[Senate Hearing 111-360]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 111-360

    ACCESS TO PREVENTION AND PUBLIC HEALTH FOR HIGH-RISK POPULATIONS

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

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                                   ON

    EXAMINING ACCESS TO PREVENTION AND PUBLIC HEALTH FOR HIGH-RISK 
                              POPULATIONS

                               __________

                            JANUARY 27, 2009

                               __________

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


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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

               EDWARD M. KENNEDY, Massachusetts, Chairman

CHRISTOPHER J. DODD, Connecticut     MICHAEL B. ENZI, Wyoming,
TOM HARKIN, Iowa                     JUDD GREGG, New Hampshire
BARBARA A. MIKULSKI, Maryland        LAMAR ALEXANDER, Tennessee
JEFF BINGAMAN, New Mexico            RICHARD BURR, North Carolina
PATTY MURRAY, Washington             JOHNNY ISAKSON, Georgia
JACK REED, Rhode Island              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

                       TUESDAY, JANUARY 27, 2009

                                                                   Page
Harkin, Hon. Tom, a U.S. Senator from the State of Iowa, opening 
  statement......................................................     1
Lavizzo-Mourey, Risa, M.D., M.B.A., President and CEO, Robert 
  Wood Johnson Foundation, Princeton, NJ.........................     4
    Prepared statement...........................................     6
Stevens, David M., M.D., Director of the Quality Center and 
  Associate Medical Director, National Association of Community 
  Health Centers, Bethesda, MD...................................    12
    Prepared statement...........................................    13
Meit, Michael, M.A., M.P.H., Principal Research Scientist for 
  NORC at the University of Chicago and Deputy Director of the 
  NORC Walsh Center for Rural Health Analysis, Chicago, IL.......    15
    Prepared statement...........................................    17
Butler, Robert, M.D., President and CEO, International Longevity 
  Center--USA, New York, NY......................................    21
    Prepared statement...........................................    23
Hagan, Joseph F., Jr., M.D., F.A.A.P., Clinical Professor of 
  Pediatrics, University of Vermont College of Medicine, 
  Burlington, VT.................................................    24
    Prepared statement...........................................    26
Iezzoni, Lisa I., M.D., M.Sc., Professor of Medicine, Harvard 
  Medical School and Associate Director of the Institute for 
  Health Policy at the Massachusetts General Hospital, Boston, MA    30
    Prepared statement...........................................    32

                          ADDITIONAL MATERIAL

Statements, articles, publications, letters, etc.:
    Kennedy, Hon. Edward M., a U.S. Senator from the State of 
      Massachusetts..............................................    56
    Coburn, Hon. Tom, M.D., a U.S. Senator from the State of 
      Oklahoma...................................................    57

                                 (iii)

  

 
    ACCESS TO PREVENTION AND PUBLIC HEALTH FOR HIGH-RISK POPULATIONS

                              ----------                              


                       TUESDAY, JANUARY 27, 2009

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 9:02 a.m. in Room 
SR-385, Russell Senate Office Building, Hon. Tom Harkin 
presiding.
    Present: Senators Harkin, Sanders, Casey, and Merkley.

                  Opening Statement of Senator Harkin

    Senator Harkin. Good morning. The Senate Committee on 
Health, Education, Labor, and Pensions will come to order.
    The committee, as you know, is holding a series of hearings 
as we gather testimony in helping us craft comprehensive 
healthcare reform for this year.
    This morning, we will be hearing from a distinguished panel 
of witnesses about access and how we improve access for 
preventive care and wellness and public health for vulnerable 
populations--groups that have been traditionally neglected and 
underserved, including people with disabilities, people who 
live in rural areas, our senior citizens, children, and 
especially those who live in poverty.
    Last month, looking ahead to this task of drafting this 
comprehensive reform, Senator Kennedy asked me to chair the 
Prevention and Public Health Working Group. I am convinced that 
this has got to be the central focus of any reform legislation 
because we will never get these costs under control until we 
place a major new emphasis on wellness and disease prevention, 
while strengthening America's public health system.
    We are in the early weeks of America's great debate about 
national healthcare reform. I have laid down a public marker of 
my own, saying that 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.
    Well, I will lay down a second marker this morning. If we 
fail to seize this unique opportunity to expand access to 
preventive services and public health for vulnerable, high-risk 
populations, then that, too, would be a terrible failure.
    We must seize this unique moment to rectify some of the 
most outrageous inequities and pockets of neglect in our 
healthcare system. It is a matter of simple justice. It is also 
a matter of basic economics.
    Because when citizens from these vulnerable, high-risk 
populations show up at the emergency room with late-stage 
illnesses because of chronic neglect and lack of preventive 
care, then we all pay, and we all pay more.
    I look forward to hearing from our witnesses, getting their 
best thinking about expanding access to prevention and public 
health. We have six highly respected witnesses. I will take my 
opportunity to kind of introduce them all right now, and then I 
will call upon them individually for their testimony.
    Dr. Risa Lavizzo-Mourey is the president and CEO of the 
Robert Wood Johnson Foundation, a private philanthropic 
organization whose goal is to improve the health and healthcare 
of all Americans.
    Under Dr. Lavizzo-Mourey's leadership, the Robert Wood 
Johnson Foundation has targeted a set of high-impact 
priorities, including improving patient care and strengthening 
State and local public health systems and halting the rise in 
child obesity by 2015.
    I was also pleased to learn that Dr. Lavizzo-Mourey still 
practices at a Federally Qualified Community Health Center, the 
Chandler Clinic, in New Brunswick, NJ.
    Dr. David Stevens is director of the Quality Center and 
associate medical director of the National Association of 
Community Health Centers, also a research professor in the 
Department of Health Policy at the George Washington University 
School of Public Health and Health Services.
    Dr. Stevens is also a member of the Commissioned Corps of 
the U.S. Public Health Service, and he continues to provide 
clinical care at a Federally Qualified Health Center which 
serves Prince George's County and Southern Maryland.
    Mr. Michael Meit serves as the principal research scientist 
for NORC, the National Opinion Research Center, at the 
University of Chicago. At NORC, he is also the deputy director 
of the NORC Walsh Center for Rural Health Analysis, responsible 
for NORC projects in the area of rural health, public health, 
and preparedness.
    Mr. Meit recently finished a term on the National Advisory 
Committee for Rural Health and Human Services, and he currently 
chairs the National Rural Health Association's Rural Public 
Health Interest Group.
    Dr. Iezzoni is not here right now but I will introduce her 
anyway.
    Dr. Iezzoni is professor of medicine at Harvard Medical 
School and associate director of the Institute for Health 
Policy at the Massachusetts General Hospital in Boston. Dr. 
Iezzoni studies healthcare quality, delivery systems, and 
policy issues relating to persons with disabilities.
    In 2006, she co-authored a book, ``More Than Ramps: A Guide 
to Improving Healthcare Quality and Access for People with 
Disabilities.''
    Dr. Robert Butler is president and CEO of the International 
Longevity Center and professor of geriatrics at the Brookdale 
Department of Geriatrics and Adult Development at Mount Sinai 
Medical Center in New York City. Of course, we all know Dr. 
Butler was the founding director of the National Institute on 
Aging at the National Institutes of Health.
    Finally, Dr. Joseph Hagan. Dr. Joseph Hagan is a clinical 
professor of pediatrics at the University of Vermont College of 
Medicine. It kind of looks like Vermont out there today, now 
that I think about it.
    [Laughter.]
    Dr. Hagan has received numerous awards for teaching and for 
clinical medicine, also served as an advisor to the Vermont 
Department for Children and Families. He is a fellow of the 
American Academy of Pediatrics and serves on a number of 
committees and as liaison to the Centers for Disease Control 
Task Force on Community Preventive Services for the academy.
    Thank you for being here today.
    Well, as I have said before that prevention and public 
health is the missing piece--has been the missing piece in 
healthcare reform for far too long. We need to guarantee that 
our most vulnerable, high-risk populations have equal access to 
preventive services and public health.
    This is an extraordinarily important hearing. I appreciate 
the witnesses for being here. I thank you for your wonderful 
written statements. They will all be made a part of the record 
in their entirety.
    At the outset, I just want to say two things. First, I hope 
that we can continue to consult with you as we proceed over the 
next weeks and months in developing this. I want my staff to be 
working with you, and to the extent that I can also personally 
work with each of you, to make sure that what we are talking 
about this morning doesn't just get left behind, that we fully 
integrate this into our healthcare reform.
    And second, just to say that we had to move the hearing up 
because the Appropriations Committee meeting is at 10:30 a.m., 
and I am going to have to leave about that time. If we are not 
quite finished, I might ask one of my colleagues to take over 
the chair for the remainder of that hearing if they are not on 
Appropriations Committee at that time.
    We thank you all for being here and for all of your great 
work in all of these areas of prevention and wellness for so 
long.
    I will start with you, Dr. Lavizzo-Mourey, and we will just 
go down in that order.
    Dr. Butler is just walking in the room. Hi, Bob. How are 
you? Sorry about the weather out there.
    [Laughter.]
    Don't tell me you walked?
    Dr. Butler. Yes.
    Senator Harkin. He walks everywhere. Alright. Bob, I just 
introduced you, so I am not going to introduce you again.
    We will start with Dr. Lavizzo-Mourey. If you could just 
sort of sum up? I read your summaries also last night. They are 
great summaries. If you could just give us about 5 minutes of 
the most important things you think we ought to think about so 
we can at least have some discussion before 10:30 a.m.
    Dr. Lavizzo-Mourey. Absolutely. Thank you.
    Senator Harkin. Thank you very much.

