobacco abuse, alcohol abuse, all that kind of stuff, 
which leads to all other kinds of chronic illnesses.
    We have to focus on the mental health conditions again of 
our kids in schools and how by getting to that early on, and 
even adults, that a lot of times you can solve a lot of our 
physical ailments in this country. That's got to be a part of 
this wellness. Think of mental health as wellness and 
prevention as a part of this whole endeavor.
    Well, that's my speech anyway. You're all leaders in this 
and I just encourage you to keep going and give us the benefit 
of your wisdom, your knowledge. I mean it sincerely. You are 
doing great things out there in these States, and we've got to 
incorporate these. We've just got to incorporate these into 
what we're doing, so that we have this collaboration between 
the Federal, the State, the local, the private, and the public 
sector and we can put all this together.
    Well, I thank you all very much for all your great 
leadership in this. Like I said, we'll leave the record open 
for 10 days. I've got 2 minutes left. I can make it.
    Thank you all.
    [Additional material follows.]

                          ADDITIONAL MATERIAL

                 Prepared Statement of Senator Kennedy

    The Nation is facing a worsening health care crisis that 
demands our immediate attention. As a nation, we spend $2 
trillion a year on care, yet one in two Americans suffer from 
chronic diseases that decrease quality of life and increase 
health costs. Estimates indicate that close to 200 million 
Americans alive today will have a chronic illness, and that $1 
in $4 will soon be spent on health care. Without basic reform, 
the burden and the cost of treating these chronic conditions 
will not be sustainable for future generations.
    In order to end this crisis, we need to deal with the 
factors that lead to the development of chronic disease. Poor 
diet, physical inactivity, smoking, and alcohol use account for 
38 percent of deaths related to chronic disease among 
Americans. In particular, the lack of good nutrition and the 
lack of exercise have led to unprecedented increases in the 
rates of obesity. About one in three adults and a staggering 
one in six children and adolescents in the United States are 
obese, and are therefore at increased risk of diabetes, heart 
disease and other chronic conditions. Tobacco use leads to 
conditions such as lung cancer, chronic obstructive pulmonary 
disease and heart disease, which are estimated to cost Fortune 
500 companies $157 billion each year.
    Many factors lead to chronic disease, but it is estimated 
that 75 percent of health care expenditures associated with 
these conditions are preventable. Prevention and early 
detection of such diseases is obviously a critical aspect of 
health reform. One-hundred thousand lives could be saved each 
year through the use of five basic services that include taking 
daily aspirin, putting an end to smoking, screening for 
colorectal disease and breast cancer, and immunization for 
influenza. Early detection of mental health and substance use 
disorders will lead to reduced symptoms and enhanced quality of 
life. For every dollar spent on initiatives to increase 
physical activity, improve nutrition and prevent smoking, a 
total of $5.60 can be saved in health costs. Even though a 
great deal is known about the power of prevention, less than 5 
percent of all health expenditures are spent on prevention.
    Prevention initiatives also need to address economic, 
social and physical issues that often make it difficult for 
people to make healthy choices. Limited access to healthy food 
and neighborhoods that are not conducive to physical activity 
can prevent Americans from making healthy choices, especially 
in low income and minority communities that suffer a 
disproportionate burden of chronic disease and are less likely 
to have preventive services available. By providing such 
services, we can significantly improve the health of Americans 
and significantly reduce health costs.
    Many States are exploring a number of innovative prevention 
initiatives to combat the effects of chronic illness on their 
residents. In Massachusetts, the combined cost of treating 
chronic diseases and the loss in productivity is $34 billion a 
year. In response, the Massachusetts Office of Health and Human 
Services initiated the ``Mass In Motion,'' a multi-faceted 
program that includes regulations to promote healthy eating and 
physical activity, grants to cities and towns to make wellness 
initiatives a priority, and a new Website to give residents 
advice on how to make healthy eating and physical activity part 
of their daily lives. This is one of the many important 
initiatives we will hear about today that focus on reducing the 
burden of chronic disease on our people.