 STATEMENT OF RISA LAVIZZO-MOUREY, M.D., M.B.A., PRESIDENT AND 
       CEO, ROBERT WOOD JOHNSON FOUNDATION, PRINCETON, NJ

    Dr. Lavizzo-Mourey. Good morning, and thank you. I want to 
thank Chairman Kennedy and Ranking Member Enzi and, of course, 
you, Senator Harkin, for the invitation to speak to the 
committee on these important issues of prevention and public 
health among our most vulnerable populations.
    As you have already mentioned, in addition to being the CEO 
of the Robert Wood Johnson Foundation, I have the privilege of 
working at a community health center. This center provides care 
to many people who are low-income vulnerable people and have 
many chronic illnesses.
    As I care for these people, I often think to myself 
wouldn't it have been better if our system had been able to 
prevent the illnesses that we provide care for at that setting?
    Certainly, as Congress considers this important opportunity 
to expand coverage--and that must be a priority--I am, as you 
have already mentioned, so thrilled that you are considering 
other areas, like quality, reducing spending, and improving the 
capacity of our public health system to make people healthier 
by focusing on social determinants of health that actually will 
allow us to prevent disease and promote health.
    You have often spoken of ``sickcare'' and how our system 
needs to move from a focus on sickcare to healthcare, and I 
certainly agree with that and applaud you. These challenging 
times give us an opportunity to take unprecedented steps to 
invest in more prevention and public health that can help our 
population stay healthy in the first place.
    Now improving health and investing in preventive services 
makes good fiscal sense. A recent report by Trust for America's 
Health has found that even small strategic investments in 
proven community prevention programs can result in dramatic 
savings.
    An investment of as little as $10 per person per year in 
programs that increase physical activity, improve nutrition, 
and reduce tobacco use can save $16 billion over 5 years for 
our country, and that is savings to Medicare, Medicaid, and 
private payers. Clinical prevention services, such as childhood 
immunizations, also play a critical role in keeping us healthy.
    Disease prevention and health promotion must be a priority, 
but this is an area that has largely been ignored or 
chronically underfunded at the Federal, State, and local 
government levels. As you consider health reform proposals, I 
urge you to increase stable funding and incentives for both 
community-based programs and clinical preventive services.
    An important first step is being taken now by Congress and 
the administration under your leadership, Senator Harkin, to 
increase the investment in prevention in the Economic Recovery 
and Investment Act, and this unprecedented investment will pay 
off.
    However, there are a tremendous number of promising and 
successful efforts to improve health and prevent disease in 
schools, neighborhoods, and workplaces across the country that 
are reaching the most vulnerable populations where they live, 
work, learn, and play. I have provided many examples in my 
written testimony, but I would like to just highlight a few for 
you that show how people are engaging populations at school, in 
neighborhoods, and where they work.
    First, schools. For too many schools, particularly in under 
resourced communities, recess is a vestige of the past. Yet 
there is an innovative program called Sports4Kids that is 
transforming recess across the country using trained, full-time 
coaches--many of them from Americorps volunteers--who teach 
kids how to resolve conflicts and engage them in games that 
everyone can play in.
    The kids then return to the classroom more focused, 
cooperative, and ready to learn. Fights and injuries are 
reduced, and they have had some good physical activity while 
out on the playground.
    Schools are also a logical place to address the epidemic of 
childhood obesity, which, as we all know, affects 23 million 
children and adolescents in our country, nearly a third of the 
Nation's kids ages 2 to 19. Of course, African-American, 
Latino, Native American, and Asian-American and Pacific 
Islander kids living in low-income communities are the hardest 
hit.
    Our foundation is committed to reversing this epidemic by 
increasing the access to healthy foods and opportunities for 
physical activity in schools and communities, especially in 
those with the fewest resources. The Alliance for a Healthier 
Generation's Healthy Schools Program works to improve nutrition 
and physical activity as well as staff wellness in schools 
nationwide.
    Senator Harkin, I know that you visited the Oak Street 
Middle School in Iowa this fall and saw for yourself how they 
are taking soda out of the vending machines, replacing it with 
water, offering more fruits and vegetables in the cafeteria, 
and creating programs where kids can walk during recess and 
before and after school.
    Let me turn to neighborhoods and give you an example there. 
Neighborhoods and communities also have opportunities to 
prevent obesity and to help people live healthier lives by 
providing access to affordable nutritious foods. If they don't 
have opportunities to these foods or the opportunity to engage 
in activity, they are more likely to lead unhealthy lives.
    Let me just briefly tell you about the Food Trust program 
that started in Philadelphia and has leveraged their resources 
from $60 million to $90 million and created over 60 new 
supermarkets that provide access to food--healthy foods and 
also play a critical role in developing public-private 
partnerships.
    In closing, let me just say that, as I have said in my 
written testimony, there are many opportunities for us to 
invest in worksite wellness programs, some of which, over a 3-
year period can save as much as $105 million by reducing 
absenteeism and healthcare costs.
    By supporting policies and programs that keep us healthy in 
government, in public health system, in business, we can work 
with faith-based groups to help our populations be healthier. 
Investing in prevention can save money and reduce the burden of 
preventable diseases, such as heart disease, cancer, and 
diabetes.
    I believe that we have to reconfigure the way we spend in 
order to build a culture of wellness in this country by having 
insurance policies that encourage wellness, urban planning that 
encourages wellness through sidewalks and the way we zone our 
communities, and by developing more public-private partnerships 
that provide access to grocery stores, as I have mentioned, and 
other healthy opportunities.
    The Robert Wood Johnson Foundation is committed to working 
with you, and we stand ready to do all that we can to build 
this culture of wellness and make progress toward good health 
for all Americans.
    Thank you.
    [The prepared statement of Dr. Lavizzo-Mourey follows:]
        Prepared Statement of Risa Lavizzo-Mourey, M.D., M.B.A.
    Good morning. Thank you to Chairman Kennedy, Ranking Member Enzi, 
Senator Harkin and members of the committee for this opportunity to 
testify about the importance of investing in prevention and public 
health, particularly in programs that reach the most vulnerable among 
us. I am Dr. Risa Lavizzo-Mourey, president and CEO of the Robert Wood 
Johnson Foundation, the Nation's largest philanthropy devoted 
exclusively to improving the health and health care of all Americans.
    I still practice medicine at a federally qualified community health 
center, the Chandler Clinic, in New Brunswick, NJ, about 25 minutes 
from the Foundation's headquarters in Princeton. The clinic provides 
health care to thousands of the area's most vulnerable, low-income or 
uninsured families, from prenatal care to elder care. Many of my 
patients have multiple chronic illnesses, and the clinic fills a 
critical gap in providing them with medical care to treat those 
illnesses.
    But I often think about how our system fails my patients, and how 
much better off they would be if they had not developed their 
illnesses--many of them preventable--in the first place. As a 
physician, I have a place in my heart for the advice that ``an apple a 
day keeps the doctor away.'' But, as an agent of social change, I am 
pragmatic enough to see the emptiness of these words if patients cannot 
find an apple in their home, in their schools or in their corner store.
    When I see a patient with diabetes, I can check her feet and 
examine her eyes. I can monitor her blood pressure and her hemoglobin 
A1C. I can prescribe medicine to help control her disease. I can 
counsel her about how important it is that she eat plenty of fruits and 
vegetables; cut out sugar; reduce salt and fat; maintain a healthy 
weight and be physically active. But, more often than not, that patient 
doesn't have access to affordable, nutritious foods; there aren't 
grocery stores in her neighborhood. She may not be able to exercise 
because there aren't good sidewalks, or because she doesn't feel safe 
walking in her neighborhood.
    What I can't always do in the clinic is help my patients to manage 
their illnesses very effectively, or keep them from getting sick in the 
first place, because they're up against a daunting array of problems 
and challenges in their homes, their neighborhoods, and their schools.
    I would argue that, even if my patients had the same health 
insurance that I have, if they had the same access to high-quality 
clinical care, their health status would still be unequal, because of 
these persistent challenges outside of the health care system.
    Certainly, as Congress considers opportunities for health reform 
this year, expanding health care coverage must be a priority. But 
increasing access to health care alone will not be sufficient. 
Meaningful health reform must also include efforts to improve the 
quality, value and equality of care; bring down spending; strengthen 
the public health system's capacity to protect our health; address the 
social determinants of health; and prevent disease and promote 
healthier lifestyles.
                        the value of prevention
    Senator Harkin, I've often heard you say that we have a ``sickcare 
system'' not a health care system, and I couldn't agree more that it's 
time to change that. During these challenging times, we also have an 
unprecedented opportunity for real change, and to invest more in 
prevention and public health efforts that can reduce illness and 
disease in the first place and help people stay healthy. Whether or not 
a person stays well in the first place has little to do with seeing a 
doctor. Our aim should be to keep as many people healthy and out of the 
health care system as possible.
    Improving preventive services makes good sense for people's health, 
but it can also make good fiscal sense. A recent report from the Trust 
for America's Health (TFAH) that the Robert Wood Johnson Foundation and 
The California Endowment supported found that even a small, strategic 
investment in proven community-based prevention programs could result 
in significant savings in health care costs. An investment of $10 per 
person per year in programs to increase physical activity, improve 
nutrition, and prevent smoking and other tobacco use could save the 
country--Medicare, Medicaid and private payers--more than $16 billion 
annually within 5 years. That's a return of $5.60 for every $1 
invested.\1\
---------------------------------------------------------------------------
    \1\ Levi J, Segal LM, Juliano C. Prevention for a Healthier 
America: Investments in Disease Prevention Yield Significant Savings, 
Stronger Communities (2008). Available online at http://www.rwjf.org/
publichealth/product.jsp?id=32711.
---------------------------------------------------------------------------
    Clinical preventive services (for example, childhood immunizations; 
screening for hypertension, diabetes and certain cancers; and 
counseling smokers to quit) also play a critical role in keeping us 
healthy, and should be a part of any comprehensive effort to improve 
the health of all Americans. Many of those services are cost-saving or 
cost-effective.\2\
---------------------------------------------------------------------------
    \2\ See Maciosek MV, Coffield AB, Edwards NM, Flottemesch TJ, 
Goodman MJ, Solberg LI. ``Priorities Among Effective Clinical 
Preventive Services: Results of a Systematic Review and Analysis.'' Am. 
J. Prev. Med. vol. 31, no. (1): 52-61. 2006a and National Business 
Group on Health. A Purchaser's Guide to Clinical Preventive Services: 
Moving Science into Coverage, 2007.
---------------------------------------------------------------------------
    Disease prevention and health promotion must be a priority, but 
this is an area that has been largely ignored and chronically 
underfunded by Federal, State and local governments. As you consider 
proposals for health reform, I urge you to increase stable funding and 
incentives for both community-based programs and clinical preventive 
services. An important first step is being taken by Congress and the 
Obama administration--with your leadership, Senator Harkin--in the 
increased investment in prevention proposed in the Economic Recovery 
and Investment Act. This would be an unprecedented investment in public 
health. We must make sure that in the context of health reform, we 
assure continued funding of these programs.
             prevention programs for vulnerable populations
    A tremendous range of promising and successful efforts to improve 
health and prevent disease are taking place in schools, neighborhoods 
and workplaces across the country, reaching the most vulnerable people 
where they live, work, learn and play. These are the places where 
health really happens, more than in hospitals and in clinics. Let me 
provide some illustrative programs that are improving the health of 
populations by engaging people at school, in their neighborhoods and at 
work.
Schools
    Fifty-six million children attend an elementary or secondary school 
in the United States,\3\ and schools offer a prime opportunity to reach 
kids where they spend most of their time. The Robert Wood Johnson 
Foundation has a long history of investing in the expansion of school-
based health centers, which now number more than 1,500 across the 
country and provide critical health and health care services to 
vulnerable children and, in some cases, their families.
---------------------------------------------------------------------------
    \3\ Upcoming Statistical Abstract of the United States: 2009, Table 
211. See http://www.census
.gov/compendia/statab/.
---------------------------------------------------------------------------
    Health care, mental health and dental care are critical services to 
provide in school-based health clinics to reach children where they 
spend most of their time, but equally important is making sure that 
children are engaged in activity during the day that is safe and 
promotes learning. Recess at school should fulfill this need, but more 
and more schools are cutting the duration of recess time. We also see 
racial and ethnic disparities in cuts to recess: 14 percent of 
elementary schools with a minority enrollment, at least 50 percent do 
not schedule any recess for first graders; that compares with 2 percent 
of schools with less than 6 percent minority enrollment.\4\ But often, 
when recess is in place, teachers, principals and schools nurses tell 
us how much they dread it: recess is when the fights break out; recess 
is when kids get injured. We've recently invested in an $18-million 
expansion of an innovative program called Sports4Kids, which is working 
to transform recess in schools across the country, using trained, full-
time site coordinators who serve as coaches during recess and 
throughout and after the school day. Coaches, many of them AmeriCorps 
volunteers, teach students simple ways--like Rock/Paper/Scissors--to 
resolve conflicts and introduce them to games like Four Square and 
kickball, where everyone gets to play. Kids return to the classroom 
more focused, cooperative and ready to learn. Fights and injuries on 
the playground are down.
---------------------------------------------------------------------------
    \4\ National Center for Education Statistics. Calories in, Calories 
Out: Food and Exercise in Public Elementary Schools, 2005. Fast 
Response Survey System (FRSS 2005): May 2006.
---------------------------------------------------------------------------
    Schools are also a logical place to address the epidemic of 
childhood obesity, another important area for focusing on prevention. 
More than 23 million children and adolescents are obese or overweight--
nearly a third of our Nation's kids ages 2 to 19--and African-American, 
Latino, Native American, Asian-American and Pacific Islander children 
living in low-income communities are hit hardest.\5\ The Robert Wood 
Johnson Foundation is investing $500 million over 5 years to reverse 
the epidemic, focusing on improving access to healthy foods and 
opportunities for physical activity in schools and communities, 
especially those with the fewest resources.
---------------------------------------------------------------------------
    \5\ Ogden CL, Carroll MD and Flegal KM. ``High Body Mass Index for 
Age Among U.S. Children and Adolescents, 2003-2006.'' Journal of the 
American Medical Association, 299(20):2401-2405, 2008.
---------------------------------------------------------------------------
    For instance, we are the major funder of the Alliance for a 
Healthier Generation's Healthy Schools Program, which works to improve 
nutrition, physical activity and staff wellness in schools nationwide. 
The program currently reaches more than 4,000 schools through in-person 
and online support--and more than 2 million students in all 50 States--
with a particular emphasis on States with the highest rates of 
childhood obesity. Any school can sign up to join online and take 
advantage of free resources and tools to help create a healthier 
environment.
    Senator Harkin, I know you're familiar with the program, and that 
you visited the Oak Street Middle School in Iowa this fall to see the 
changes, big and small, that the school has made through that program: 
getting soda out of the vending machines and getting water in; offering 
more fruits and vegetables in the cafeteria and getting rid of fried 
foods; and creating programs to encourage students to walk during 
recess.
    The Alliance also has achieved major successes at the national 
level, such as forging an agreement with top beverage companies that 
already has resulted in a 58 percent reduction in the number of 
beverage calories shipped to schools. A similar agreement with snack 
food companies is helping to get healthier foods that comply with 
Alliance nutrition standards into schools. These are the kind of broad-
scale changes that are needed to help local schools make healthy 
changes.
                     neighborhoods and communities
    Neighborhoods and communities also present promising opportunities 
to prevent obesity, for people of all ages. As I said, if people don't 
have access to nutritious, affordable foods, and if they don't have 
opportunities to walk and play outside, it severely limits their 
opportunity to be healthy and to prevent and manage disease.
    On average, low-income rural and urban communities have 25 percent 
fewer supermarkets than their wealthier counterparts. This scarcity of 
supermarkets coincides with a higher incidence of preventable diseases 
such as cardiovascular disease, cancer and diabetes. In a study of more 
than 10,000 people, African-Americans' intake of fruits and vegetables 
increased 32 percent for each supermarket located in the 
neighborhood.\6\
---------------------------------------------------------------------------
    \6\ Morland, K., Wing, S. Diez Roux, A. ``The Contextual Effect of 
the Local Food Environment on Resident's Diets: The Atherosclerosis 
Risk in Communities Study.'' American Journal of Public Health; Nov. 
2002; 92, 11.
---------------------------------------------------------------------------
    In Philadelphia, The Food Trust's Supermarket Campaign is helping 
to increase the number of supermarkets in low-income neighborhoods, 
improving access to fresh food and creating new jobs in the community. 
The initiative brings leaders from the supermarket industry together 
with public health and economic development professionals to address 
the barriers to supermarket development, securing public funds for pre-
development and capital costs and developing a profitable business 
model to ensure sustainability. The Food Trust has played a critical 
role in forming a public-private partnership to support Pennsylvania's 
Fresh Food Financing Initiative. With $30 million in funding from the 
Commonwealth of Pennsylvania, this exciting initiative has leveraged an 
additional $90 million, thus far leading to 1.4 million square feet of 
new food retail space in 60 projects. The Robert Wood Johnson 
Foundation is supporting plans to replicate this success in Illinois, 
Louisiana and New Jersey.
    As we consider the importance of taking prevention to where people 
will most benefit, the kinds of community-based programs that we think 
will lead to the kinds of cost savings that the TFAH report describes, 
we are also investing in a new program, called Healthy Kids, Healthy 
Communities. This initiative supports comprehensive approaches to 
combat childhood obesity in communities across the country. Nine 
leading sites are now working to increase local opportunities for 
physical activity and access to healthy, affordable foods for 
vulnerable children and families.
    In Seattle/King County, in my home State of Washington, the Healthy 
Kids, Healthy Communities partnership focuses on policies that support 
healthy eating and active living in four public housing sites, linking 
public housing residents, housing authorities and community 
organizations to increase opportunities for physical activity and 
consumption of healthy foods. An additional 60 grants will be awarded 
for this program by the end of the year, with particular attention to 
communities in the 15 States with the highest rates of obesity.
    Although the majority of the Foundation's work to prevent and 
reduce obesity is focused on children, we also have supported efforts 
to ensure that older adults get the physical activity they need to stay 
healthy. A strong body of scientific evidence shows that physical 
activity can contribute to older adults' improved health and functional 
ability, as well as reduce chronic illness and disability.\7\ Yet only 
22 percent of adults 55-64, and 15 percent of adults 65 and older, 
exercise at least three times a week.\8\
---------------------------------------------------------------------------
    \7\ For an overview, see RWJF's National Blueprint: Increasing 
Physical Activity Among Adults Age 50 and Over, March 2001. Available 
at http://www.rwjf.org/files/publications/other/
Age50BlueprintSinglepages.pdf.
    \8\ Centers for Disease Control and Prevention (CDC). Behavioral 
Risk Factor Surveillance System Survey Data. Atlanta, Georgia: U.S. 
Department of Health and Human Services, Centers for Disease Control 
and Prevention, 2007.
---------------------------------------------------------------------------
    Our Active for Life program focuses on delivering research-based 
physical activity programs to large numbers of mid-life and older 
adults and works to sustain such programs through existing community 
institutions, including community or senior centers, recreation 
centers, public health departments, housing authorities and religious 
institutions. In Memphis, for example, the Church Health Center 
collaborates with two community partners--the Metropolitan Inter-Faith 
Association and New Pathways Community Development Corporation--to 
provide telephone counseling to motivate older adults participating in 
the program.
    Ensuring that all children get a healthy start in life is probably 
one of the most important steps toward promoting health that we can 
take as a nation. The Nurse-Family Partnership--supported by a range of 
public and private funding sources, including RWJF--works in 28 States 
to pair young, low-income pregnant women and first-time mothers with 
nurses who provide home visits during pregnancy and through the child's 
second birthday. Nurses counsel their clients about the importance of 
prenatal care, proper diet and avoiding cigarettes, alcohol and illegal 
drugs and help parents develop skills and strategies for caring for 
their babies responsibly. In addition, they work with the moms to 
develop a vision for their own future, including plans to continue 
their education and find work.
    A 15-year study found that participants have positive outcomes in 
reducing child abuse and neglect, reducing behavior and intellectual 
problems among children, reducing arrests among children by age 15, and 
reducing emergency room visits for accidents and poisoning. A 2005 
analysis by the RAND Corporation also found a $5.70 return for every 
dollar invested in the program.\9\
---------------------------------------------------------------------------
    \9\ Karoly LA, Kilburn MR and Cannon JS. Early Childhood 
Interventions: Proven Results, Future Promise. Santa Monica, CA: RAND, 
2005. Available online at http://www.rand.org/pubs/monographs/2005/
RAND_MG341.pdf.
---------------------------------------------------------------------------
    Another community-based prevention program for which we have solid 
evidence of success is Chicago's CeaseFire program. CeaseFire takes a 
public health approach to reduce neighborhood violence, working with 
community-based organizations to develop and implement strategies to 
prevent and reduce violence, with particular emphasis on shootings and 
killings. CeaseFire involves outreach workers, faith leaders and other 
community leaders to change community norms around violence and 
retaliation. They also hire former offenders who operate as ``violence 
interrupters'' and who intervene directly to prevent violent incidents. 
Public education campaigns round out the intervention to reinforce the 
message that shootings and violence are not acceptable. One poster used 
in Chicago shows a child's face, with the tagline ``Don't shoot. I want 
to grow up.'' It's very powerful, and we have the data to prove it.
    An extensive evaluation by the U.S. Department of Justice shows 
that the program reduces shootings and killings and makes neighborhoods 
safer. CeaseFire neighborhoods have seen up to a 73 percent reduction 
in shootings and killings. CeaseFire also provides help for young 
people to find jobs, educational opportunities and drug counseling. 
Replication efforts are currently underway in other cities--Baltimore, 
Pittsburgh, and Kansas City, MO--with plans for expansion to New York, 
Albany, Rochester and Buffalo.
    Homelessness is a growing problem, exacerbated today, of course, by 
the mortgage finance meltdown. Roughly 70 percent of the chronically 
homeless in America are burdened with serious health problems, mental 
health issues, or problems with substance abuse. For many, those 
concerns are the root causes of their homelessness. Simply providing 
four walls and a roof only offers a partial solution.
    Since 1991, the Corporation for Supportive Housing has been working 
to respond to the need for housing that's tightly connected to medical 
and social services to get and keep clients off the streets. The 
corporation tests the feasibility of supportive housing, raises funds 
to support its projects, and offers technical assistance to local and 
State agencies dealing with chronic homelessness. The idea is to create 
a secure, inviting environment where formerly homeless tenants feel 
safe and have a sense of dignity.
    Research shows that getting chronically homeless people into 
supportive housing reduces use of shelters and hospitals, and time 
spent in jail.\10\ Studies also demonstrate the cost-effectiveness of 
supportive housing. In Los Angeles, for example, where a single day's 
stay at a mental hospital averages $607, the daily cost of 
incarceration is $85, and a shelter's daily cost is $37.50. The 
equivalent cost of supportive housing remains the lowest, at $30. Cost 
comparison studies in Boston, Chicago, New York and other cities show 
similar findings.
---------------------------------------------------------------------------
    \10\ Culhane DP, Metraux S and Hadley T. ``Public Service 
Reductions Associated with Placement of Homeless Persons with Severe 
Mental Illness in Supportive Housing.'' Housing Policy Debate, 13(1): 
pp. 107-163, 2002.
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Workplaces
    When I talk about non-medical interventions that affect health, I 
have to mention the Robert Wood Johnson Foundation Commission to Build 
a Healthier America.\11\ The Commission is chaired by Mark McClellan 
and Alice Rivlin, and is exploring the impact that factors like 
education, housing, income and race have on health. Over the last year, 
the Commission has held a series of field hearings: in North Carolina, 
the focus was on the links between early childhood development and 
health; in Philadelphia, on the ways that physical and social 
environments affect health.
---------------------------------------------------------------------------
    \11\ See http://www.commissiononhealth.org.
---------------------------------------------------------------------------
    In December, a field hearing in Denver focused on the relationship 
of work and the workplace to health. When I think of health promotion 
initiatives in the workplace, the first thing that comes to mind is 
that we know that smoke-free policies improve workers' health. A 
complete smoking ban in the workplace reduces smoking prevalence among 
employees by 3.8 percent and daily cigarette consumption by 3.1 
cigarettes among employees who continue to smoke.\12\ And in New York 
City, smoking prevalence among adults decreased by 11 percent 
(approximately 140,000 fewer smokers) from 2002 to 2003 following the 
implementation of a comprehensive municipal smoke-free law, a cigarette 
excise tax increase, a media campaign, and a cessation initiative 
involving the distribution of free nicotine replacement therapy.\13\
---------------------------------------------------------------------------
    \12\ Fichtenberg CM, Glantz SA. Effect of Smoke-Free Workplaces on 
Smoking Behaviour: Systematic Review. British Medical Journal. 
2002;325:188.
    \13\ Frieden TR, Mostashari F, Kerker BD, Miller N, Hajat A, 
Frankel M. Adult Tobacco Use Levels After Intensive Tobacco Control 
Measures: New York City, 2002-2003. American Journal of Public Health. 
2005;95(6):1016-1023.
---------------------------------------------------------------------------
    We at RWJF are proud to have supported numerous successful smoke-
free workplace initiatives. But the Commission's hearing focused more 
broadly on work and health, and highlighted some promising and creative 
workplace health initiatives.
    On average, American adults spend nearly half of their waking hours 
at work.\14\ Where we work influences our health, not only by exposing 
us to physical environments and conditions that have health effects, 
but also by providing a setting where healthy activities and behaviors 
can be promoted. In addition to features of worksites, the nature of 
the work we do and how it is organized also can affect our physical and 
mental health. Work can provide a sense of identity, social status and 
purpose in life, as well as social support. For most Americans, 
employment is the primary source of income, giving them the means to 
live in homes and neighborhoods that promote health and to pursue 
health-promoting behaviors.
---------------------------------------------------------------------------
    \14\ ``Table 1. Time Spent in Primary Activities (1) and Percent of 
the Civilian Population Engaging in Each Activity, Averages Per Day by 
Sex, 2007 Annual Averages. Economic News Release. Washington, DC: U.S. 
Department of Labor, Bureau of Labor Statistics, 2007.
---------------------------------------------------------------------------
    Healthy workers and their families are likely to incur lower 
medical costs and be more productive, while those with chronic health 
conditions generate higher costs in terms of health care use, 
absenteeism, disability and overall reduced productivity.
    Workplace-based wellness and health promotion programs are employer 
initiatives directed at improving the health and well-being of workers 
and, in some cases, their dependents.\15\ Although most workplace-based 
wellness programs focus primarily on providing traditional health-
promotion and disease management programs on site, some model programs 
integrate on-site elements with health resources outside of the 
workplace and incorporate these benefits into health insurance plans. 
While larger worksites offer more health promotion programs, services 
and screening programs and policies, only 7 percent of employers in 
2004 offered a comprehensive worksite health promotion program that 
incorporated five key elements defined in Healthy People 2010: health 
education, links to related employee services, supportive physical and 
social environments for health improvement, integration of health 
promotion into the organization's culture, and employee screenings with 
adequate treatment and follow up.\16\ But in Denver, we heard about 
some workplace programs with promising and impressive results. The 
insurance company USAA's Take Care of Your Health program centers 
around simple health messages to employees and their families that are 
reinforced by programs at several levels, including individual health 
risk assessments and campus-wide policies. Wellness programs--ranging 
from on-site fitness centers and healthier food choices in worksite 
cafeterias to lifestyle coaching--are integrated with disability 
management, a consumer-driven health plan and paid time off. 
Participants have achieved reductions in weight, smoking rates and 
overall health risk status, and the decrease in participants' workplace 
absences has saved more than $105 million over 3 years.
---------------------------------------------------------------------------
    \15\ Goetzel RZ, Ozminkowski RJ. ``The Health and Cost Benefits of 
Work Site Health-Promotion Programs.'' Annual Review of Public Health, 
29: 303-23, 2008.
    \16\ Linnan L, Bowling M, Childress J, et al. ``Results of the 2004 
National Worksite Health Promotion Survey.'' American Journal of Public 
Health, 98(8): 1503-9, 2008.
---------------------------------------------------------------------------
                               conclusion
    Whether or not a person stays well in the first place has much to 
do with his or her daily behaviors and environment. Our aim should be 
to stop poor health and disease before it starts and keep as many 
people healthy and out of the health care system as possible. Strategic 
investment in disease prevention and population health saves lives, 
strengthens families and communities, makes for more productive workers 
and reduces health care spending. By supporting policies and programs 
that keep us healthy, the government, the public health system, 
businesses, community organizations, schools and faith-based groups can 
do more to meet our collective responsibility to help citizens lead 
healthier lives.
    Even though America spends more than $2 trillion annually on health 
care, we do not have the healthiest people. Ninety-five percent of 
health spending goes toward medical care and biomedical research, and 
only 5 percent to public health and disease prevention. Yet public 
health threats like inactivity, obesity and tobacco use are putting 
millions of adults and children at risk for unprecedented levels of 
major chronic diseases--many of them preventable. By investing in 
prevention, we could save money and reduce the burden of preventable 
diseases such as heart disease, cancer and diabetes.
    Right now, America's health care system is set up to focus on 
treating people once they already have a health problem. We must shift 
that focus to preventing people from getting sick in the first place, 
investing in policies and programs that make it easier for all 
Americans to enjoy the benefits of good health.
    I am not here to ask for big new Federal spending. What I believe 
we need is to reconfigure what we spend to build a ``culture of 
wellness'' in this country--ensuring that wellness is a consideration 
in the insurance policies that employers offer; in urban planning so 
that sidewalks are safe and inviting; in building more public-private 
partnerships like the Food Trust so that more people have access to the 
kind of grocery stores that you and I use.
    The good news is that there is a lot of health promotion going on 
in some communities--and I've told you a lot about those. We need to 
work together to make sure that programs that are working are available 
in more communities across this country, especially communities where 
residents are most disadvantaged and farthest from being as healthy as 
they could be if they had the opportunity to make healthier choices. We 
at the Foundation believe that this country can be healthier and we 
stand ready to work with others who will help create the national 
``culture of wellness'' that can speed our progress toward good health 
for all. Now more than ever, we have the opportunity for comprehensive, 
meaningful health reform, and we must take bold steps where we have 
been timid in our policies to protect and preserve health, to rebuild 
what we have let crumble in public health, to help our people stay 
healthy and our businesses stay competitive.

    Senator Harkin. Thank you very much, Doctor.
    Now we will go to Dr. Stevens. Dr. Stevens, I have already 
previously introduced you. Please proceed.

 STATEMENT OF DAVID M. STEVENS, M.D., DIRECTOR OF THE QUALITY 
CENTER AND ASSOCIATE MEDICAL DIRECTOR, NATIONAL ASSOCIATION OF 
             COMMUNITY HEALTH CENTERS, BETHESDA, MD

    Dr. Stevens. Sure. I want to say good morning to members of 
the committee, and I, too, would like to thank you, Senator 
Harkin, and Senator Enzi and Chairman Kennedy for inviting me 
here today.
    It is my privilege to present on behalf of the 18 million 
Americans currently receiving care at our Nation's community 
health centers and the countless others from across the country 
that make up the community health center movement. As the 
health providers that stand at the nexus of cost, quality, and 
access, health centers can offer great insights into this 
committee's efforts.
    Given the subject of today's hearings, I just wanted to 
briefly discuss the patients we serve. Today, health centers 
nationwide provide primary and preventive care to 18 million 
people. Seventy-one percent are at or below poverty. Thirty-
nine percent are uninsured. Thirty-five percent are on 
Medicaid, and 64 percent of health center patients are of 
ethnic minorities, half from rural areas, half from urban, and 
our patients are also more likely to be disabled than others in 
other primary care settings.
    How well do health centers do in averting disease through 
primary prevention, which is early detection of disease; 
through secondary prevention, which is preventing or 
ameliorating complications of chronic disease; or tertiary 
prevention?
    Research has found that health center patients, both 
uninsured and Medicaid recipients, receive significantly higher 
levels of health promotion counseling then their counterparts. 
This includes higher rates of counseling on physical activity, 
smoking, and alcohol use, the three top contributors to 
mortality in our Nation.
    A study from GW also documented higher rates of secondary 
preventive services, such as Pap smear, mammography, and 
cholesterol testing, than Medicaid or uninsured patients in 
other settings.
    Health centers also excel in tertiary prevention. For 
example, health center patients with diabetes have improved 
glucose control, improved cholesterol levels, and greater use 
of medicines that prevent kidney failure and heart attack.
    This excellence in prevention has led to significant 
overall cost savings. For example, in South Carolina, patients 
with diabetes enrolled in the State Employees Health Plan 
treated in non-health center settings were four times more 
costly than those in the same plan who were treated in 
community health center. The health center patients also had 
lower rates of emergency room use and hospitalization.
    This excellence in prevention has led to a reduction in 
health disparities. Nationwide data shows that low-income 
Hispanic, African-American, and Medicaid female health center 
patients have a significantly higher likelihood of receiving a 
mammogram versus their counterparts. Each of these groups of 
health center patients also surpass the Healthy People 2010 
target of 70 percent.
    Health centers improve the overall quality of life, which 
is probably the most important thing, for their patients and 
communities. In a study of the impact of community health 
centers, Health Disparities Collaborative effort on diabetes 
evidence showed that over a lifetime the incidence of 
blindness, kidney failure, and coronary artery disease were 
reduced.
    The Health Disparities Collaborative, a health center 
quality initiative to improve the delivery systems at health 
centers, does provide a framework for how our Nation could 
change the healthcare system.
    Why are health centers so effective in providing preventive 
services? Well, first, we firmly believe that health center 
success is rooted in the FQHC comprehensive primary care model. 
Essential components of the model include location in high-need 
area, comprehensive health and enabling services, open to all 
regardless of ability to pay, control by consumer majority 
board, and strict performance and accountability requirements.
    Another reason is our track record of partnerships with 
schools, community agencies, and local governments. As Senator 
Harkin knows from Iowa, where Ted Boesen and the health centers 
led in the Iowa Collaborative--or they lead because it is still 
going on--in the Iowa Collaborative Safety Net Provider 
Network, health centers form effective partnerships with free 
clinics, rural health clinics, local and State health 
departments, providers, and other community-based organizations 
and academia to improve access and the quality of preventive 
and primary care services.
    We believe that health reform must recognize the need for 
fundamental system change. According to a recent article by 
Nolte and McKee in Health Affairs, our Nation is last among 19 
industrial nations for preventing potentially preventable 
deaths for people under the age of 75. According to the CDC, we 
are 29th in the world in infant mortality.
    To address these alarming statistics, health reform must 
enhance the collaboration between public health and 
comprehensive healthcare modeled by health centers. We should 
ensure that with the necessary insurance coverage expansions we 
do not neglect access and the way in which prevention and 
primary care are delivered.
    With our 43-year track record of improving health and 
enhancing preventive care community by community, we stand 
ready and willing to engage in this effort, for it, indeed, 
takes a village to improve our Nation's health status.
    Thank you, Senator.
    [The prepared statement of Dr. Stevens follows:]
               Prepared Statement of David Stevens, M.D.
    Good morning, members of the committee. First, I would like to 
thank the committee for inviting me here today. It is my privilege to 
present on behalf of the 18 million Americans currently receiving care 
at our Nation's community health centers, and the countless others from 
across this country who make up the community health centers movement. 
As the health providers that stand at the nexus of cost, quality, and 
access, health centers can offer great insights into this committee's 
efforts.
    Given the subject of today's hearing, let us discuss briefly the 
patients we serve. Today, health centers nationwide provide primary and 
preventive care to 18 million patients; 71 percent are at or below 
poverty, 39 percent are uninsured, and 35 percent are on Medicaid. 
Sixty-four percent of health center patients are ethnic minorities; 
half are rural residents, half urban. Our patients are also more likely 
to be disabled than patients in other primary care settings.
    How well do health centers do in averting disease through primary 
prevention, early detection of disease through secondary prevention, 
and preventing or ameliorating complications in patients with chronic 
disease, or tertiary prevention?
    A recent GW analysis found that CHC (Community Health Center) 
patients, both uninsured and Medicaid recipients, receive significantly 
higher levels of health promotion counseling than their counter parts. 
This includes higher rates of counseling on physical activity, smoking 
and alcohol use--the three top contributors to mortality in our Nation. 
The study also documented higher rates of secondary prevention services 
such as Pap smear, mammography, and cholesterol testing than Medicaid 
or uninsured patients in other settings.
    Health centers also excel in tertiary prevention. For example, 
health center patients with diabetes have improved glucose control, 
improved cholesterol levels, and greater use of medicine to prevent 
kidney failure and heart attack.
    This excellence in prevention has led to significant overall cost 
savings.
    For example, in South Carolina, diabetic patients enrolled in the 
State employees' health plan treated in non-CHC settings were four 
times more costly than those in the same plan who were treated in a 
community health center. The health center patients also had lower 
rates of ER use and hospitalization.
    This excellence in prevention has led to a reduction in health 
disparities.
    Nationwide data shows that low-income Hispanic, African-American, 
and Medicaid female health center patients have a significantly higher 
likelihood of receiving a mammogram versus their counterparts. Each of 
these groups of health center patients also surpasses the Healthy 
People 2010 target of 70 percent.
    In another example, health center patients on average have lower 
rates of low-birth weight than their U.S. counterparts, with notably 
lower rates of low-birth weight for Black, Hispanic, and Asian women.
    Health centers improve the overall quality of life for their 
patients and communities. In a study of the impact of community health 
centers' Health Disparities Collaborative (HDC) effort on diabetes, 
evidence showed that over a lifetime, the incidence of blindness, 
kidney failure, and coronary artery disease were reduced. The Health 
Disparities Collaboratives, a health center quality initiative to 
improve the delivery systems at Health Centers provides a framework for 
how the United States could change the healthcare system.
    Why are health centers so effective in providing preventive 
services?
    We firmly believe that health center success is rooted in the FQHC 
(Federally Qualified Health Center) comprehensive primary care model. 
Essential components of the model include: location in a high-need 
area; comprehensive health and enabling services; open to all 
regardless of ability to pay; control by consumer-majority board; and 
strict performance and accountability requirements.
    Another reason is our track record of partnerships with schools, 
community agencies and local governments. As Senator Harkin knows from 
Iowa, where Ted Boesen and the health centers lead in the Iowa 
Collaborative Safety Net Provider Network, health centers form 
effective partnerships with free clinics, rural health clinics, local 
and State health departments, providers, other community-based 
organizations, and academia, to improve access, and the quality of 
preventive and primary care services.
    Yet, there is still room to do more. A February 2002 NEJM study 
demonstrated that lifestyle interventions with pre-diabetes patients 
could reduce the onset of diabetes by 58 percent, while drug therapy 
could reduce the onset by over 30 percent. When the CDC piloted this on 
the ground at 5 health centers, it worked. But we need to develop a 
sustainable way to fund this type of public health/health center 
collaboration on a larger scale.
    We believe that Health Reform must recognize the need for 
fundamental systemic change. According to a recent article by Nolte and 
McKay in Health Affairs, our Nation is last place among 19 
industrialized Nations in potentially preventable deaths for people 
under the age of 75. According to the CDC, we are 29th in the world in 
infant mortality. To address these alarming statistics, health reform 
must enhance the collaboration between public health and comprehensive 
primary healthcare modeled by health centers. We should ensure that 
with the necessary insurance coverage expansions, we do not neglect 
access and the way in which prevention and primary care are delivered. 
With our 43 year track record of improving health and enhancing 
preventative care, community-by-community, we stand ready and willing 
to engage in this effort, for it indeed takes a village to improve our 
Nation's health status.

    Senator Harkin. Thank you very much, Dr. Stevens.
    There is a question I want to ask you more about and that 
is why they are so different. Why, why, why? And using that 
model in other places.
    Mr. Meit. Again, looking at rural health, where we have 
some real problems in rural America.
    Mr. Meit. Yes, absolutely. Thank you very much.
    Senator Harkin. Welcome. Thank you. Please proceed.

  STATEMENT OF MICHAEL MEIT, M.A., M.P.H., PRINCIPAL RESEARCH 
  SCIENTIST FOR NORC AT THE UNIVERSITY OF CHICAGO AND DEPUTY 
 DIRECTOR OF THE NORC WALSH CENTER FOR RURAL HEALTH ANALYSIS, 
                          CHICAGO, IL

    Mr. Meit. I would like to start by thanking the committee 
for inviting me to provide testimony today.
    Today, I am going to talk about the need for public health 
capacities in rural jurisdictions rather than the need for 
accessible healthcare services, and I want to begin by 
emphasizing that access to healthcare services remains a 
critical challenge throughout the rural United States and one 
that must not be overlooked.
    My intent is not to minimize the issue of access to 
healthcare services, but rather to demonstrate that the issues 
that we face today, issues such as increasing concern over 
infectious disease, increasing prevalence of chronic conditions 
and preventable conditions, and issues such as emergency 
preparedness, these issues call for access to a strong public 
health system throughout our rural communities, in addition to 
a strong healthcare delivery system.
    Public health capacities in rural areas are strained, and 
they are often nonexistent. This is particularly true in our 
frontier areas, but also true through much of the United States 
and throughout rural America.
    Why do we need strong public health capacities in rural 
America? Well, I think if you look at the health data, they 
speak for themselves.
    In August 2001, the CDC released its first-ever report on 
health status relative to community urbanization levels. I 
might also add that this is the only time the CDC has done a 
report looking at health status relative to community 
urbanization levels. This is the only time they have looked at 
rural health status specifically.
    Specific findings from that report demonstrated a number of 
disparities in health status between rural and urban Americans, 
including higher rates of smoking, increased heart disease 
mortality, higher suicide rates, higher mortality rates from 
unintentional injury, and lower rates of health insurance 
coverage.
    Recent analyses conducted by NORC at the University of 
Chicago further show that rural residents are more likely to 
report their overall health status to be fair or poor and 
report higher prevalence of chronic preventable conditions, 
such as hypertension, arthritis, diabetes, and cardiovascular 
disease. In my written testimony, you will see some of those 
charts that display that.
    At this point, I would like to shift focus from describing 
the problem to providing some tangible recommendations for 
improving public health capacities in rural areas. The first of 
these comes from the National Rural Health Association (NRHA), 
which in 2004 released a policy statement on rural public 
health.
    First, the rural public health workforce, most of which has 
no formal education in public health, needs support through 
training that is accessible to them in their rural communities. 
We are talking about distance education and continuing 
education provided through distance technologies.
    There are fewer public health workers per capita in rural 
America, and they simply cannot get away from their jobs to 
attend trainings hundreds of miles away.
    Second, communication systems and technological capacities 
within rural public health systems need to be strengthened to 
be able to effectively deliver health prevention messages, 
manage public health emergencies, conduct effective disease 
surveillance, and receive up-to-date health information.
    The technological capacities in our rural health 
departments are not up to par at this point. And again, that is 
assuming that a community is served by a health department. 
Many communities, to this day, are not.
    And third, greater flexibility is needed in the use of 
public health resources to respond to local public health 
priorities. I think this last point is worthy of a bit more 
attention.
    At NORC, we conducted a study on this issue that 
demonstrated that rural health departments have proportionately 
less local funding as compared to urban health departments. 
This means that rural health departments have less funding that 
they control to respond to locally identified needs.
    Allowing greater flexibility in the use of State and 
Federal funding would make rural agencies more responsive and, 
I believe, more effective. I think this could be accomplished 
by tying State and Federal funds to local public health 
assessments and holding health departments accountable to 
addressing their locally identified needs.
    As the system stands now, local health departments must 
implement categorically defined programs from State and Federal 
agencies rather than locally defined priorities.
    In addition to the NRHA recommendations, I would like to 
offer one more. I believe that the CDC, our Nation's premier 
public health agency, should establish an Office of Rural 
Public Health dedicated to providing leadership within CDC on 
rural public health issues. A key deliverable of that office 
should be an annual report on rural health status.
    Recall that CDC has only once conducted a comprehensive 
report on health status by levels of urbanization, and that 
report has not been updated since 2001. Unless we have a clear 
grasp of the issues we face and up-to-date data to support 
them, we cannot effectively address those issues.
    In closing, I would like to make one final point. There is 
a connectedness between our rural and our urban communities. 
Rural health is in all of our interests. If our rural 
communities are not safe and healthy, all of us are placed at 
increased risk, whether from infectious diseases or food-borne 
outbreaks that are not identified early or from the tremendous 
costs of preventable chronic conditions that are borne out by 
all of us through high insurance premiums and costs to our 
healthcare systems.
    Again, thank you for allowing me to testify today.
    [The prepared statement of Mr. Meit follows:]
            Prepared Statement of Michael Meit, M.A., M.P.H.
    When the topic of ``rural health'' is raised, whether by 
policymakers, the general public, or even public health professionals, 
the conjured vision is often one of individuals having difficulties 
accessing healthcare services due to a lack of facilities and/or 
providers. While the issue of access to care remains a critical 
challenge throughout rural America, and one that must not be 
overlooked, we must take a broader view of rural health. It is clear 
that rural citizens face significant health disparities when compared 
to the general population and that access to healthcare services, 
albeit important, is only one of many factors influencing their health. 
Other factors, such as health behaviors among rural citizens, 
persistent poverty, disease surveillance challenges created by smaller 
populations, unique environmental factors, and too many others to list, 
call for a public health response to addressing rural health concerns.
    From a historical perspective, the lack of public health focus in 
rural jurisdictions is not a surprise. The field of public health 
emerged in the late 18th century as an urban concern, dealing with 
issues of sanitation and infectious disease that were common in urban 
centers. Rural areas, on the other hand, were considered by their very 
nature to be healthy--clean water and clean air were thought to be 
curative, and sick urban residents were often sent to the country to 
recuperate. Only when urban public health issues began to be addressed, 
and health data started to demonstrate that rural residents were now 
less healthy than their urban counterparts, did it become evident that 
public health interventions could also benefit rural citizens. This was 
articulately stated in 1899 by Pennsylvania Governor Daniel H. 
Hastings, who reported to the Pennsylvania legislature that it was 
fiction to assume ``that the country districts are naturally so healthy 
that there is no need for laws to prevent disease.'' \1\ Still, it 
wasn't until the early 1900s, over 100 years after the development of 
the first urban health departments, that a second wave of public health 
capacity development began, this time in rural jurisdictions. Around 
this same time, however, great advances were also being made in 
medicine, and the primary focus of rural health activity soon shifted 
to ensuring access to health care services rather than public health 
preventive measures. I do not say this to denigrate the importance of 
providing access to health care services--medical services are clearly 
a critical component to ensuring healthy rural populations--but rather 
to demonstrate an imbalance in our rural focus between care and 
prevention. To ensure a healthy population, both are clearly necessary.
---------------------------------------------------------------------------
    \1\ ``Biennial Message, Governor Daniel Hartman Hastings, January 
1, 1899,'' Pennsylvania Archives, 4th ser., 12 (Harrisburg, PA, 1902), 
315.
---------------------------------------------------------------------------
    To see the need for public health prevention in rural jurisdictions 
one must only look at the health data, which speak for themselves. In 
August, 2001, the National Center for Health Statistics at the Centers 
for Disease Control and Prevention released the 25th annual statistical 
report on the Nation's health. This report presented the first look at 
the Nation's health status relative to community urbanization level. 
Specific findings demonstrated a number of disparities in health status 
between rural and non-rural citizens including the following:

     teenagers and adults in rural counties were more likely to 
smoke;
     residents of rural communities had the fewest dental care 
visits;
     death rates for working-age adults were highest in the 
most rural and most urban areas;
     heart disease mortality rates where higher among rural 
residents;
     suicide rates were higher among rural residents;
     rural areas had a high percentage of residents without 
health insurance; and
     residents of rural areas had the highest death rates for 
unintentional injuries in general, and for motor-vehicle injuries 
specifically.\2\
---------------------------------------------------------------------------
    \2\ Health, United States, 2001 With Rural and Urban Health 
Chartbook. Hyattsville, MD: Centers for Disease Control and Prevention, 
National Center for Health Statistics; 2001.