    We look forward to hearing about those prevention 
initiatives as we work on health reform. Chronic disease can 
affect all Americans, and we need to focus on the steps we know 
will work best. The power of prevention is an essential element 
of health reform--the best way to address the unsustainable 
increase in health costs related to chronic conditions is to 
prevent the conditions in the first place. I commend Senator 
Harkin for chairing this important hearing and for emphasizing 
that prevention must be one of the principal pillars of overall 
health reform.
     Prepared Statement of Douglas McCarthy and Kimberly Mueller*, 
                   Issues Research, Inc.--Case Study
    ABSTRACT: Community Care of North Carolina (CCNC) is a public-
private partnership between the State and 14 nonprofit community care 
networks. The networks comprise essential local providers that deliver 
key components of a ``medical home'' for low-income adults and children 
enrolled in Medicaid and the State Children's Health Insurance Program. 
Community-based delivery systems promote the development of locally led 
approaches that leverage resources and relationships to meet statewide 
goals. Local networks and primary care physicians receive supplemental 
funding for care management and quality improvement initiatives 
supported by statewide performance measurement and benchmarking 
activities. Results suggest that the program has yielded cost savings 
while promoting improvements in care of patients with chronic 
conditions. CCNC's experience may be relevant to other States 
considering how to improve primary care case management programs, or 
how to better address the needs of low-income individuals in areas that 
lack effective mechanisms for coordinating care.
---------------------------------------------------------------------------
    * The authors gratefully acknowledge Chris Collins, M.S.W., program 
consultant for Community Care of North Carolina, and Anne Braswell, 
senior analyst and HealthNet program manager, North Carolina Office of 
Rural Health and Community Care, both of whom kindly provided 
information for the case study. We also thank L. Allen Dobson, M.D., 
vice president for clinical practice development at Carolinas 
Healthcare System and formerly assistant secretary in the North 
Carolina Department of Health and Human Services, and other staff at 
the CCNC central office who provided feedback on a previous draft of 
the case study. The authors also thank the staff at The Commonwealth 
Fund for advice on and assistance with case study preparation. 
Editorial support was provided by Joris Stuyck.
    This study was based on publicly available information and self-
reported data provided by the case study institution(s). The 
Commonwealth Fund is not an accreditor of health care organizations or 
systems, and the inclusion of an institution in the Fund's case studies 
series is not an endorsement by the Fund for receipt of health care 
from the institution.
    The aim of Commonwealth Fund-sponsored case studies of this type is 
to identify institutions that have achieved results indicating high 
performance in a particular area of interest, have undertaken 
innovations designed to reach higher performance, or exemplify 
attributes that can foster high performance. The studies are intended 
to enable other institutions to draw lessons from the studied 
institutions' experience that will be helpful in their own efforts to 
become high performers. It is important to note, however, that even the 
best-performing organizations may fall short in some areas; doing well 
in one dimension of quality does not necessarily mean that the same 
level of quality will be achieved in other dimensions. Similarly, 
performance may vary from one year to the next. Thus, it is critical to 
adopt systematic approaches for improving quality and preventing harm 
to patients and staff.
---------------------------------------------------------------------------
                                overview
    In August 2008, the Commonwealth Fund Commission on a High 
Performance Health System released a report, Organizing the U.S. Health 
Care Delivery System for High Performance, that examined problems 
engendered by fragmentation in the health care system and offered 
policy recommendations to stimulate greater organization for high 
performance.\1\ In formulating its recommendations, the Commission 
identified six attributes of an ideal health care delivery system 
(Exhibit 1).



    Community Care of North Carolina (CCNC) is 1 of 16 case study sites 
that the Commission examined to illustrate these six attributes in 
diverse organizational settings. Exhibit 2 summarizes findings for 
CCNC. Information was gathered from staff in the CCNC central office 
and from a review of supporting documents.\2\ Although case study sites 
varied in the manner and degree to which they exhibited the six 
attributes, all offered ideas and lessons that may be helpful to other 
organizations seeking to improve their capabilities for achieving 
higher levels of performance.\3\


                       organizational background
    Established in 1998, CCNC is a public-private partnership that 
provides key attributes of a primary care ``medical home'' and 
population-based care management for more than 800,000 low-income 
adults and children enrolled in Medicaid and the State Children's 
Health Insurance Program (SCHIP). CCNC is a community-based delivery 
system that builds on and enhances the State's Medicaid primary care 
case-management program, known as Carolina ACCESS, which has been in 
operation since 1991.