    More recent analyses conducted by NORC at the University of Chicago 
in 2008 confirm many of the findings from the 2001 CDC report, and 
demonstrate the ongoing challenges faced by rural residents, who are 
more likely to report their overall health status to be fair or poor 
than non-rural residents (Figure 1), and who report prevalence of 
chronic, preventable conditions to a greater degree than non-rural 
residents (Figure 2).



    To effectively address these issues, I believe that a robust public 
health infrastructure is needed that provides services to all citizens 
in all communities. Public health has been called a system of 
``organized community efforts aimed at the prevention of disease and 
promotion of health.'' Its work is often described as three core 
functions: assessing the health needs of a population, developing 
policies to meet these needs, and assuring that services are always 
available and organized to meet the challenges at the individual and 
community levels. While aspects of these functions may be delegated to, 
or voluntarily carried out by, private-sector professionals and 
organizations, ultimate responsibility and accountability rests with 
governments at the local, State, and Federal levels. The issues that we 
face in rural communities clearly require a coordinated response from 
both our governmental public health system and our private health care 
delivery system. However, in many rural jurisdictions the governmental 
public health authority either lacks capacity, or doesn't even exist. 
Many rural and frontier areas have no local health department at all, 
and those public health departments that do serve rural areas face 
significant challenges in recruiting and retaining qualified personnel, 
especially those with formal public health training such as public 
health nurses and epidemiologists.
    In 2004, the National Rural Health Association (NRHA) took a 
critical look at the health issues facing rural Americans and the 
capacities of both the healthcare delivery system and the public health 
system to address them. The association recognized that the healthcare 
delivery system alone will not be able to eliminate the health 
disparities faced throughout the rural United States and adopted the 
following recommendations \3\:
---------------------------------------------------------------------------
    \3\ NRHA policy statement available online at http://
www.nrharural.org/advocacy/sub/policy 
briefs/public_hlth.pdf.

     All citizens and all communities should have comparable 
access to agencies and individuals that assure the provision of the 
essential public health services. Whether provided locally or on a 
regional basis, by governmental agencies or the private sector, every 
citizen has the right to expect access to the full complement of 
essential public health services in their community.
     Public health is a common good and that there is a 
governmental responsibility to assure access to essential public health 
services in every community. Regardless of who actually provides the 
service, there is a governmental responsibility to provide oversight 
and the governmental public health infrastructure must be strengthened 
to support this role.
     The rural public health workforce needs support through 
training and continuing education that is accessible to them in their 
rural communities, and that is appropriate for their current level of 
training and experience. A key ingredient to assuring adequate public 
health services is a competent public health workforce. Whether 
employed in the public or private sector, public health workers must be 
well versed in their field.
     Communication systems and technological capacities within 
the rural public health system need to be strengthened. In order to 
effectively manage public health emergencies, conduct disease 
surveillance, or simply receive up-to-date public health information, 
rural public health must have access to advanced communications systems 
and technologies.
     Greater flexibility is needed in the use of public health 
resources to respond to local public health priorities. The current 
public health system is limited by categorical funding which often 
forces it to address State and Federal priorities rather than local 
needs. Public health works best when it is responsive to locally 
identified priorities. Funding streams need to support rather than 
inhibit this responsiveness.

    This last point is worthy of a bit more attention. It is important 
to note that while local health departments typically receive funding 
from local tax sources in addition to State funding and Federal pass-
through funding, rural health departments (where they exist) rely 
disproportionately on State and Federal funding as compared to their 
urban counterparts. Having proportionately less local funding, which 
the health department has greater control over, means that rural health 
departments have less capacity to respond to local needs than non-rural 
health departments. State and Federal funding could be distributed to 
more effectively allow for local flexibility by tying program 
activities to local health assessments and holding the health 
departments accountable to addressing those locally identified needs. 
As the system works now, health departments are required to implement 
programs within the categorically funded focus areas, which may or may 
not correspond to local needs. Figure 3 shows findings from a recent 
NORC at the University of Chicago study detailing the proportion of 
rural versus urban local health department funds by source.



    In addition to the NRHA recommendations, which I believe are all 
sound, I would like to offer one more that I feel would benefit rural 
communities in a tangible way. Earlier I discussed the CDC's 2001 
report on health status relative to community urbanization levels. 
These data continue to be the basis for much of our understanding of 
rural health status, but they are clearly dated. CDC should regularly 
conduct analyses relative to community urbanization levels. Further, I 
would recommend that CDC establish an office dedicated to investigating 
issues of importance to rural public health--a report on rural health 
status could be an annual deliverable from that office. I think it is 
notable that the only dedicated office with a rural focus within the 
Department of Health and Human Services exists within the Health 
Resources and Services Administration (HRSA). That office does 
considerable work to ensure access to healthcare services for rural 
citizens, and its value to improving health in rural communities is 
immeasurable. A similar dedicated focus at CDC could provide the same 
kind of dedicated Federal attention for public health and prevention, 
that HRSA provides for access to health care services.
    In closing, I would like to make one final point. This issue of 
rural health is not just a rural issue. Ensuring the health and well-
being of our rural citizens is in the interest of all of us, rural, 
urban and suburban. We live in a mobile society, and there are strong 
connections between urban and rural communities, including familial 
relationships, agricultural production and delivery, and commerce. We 
need a strong system in place in our rural communities that both 
ensures access to quality health services and a strong public health 
infrastructure that delivers important health messages to its citizens, 
identifies and mitigates the effects of infectious diseases and 
foodborne outbreaks, and helps to respond effectively to emergencies 
such as natural disasters and infectious disease outbreaks. In the end, 
it is important to recognize that the health of all of us depends upon 
all of our communities having effective health care delivery and public 
health capacities.

    Senator Harkin. Thank you very much, Mr. Meit.
    Dr. Iezzoni is on her way here. I know she has entered the 
building. We will just move ahead.
    Dr. Butler, I introduced you before here, but a longtime 
friend, founder of our National Institute on Aging at NIH, and 
the foremost expert on the problems of aging. Of course, what 
we are looking at here is preventive healthcare and wellness 
and how we get that to our elderly population. I, of course, 
read your testimony last night.
    Welcome again to this committee. You have been here many 
times in the past and I appreciate your being here again this 
morning.

     STATEMENT OF ROBERT BUTLER, M.D., PRESIDENT AND CEO, 
       INTERNATIONAL LONGEVITY CENTER--USA, NEW YORK, NY

    Dr. Butler. It is a pleasure to be here. I want to speak 
from the perspective of gerontologists and geriatricians and in 
the context of the country, the United States, that actually 
over the last years has dropped from 11th place in life 
expectancy to 42d place in life expectancy. It is very serious.
    People not only want to live long, but they want to remain 
in good health. We pretty much know what the necessary 
ingredients are, but it is very difficult to live up to those 
requirements. I would like to identify seven key features of 
healthy aging.
    One is an appropriate low-calorie diet with seven to nine 
fruits and vegetables each day, multivitamins with particular 
attention to vitamin C, which requires, in turn, exposure to 
sunlight in order to activate vitamin D.
    Second is the vast importance of physical activity, not 
just aerobics four or five times a week, but muscle 
strengthening, particularly of the quadriceps or the thigh 
muscle because it is the number-one predictor of frailty in old 
age. Just doing squats makes an enormous difference.
    Falls are the No. 12 cause of death in people over 65 years 
of age, and obviously, balance and muscle are crucial, as are 
flexibility and posture.
    Third is obviously smoking cessation.
    Fourth is the very moderate use of alcohol, the equivalent 
of no more than one glass of wine per day.
    Fifth, and the most difficult of all, managing stress 
through meditation, yoga, visualization, mini vacations, 
appropriate sleep.
    Sixth, and then a couple that are not often mentioned. 
Building a strong support system and a social network of 
friends and relationships. This may be one reason women outlive 
men by over 5 years because they seem more gifted at dealing 
with intimacy issues of grief and problems than we men are.
    Seventh, is a sense of purpose. We discovered this in the 
1950s in our work at the National Institutes of Health that 
people who had a purpose in life, something to get up for in 
the morning, actually not only live longer, but they live 
better.
    It is not a bad idea for older people, particularly in 
these times, to continue to work. After all, we are living 
longer. We really should work longer. It would make a huge 
difference in the Social Security system as we discovered in 
hearings, in such a hearing as this some many years ago.
    Of course, people should be providing active help and 
resources to other people. Think of all the scientists, 
engineers, mathematicians who could be contributing 
tremendously to after-school enrichment programs for kids in a 
country that is number 18 in science and math literacy.
    We know that perhaps no more than 25 percent of our health 
and longevity depends upon genes. That is power. That means 75 
percent of it is up to us.
    Now in order to assist people to maintain healthy aging by 
undertaking the activities I described, how can we help them? 
Some help, of course, could be derived from the doctor-patient 
relationship. The truth is today doctors have about 12 minutes 
per patient. We have to turn to a larger message. We have to be 
much more concerned with the public health system.
    Doctors today are primarily engaged in a sickness system, 
not a healthcare system. Doctors and hospitals do not have 
incentives to maintain health. They, in fact, have incentives 
through profit through disease. I say this as a physician.
    I believe we have to expand our efforts at prevention 
through a broad public health perspective. For example, there 
are some 15,000 senior centers throughout the United States. 
These are community facilities--5,000 of which receive some 
support from our Administration on Aging.
    The utilization rate, however, is not what it should be. 
Relatively few people attend these senior centers. They need to 
be dramatically transformed.
    First, they should be health promotion centers themselves, 
promoting exercise, squats, and the like. They should also be 
dedicated to deriving from such older persons more direct 
purpose of activities that would be constructive for society.
    Now taxation and education were very effective in the 50 
percent reduction of smokers in the United States since 1964. 
On the other hand, alcohol in America is marked by a 
significant number of hard-core alcoholics affecting one out of 
every four American families.
    We are not being adequately attentive to the problems of 
alcoholism in America. It accounts for most abuse within 
families, contributes significantly, about 20 percent of all 
the highway fatalities and other accidents. At times, people 
get misdiagnosed as Alzheimer's disease when they have 
alcoholic dementia.
    Alcohol taxes used to constitute a significant part of 
Federal revenue. In fact, there has only been a few increases 
in liquor taxes since the 1950s. This is an issue that I think 
should be revisited by Congress if we are going to have a 
serious health promotion effort in this country.
    Now I would like to call upon all citizens of America, 
including our new President, the President's Council on 
Physical Fitness and Sports, U.S. Preventive Task Force, and 
other appropriate organizations, to help sponsor a national 
walking movement where friends, neighbors, and families could 
walk together. This is not expensive. It doesn't require 
membership in a health club.
    Of course, healthy aging is a life course issue. It is not 
something you simply introduce at 50, 60, or beyond. A few 
years ago, several of us wrote a widely quoted paper in the New 
England Journal of Medicine on the problem of obesity in 
America and the prospect that we could lose 3 to 5 years of the 
30 years of additional years of life that we had gained in the 
20th century.
    Further, we said, for the first time in our history, our 
children might not live as long as their parents. It is, 
indeed, dreadful to see 10-year-old children with obesity and 
old-age type 2 diabetes. A national walking movement is simple, 
but an important way to deal with the problem of obesity.
    Finally, and to repeat, it is urgent to realize the cost of 
failed health promotion and disease prevention. We must now go 
beyond the doctor-patient relationship to achieve the goals of 
healthy aging, which requires, of course, healthy living 
throughout life. It is never too late to start and always too 
soon to stop.
    On another occasion, I might speak of a new paradigm 
derived from recent remarkable advances and understanding of 
the basic biology of aging. For it is now possible to slow 
aging while simultaneously delaying the onset of diseases 
associated with aging. That is a big step forward.
    Thank you.
    [The prepared statement of Dr. Butler follows:]
               Prepared Statement of Robert Butler, M.D.
                             healthy aging
    People not only want to live long, but to remain in good health. We 
pretty much know what the necessary ingredients are, but it is very 
difficult to live up to the requirements.
    The seven key features of healthy aging are:

    1. Appropriate low caloric diet with 7-9 fruits and vegetables each 
day, multivitamins in particular vitamin D (with sunlight to activate 
vitamin D).
    2. Physical activity including: (1) aerobics, that is reasonably 
strenuous walk 5 days a week, (2) muscle strengthening, particularly of 
the quadriceps or thigh muscle, through squats. It is known that the 
quadriceps is the primary predictor of frailty in old age. Falls is the 
No. 12 cause of death for people over 65 and muscle strength and 
balance are critical, (3) Balance, (4) Flexibility, and (5) Posture.
    3. Smoking Cessation
    4. Moderate use of alcohol, the equivalent of no more than one 
glass of wine per day.
    5. Managing stress, most difficult of all efforts through 
meditation, yoga, visualization, mini vacations and appropriate sleep.
    6. Building a strong support system and social network of friends 
and relationships. This may be one reason why women outlive men, 
because they have a stronger capacity for dealing with intimacy.
    7. A sense of purpose--something to get up for in the morning. We 
discovered in studies we did at the National Institutes of Health back 
in the 1950s and 1960s that those individuals that had something to get 
up for in the morning, something purposeful, lived longer and better.

    Since people are living longer, they should work longer for health 
reasons and to reduce Social Security costs. Older persons should also 
actively volunteer, providing services to others.
    We know that perhaps no more than 25 percent of our health and 
longevity depends upon genes. Thus some 75 percent is up to us. This 
offers us a lot of power, but also entails genuine responsibility and 
self care.
    In order to assist people to maintain healthy aging by undertaking 
the activities described, how can we help them? Some help of course, 
can be derived from the doctor-patient relationship. But doctors today 
have no more than 12 minutes on average to spend with their patients. 
Fundamentally, we have a sickness system, not a health system. In 
general, neither doctors nor hospitals have incentives to maintain 
health--they profit through disease.
    I believe we have to expand our efforts in prevention, through a 
broad public health perspective. For example, there are some 15,000 
senior centers throughout the United States. These are community 
facilities, 5,000 of which receive some support from our Administration 
on Aging. The utilization rate is not what it should be. Senior centers 
need to be modernized in at least two respects, both of which are 
supportive of healthy aging. One is senior centers should promote 
exercise, diet, etc. Two, closely related to purpose, older people 
should be encouraged to contribute more directly to the community. 
These modernizations of senior centers would help maintain healthy 
aging.
    Taxation and education were very effective in the 50 percent 
reduction of smokers in the United States since 1964. On the other 
hand, alcohol in America is marked by a significant number of hard core 
alcoholics affecting one of every four American families, accounting 
for most domestic abuse and a significant contribution to highway 
fatalities and other accidents. Alcohol taxes used to constitute a 
significant part of Federal revenue. In fact, there have been only a 
few increases in liquor taxes since 1950. This is an issue that should 
be revisited by Congress.
    I call upon citizens of America, the President's Council on 
Physical Fitness and Sports, the U.S. Prevention Task Forces and other 
appropriate organizations to help sponsor a national walking movement 
where friends, neighbors, and families could walk together. This is not 
expensive and it does not require membership in a health club.
    Of course, healthy aging is a life course issue, it is not 
something you simply introduce at 50, 60 or beyond. A few years ago, 
several of us wrote a widely quoted paper in the New England Journal of 
Medicine on the problem of obesity in America and the prospect that we 
might lose 3 to 5 years of life expectancy from the 30 additional years 
of life we gained in the 20th Century. Further, for the first time in 
our history, our children might not live as long as their parents. It 
is quite terrible to see 10-year old children who are obese and who 
already have type 2 old-age diabetes.
    A national walking movement is a simple, but an important step in 
dealing with the problem of obesity.
    Finally, and to repeat, it is urgent to realize the cost of failed 
health promotion and disease prevention. We must now go beyond the 
doctor-patient relationship to achieve the goals of healthy aging which 
requires healthy living throughout life. It is never too late to start 
and always to soon to stop.

    Senator Harkin. Thank you very much, Dr. Butler. It is good 
to see you again.
    I see Dr. Iezzoni is here, but I will go ahead with Dr. 
Hagan, and then we will finish up with you.
    Dr. Hagan, again, welcome. If you could summarize your 
statement, we would certainly appreciate it.

       STATEMENT OF JOSEPH F. HAGAN, JR., M.D., F.A.A.P.,

          CLINICAL PROFESSOR OF PEDIATRICS, UNIVERSITY

         OF VERMONT COLLEGE OF MEDICINE, BURLINGTON, VT

    Dr. Hagan. Thank you.
    Good morning. It is my honor to represent the American 
Academy of Pediatrics (AAP) at today's hearing.
    Senator Harkin, thank you for this opportunity. I do 
apologize for the Vermont weather. I don't think you should 
blame Senator Sanders. I take full responsibility for bringing 
the snow with me.
    [Laughter.]
    Senator Harkin. All right.
    Dr. Hagan. Preventive healthcare is a fundamental 
investment in the health of all children and adults. In 
pediatrics, preventive healthcare is vital as it has lifelong 
impact. In the design of any healthcare system, inadequate 
attention to preventive care mortgages future health and 
welfare not only of children, but of society itself.
    Pediatric preventive healthcare is fundamentally different 
from adult preventive health. We recommend that all children 
receive regular well-child care visits based on the American 
Academy of Pediatrics Bright Futures recommendations for 
preventive pediatric healthcare.
    In addition to receiving immunizations and important 
screenings, children are tracked for appropriate growth and 
developmental milestones. There is no comparable analog in 
adult health for this schedule of regular preventive visits or 
for tracking growth parameters, such as physical growth, body 
mass index, and developmental achievement.
    The AAP has focused on developing effective systems of 
pediatric healthcare. We wish to recommend three successful 
models for promoting child health--the medical home, Bright 
Futures, and EPSDT (Early and Periodic Screening, Detection, 
and Treatment).
    In a medical home, care is delivered--or directed by 
competent, well-trained physicians who provide primary care, 
managing all aspects of pediatric care--preventive, acute, and 
chronic. A medical home delivers care that is accessible. It is 
continuous and comprehensive. It is family centered. It is 
coordinated, compassionate, and culturally effective.
    A high-performing healthcare system requires medical homes 
that promote system-wide quality with optimal health outcomes, 
family satisfaction, and value.
    Bright Futures is a national standard for the components of 
quality well-child care. Bright Futures serves as a 
comprehensive guide to health promotion and guidance for 
preventive care to be used by all healthcare professionals 
caring for children and adolescents. I am honored to have 
served as co-editor of these guidelines.
    This national initiative is funded by HRSA's Maternal and 
Child Health Bureau and is developed and implemented and 
supported by multidisciplinary experts from national 
organizations and agencies.
    Community health centers, which provide important access to 
care for children, are increasingly using Bright Futures to 
guide well-child care. Many States have used Bright Futures to 
inform their Medicaid and State Child Health Insurance 
Programs.
    For example, the State of Iowa has used Bright Futures to 
update and benchmark its EPSDT measures and the EPSDT health 
program. In the private sector, the National Business Group on 
Health used Bright Futures as its model in crafting and testing 
its model benefits package for maternal and child health.
    Now, since 1967, the Medicaid program has required that all 
States provide medically necessary care to children under the 
EPSDT standard. EPSDT should serve as the fundamental principle 
for any benefits package for children under healthcare reform, 
and the Bright Futures guidelines should be the standard for 
well-child care under EPSDT.
    Now, in addition to these positive models for the care of 
children, the academy has also studied other models that have 
been less successful. We urge you not to place significant 
reliance on the following models when developing a 
comprehensive healthcare reform package.
    Retail-based clinics fail to provide a medical home that 
can offer consistent and comprehensive care to children and are 
unequipped to provide virtually any form of pediatric or adult 
preventive healthcare.
    Health savings accounts typically fail to promote child 
health by not requiring first dollar coverage for most 
pediatric well-child or preventive care.
    Some have suggested using the Federal Employees Health 
Benefits Program Basic Option under Blue Cross Blue Shield as 
the basic benefits package under healthcare reform. The academy 
considers this benefit package to be inadequate, particularly 
for children with special healthcare needs. A more appropriate 
private sector model can be found in the National Business 
Group's model benefits package.
    And finally, the U.S. Preventive Services Task Force 
provides an excellent evidence base for the determination of 
appropriate screening in adult preventive health services, but 
it has made few recommendations that apply to children and 
adolescents. Bright Futures would be a more appropriate set of 
guidelines for use in pediatric preventive care.
    The academy commends you, Mr. Chairman, for calling 
attention to the preventive healthcare needs of children. We 
look forward to working with Congress to craft a healthcare 
reform package that moves our healthcare system further towards 
promotion of health and wellness, particularly for children and 
youth.
    I appreciate this opportunity to testify. I would be 
honored to work with you in the future and will be pleased to 
answer any questions.
    Thank you.
    [The prepared statement of Dr. Hagan follows:]
       Prepared Statement of Joseph F. Hagan, Jr., M.D., F.A.A.P.
    Good morning. I appreciate this opportunity to testify today before 
the Committee on Health, Education, Labor, and Pensions on access to 
preventive health care for children. My name is Joseph F. Hagan, Jr., 
M.D., F.A.A.P., and I am proud to represent the American Academy of 
Pediatrics (AAP), a non-profit professional organization of 60,000 
primary care pediatricians, pediatric medical sub-specialists, and 
pediatric surgical specialists dedicated to the health, safety, and 
well-being of infants, children, adolescents, and young adults. I am a 
pediatrician in private practice in Burlington, Vermont and Clinical 
Professor in Pediatrics at the University of Vermont College of 
Medicine and the Vermont Children's Hospital. I served as co-chair of 
the Bright Futures Steering Committee, and I co-edited the Bright 
Futures Guidelines for Health Supervision of Infants, Children, and 
Adolescents 3rd edition--the national standard of well-child care for 
children. I have also authored chapters on preventive care in two of 
the three major pediatric textbooks.
    Preventive health care is a fundamental investment in the health of 
all children and adults. In pediatrics, preventive health is vital 
because it can have lifelong impacts. Inadequate attention to 
preventive care in the design of any health care system mortgages the 
future health and welfare not only of children, but of society itself. 
Research across a broad range of interventions has shown that 
preventive health and wellness for children consistently produces a 
high return on investment.\1\ Three key principles govern pediatric 
preventive care: (1) Prevention works, (2) Families matter, and (3) 
Health promotion is everybody's business.
---------------------------------------------------------------------------
    \1\ Bibliography of studies assembled by the Partnership for 
America's Economic Success available at http://
www.partnershipforsuccess.org/index.php?id=15&MenuSect=3#benefits.
---------------------------------------------------------------------------
                pediatrics is a preventive model of care
    Pediatrics is preventive care. The entire model of pediatric health 
care focuses around promoting optimal physical, mental, and social 
health and well-being for all infants, children, adolescents, and young 
adults. Pediatric preventive care can be seen as a set of concentric 
circles, with the child at its heart:
    Prevention works: Primary prevention involves the prevention of 
disease or illness before it occurs. In pediatrics, the well-known 
schedule of immunizations is proven to protect children against a wide 
range of previously deadly illnesses like polio and rubella. Other 
examples of primary prevention include health promotion and 
anticipatory guidance for the development of healthy lifestyles, such 
as good nutrition and regular physical activity.
    Another core principle of pediatrics is secondary prevention, which 
is early screening for a wide range of conditions that can lead to poor 
health. Newborn screening programs can identify metabolic conditions 
whose ill effects can be averted or mitigated with changes in diet or 
other interventions. Toddlers are screened for healthy development so 
that developmental delays can be detected and treatments provided 
early, when they can be most effective. Children are screened routinely 
for problems with vision or hearing that can profoundly impact healthy 
development. Lead screening can identify children who are being exposed 
to dangerous lead levels in their environment.
    In order for preventive care to be comprehensive and consistent, it 
must be delivered in a medical home. The medical home is defined as 
medical care that is accessible, continuous, comprehensive, family 
centered, coordinated, compassionate, and culturally effective.\2\ The 
medical home allows for the delivery of quality pediatric preventive 
care in a manner that avoids duplication of efforts and provides 
appropriate follow-up or interventions.
---------------------------------------------------------------------------
    \2\ American Academy of Pediatrics Medical Home Initiatives for 
Children With Special Needs Project Advisory Committee. The Medical 
Home. Pediatrics, Vol. 110 No. 1 July 2002.
---------------------------------------------------------------------------
    Families matter: A successful system of care for infants, children 
and adolescents is family-centered. In most cases, pediatric care 
involves treating not only the child, but also providing guidance to 
the family as a whole. Parents and caregivers may require guidance on 
issues related to appropriate expectations for different stages of 
child development, proper nutrition, or violence in the home. Focusing 
on the family's growth, development and concerns in parallel with the 
growth and development of the child is a central activity in pediatric 
care.
    Health promotion is everybody's business: Communities can have a 
significant impact on the health and well-being of residents. Families 
benefit from a broad range of community-based services, including 
mental health services, education services and services for children 
and youth with special health care needs. Child care and schools play a 
vital role in promoting the health of children, including health 
education programs, food services, and promotion of physical activity. 
Access to green spaces and recreational areas provides opportunities 
for play and exercise. These programs and services, coupled with 
primary care provided in a medical home, constitute a community-based 
system of care and are central to promoting family well-being. The AAP 
is expanding its Federal advocacy efforts to highlight the preventive 
health aspects of issues including transportation policy, education 
policy, energy policy and climate change, and Federal nutrition 
programs.
    By placing health promotion, anticipatory guidance, and family 
engagement at the heart of all care, pediatric health care in the 
medical home can serve as a model for transforming our health care 
system.
          children have different preventive health care needs
    Pediatric preventive health care is fundamentally different from 
adult preventive health. It is recommended that all children receive 
regular well-child care visits based on the AAP/Bright Futures 
Recommendations for Preventive Pediatric Health Care, also known as the 
Periodicity Schedule, which sets out a series of examinations at 
specific developmental stages.\3\ In addition to receiving 
immunizations and important screenings, children are tracked for 
appropriate growth and developmental milestones. There is no comparable 
analog in adult health for this schedule of regular preventive visits 
to the physician, or for tracking growth parameters such as head 
circumference and Body Mass Index.
---------------------------------------------------------------------------
    \3\ For more information on Bright Futures, see http://
brightfutures.aap.org/.
---------------------------------------------------------------------------
    Successful pediatric preventive care is dependent entirely upon 
partnership with the family to provide the elements necessary for 
health promotion. Most children have no responsibility for and indeed 
no control over most aspects of their own health, including access to 
care, appropriate nutrition, shelter, cleanliness, or nurturing. 
Pediatric preventive health efforts must focus, therefore, on education 
and engagement of parents and caregivers, with emphasis gradually 
shifting to the child's own responsibility for good health as he or she 
grows up. Health professionals who have pediatric patients with special 
health care needs must seek to understand the family's composition and 
social circumstances and the impact the special needs have on family 
functioning.
     all children need pediatric-specific models of preventive care
    In recent decades, the American Academy of Pediatrics has focused 
on developing and studying effective systems of pediatric health care. 
We are proud to describe successful models for promoting child health.
    The Medical Home: In a medical home, care is delivered or directed 
by competent, well-trained physicians who provide primary care, 
managing and facilitating all aspects of pediatric care: preventive, 
acute and chronic. The Academy has led the development of a body of 
literature surrounding the medical home, including dozens of studies 
that examine the impact of care coordination on patient outcomes. The 
U.S. Department of Health and Human Services' Healthy People 2010 goals 
and objectives state that ``all children with special health care needs 
will receive regular ongoing comprehensive care within a medical 
home,'' and multiple Federal programs require that all children have 
access to an ongoing source of health care. A high performance health 
care system requires medical homes that promote system-wide quality 
with optimal health outcomes, family satisfaction, and value.
    Bright Futures: Bright Futures: Guidelines for Health Supervision 
of Infants, Children and Adolescents is the national standard for 
quality well-child care, serving as a comprehensive guide to pediatric 
health promotion and guidance on preventive care for use by all health 
professionals.\4\ The Guidelines address the care needs of all children 
and adolescents, including children and youth with special health care 
needs and children from families with diverse cultural and ethnic 
backgrounds. Bright Futures recognizes that effective health promotion 
and disease prevention require coordinated efforts among medical and 
nonmedical professionals and agencies, including public health, social 
services, mental health, home health, parents, caregivers, families and 
many other members of the broader community. This national initiative 
is funded by the Health Resources and Services Administration's 
Maternal and Child Health Bureau and developed, implemented and 
supported by multidisciplinary experts, national organizations, and 
agencies addressing child and adolescent health issues.
---------------------------------------------------------------------------
    \4\ Bright Futures: Guidelines for Health Supervision of Infants, 
Children and Adolescents. 3rd Ed. American Academy of Pediatrics, 2008.
---------------------------------------------------------------------------
    Pediatricians and other child health care providers should follow 
Bright Futures Guidelines for pediatric well-child care at all 
preventive care visits as prescribed by the AAP/Bright Futures 
Periodicity Schedule. One of the great strengths of Bright Futures is 
its adaptability to any setting or provider model; it can be used in 
whole or in part, by physicians, nurses, or other health care 
professionals, and in delivery settings ranging from clinics to school-
based health centers. Many States have used Bright Futures to inform 
their Medicaid and State Child Health Insurance Program well-child care 
standards; for example, the State of Iowa uses Bright Futures to update 
and benchmark its EPSDT health program.\5\ Oklahoma uses Bright Futures 
family tip sheets as a resource for anticipatory guidance and follows 
the well-child screening guidelines. Massachusetts has included Bright 
Futures as a reference for the delivery of comprehensive care in 
Medicaid, public health programs, and school-based health centers. The 
National Business Group on Health used Bright Futures as its model in 
crafting its Model Benefits Package for Maternal and Child Health.\6\
---------------------------------------------------------------------------
    \5\ For more information on Iowa's use of Bright Futures in its 
EPSDT program, see http://www.iowaepsdt.org/EPSDTNews/2007/Winter07/
IdentifyDevelConcerns.htm.
    \6\ National Business Group on Health. Investing in Maternal and 
Child Health. Available at http://www.businessgrouphealth.org/
healthtopics/maternalchild/investing/docs/mch_toolkit
.pdf.
---------------------------------------------------------------------------
    Early and Periodic Screening, Detection, and Treatment (EPSDT): 
Since 1967, the Medicaid program has required States to provide all 
medically necessary care to children under the EPSDT standard. EPSDT 
directs States to cover not only appropriate screening of children, but 
the treatment necessary to address any conditions or needs identified. 
EPSDT should serve as the fundamental principle for any benefits 
package for children under health care reform. Bright Futures 
Guidelines should be the standard of well-child care within EPSDT.
    In addition to promoting these positive models of care for 
children, the Academy has also studied other models that are less 
successful. We urge you not to place significant reliance on these 
models when developing a comprehensive health care reform package:
    Retail-based Clinics (RBCs): RBCs fail to provide a medical home 
that can offer consistent, comprehensive care to children. With their 
focus on providing care for adults and episodes of illness, RBCs are 
unequipped to provide well-child care, anticipatory guidance, or 
virtually any form of pediatric preventive health care. They are in 
direct opposition to the fundamentals of preventive care because they 
fragment the care delivery process. In fact, they can be a disruptive 
influence on the continuous engagement and follow-up of families and 
their children.\7\
---------------------------------------------------------------------------
    \7\ Retail-Based Clinic Policy Work Group. AAP Principles 
Concerning Retail-Based Clinics. Pediatrics, Vol. 118 No. 6, December 
2006.
---------------------------------------------------------------------------
    Health Savings Accounts (HSAs): HSAs fail to promote child health 
by not requiring first-dollar coverage for most pediatric well-child or 
preventive care. By requiring families to pay out-of-pocket for 
virtually all care except catastrophic needs, HSAs can present a 
serious barrier for families to pursue pediatric preventive care 
according to the Periodicity Schedule as well as timely illness care. 
HSAs are particularly unsuitable for families with children with 
special health care needs. The ongoing health care needs of these 
children quickly drain these accounts and parents find themselves 
unable to access the critically needed services for this vulnerable 
population of children.\8\
---------------------------------------------------------------------------
    \8\ American Academy of Pediatrics Committee on Child Health 
Financing. High-Deductible Health Plans and the New Risks of Consumer-
Driven Health Insurance Products. Pediatrics, Vol. 119 No. 3, March 
2007.
---------------------------------------------------------------------------
    Federal Employees Health Benefits Program (FEHBP) Basic Option: 
Some have recommended using the FEBHP Basic Option under Blue Cross 
Blue Shield as the basic benefits package under health care reform. The 
Academy considers this benefits package to be inadequate, particularly 
for children with special health care needs and complex conditions.\9\ 
A more appropriate pediatric private sector model can be found in the 
National Business Group on Health's Model Benefits Package for Maternal 
and Child Health, which recognizes the importance of Bright Futures and 
associated preventive care. In addition, the AAP makes recommendations 
for the full scope of health care benefits for children birth through 
age 21.\10\
---------------------------------------------------------------------------
    \9\ National Health Policy Forum. EPSDT: Medicaid's Critical But 
Controversial Benefits Program for Children. Issues Brief No. 819, 
November 20, 2006. Available at http://www.nhpf.org/library/issue-
briefs/IB819_EPSDT_11-20-06.pdf.
    \10\ American Academy of Pediatrics Committee on Child Health 
Financing. Scope of Health Care Benefits for Children from Birth to Age 
21. Pediatrics, Vol. 117 No. 3, March 2006.
---------------------------------------------------------------------------
    Recommendations of the U.S. Preventive Services Task Force 
(USPSTF): While the USPSTF provides an excellent basis for the 
determination of appropriate screening for adult preventive health 
services, USPSTF has made few recommendations that apply to children 
and adolescents. Most of these findings related to children and 
adolescents result in a classification of ``I'' for insufficient 
evidence. In some cases, the USPSTF finds that there is enough evidence 
to recommend a preventive service or counseling for adults, but not 
enough evidence to recommend the same service for children and 
youth.\11\
---------------------------------------------------------------------------
    \11\ For more information on the U.S. Preventive Services Task 
Force and its recommendations, see http://www.ahrq.gov/clinic/
uspstfix.htm.
---------------------------------------------------------------------------
    Bright Futures would be a more appropriate set of guidelines to use 
for pediatric preventive care than the recommendations of the USPSTF. 
The Bright Futures Guidelines made extensive use of the USPSTF 
guidelines that existed and is transparent in its use of other 
available evidence. However, performing only the handful of current 
USPSTF-recommended pediatric preventive care screenings would lead to 
missed opportunities in disease prevention, disease detection and 
necessary early intervention.
        more research is needed to build the evidence base for 
                       pediatric preventive care
    Health supervision of an individual child is a complex package of 
services that is provided over the child's lifetime. It includes not 
only preventive and screening interventions that are recommended for 
all children, but also addresses the particular needs of that child in 
the context of family and community. Studying the outcomes over a 
child's lifetime of health supervision at this level of integration can 
be a daunting task.
    For many interventions that are commonly performed in child or 
adolescent care, no, or few, properly constructed studies have been 
done that link that intervention with intended health outcomes. Absent 
evidence does not demonstrate a lack of usefulness, however. The lack 
of evidence most often simply reflects a lack of study. Filling in the 
gaps in evidence is highly desirable, and additional research is 
strongly encouraged.\12\
---------------------------------------------------------------------------
    \12\ Bright Futures: Guidelines for Health Supervision of Infants, 
Children and Adolescents. 3rd Ed. ``Rationale and Evidence.'' American 
Academy of Pediatrics, 2008.
---------------------------------------------------------------------------
    The American Academy of Pediatrics commends you, Mr. Chairman, for 
holding this hearing today to call attention to the preventive health 
care needs of children. As you study the entire health care system and 
address the need to assure every person achieves the best possible 
outcome, please remember that quality, comprehensive preventive child 
health services are essential to any effort to prevent morbidity and 
cost in the adult population. Any successful effort to reform our 
health care system must recognize the interdependence of initiatives on 
preventive care, health information technology, and quality improvement 
to achieve the desired goals. We look forward to working with Congress 
to craft a health care reform package that moves our health care system 
further toward promotion of health and wellness, particularly for 
children and youth. I appreciate this opportunity to testify, I would 
be honored to work with you in the future and I will be pleased to 
answer any questions you may have.

    Senator Harkin. Thank you very much, Dr. Hagan.
    I don't mean to play favorites here, but of all the things 
we are thinking about in prevention and in wellness, you have 
really got to start with kids really early on because that 
determines everything later on. We have really got to focus 
on--sorry, Dr. Butler, I know aging and----
    [Laughter.]
    Dr. Butler. Oh, I agree. You have to start with kids.
    Senator Harkin. You have got to get these kids early on.
    Dr. Iezzoni, thanks for being here. Sorry for all the snow 
and everything out there, but----
    Dr. Iezzoni. I think you are sending it out my way later 
today.
    Senator Harkin. I introduced you earlier. I said Dr. 
Iezzoni is a professor of medicine at Harvard Medical School, 
associate director of the Institute for Health Policy at the 
Massachusetts General Hospital in Boston. Has published and 
spoken widely on risk adjustment and, again, has been a member 
of the Institute of Medicine and the National Academy of 
Sciences, focusing on prevention and wellness as it pertains to 
people with disabilities, which is a particular focus of mine, 
as you probably know.
    Thanks for being here, Dr. Iezzoni.