    CCNC has grown from a pilot project into a program encompassing the 
entire State through 14 local community care networks (Exhibit 3) that 
cover geographic areas ranging from a single county to a region 
comprising 27 counties (one network includes provider sites dispersed 
among counties throughout the State). Networks were developed by local 
physicians and other Medicaid providers through a request-for-proposals 
process initiated by the State. This State-local partnership is 
structured to leverage local resources and relationships to meet local 
needs and promote local responsibility for systemwide principles of 
collaboration, population health management, and accountability.


    Each local network is a nonprofit organization that facilitates a 
partnership among essential local providers including hospitals, 
primary care physicians, county health and social service departments, 
and other key stakeholders that vary from network to network (e.g., 
county medical societies, which help build relationships with 
specialist physicians). Several networks also include State-designated 
Local Management Entities that oversee and coordinate the provision of 
local mental health, developmental disability, and substance abuse 
services.
    About 3,000 physicians in 1,200 primary care practice sites 
currently participate in CCNC networks statewide, representing about 
half of North Carolina's primary care practices. Physicians contract 
with the State's Department of Medical Assistance to participate in 
Carolina ACCESS, then contract with a local community care network to 
participate in CCNC. Key participation requirements include providing 
primary preventive care services, assuring 24-hour coverage, 
coordinating the use of specialty care, and participating in care 
management and quality improvement activities.
    The State of North Carolina partners with the program to provide 
resources, information, and technical support, such as analyzing 
Medicaid claims data and sponsoring statewide audits for performance 
measurement and benchmarking purposes. The North Carolina Office of 
Rural Health and Community Care serves as a central program office 
under the sponsorship of the State's Department of Health and Human 
Services. The North Carolina Foundation for Advanced Health Programs, a 
nonprofit organization, also provides staffing and grant-funding 
opportunities.
    The State pays local networks $3.00 per member per month (PMPM) to 
cover the cost of network management activities, including the salaries 
of a full-time program director, a part-time medical director, full- or 
part-time consultant pharmacists, and a team of care managers. Network 
management fees are intended to be competitive with those charged by 
commercial disease management vendors for similar services. Some 
networks also receive grant monies for specific initiatives relevant to 
their respective enrolled populations.
    Physicians are paid on a fee-for-service basis (fees are set at 95 
percent of Medicare rates), supplemented by an additional $2.50 PMPM 
for medical home and population-management activities. This 
supplemental funding helps providers take a more active role in 
managing the health needs of their patient populations, for example by 
providing preventive care services and identifying patients in need of 
care management.
                         information continuity
    Many physician practices participating in CCNC have not yet 
implemented electronic medical records. To encourage adoption, 
Community Care plans to use savings from other initiatives to promote 
the adoption of health information technology among local essential 
providers. In the interim, CCNC is partnering with Blue Cross Blue 
Shield of North Carolina on a statewide electronic prescribing 
initiative. The CCNC central office will provide educational, 
technical, and grant support to help participating practices adopt the 
technology to transmit prescriptions electronically and thus improve 
administrative efficiency and patient safety. Some local networks are 
developing related information technology solutions. For example, one 
network provides its physicians with handheld computers that include 
tools for promoting cost-effective drug prescription.\4\
    Care managers throughout the program use a secure, Web-based case 
management information system (CMIS) to help coordinate the care of 
enrollees. The system includes modules for patient information such as 
diagnoses and service use derived from claims data; reporting on 
guideline compliance at the individual and population levels; patient 
assessment and care planning to document problems, goals, and 
interventions provided; and secure messaging among care managers. The 
CCNC central office supplements the CMIS with additional data derived 
from Medicaid claims to help identify patients with target conditions 
and measure service use. Data derived from chart audits are used for 
measuring process and outcome quality to assess performance.
   care coordination and transitions: toward greater accountability 
                     for total care of the patient
    CCNC's care management activities are designed to help mitigate the 
long-term medical and financial risks from poorly controlled chronic 
diseases. Local community care networks hire case managers who work in 
concert with primary care providers (``medical homes'') to identify 
patients who will benefit most from targeted care management 
interventions, such as patients making repeated ER visits; patients 
diagnosed with asthma, diabetes, or heart failure; and patients who 
have two or more chronic conditions (including mental health 
conditions) with high service use or activity limitations indicating 
complex care needs. Care managers identify high-risk patients through 
the CMIS and from case-identification lists provided by the CCNC 
central office, notifications of admissions provided by hospitals, and 
physician referrals.