    STATEMENT OF LISA I. IEZZONI, M.D., M.SC., PROFESSOR OF 
MEDICINE, HARVARD MEDICAL SCHOOL AND ASSOCIATE DIRECTOR OF THE 
   INSTITUTE FOR HEALTH POLICY AT THE MASSACHUSETTS GENERAL 
                      HOSPITAL, BOSTON, MA

    Dr. Iezzoni. Thank you very much, Senator, for having me 
here. I appreciate that.
    I would like to make four points in my brief comments this 
morning. The first is that 40 million to 50 million Americans 
live with disabilities, and they face the same risk of 
developing preventable acute and chronic health conditions as 
do other people.
    In fact, because of their underlying health conditions, 
some individuals with disabilities might have higher risks than 
other people of developing certain types of preventable health 
problems.
    Second, individuals with disabilities experience high rates 
of disadvantages relating to their personal, social, economic, 
and environmental determinants of health, as recognized by the 
Secretary's Advisory Committee on National Health Promotion and 
Disease Prevention Objectives for 2020.
    Compared with nondisabled individuals, people with 
disabilities are much more likely to have low levels of 
education, lower levels of employment, higher rates of poverty. 
Twenty-five percent of working-age adults with disabilities 
live in poverty, compared with 9 percent of other working-age 
individuals.
    Problems finding safe, accessible, and affordable housing. 
Higher rates of depression, anxiety, and stress. Thirty-four 
percent of persons with major difficulties walking report being 
frequently depressed or anxious, compared with 3 percent of 
those without disabilities.
    Higher likelihood of being victims of crime or domestic 
violence. Higher rates of being overweight and obese, and 
higher rates of tobacco use.
    However, individuals with disabilities can be unaware of 
their health risks and the need for screening and preventive 
services. Some persons engage in magical thinking, the notion 
that because they have a serious health problem that nothing 
more can go wrong with their health. Therefore, they do not 
seek the preventive services----
    Senator Harkin. True.
    Dr. Iezzoni [continuing]. That one should recommend. These 
disadvantages heighten the risk that persons with disabilities 
may not achieve the national health goals envisioned by the 
Healthy People 2020 Advisory Committee, which is for every 
American to live long and healthy lives.
    Surveys, in fact, find that adults reporting disabilities 
are 30 percent more likely than nondisabled respondents to 
report being in fair or poor health.
    Third, persons with disabilities face major externally 
imposed barriers to obtaining their healthcare services and 
public health intervention. Frankly, discriminatory and 
stigmatizing societal attitudes are still at play.
    A survey of Los Angeles County residents with sensory or 
physical disabilities found that 18 percent of persons 
reporting severe disabilities describe being treated unfairly 
by their healthcare provider because of their disability.
    Smokers with major difficulties walking are 20 percent less 
likely than other smokers to be asked about their smoking 
histories by their physicians during routine annual checkups. 
Recommendations from several groups about distributing 
ventilators and other scarce resources during influenza 
pandemics categorically exclude individuals with disabilities 
from obtaining those resources.
    Physical access barriers. The survey of Los Angeles County 
residents found that 31 percent of people with severe physical 
or sensory disabilities reported physical barriers to getting 
into their healthcare provider.
    Many factors might explain lower rates of screening and 
preventive service use among persons with disabilities, 
including competing health demands and patient preferences. 
Nonetheless, equipment inaccessibility likely contributes to 
lower rates of service use.
    Persons who cannot stand to be weighed report not knowing 
their weight. Some with spinal cord injury joke about weighing 
the same as they did the day they were injured because they 
haven't been weighed since then.
    Women with spinal cord injury who became pregnant described 
being weighed during prenatal care visits on laundry or freight 
scales in hospital basements or loading docks.
    Women with major difficulties walking are 40 percent less 
likely than other women to get Pap smears. Some women with 
major mobility problems report never having had a Pap smear 
because they cannot get onto the fixed-height examination table 
in their physician's office.
    Women with major difficulties walking are 30 percent less 
likely than other women to get mammograms. Although wheelchair-
accessible mammography equipment does exist, many facilities 
have not yet installed those machines.
    Communication barriers. Inaccessible communication poses 
barriers for persons who are deaf or hard of hearing, blind or 
low vision, individuals with speech impairments, and persons 
with cognitive and developmental disabilities.
    According to the Nutrition Labeling and Education Act of 
1994 requirements, nutrition labeling on packaged food can use 
print as small as 8-point type. Nutrition labels provide 
critical guidance for consumers concerned about purchasing 
healthy foods. However, the type size on these labels is too 
small for people with low vision to read at the grocery store.
    Women who are deaf or hard of hearing are 20 percent less 
likely than other women to get mammograms. The reasons for this 
are unclear, but one factor likely relates to communication 
barriers. Unless a sign language interpreter accompanies them, 
they may be unable to follow instructions from the mammography 
technician, who disappears behind a protective radiation shield 
while taking the image.
    Without being able to see the technician, the woman may be 
unaware of when to hold her breath to avoid motion artifact 
when the equipment generates the mammogram image and might have 
a bad experience obtaining the test.
    Financial barriers. Although people with disabilities are 
more likely than others to have social safety net health 
insurance, there are many who are still uninsured. In 
particular, individuals with disabilities in States with 
restrictive Medicaid coverage policies have high rates of being 
uninsured.
    In the South, for example, 39 percent of low-income workers 
reporting disabilities lack health insurance. The nationwide 
uninsur-
ance figure for this population subgroup is 24 percent.
    Fourth, and finally, the public policy implications. Now 
these problems have been noticed before. In 2000, Healthy 
People 2010 cautioned that, ``As a potentially underserved 
group, people with disabilities would be expected to experience 
disadvantages in health and well-being compared with the 
general population.''
    On July 26, 2005, the 15th anniversary of the ADA being 
signed, the U.S. Surgeon General issued a call to action, 
warning that people with disabilities can lack equal access to 
healthcare. Nevertheless, more efforts are needed to eliminate 
barriers to public health and preventive services faced by 
persons with disabilities.
    According to the Institute of Medicine report entitled, 
``The Future of Disability in America,'' the number of 
Americans with disabilities will likely grow substantially in 
coming decades. Improving access to health promotion and 
disease prevention, programs for people with disabilities 
should be a national public health priority.
    Thank you.
    [The prepared statement of Dr. Iezzoni follows:]
           Prepared Statement of Lisa I. Iezzoni, M.D., M.Sc.
    In the United States, 40 to 54 million persons have disabilities. 
They face the same risks of developing preventable acute and chronic 
health conditions as do other people. Disabilities are diverse, but 
many are caused by serious medical conditions that leave persons with a 
narrow margin of health. Thus, depending on their underlying health 
conditions, some individuals with disabilities might have higher risks 
than other people of developing certain preventable health problems.
                         determinants of health
    Rates of disabilities vary across demographic subgroups within the 
U.S. population. Disability rates rise with increasing age: 6 percent 
among persons ages 5-15 years; 7 percent for ages 16-20; 13 percent for 
ages 21-64; 30 percent for ages 65-74; and 53 percent for ages 75 and 
older.\1\ Across the population age 5 and older, females (16 percent) 
have slightly higher rates of disabilities than males (14 percent). 
Among adults in different racial and ethnic groups, American Indian or 
Alaskan Native populations report the highest disability rates (30 
percent), compared with 21 percent for black persons, 20 percent for 
white persons, 17 percent for Hispanic individuals and for Native 
Hawaiian and other Pacific Islanders, and 12 percent for Asians.\2\
---------------------------------------------------------------------------
    \1\ W Erickson and C Lee. 2007 Disability Status Report: United 
States. Ithaca, NY: Cornell University Rehabilitation Research and 
Training Center on Disability Demographics and Statistics, 2008. The 
population prevalence figures come from the 2007 American Community 
Survey.
    \2\ LA Wolf, BS Armour, and VA Campbell. Racial/Ethnic Disparities 
in Self-Rated Health Status Among Adults With and Without 
Disabilities--United States, 2004-2006. Morbidity and Mortality Weekly 
Report 2008;57(39):1069-1073. Figures come from respondents age greater 
than or equal to 18 years to the Behavioral Risk Factor Surveillance 
System surveys.
---------------------------------------------------------------------------
    Many persons with disabilities confront sociodemographic 
disadvantages and have other attributes that heighten their risks for 
preventable health problems. Compared with nondisabled individuals, 
persons with disabilities are much more likely to have \3\:
---------------------------------------------------------------------------
    \3\ LI Iezzoni and BL O'Day. More Than Ramps: A Guide to Improving 
Health Care Quality and Access for People with Disabilities. New York: 
Oxford University Press, 2006. Unless otherwise noted, the statistics 
listed below this paragraph come from various national health surveys 
but may not represent exactly circumstances in 2009.

     Lower levels of education: among adults with disabilities, 
30 percent have less than a high school education, compared with 17 
percent among those without disabilities.
     Lower rates of employment: 37 percent of working-age 
adults with disabilities are employed, compared with 80 percent of 
nondisabled working-age adults.\4\
---------------------------------------------------------------------------
    \4\ Erickson and Lee, 2008. The employment figures come from the 
2007 American Community Survey.
---------------------------------------------------------------------------
     Higher rates of poverty: 25 percent of working-age adults 
with disabilities live in poverty compared with 9 percent of other 
working-age adults.\5\
---------------------------------------------------------------------------
    \5\ Ibid. The poverty figures come from the 2007 American Community 
Survey. Among disability categories, persons with ``mental'' 
disabilities had the highest poverty rate (32 percent) and those with 
``sensory'' disabilities the lowest poverty rate (22 percent).
---------------------------------------------------------------------------
     Problems finding safe, accessible, and affordable housing: 
for example, 20 percent of persons with major difficulties walking have 
trouble using the bathrooms in their homes because of physical barriers 
\6\; a study of 14 federally funded public housing facilities in the 
Kansas City area found that 14 percent-29 percent did not comply with 
various Federal disability access regulations \7\; and a survey of Los 
Angeles County residents with disabilities found that 25 percent need 
home modifications but do not have them.\8\
---------------------------------------------------------------------------
    \6\ LI Iezzoni. When Walking Fails: Mobility Problems of Adults 
with Chronic Conditions. Berkeley: University of California Press, 
2003: p. 88. This figure comes from the 1994-1995 National Health 
Interview Survey Disability Supplement. Despite its age, this survey 
continues to offer the most comprehensive information available about 
the lives of Americans with disabilities.
    \7\ K Froehlich-Grobe, G Regan, JY Reese-Smith, KM Heinrich, and RE 
Lee. Physical Access in Urban Public Housing Facilities, Disability and 
Health Journal. 2008;1:25-29.
    \8\ E Bancroft, A Lightstone, and P Simon. Environmental Barriers 
to Health Care Among Persons with Disabilities--Los Angeles County, CA, 
2002-2003. Mortality and Morbidity Weekly Report. 2006;55(48):1300-
1303. The survey involved only 1,333 persons reporting physical or 
sensory disabilities.
---------------------------------------------------------------------------
     Higher rates of depression, anxiety, strong fears, and 
stress: for example, 34 percent of persons with major difficulties 
walking report being frequently depressed or anxious, compared with 3 
percent among those without disabilities.
     Higher likelihood of being victims of crimes or domestic 
violence although, as the U.S. Department of Justice acknowledges, 
statistics for this population are hard to acquire: persons with 
certain types of disabilities may be unable to file reports; others who 
are abused physically and psychologically by caregivers fear losing 
essential assistance with activities of daily living.\9\
---------------------------------------------------------------------------
    \9\ U.S. Department of Justice, Office of Justice Programs, Office 
for Victims of Crime. The OVC worked with the National Organization for 
Victim Assistance on a project Working with Crime Victims with 
Disabilities, which explored these issues. www.ojp.gov/ovc/
publications/factshts/disable.htm.
---------------------------------------------------------------------------
     Higher rates of being overweight and obese: for example, 
27 percent of adults with major physical and sensory impairments are 
obese, compared with 19 percent among those without major impairments.
     Higher rates of tobacco use: for example, 47 percent of 
adults with major difficulties walking use tobacco, compared with 26 
percent of nondisabled adults.

    In addition, interviews with individuals with disabilities find 
they can be unaware of their health risks and need for screening and 
preventive services. Some persons describe ``magical thinking''--the 
belief that because they already have one significant impairment 
nothing more can go wrong with their health.\10\ They therefore do not 
seek or receive routine screening services, such as those recommended 
by the U.S. Preventive Services Task Force (USPSTF).
---------------------------------------------------------------------------
    \10\ Iezzoni and O'Day, 2006.
---------------------------------------------------------------------------
    Thus, individuals with disabilities experience high rates of 
disadvantages relating to the personal, social, economic, and 
environmental determinants of health as recognized by the Secretary's 
Advisory Committee on National Health Promotion and Disease Prevention 
Objectives for 2020.\11\ These disadvantages heighten the risks that 
persons with disabilities will not achieve the national health goal 
envisioned by the committee, of living long and healthy lives. Not 
surprisingly, surveys find that adults reporting disabilities are 30 
percent more likely than nondisabled respondents to report being in 
fair or poor health.\12\ These health disparities are particularly 
marked for certain population subgroups: for example, 33 percent more 
black respondents with disabilities than black respondents without 
disabilities report fair or poor health, as do 38 percent more disabled 
American Indian/Alaskan Natives than their nondisabled counterparts.
---------------------------------------------------------------------------
    \11\ Secretary's Advisory Committee on National Health Promotion 
and Disease Prevention Objectives for 2020. Phase I Report. 
Recommendations for the Framework and Format of Healthy People 2020. 
October 28, 2008. This committee, which operates under FACA rules, is 
chaired by Dr. Jonathan Fielding, Director of Public Health and Health 
Officer, Los Angeles County, and it has 13 members. I am a committee 
member.
    \12\ Wolf, Armour, and Campbell, 2008. Figures come from 
respondents age greater than or equal to 18 years to the Behavioral 
Risk Factor Surveillance System surveys.
---------------------------------------------------------------------------
        barriers to public health and health promotion services
    Persons with disabilities face several major externally imposed 
barriers to accessing health care services and public health 
interventions.
           discriminatory and stigmatizing societal attitudes
    Despite significant gains in civil rights and greater participation 
in daily community life, persons with disabilities continue to confront 
discriminatory and stigmatizing attitudes. These attitudes may possibly 
extend to health care settings. For instance \13\:
---------------------------------------------------------------------------
    \13\ Iezzoni and O'Day, 2006.

     Smokers with major difficulties walking are 20 percent 
less likely than other smokers to be asked about their smoking 
histories by their physicians during routine annual check-ups. However, 
scientific evidence suggests that when physicians ask about patients' 
smoking histories, even this simple act can encourage attempts to quit 
smoking. Some persons with walking difficulties may have limited lung 
capacity, increasing their risks of respiratory infections and other 
pulmonary complications. Ceasing smoking is therefore critical in this 
population.
     Women of child-bearing age with major difficulties walking 
are 70 percent less likely than other women to be asked about 
contraception during routine physician office visits. However, if these 
women are sexually active, they face risks of unintended pregnancy. 
They may also have heightened risks of complications (such as deep vein 
thrombosis) from hormonal contraceptives or have trouble with manual 
dexterity, making barrier contraceptives less feasible. Therefore, 
safely and effectively preventing unintended pregnancy can require 
consultation with their physicians.

    Stigmatizing attitudes could contribute to these findings. For 
instance, physicians may choose not to discuss smoking with disabled 
patients under the distorted belief that smoking brings consolation to 
otherwise unhappy lives. Physicians may not discuss contraception with 
disabled women under another erroneous belief that they are not 
sexually active and at risk of unintended pregnancy. In a survey of Los 
Angeles County residents with sensory or physical disabilities, 13 
percent reported being treated unfairly at their health care provider's 
office because of their disability; 18 percent of persons reporting 
severe disabilities described unfair treatment.\14\
---------------------------------------------------------------------------
    \14\ Bancroft, Lightstone, and Simon, 2006.
---------------------------------------------------------------------------
    One particularly worrisome issue involves distribution of scarce 
resources during public health emergencies, such as provision of 
mechanical ventilators during a pandemic influenza outbreak. While the 
U.S. Department of Health and Human 
Services acknowledges that such shortages will likely occur in the 
event of an influenza epidemic, DHHS has offered little guidance on how 
to allocate scarce resources. Other groups have provided 
recommendations for distributing ventilators and other scarce 
resources, some categorically excluding individuals with 
disabilities.\15\ It is critical to conduct an open and transparent 
debate with the public and government officials about allocation 
guidelines before a pandemic public health emergency occurs.
---------------------------------------------------------------------------
    \15\ DB White, MH Katz, JM Luce, and B Lo. Who Should Receive Life 
Support During a Public Health Emergency? Using Ethical Principles to 
Improve Allocation Decisions. Annals of Internal Medicine. 
2009;150:132-138.
---------------------------------------------------------------------------
                        physical access barriers
    Little systematic information is available about the accessibility 
of health care facilities. A survey of Los Angeles County residents 
with physical or sensory disabilities found that 22 percent had 
difficulty accessing their health care provider's office; non-Hispanic 
black respondents and persons with severe disabilities reported the 
highest rates of physical barriers (33 percent and 31 percent, 
respectively).\16\ Plentiful anecdotal reports suggest that basic 
equipment required for routine health and screening services is 
frequently physically inaccessible, including:
---------------------------------------------------------------------------
    \16\ Bancroft, Lightstone, and Simon, 2006.

     Weight scales;
     Examination tables; and
     Mammography machines.

    Many factors may explain lower rates of screening and preventive 
service use among persons with disabilities, including competing health 
demands and patient preferences. Nonetheless, equipment inaccessibility 
likely contributes to lower levels of service use among persons with 
disabilities as suggested by the following examples \17\:
---------------------------------------------------------------------------
    \17\ Ibid.

     Persons who cannot stand to be weighed report not knowing 
their weight. Some with spinal cord injuries (SCI) joke about weighing 
the same as the day they were injured because they have not been 
weighed since. Women with SCI who become pregnant describe being 
weighed during prenatal care visits on laundry or freight scales in 
hospital basements or loading docks.
     Women with major difficulties walking are 40 percent less 
likely than other women to get Pap smears, which are recommended with 
Grade A evidence by the USPSTF to prevent cervical cancer deaths.\18\ 
Some women with major mobility problems report never having had a Pap 
smear because they cannot get onto the fixed-height examination table 
in their physicians' office.
---------------------------------------------------------------------------
    \18\ U.S. Preventive Services Task Force. Guide to Clinical 
Preventive Services, 2008. www.ahrq
.gov.
---------------------------------------------------------------------------
     Women with major difficulties walking are 30 percent less 
likely than other women to get mammograms, which are recommended by the 
USPSTF every 1 to 2 years for women age 40 and older (Grade B 
evidence). Although wheelchair accessible mammography equipment does 
exist, many facilities have not yet acquired these machines. Women with 
major walking difficulties report being unable to obtain adequate 
images or having such unpleasant initial experiences that they do not 
return for their periodic screening.
                         communication barriers
    Inaccessible communication poses barriers for persons who are deaf 
or hard of hearing, blind or low vision, individuals with speech 
impairments, and persons with cognitive and developmental disabilities. 
Persons may not receive the information they need to manage their 
health in formats that they can access or understand. In addition, 
failures of information transfer during screening or preventive 
services can compromise clinical procedures. These communication 
barriers are diverse. Several examples include the following:

     According to the Nutrition Labeling and Education Act 1994 
requirements, nutrition labeling on packaged foods can use print as 
small as 8-point type.\19\ Footnotes and caloric conversion information 
can be as small at 6-point type. Nutritional labels provide critical 
guidance for consumers concerned about purchasing healthy foods. 
However, the type size on these labels is too small for persons with 
low vision to read, and information is not readily available in other 
formats (e.g., Braille). Although nutritional information on specific 
products may be available through other sources (e.g., manufacturer Web 
sites), consumers need information at the time of purchase.
---------------------------------------------------------------------------
    \19\ U.S. Food and Drug Administration, Office of Regulatory 
Affairs. Guide to Nutrition Labeling and Education Act Requirements, 
August 1994. www.fda.gov/ora/inspect_ref/igs/nleatxt
.html. Print must be in easy to read type styles, with nutrition facts 
in bold face: 21 CFR 101.9(d).
---------------------------------------------------------------------------
     Women who are deaf or hard of hearing are 20 percent less 
likely than other women to obtain mammograms. The reasons for this are 
unclear, but two factors might contribute. Some persons who are deaf 
and use American Sign Language (ASL) as their primary language report 
that they have little knowledge about routine preventive health 
services, such as information frequently provided through Public 
Service Announcements (PSAs). They do not listen to radio and watch 
limited television, needing closed captioning to access auditory 
television content. With English as their second language, they also 
may not routinely read magazines or newspapers and see print PSAs. 
Second, some women who communicate using ASL describe difficult 
situations in mammography suites. Unless an ASL interpreter accompanies 
them, they may be unable to follow instructions from the mammography 
technician, who disappears behind a protective radiation shield when 
taking the image. Without being able to see the technician, the woman 
may be unaware of when to hold her breath (to avoid motion artifact 
while the equipment generates the mammogram image). A simple system of 
readily visible light cues could rectify this situation (e.g., a red 
light for holding breath; a green light for breathing normally).
     Ineffective communication between patients and physicians 
may generate fears and anxieties that are long-lasting, compromising 
future care. Some persons who are deaf report physicians being 
unwilling to hire ASL interpreters for routine office visits, 
preferring instead to communicate by note-writing. One young woman 
described being unaware what was going to happen when she had her first 
Pap smear. The physician failed to explain the procedure (e.g., 
insertion of the speculum), producing such profound distress that the 
woman insists she will not return again for subsequent screening. 
Although the Americans with Disabilities Act requires effective 
communication during clinical encounters, a Catch-22 confounds this 
mandate. Physicians are prohibited from charging patients for the costs 
of the ASL or other sign language interpreters, and interpreter fees 
often exceed reimbursement for the services. Thus, despite the legal 
mandate, physicians have a financial disincentive to hire sign language 
interpreters.
                       financial access barriers
    Although persons with disabilities are more likely than others to 
have ``social safety net'' health insurance, some are uninsured. In 
particular, individuals with disabilities in States with restrictive 
Medicaid coverage policies have high rates of being uninsured. In the 
South, for example, 39 percent of low-income workers reporting 
disabilities lack health insurance (the nationwide uninsurance figure 
for this population subgroup is 24 percent).\20\ Without health 
insurance coverage, persons may lack access to critical screening and 
preventive health services.
---------------------------------------------------------------------------
    \20\ These unpublished figures come from our ongoing analyses of 
the 2000-2005 Medical Expenditure Panel Survey, produced by the Agency 
for Healthcare Research and Quality.
---------------------------------------------------------------------------
                       public policy implications
    Public health officials have recognized the barriers experienced by 
persons with disabilities.

     In 2000, Healthy People 2010, cautioned that ``as a 
potentially underserved group, people with disabilities would be 
expected to experience disadvantages in health and well-being compared 
with the general population.''
     On July 26, 2005, the U.S. Surgeon General issued a Call 
to Action warning that people with disabilities can lack equal access 
to health care.

    Nevertheless, more efforts are needed to eliminate barriers to 
public health and preventive services faced by persons with 
disabilities. According to the Institute of Medicine report, The Future 
of Disability in America, the number of Americans with disabilities 
will likely rise substantially in coming decades.\21\ Aging ``baby 
boomers'' will fuel much of this growth, with this enormous cohort 
entering age ranges with greatest disease and disability risks. 
Although rates of some serious limitations among elderly persons have 
declined, sobering reports warn of higher rates of potentially 
impairing conditions among children and working age adults. Much of 
this growing risk relates to preventable health conditions, such as 
those caused by overweight and obesity. Improving access to health 
promotion and disease prevention programs for persons with disabilities 
should be a national public health priority.
---------------------------------------------------------------------------
    \21\ Institute of Medicine Committee on Disability in America. 
Field MJ, Jette AM, eds. The Future of Disability in America. 
Washington, DC: National Academies Press, 2007.