     Care managers assist in patient education and follow-up to 
promote treatment adherence and support lifestyle changes, help 
patients coordinate their care and access needed services, and collect 
data on process and outcome measures. During home visits, for example, 
care managers assess medication use for review by a consultant 
pharmacist and provide feedback to primary care physicians when 
patients are not adhering to their treatment regimen.
     Care managers also assess the psychosocial needs of 
patients and address barriers to care such as communication or 
transportation needs. For example, care managers may assist patients in 
scheduling follow-up appointments and by facilitating access to 
community-based services for behavioral health care, housing and 
shelter aid, or vocational and family support when needed.\5\
     A care-transitions program is currently under development 
as part of the chronic care initiative to help reduce hospital re-
admissions among patients with complex chronic illness. In the 
Cumberland Network, for example, care managers based in the hospital 
coordinate directly with hospital staff to facilitate patient 
transitions to the community.

    Each case manager is responsible for monitoring a population of 
3,000 to 4,000 Medicaid patients (all patients are assigned to a case 
manager regardless of their current need for service), typically 
managing an active caseload of 150 to 200 patients. Because care 
managers may coordinate care for patients across multiple physician 
practices, they seek to develop personal relationships with physicians 
in the network so that they can effectively communicate about patient 
needs.\6\ To ensure consistency across the system, CCNC network leaders 
and program staff collaborated to develop the Standardized Case 
Management Plan, which offers benchmarks and guidelines for care 
management activities and reporting across networks. The plan includes 
action steps for network coordinators and case managers, as well as 
strategies for characterizing service intensity levels.
    CCNC contracts with Area Health Education Centers (AHECs) to 
conduct randomized chart reviews of a representative sample of patients 
seen in each participating practice to assess compliance with care 
management guidelines. The clinic receives feedback from this audit to 
help improve the delivery of care. Local providers generally view the 
activities of the case managers as offering added value to the services 
provided by the practice. In a recent study of innovations in rural 
primary care management, physicians commented positively that care 
managers ``add tangible benefits for the patient that the provider does 
not have time to offer.'' \7\
              peer review and teamwork for high-value care
    Clinical directors elected by each regional network meet regularly 
to select targeted diseases or care processes for improvement. The 
group adheres to certain guiding principles in selecting a quality 
improvement initiative (Exhibit 4). The group reviews and identifies 
relevant best-practice models, creates network-wide quality 
initiatives, defines outcome and process measures, and rolls them out 
to local practice sites. Outcome data may include utilization measures, 
while process data may include periodic assessments or treatment 
planning. Claims databases and regular chart reviews provide a source 
for collecting and monitoring these data. Clinical areas targeted for 
improvement statewide include asthma, diabetes, and heart failure, 
along with appropriate use of medications (specific initiatives will be 
described in the next section).


    Local medical management committees implement these statewide 
initiatives, along with their own, locally developed initiatives, using 
a rapid-cycle quality improvement model. Local clinical directors work 
with peers in the community to support and encourage quality 
improvement efforts. Networks covering multiple counties may also 
designate part-time physician ``champions'' to work with physician 
practices in each community. Some networks also employ quality 
improvement ``coaches'' to assist in practice redesign efforts, 
although this is not yet a systemwide undertaking.
    All CCNC networks work together with the State to define, track, 
and report performance measures. Clinical directors choose performance 
measures that are evidence-based best-practice guidelines and can be 
measured using existing data sources, such as Medicaid claims and chart 
audits. CCNC physicians receive a quarterly practice profile detailing 
their performance on utilization and disease management measures, such 
as total costs per member per month and rates of asthma 
hospitalizations and diabetes control.
                         continuous innovation
    The public-private partnership and community-based delivery model 
promotes the development of targeted initiatives that can be developed 
in a flexible manner to meet local, regional, or statewide needs, and 
the benefits of these initiatives can be shared among the networks.
    Asthma Initiative. The asthma initiative supports physicians in: 
(1) improving routine identification, assessment, and severity staging 
of asthma to determine appropriate treatment; (2) reducing unintended 
variations in care through adherence to national practice guidelines; 
(3) educating patients, families, and school personnel in asthma 
management; and (4) reporting outcomes. Program results reported by 
CCNC appear promising.

     Since the program's inception in 2004, there has been a 21 
percent increase in severity staging and a 112 percent increase in the 
administering of flu shots to asthma patients. More than 90 percent of 
staged patients are using appropriate medications.
     Between 2003 and 2006, asthma-related hospitalizations 
decreased 40 percent, from 2.6 to 1.5 admissions per 1,000 member-
months, and emergency visits decreased 17 percent, from 13.2 to 11.0 
visits per 1,000 member-months (Exhibit 5).



    Diabetes Initiative. The diabetes initiative promotes the use of 
the American Diabetes Association's Clinical Practice Recommendations, 
along with tools to support their implementation. Case managers are 
trained to work with physicians to educate patients in disease self-
management, targeting those at highest risk. CCNC reports increases in 
the provision of some chronic care services, such as blood lipid 
testing, which was received by 66 percent of diabetics in 2004 as 
compared with 77 percent in 2005.
    An analysis of diabetes outcomes found that in 2006, on five of six 
measures, CCNC met or exceeded a benchmark set by the National 
Committee for Quality Assurance's Diabetes Physician Recognition 
Program (Exhibit 6).\8\ For example:

     Forty-seven percent of CCNC diabetes patients achieved 
optimal control of their blood sugar (hemoglobin A1c less than 7 
percent), versus the benchmark of 40 percent.
     Fifty-six percent of CCNC diabetes patients achieved 
optimal control of blood cholesterol (LDL-C less than 100 mg/dL), 
versus the benchmark's 36 percent.



    In a locally developed refinement of this statewide initiative, 
Cabarrus County established a disease management center and registry to 
sharpen their focus on diabetes. The registry tracks process and 
outcome measures including hemoglobin A1c, blood pressure, eye, and 
foot exams, regardless of patients' coverage. Practices use the data to 
evaluate and improve the delivery of care, as well as to compare the 
care received by Medicaid and uninsured patients with that provided to 
privately insured patients.\9\
    Prescription Advantage List. The prescription advantage list (PAL) 
is a voluntary drug list developed by CCNC clinical directors and the 
North Carolina Physicians Advisory Group in cooperation with the State. 
The list ranks drugs within therapeutic categories (by highest 
frequency and opportunity to impact quality and cost) to encourage the 
use of less-expensive drugs, including generics and over-the-counter 
medications, whenever appropriate. CCNC providers receive quarterly 
feedback on a PAL scorecard showing the percentage of prescribed PAL 
drugs and the use of over-the-counter medications for their enrolled 
population. CCNC reports that this program has been associated with 
lower overall pharmacy spending and annual savings of nearly $1 million 
by the State.\10\
    Nursing Home Polypharmacy Initiative. The initiative reviewed drug 
regimens of 9,000 nursing home Medicaid patients and made 
recommendations to physicians in order to optimize overall drug 
management and reduce costs where appropriate. These efforts led to 
more than 8,000 recommendations, 74 percent of which were implemented, 
and an estimated $9 million in cumulative savings since 2002, according 
to program figures. CCNC reports that this effort improved patient 
health care through reduction of drug duplications and adverse drug-
drug interactions.
    In addition to these statewide initiatives, local community care 
networks undertake their own targeted initiatives. For example, 
AccessCare--a statewide network with the largest registry of pediatric 
Medicaid patients in the State--engaged in a quality improvement 
intervention for gastroenteritis that reduced hospital admissions to 
levels substantially lower than those of a control group. Key 
components of the intervention included expert-led physician education 
on evidence-based care, peer-to-peer teaching and sharing of tools and 
resources, and performance feedback.\11\
                    easy access to appropriate care
    Medical Home. Each CCNC enrollee selects or is assigned a personal 
primary care provider who serves as a ``medical home.'' This role 
extends to providing acute and preventive services and facilitating 
patient access to care through specialty referrals and after-hours 
coverage. Some networks work with their medical homes to increase 
after-hours and weekend availability. Providers in Pitt County, for 
example, created a community pediatric after-hours clinic staffed by a 
pediatrician and medical residents offering services during the evening 
hours every day of the year.\12\
    CCNC engages patients in the medical home model through an 
educational campaign called ``The Right Call Every Time: Your Medical 
Home.'' The campaign touts the value of preventive services and 
continuity of care with the same practice. In addition to distributing 
patient-education materials that inform patients of the benefits of a 
medical home, providers and care managers work with patients on 
shifting triage toward the primary care setting and away from the ER 
when appropriate.
    Mental Health Integration. In the last 2 years, four CCNC networks 
have worked with State mental health agencies and local management 
entities to pilot a model for integrating mental health care into 
routine medical care. This program seeks to better manage Medicaid 
enrollees with co-occurring behavioral and physical health needs, and 
to serve them in the most appropriate setting by: (1) providing 
education, resources, and support to primary care physicians to 
increase their comfort level in identifying and treating depression in 
their patients; (2) improving communication and coordination between 
primary care physicians and behavioral health care specialists; and (3) 
implementing a system of standardized screening and assessment tools 
and evaluation measures.
    The Mental Health Integration pilot has led to several 
communitywide mental health planning efforts and to a grant program to 
help offset the start-up costs involved in co-locating mental health 
professionals in primary care sites. Another pilot innovation is 
``reverse co-location,'' which creates access to preventive primary 
care in behavioral health practices. To promote this complex change in 
practice (a much more difficult undertaking than traditional clinical 
practice improvement), CCNC is participating in the statewide ICARE 
Partnership (www.icarenc.org), which brings stakeholders together to 
help break down barriers between disciplines and to address policy 
issues such as discrepancies in payment and regulations.
    HealthNet Collaborative Networks. Under the State's HealthNet 
program, CCNC networks are partnering with local safety-net providers 
and indigent care programs (such as free clinics and reduced-fee 
programs offered by community and rural health centers and public 
health departments) to create integrated networks of care for uninsured 
adults.\13\ The goal is to leverage CCNC's case management capabilities 
and physician pool to increase the number of uninsured with a medical 
home, improve accessibility and quality of care, and promote continuity 
of coverage regardless of the funding source. By creating a single 
triage process to assess and meet the needs of low-income individuals--
who often alternate between periods of eligibility and ineligibility 
for Medicaid coverage--an integrated program helps assure that patients 
receive appropriate care while also conserving free care and other 
resources to serve more of those in need.
    The State provides technical assistance and funding to support 16 
HealthNet collaborative networks that serve uninsured adults with 
incomes up to 200 percent of the Federal poverty level. Local networks 
set eligibility criteria and operating parameters based on local 
resources and capabilities. The HealthNet program will reach about 
45,000 uninsured adults in 27 counties during its first year, with 
plans to expand to 10 more counties in the coming year. The CCNC case 
management information system is being updated with software 
functionalities used by indigent care networks for enrollment and 
referral, managing provider commitments, and tracking service 
utilization and value of care provided for the uninsured population.
                       recognition of performance
    In addition to the results of the specific interventions described 
above, Exhibit 7 discusses areas where CCNC is achieving higher levels 
of performance.


                      insights and lessons learned
    CCNC was created to enhance and build upon North Carolina's 
existing primary care case management program through community-based 
organized delivery systems that could manage large populations. Primary 
care providers working alone simply did not have the tools, 
information, or support to manage care for the State's many Medicaid 
beneficiaries with complex medical and social problems. Under the CCNC 
program, these community health partners have come together in 
partnership with the State to employ a population health management 
approach in existing practice arrangements.
    This system of care was created through an evolutionary, 
collaborative process involving State officials, physician leaders, and 
professional organizations. According to University of North Carolina 
professor of family medicine Beat Steiner, M.D., M.P.H., and his 
colleagues, some of the factors contributing to the success of this 
statewide system include visionary and sustained leadership, a strong 
State infrastructure to oversee the program, starting small to 
demonstrate success at a local level, and disseminating best practices 
through pilot programs. The perceived external threats of possible 
Federal funding cuts and outside interference from commercial insurers 
also motivated physicians to try a new approach.\17\
    Stakeholders shaped the program around five key principles: (1) a 
public-private partnership that unites and strengthens local essential 
providers; (2) physician leadership and local control; (3) a focus on 
quality of care and population health management; (4) shared State/
local responsibility; and (5) shared incentives. Steiner and colleagues 
point out that this federated organizational structure enables 
statewide collaborative learning while also promoting local physician 
participation and stronger linkages with the community than would be 
likely under a more centralized approach. While local control helps 
communities respond to local needs, it also means that quality 
improvement remains variable across the State.
    Participation in local community care networks can empower primary 
care physicians, whose role in the health system is often undervalued 
in traditional care arrangements. ``Doctors can come to the table to 
meet with other players and offer input [on how to improve care],'' 
says Chris Collins, M.S.W., a program consultant to CCNC and formerly 
an executive director of a local network, who notes that this ``gives 
them a voice to drive change from the bottom up.'' Giving physicians an 
opportunity for involvement increases their motivation to engage in 
network quality improvement initiatives, she says.
    Current challenges affecting CCNC's future development, according 
to Steiner and colleagues, include the adequacy of the network 
management fee to fund effective care management for high-risk 
populations, the need to extend care coordination to include not just 
primary care physicians but subspecialists who treat patients with 
complex care needs, the ability to parlay focused quality improvement 
initiatives into larger practice re-design efforts that can lead to 
transformative system-level change, and the limitations of current data 
systems in supporting robust outcomes measurement. Comparison to other 
case study sites suggests that CCNC could realize further improvements 
through structural interventions such as the adoption of electronic 
health records and the ``advanced access'' model of patient scheduling, 
which can reduce patient waiting times and increase practice 
efficiency.
    CCNC's experience may be relevant to other States considering how 
to improve the effectiveness of primary care case management programs, 
or how to better address the needs of Medicaid and SCHIP patients in 
areas that lack effective mechanisms for coordinating and improving 
care. Savings gained from an improved coordination of care could be 
used to help fund public program enrollment expansions. How the 
financial and clinical results achieved in North Carolina would compare 
with outcomes attained in other State Medicaid programs with 
alternative forms of managed care (such as those that contract with 
private health plans) remains a question for further evaluation.
    In summary, local community care networks are a central element in 
the strategy to provide access to quality health care for low-income 
citizens of North Carolina. A community-based approach to implementing 
enhanced primary care case management appears to be promoting broad 
physician participation and making more effective and efficient use of 
resources to help improve population health.
                                 Notes
    1. A. Shih, K. Davis, S. Schoenbaum, A. Gauthier, R. Nuzum, and D. 
McCarthy, Organizing the U.S. Health Care Delivery System for High 
Performance (New York: Commonwealth Fund Commission on a High 
Performance Health System, Aug. 2008).
    2. Information on CCNC was synthesized from a telephone interview 
with Chris Collins, M.S.W., program consultant for Community Care of 
North Carolina; e-mail communication with L. Allen Dobson, M.D., vice 
president for clinical practice development at Carolinas Healthcare 
System and formerly assistant secretary for health policy and medical 
assistance in the North Carolina Department of Health and Human 
Services, and with Beat Steiner, M.D., M.P.H., professor of family 
medicine at the University of North Carolina at Chapel Hill; feedback 
from staff in the CCNC central office; a review of supporting documents 
including those on the CCNC Website (www.communitycarenc.com); reports 
of the State Division of Medical Assistance; and the following 
publications or presentations: S. Wilhide and T. Henderson, Community 
Care of North Carolina: A Provider-Led Strategy for Delivering Cost-
Effective Primary Care to Medicaid Beneficiaries (Washington, DC: 
American Academy of Family Physicians, June 2006); R. Arora, J. Boehm, 
L. Chimento, et al., Designing and Implementing Medicaid Disease and 
Care Management Programs: A User's Guide (Rockville, MD: Agency for 
Healthcare Research and Quality, Mar. 2008); D.L. Hewson, ``Improving 
Medicaid Quality and Controlling Costs by Building Community Systems of 
Care,'' presented at the Medical Homes Summit of the National Academy 
for State Health Policy and the Patient-Centered Primary Care 
Collaborative, Washington, DC, July 2008; D.L. Hewson, ``The North 
Carolina Experience,'' presented at ``Communities Connect: Putting the 
Pieces Together,'' a conference held in Seattle, WA, June 2008. Other 
sources are noted below.
    3. A summary of findings from all case studies in the series will 
be found in D. McCarthy, K. Mueller, J. Wrenn, et al., Organizing for 
Higher Performance: Case Studies of Organized Delivery Systems. Series 
Introduction and Methods (New York: The Commonwealth Fund, Nov. 2008).
    4. S. Wegner, presentation at the workshop ``Appropriate Drug Use 
and Prescription Drug Programs: Adding Value by Improving Quality,'' 
sponsored by the Agency for Healthcare Research and Quality, Denver, 
CO, Nov. 5-7, 2001, http://www.ahrq. gov/news/ulp/pharm/pharm7.htm.
    5. P. Silberman, S. Poley, and R. Slifkin, Innovative Primary Care 
Case Management Programs Operating in Rural Communities: Case Studies 
of Three States (Chapel Hill, N.C.: Cecil G. Sheps Center for Health 
Services Research, University of North Carolina, Jan. 2003).
    6. B. Steiner, A.C. Denham, E. Ashkin, et al., ``Community Care of 
North Carolina: Improving Care Through Community Health Networks,'' 
Annals of Family Medicine, July/Aug. 2008 6(4):361-67.
    7. Silberman, Poley, and Slifkin, Innovative Primary Care, 2003.
    8. Steiner Denham, Lashkin, et al., ``Community Care of North 
Carolina,'' 2008.
    9. L.A. Dobson, Jr., and T.L. Wade, ``Cabarrus County: A Study of 
Collaboration,'' North Carolina Medical Journal, May/June 2005, 
66(3):234-36.
    10. Mercer Government Human Services Consulting, Letter to Mr. 
Jeffrey Sims, State of North Carolina Division of Medical Assistance, 
Aug. 2005. Available at www.communitycarenc.com.
    11. A.J. Zolotor, G.D. Randolph, J.K. Johnson, et al., 
``Effectiveness of a Practice-Based, Multimodal Quality Improvement 
Intervention for Gastroenteritis Within a Medicaid Managed Care 
Network,'' Pediatrics, Sept. 2007 120(3):e644-e650.
    12. C.F. Willson, ``Community Care of North Carolina: Saving State 
Money and Improving Patient Care,'' North Carolina Medical Journal, 
May/June 2005 66(3):229-33.
    13. Information on HealthNet was obtained from Anne Braswell, 
senior analyst and HealthNet program manager, North Carolina Office of 
Rural Health and Community Care.
    14. K. Lurito, Mercer Government Human Services Consulting, Letter 
to Mr. Jeffrey Sims, State of North Carolina Division of Medical 
Assistance, Sept. 2007. Available at www.communitycarenc.com.
    15. T.C. Ricketts, S. Greene, P. Silberman, et al., Evaluation of 
Community Care of North Carolina Asthma and Diabetes Management 
Initiatives: January 2000-December 2002 (Chapel Hill, N.C.: University 
of North Carolina, Apr. 2004).
    16. Ash Institute for Democratic Governance and Innovation, 
Community Care of North Carolina Honored as Innovations in American 
Government Award Winner (Cambridge, Mass.: John F. Kennedy School of 
Government, Sept. 2007), http://www.innovationsaward.harvard.edu/
AnnieECasey.cfm.
    17. Steiner, Denham, Lashkin, et al., ``Community Care of North 
Carolina,'' 2008.
    [The committee will be adjourned subject to the call of the 
chair.]