    Senator Harkin. Thank you, Dr. Iezzoni.
    Very good. I appreciate it. Thanks for being here today.
    Well, thank you all very much for being here, but more than 
that, as I said earlier, thank you for your almost lifetime of 
involvement in preventive healthcare and prevention. I think 
you can see from the testimony here that we have everything, 
well, from early childhood to rural populations, disadvantaged, 
low income, people with disabilities.
    We have a broad spectrum of people out there that if they 
are not getting adequate access to the sickcare system that we 
have today, if we are really going to change this system and 
make it more preventive and wellness-based, public health-
based, if we just move the present system that way, they are 
going to be left behind, too.
    So, again, your testimonies are great. I just had this 
sense that we really need to put this together in a form, and 
my staff is working on that--Jenelle and Lee, others are 
working on this--to put together a package that would span this 
spectrum here that we have today of how we change some of these 
policies to reach out.
    You know, people say, ``Well, it will cost money.'' Well, 
it may cost money, sure. But, it is going to, as you point out, 
save us a lot of money early on and also later on.
    In terms of people with disabilities, you know, you 
mentioned the unemployment. Perhaps one of the most perplexing 
and just--I don't know the right word--just confounding, 
perplexing, and irritating and dismal figures that I have seen 
since the passage of the ADA, Americans with Disabilities Act, 
is that people with disabilities are unemployed at the rate of 
63 percent.
    About 63 percent of people with disabilities are 
unemployed, who want to work and could work, but they are 
unemployed--63 percent. We are worried now about 7 percent 
unemployment among the general population.
    So, again, you know, this part of our society--and I know 
from all my work in this area that if you are talking about 
exercise and you are talking about diets and you are talking 
about nutrition, they are just totally left out of the picture. 
Totally left out.
    With that, I mean, and with more of a full integration, 
people can work. They can get the jobs and everything.
    I didn't mean to go on like that. This is one thing that we 
really need your help on how we put this together. And as I 
said early on, I hope we can continue to rely upon your 
expertise as we move ahead on this.
    There is one question I want to ask of all of you, though, 
before I turn to Senator Merkley. Do you have to leave pretty 
soon?
    I will tell you what. I will save my question. I will turn 
to Senator Merkley. Go ahead for any statements you want to 
make or any questions. Go ahead, Jeff, and then I will come 
back. I have more time.
    Senator Merkley. Thank you very much, Mr. Chair.
    No statement, but a couple of questions.
    The first is I believe, Dr. Hagan, you referred to the 
model of retail-based clinics being a model that doesn't work 
well. Can you expand a little bit? We have our rural health 
clinics and our school-based clinics and our Federally 
Qualified Health Centers, and I am not familiar with your 
commentary on retail-based clinics. If you can just give a 
little sense of that.
    Dr. Hagan. I am relieved because I hesitate to hear retail-
based clinics in the same sentence as Federally Qualified 
Health Centers. Retail-based clinics have been--are just as 
they say. They are open in your local Wal-Mart or your local 
drug store. They often employ a nurse or a nurse practitioner 
to provide walk-in episodic care.
    Now it may or may not be a good place to go for a sore 
throat, but it certainly is not a medical home. When the retail 
establishment closes, so does the health center. When you need 
help after hours, you go to the emergency room. I mean, that is 
a very expensive nonsystem of care.
    It has become prevalent in many parts of the country, 
thankfully not yet in New England.
    Senator Merkley. Thank you very much.
    Second question I wanted to ask for whoever would like to 
respond to it is many of you have talked about clinics and the 
role of primary care physicians. The demographics, I believe, 
of the number of primary care physicians is not encouraging, in 
part because so many doctors are reaching retirement age in 
general and in part because of the financial incentive for 
folks to move from primary care into specialties.
    As we look at that curve ahead of us in which so many more 
citizens are aging and needing additional healthcare, yet so 
many physicians are retiring and those who aren't retiring are 
in referring specialties, how do we address this? How do we 
particularly address it in the context of physician services in 
rural areas?
    Dr. Stevens. Senator Merkley, if I could say a few words 
about that? First of all, I think your observation is quite 
accurate. I made comparisons to other countries, and those 
countries had at least 50 percent of their clinicians who are 
in primary care and we have only about a third. There is a 
direct relationship between our primary care infrastructure and 
our ability to deliver wellness and also, Dr. Hagan, in terms 
of a system where there is a medical home.
    Two things, in other countries and our country. One is, is 
to have policies that influence the distribution of primary 
care physicians and that encourage clinicians to go into 
primary care.
    One of the programs that we have now that has been quite 
successful--in fact, I was in it--is the National Health 
Service Corps, for example, where there are incentives and 
there is support for physicians who go into primary care. You 
know better than I do in terms of the debt and the other 
issues--in fact, in Great Britain, in the United Kingdom, 
primary care physicians are paid more than they are in the 
United States.
    We need to have policies and encourage people to go into 
primary care, so they know they can get a good living. And 
secondly, we need to encourage people like the National Health 
Service Corps and other programs to go into areas where there 
is a greater need for them.
    Dr. Lavizzo-Mourey. Thank you for that question. I 
certainly agree with Dr. Stevens about the incentives for going 
into primary care among physicians. I think we have to also 
recognize that much of healthcare is practiced in teams, and 
particularly teams that pair physicians with nurse 
practitioners and other healthcare providers can provide 
healthcare at the primary care level that has been demonstrated 
to be equivalent to that provided by physicians alone.
    I think as we consider how we are going to meet the 
workforce demands of the future, we need to think not only 
about primary care physicians, but teams of healthcare 
providers that can provide those services both in urban and 
rural settings.
    Dr. Butler. I think it is ironic that at the moment the 
country is growing older, we not only have a growing shortage 
of primary care physicians, but nurses. From 1985-89, when I 
served on the Physician Payment Review Commission, working for 
Congress, we tried to address the reimbursement issue, which so 
favors the procedural specialties rather than the primary 
medicine. And that is a tough one.
    Somebody is going to have to deal with it because as long 
as we have perverse incentives in favor of procedures, we are 
not going to have primary care medicine.
    Dr. Hagan. I practice primary care pediatrics in a small 
practice. I am not going to whine about the fact that surgeons 
make more than I do. I will point out that our medical students 
at the University of Vermont College of Medicine, which is not 
a terribly expensive medical school, are graduating with 
incredible debt load.
    Now, we may be able, as experienced adults, to think that 
over the years, $300,000 is not a huge number. But someone who 
is in----
    Senator Sanders. I think it is a huge number.
    Dr. Hagan. I do. I think it is a huge number, Senator. 
Thank you.
    That is what two of my medical students that I have as 
freshmen in my clinic are facing. As they are making their 
decisions about residency and about what they expect to earn 
first year out, they are drawn to orthopedics. They are drawn 
to other specialties that are going to have them feel more 
competent to address this huge debt load.
    I think if we don't address the debt load on our students, 
we are not going to be able to draw them into primary care. I 
am troubled by that.
    Mr. Meit. I agree with everything I have heard. I would add 
that, in addition to doctors and nurses, we also must remember 
that it takes a lot of other people to run healthcare 
facilities, and we also have shortages of other health 
professions, including allied health professionals. That is an 
opportunity for rural communities to provide jobs for local 
citizens within their community.
    One of the interesting demographics of rural America right 
now is that it is disproportionately older. The reason that 
rural America is disproportionately older is that the youth are 
leaving rural America. This provides job opportunities for 
youth to keep them within their communities, and I think that 
is another tremendous opportunity that we shouldn't miss.
    Dr. Stevens. Senator Merkley, there is one other thing. 
There is another solution. There is a university called A.T. 
Still University, which is an osteopathic school.
    Senator Harkin. Where?
    Dr. Stevens. In Arizona. They have, first of all, re-
designed medical education. After the first year, students are 
educated actually in community health centers across the 
country, and they are chosen on the basis of mission, about 
wanting to go into primary care and wanting to go back to 
underserved communities. There is also a dental school there.
    I think we also have to look into how we can design the 
medical school experience to encourage the right kinds of folks 
to go into primary care and to get them engaged early into what 
it is like working in different communities.
    Senator Harkin. What is the name of the school? I didn't 
hear----
    Dr. Stevens. A.T. Still.
    Dr. Butler. One of the reasons the European medical 
practices are more predominantly primary--sorry. My fault.
    Dr. Stevens. A.T. Still. I will give it to you afterwards.
    Senator Harkin. Dr. Butler.
    Dr. Butler. I was just going to indicate that we have to 
remember Europe has a very different culture. In France, for 
example, medical school is free. The prospects of more people 
going into primary care medicine is very different, where they 
do not have $40,000 to $50,000 a year in many medical schools 
today in America to pay your tuition and have on average 
$140,000 worth of debt when you leave.
    It is an extraordinarily different culture, and it is worth 
noting this distinction.
    Senator Merkley. Mr. Chair, thank you very much.
    Senator Harkin. Thanks, Senator Merkley.
    A little follow-up question on that. Well, my question was 
about incentives, but you kind of all addressed yourselves to 
what incentives we put into it.
    The one on medical school, on helping medical students who 
want to go into primary care, forgiving their debts, loans, and 
stuff so that they have that incentive I think is something 
that we have to look at.
    The other thing that has bothered me for some time now is 
that--we have one, two, three, four, five doctors here--I have 
come to know that in medical school, that you go through all 
this medical schooling and you get precious few courses in 
prevention and wellness. Has that been your history?
    I mean, how can we change that? How do we get more courses 
where students have to take courses in health and wellness and 
prevention and primary care?
    Dr. Hagan.
    Dr. Hagan. Go ahead.
    Dr. Butler. I was going to say there is a chicken and egg 
problem, too. You have to have well-trained teachers. Teachers 
come first. If we don't have the teachers that are dedicated to 
the concepts of health promotion and disease prevention, we 
have a problem.
    We have to start to make sure we get well-trained teachers. 
Similarly, in geriatrics and other neglected fields.
    Senator Harkin. Dr. Hagan.
    Dr. Hagan. I think the trend is changing. Certainly there 
is more preventive health being taught in all medical schools. 
It is required by the accreditation organizations.
    Certainly in primary care there is much more training in 
preventive healthcare. That is what Bright Futures is about. It 
is about prevention. I think that HRSA was wise in the use of 
those limited funds to focus on prevention.
    I think that it is probably not enough yet, but it is a 
whole lot more than when I was a medical student at Georgetown.
    Senator Harkin. Any other observations on that at all 
before I turn to ``Senator Community Health Center?''
    [Laughter.]
    Senator Sanders.
    Senator Sanders. I accept that title.
    [Laughter.]
    There are worse titles. I have been called worse.
    First of all, I apologize for being late, Senator Harkin. 
Everything I have heard in the last 10 minutes is like music to 
my ears. This is exactly what we should be discussing, and I 
know these are the issues you have been leading on for a very 
long time. I think we are now at the moment in history where we 
may get to implement some of these ideas.
    Let me just ask the panel--Senator Harkin and I are working 
together, along with a number of other Senators, on a number of 
issues--would you agree that it makes sense and in the long run 
saves money if we greatly expand the number of community health 
centers so that everybody in this country has access to a 
doctor, a dentist, mental health counseling, and low-cost 
prescription drugs?
    That we keep people out of emergency rooms, we get people 
before they become very ill and end up in a hospital. Does that 
investment make sense to all of you?
    Senator Harkin. Well, you have two that work in community 
health centers.
    Dr. Stevens. All I can say is ``Amen.''
    Senator Sanders. What we are working on is the quadrupling 
of community health centers over a 5-year period from an 
investment of $2 billion to $8 billion and providing a 
community health center to every underserved area in America. 
We think what the studies show is that you actually save 
substantial sums of money in doing that by keeping people 
healthy rather than having them end up in the hospital.
    Does that make sense to everybody in this room? OK.
    Let me ask you another question that was touched on a 
moment ago, all right. Senator Harkin and I and others are also 
working on this issue that Dr. Hagan talked about that I am 
sure you all talked about earlier. When people graduate from 
medical school $200,000 or $300,000 in debt, they are going to 
go to specialties to pay off their debt.
    What we are trying to do, and I think you will see 
immediately in this stimulus package--by the way, a significant 
increase in funding for the National Health Service Corps. Can 
you talk about the National Health Service Corps and your 
support or lack of support for it?
    Does it make sense to you to provide debt forgiveness and 
scholarships for those people who want to serve in underserved 
areas in primary healthcare? Does that make sense to you all?
    Dr. Stevens. Yes. I was in the National Health Service 
Corps, and I served in the South Bronx. All I can say is, I 
agree totally with you.
    Senator Sanders. One of the areas, when we talk sometimes 
about community health centers--Senator Harkin is from Iowa. I 
am from Vermont. Sometimes people think, well, this is just for 
urban areas. Believe me, it is not. Rural America faces 
enormous problems.
    In our State, we have expanded community health centers 
from 2 to 7 in the last 5 years, which have had a very, very 
positive impact. We have a number of more to go. You are all in 
support of greatly expanding funding for the National Health 
Service Corps and getting doctors out into underserved areas.
    What about, I didn't know if you went into dental care at 
all? Is that something that----
    Dr. Hagan. Senator, before we leave the National Health 
Service Corps, my only concern with that is, obviously, it 
should be expanded as to anybody who wants to use that for 
their debt recovery. That would be good. But, I think there 
should be other models as well.
    We do need pediatricians and internists in community health 
centers. We need them in rural areas, but we need them in 
Burlington. You know, it is a long time to get a well visit for 
an adult in our own town.
    The National Health Service Corps is not going to deliver 
people immediately and everywhere. I think it is a strong 
model, but I think it should not be perhaps the only model.
    Senator Sanders. You know, I read something. I don't know, 
Tom, if you are aware of this. That if we were not importing 
thousands of physicians from India and countries which 
themselves are in desperate need of doctors, if we were not 
dependent on foreign doctors, our entire primary healthcare 
system would collapse.
    Is that something, the idea that in the United States of 
America, we are not educating doctors that we need is 
incomprehensible. Is that something that----
    Mr. Meit. Yes, and I think that is particularly true in 
rural areas.
    Senator Sanders. Say a word about--I am sorry.
    Senator Harkin. Dr. Iezzoni.
    Dr. Iezzoni. Risa, you go first, and then I will.
    Dr. Lavizzo-Mourey. Very quickly, Senator, I just wanted to 
mention that in addition to providing access to care, health 
centers also provide access to high-quality care for chronic 
illness. A very powerful study has shown that Federally 
Qualified Health Centers provide a system of care that allows 
for better outcomes in diabetes care, better outcomes in other 
chronic illnesses because they use a system that also 
integrates the community and supportive environments within the 
community.
    There are two reasons to support health centers, not only 
the access that they provide to primary care services, but they 
do a great job of providing high-quality care.
    Senator Sanders. Well, the bottom line, Doctor, is when you 
have a physician who you trust and see on a regular basis, 
things are going to happen that doesn't happen when you are 
just bumping into an emergency room.
    Dr. Lavizzo-Mourey. It is that combination of the trusted 
medical home, but also a system that allows for measurement of 
quality and improvement of quality, particularly in chronic 
care.
    Senator Harkin. Yes, Dr. Iezzoni.
    Dr. Iezzoni. I certainly support dealing with the debt that 
medical students are faced with. However, I think that there is 
another issue that is preventing medical students from going 
into primary care, and that is what they see their mentors' 
lives being like. The students look at the work life of the 
primary care practitioners that they are basically apprenticed 
to, and they decide, ``I cannot do that.''
    I am from ground zero on healthcare reform, Massachusetts. 
I do not have a primary care doctor. My last primary care 
doctor, I saw her in December. She said she was leaving 
practice because she just can't take it anymore, and she wants 
to figure out how to reform the entire healthcare system.
    My primary care doctor before that, who just resigned from 
primary care a year ago, became a hospitalist, hospital-based 
medicine doctor. I actually am a professor of medicine at 
Harvard Medical School, and I do not know where I am going to 
get a primary care doctor.
    Actually, a very senior physician who I know was in a 
similar situation, called up Gary Gottlieb, the president of 
the Brigham & Women's Hospital, who managed to get him a doctor 
in the women's healthcare program because he knew a woman in 
the women's healthcare program and got a doctor for this man.
    It has really gotten to that point. I think that a lot of 
people want to go into primary care because they want to give 
the best care possible to the kind of underserved population 
that a number of us have been talking about this morning.
    With the ENM codes giving X dollars of reimbursement for 
the routine kind of visit, they simply do not have the time to 
provide the kind of quality of care that they want to provide 
as a primary care doctor. And so, their work lives become 
intractable.
    The medical students see that, and I, frankly, think that 
that is one of the contributions to people not going into 
primary care.
    Senator Sanders. Very good point.
    Senator Harkin. That is a great point. I can tell you in my 
experience in Iowa, I have a number of cases of primary care 
doctors, most of whom have come from Des Moines University's 
osteopathic teaching hospital in Des Moines, and they do a lot 
in primary care. They have gone out to places like Mason City 
and Charles City. I just happened to think of a couple of 
places where we had primary care doctors, and they lasted 
about, oh, 2, 3 years, something like that.
    They were getting married. They started having children of 
their own, and they had no time with their families. They 
couldn't take a vacation. They were on call 24 hours a day, 7 
days a week, middle of the night, middle of the day. After a 
while, you just burn out.
    And they just can't take it anymore. I have seen this. I 
have seen it happen in my State.
    Dr. Stevens. Senator Harkin.
    Senator Harkin. Yes.
    Dr. Stevens. This is building on what was just said, is we 
know a lot more about how to organize a practice, and teams 
were mentioned and how effective they can be and the use of 
data and having the right systems. We are not trained in 
medical school or, quite frankly, even nursing school about 
those.
    What we found in the health center program is having an 
infrastructure where we had support or people who could help us 
do that----
    Senator Harkin. Sure, I see what you are saying.
    Dr. Stevens [continuing]. And I would say, maybe we are 
talking about 2 to 3 percent of this whole budget, it was 
extremely important in order to learn about how to organize a 
practice, what to do with your quality outcomes, how to keep on 
improving, not rest on your laurels, and also how to build 
staff experience as well as patient experience in the practice.
    Senator Harkin. I think that is a great point because the 
cases I mentioned that I know I have in my head are all primary 
care doctors that were just kind of in a small practice of 
their own. They didn't have the infrastructure to support them, 
that type of thing, which you do in the community health center 
type system.
    That is an interesting, interesting point.
    Dr. Hagan.
    Dr. Hagan. Thank you. I think that that is very much 
embodied in the medical home model. I think that community 
health centers are excellent medical homes. There are other 
good medical homes, too.
    The current funding for Bright Futures from HRSA is 
actually about implementing these services, looking at 
implementing preventive care services in practices in many 
different styles. Community health centers like yours, private 
practices like my own certainly can be held to a bar for good 
quality preventive services.
    One must learn to develop partnerships and teamwork, not 
just with allied health professionals and the very valuable 
nurses on our staff, but also with families. Our focus now 
within the academy is to teach our fellows how to do that and 
how to raise that bar. It is a barrier.
    Senator Harkin. Mr. Meit, I am going to get to you next. 
How much--if you don't know right now, maybe my staff can find 
out. How much are we funding through HRSA that we are funding 
to Bright Futures? I have no idea.
    Dr. Hagan. When the grant started, it was a 5- or 6-year 
period, and it was, I believe, $5 million to bring together the 
tremendous number of experts who wrote it and then a smaller 
amount in that $5 million to actually implement it. That is the 
process that we are in now.
    We had about 50 experts contribute to the writing, and we 
had over 1,000 reviewers. It is a large project.
    Senator Harkin. Thank you very much.
    Mr. Meit.
    Mr. Meit. I would like to make two points. Senator Sanders, 
you mentioned oral healthcare. I want to make sure that that is 
an issue that isn't neglected because it is another critical 
issue in terms of prevention within all communities, in 
particular within rural communities, which is my focus.
    There is an undeniable link between chronic preventable 
disease and oral health. I think that needs to be stated. In 
addition, what I think is often neglected more is there is a 
link between oral health and economic viability within 
communities.
    There was an interesting study in West Virginia, where they 
did a study of welfare recipients. It was a welfare-to-work 
study. It was done probably 6 or 7 years ago. The second most 
common reason that people stated, self-report, that they stated 
for not being able to get a job was oral aesthetics.
    No. 1, was they had medical conditions that they couldn't 
get a job. No. 2, was oral aesthetics. Their teeth looked bad, 
and no one would hire them. That is a particularly striking 
issue.
    The other thing I would like to say is I am a firm believer 
in community health centers. I agree that we need more primary 
care physicians. I also want to make sure that we don't forget 
about strengthening the public health infrastructure as we have 
those capacities.
    The healthcare delivery system and public health 
infrastructure need to work hand-in-hand in creating healthy 
communities and preventing disease, and we can't build one and 
forget about the other because we clearly need both in our 
rural communities and our urban communities throughout the 
United States.
    Dr. Hagan. Senator Harkin, may I correct my----
    Senator Sanders. If I could just comment on Mr. Meit? You 
have made a very interesting point. If we want to get people to 
work--and I can tell you, and Dr. Hagan will acknowledge this, 
that in my State, you have many people who have dental health 
problems that can lead to tooth loss.
    The truth is when you walk in to get a job and you smile 
and you have no teeth in your mouth, it is kind of a badge of 
poverty. It is a badge of failure, and you are not going to get 
that job, everything being equal. It is hard to. Then you stay 
low income, and you don't pay taxes and everything else.
    You know that--you do know, of course, that Medicaid does 
not pay for dentures. Medicaid does not pay for glasses. 
Medicaid does not pay for hearing aids in the United States of 
America in the year 2009.
    You tied that to an economic issue, which is interesting. I 
hadn't thought about it in that way.
    Mr. Meit. The jobs that people are likely to get at that 
level are jobs where they may be a cashier. They are public 
jobs where they are going to be very visible.
    It is interesting to me that the thought of being able to 
buy somebody a pair of dentures, and that is the ticket for 
them to get off of welfare, it is a very low-cost approach that 
could be very effective.
    Senator Sanders. It is interesting.
    Dr. Hagan. Yes, we also recognize, Senator, that the 
transmission of the bacteria that lead to a dental illness is 
vertical and that mothers often transfer it to their children 
before 6 months of age. Before 6 months of age. It will repeat 
itself generation to generation.
    Oral health risk assessments are very much part of 
pediatric preventive care now, beginning at 6 months with 
anticipatory guidance with things directed to parents 
beforehand.
    Now if I may correct my dollar statement? It is $1 million 
total. It was $700,000 for the writing, and $300,000 
implementation, and I realized that I pulled that number out of 
the wrong hat.
    But, the oral health approach, we are indebted to the 
pediatric dentists who really helped us recognize that this is 
a major health problem for children and not simply a long-term 
problem in terms of the long-term effects, but an acute problem 
as well.
    Dr. Lavizzo-Mourey. I would like to just underscore Mr. 
Meit's comments about the public health system and have us 
think more about the preventive services that are encouraged by 
public health systems. We have spoken a lot about primary care 
and physicians' offices and screening, and those are all 
extremely valuable. I remind you that that is a small fraction 
of where we spend our lives.
    Mostly, we are in school or we are going to work or we are 
out walking or we are living our lives. The policies that will 
encourage health in those areas are the ones that are really 
going to dramatically improve the health of the country.
    As Dr. Butler suggested, that will encourage us to walk 
more, policies that will encourage our children to eat 
healthier foods, to have access to healthy foods, and to 
exercise in their communities, those things that will help us 
live long, as Dr. Butler underscored, are the same kinds of 
programs and policies that will help our children begin a 
healthy life.
    If I could just underscore one that really makes a 
difference? That is a program that focuses on young women when 
they are pregnant, before they even become mothers, a nurse-
family partnership that brings a nurse into the home of a young 
woman for 2 years.
    Studies have shown that if you follow those kids out 15 
years, they have less drug abuse. They have a greater chance of 
staying in school. Their mothers stay in school. Early on, they 
use less emergency room care. It is a cost benefit all the way 
around.
    Senator Sanders. Tom, can I----
    Senator Harkin. Yes. Go ahead.
    Senator Sanders. OK. You touched on the word ``schools.'' 
I, again, apologize for being late. I couldn't be at two places 
at the same time. I will give you an example of something about 
school-based healthcare.
    In both Bennington and in Burlington, we managed to get 
dental chairs in the school, which has had a profound impact on 
pediatric dentistry in terms of caring for a lot of low-income 
kids. It has worked phenomenally well in both Bennington and in 
Burlington.
    What do you guys think about school-based healthcare and 
dental care in general? Putting dentists in schools, perhaps 
physicians once in a while in schools, does that make sense?
    Dr. Lavizzo-Mourey. I would just comment very briefly, 
since our foundation funded a program that put 1,500 school-
based clinics around the country. And two outcomes I would 
underscore.
    One, the need for dental care and putting dental chairs 
within schools dramatically improved access to care and the 
outcomes related to it. Also mental health services, those are 
the two services that are most in need and where children 
getting those services in the school are tremendously 
beneficial.
    Senator Sanders. You have studies which show that these 
have been successful?
    Dr. Lavizzo-Mourey. Yes, and we can get those to you.
    Dr. Stevens. Many health centers, as you know, have school 
health programs as part of their work.
    Senator Sanders. In fact, in Burlington, that is what we 
are doing. The community health centers linking up.
    Dr. Stevens. We get the family involved, and that is very 
important.
    Dr. Butler. As a geriatrician, I would like to speak up for 
pediatrics.
    [Laughter.]
    Most of the diseases of old age have their beginnings at 
the beginning of life. I am not just talking about genetic 
conditions with which one might be born, but the environmental 
conditions in which children grow up, the extent to which 
behavioral and lifestyle factors come into being.
    Osteoporosis, which we think of as a bone disease of old 
age--if bone was laid down during pubescence and adolescence 
with adequate vitamin D and calcium, and in the absence of 
further alcoholism or smoking, chances of having osteoporosis 
is going to be dramatically reduced. It is as though that bone 
laid down during the pubescence and adolescence is critical.
    Sadly, in our toxic food environment, sometimes we will see 
fatty plaques, atherosclerotic plaques in toddlers in this 
culture. So, again--and that is, of course, the underlying 
base. It is hard to see stroke and so forth. I just want to put 
in a real strong plea that as a geriatrician, it makes a 
difference.
    When I first got into this field, in 1955, half of our 
older patients had no teeth at all. There has been a dramatic 
improvement, thankfully, and I lay that to the door of the 
excellent work of pediatricians.
    Dr. Hagan. Thank you for that.
    [Laughter.]
    Dr. Butler. Do the same for me sometime.
    Dr. Hagan. Absolutely, and I push calcium to my pre-
adolescents and adolescents every day.
    Senator, I can't say enough good about school-based health 
centers. I think about where do kids spend most of their time? 
It is tough to navigate childhood and adolescence, and it is 
tough to be healthy during those periods of time. Anything we 
can do to improve their health, I welcome the work of my 
colleagues.
    Amy Mellencamp, principal of Burlington High School, was 
one of our experts. Amy was a huge help to the adolescent panel 
in helping suggest what should be in the things that physicians 
talk to adolescents about so that we can be in parallel with 
what schools are passionate about.
    Absolutely, we are in favor of that.
    Dr. Butler. We haven't touched on it much, but we really do 
have to deal with overweight and obesity. I know the Robert 
Wood Johnson Foundation most certainly is. It is a terrible 
problem. It is very disheartening to see a 10-year-old child 
overweight with old age, not dying of old age, but old-age 
diabetes in this culture.
    How we alter the food habits, how we--maybe we have to make 
the lunch hour with kids a nutritional teaching experience 
rather than just pizzas and hamburgers. There has got to be 
some way we can interrupt this unfortunate cycle, which is 
going to lead to not just the obesity of children, but to a 
very deficient old age.
    Senator Harkin. Well, let me just say, Bob, that one of the 
things we have to reauthorize this year is the Child Nutrition 
Act. That is the school lunch, school breakfast, and the WIC 
program.
    Dr. Butler. Yes.
    Senator Harkin. I think we have an opportunity--at least I 
hope we do--of really making some changes in the kind of foods 
our kids eat in school, what they are served both in the lunch 
and the breakfast program, and the snacks, vegetables, fresh 
vegetables and fruits for a snack program. And getting the soft 
drinks and candies and stuff out of the vending machines.
    We have an opportunity to do that this year. I hope that, 
again, we can be talking to you and our friends in the American 
Academy of Pediatrics also about their support and suggestions 
for how we change that. But, you are right. We have got to get 
better food for our kids in school.
    The other thing is the exercise, and who mentioned that? 
One of your testimonies talked about recess and, yes, that was 
you, Dr. Lavizzo-Mourey. Yes, about how we have to structure 
better exercise programs in our schools. I have seen them. Some 
schools do them. I mean, there are models out there for what we 
can do, but it is just sort of hit or miss, here and there.
    I have said it to former Secretary Spellings a number of 
times, and I have said it to our new Secretary Duncan that we 
have No Child Left Behind in reading and in math, but how about 
no child left behind in terms of their health, just their basic 
health in school.
    It seems to me that is also an important function for our 
schools. Anyway, I just wanted to mention the reauthorization 
of the child nutrition bill this year that we really have to 
focus on.
    I guess in listening to all of you, I have got a new idea, 
Bernie.
    Senator Sanders. We are in trouble.
    [Laughter.]
    Senator Harkin. I have got a new idea. That is to marry the 
public health system with our community health centers. Because 
I was hearing about, talking about community health centers, 
they do a great job in Iowa, but someone said don't forget 
about the public health sector. I am thinking to myself, ``Why 
can't the two be joined at the hip somehow?''
    So that we have a public health input in through our 
community health centers, and then we also use the community 
health centers to back up, supplement our public health system. 
Somehow it seems to me that could be done.
    Mr. Meit. We were talking about that at the beginning of 
this session, in fact.
    Senator Harkin. Yes, we were.
    Mr. Meit. I think that is something that should be 
explored.
    Senator Harkin. Yes.
    Mr. Meit. Again, I had mentioned that the public health 
infrastructure in many rural areas is lacking or nonexistent.
    Senator Harkin. Right.
    Mr. Meit. We have a very patchwork public health system 
around the country. The community health center system is very 
strong and growing. That may be the foundation upon which we 
could build a stronger public health system. I think it is very 
worthy of exploring. I think there are some models out there 
where public health and community health centers have 
collaborated very effectively, and they could be the models for 
that.
    Integrating the public health workforce into the health 
centers I think is a phenomenal idea. It is an approach that I 
think could be very productive being able to capture the 
epidemiological data within the community. I think there are a 
lot of synergies there that I think could be very beneficial.
    Senator Harkin. I have got to think more about that.
    Dr. Hagan. Senator Sanders, you will remember when our 
first community health centers were founded in Northeast 
Kingdom 15, 20 years ago, when Madeleine Kunin was our 
governor. The Vermont Department of Health was very much a 
partner in that formation.
    Our immunization system is one of the best in the country 
because of the public-private partnership that really supports 
that connection between public health and the health delivery 
systems.
    Senator Sanders. Actually, the gentleman who helped found 
that system is sitting behind me right now and now works on my 
staff.
    Dr. Hagan. I know that.
    [Laughter.]
    Well, the other thing is that----
    Senator Harkin. Bob.
    Dr. Butler. Senator Harkin and Senator Sanders, a bit of a 
challenge that might be worth looking at with this change of 
administration is that the Departments of Agriculture and 
Health and Human Services are not really in alignment when it 
comes to nutrition.
    Senator Harkin. That is very true.
    Dr. Butler. Many of the things that the Department of 
Agriculture advance, understandably in representing the needs 
of farmers, are fructose and so forth. Whereas the very kinds 
of things that are not advantageous to the American diet, which 
may be promoted by the Department of Health and Human Services, 
are not in league.
    I don't know quite how you magically deal with that, but 
there may be some ways of kind of accommodating and coming to 
terms with the discrepancies between the two departments.
    Senator Sanders. You are probably talking to the right guy, 
who is chairman of the Agriculture and Health and Human 
Services.
    Dr. Butler. I thought I could pick on Tom.
    Senator Harkin. Well, 2 or 3 years ago I tried in the 
committee--I wasn't chairman at that time--an amendment to have 
every school in the country that participates in the lunch 
program, which is about every school, to develop a wellness 
policy.
    Now every school in America has developed a wellness 
policy. The problem is I wanted it to be a wellness policy 
based upon the recommendations of the Institute of Medicine. I 
lost that. I am coming back this year.
    Dr. Butler. Good. Come back.
    Dr. Stevens. I think another characteristic that makes 
health centers an important partner for public health, it is 
the only system I know where the care is based on the community 
needs assessment of the health needs of the community. It is a 
perfect marriage between public health and primary care.
    Senator Harkin. Yes.
    Dr. Stevens. Second, and I can follow up with your staff, 
there are two really good examples. One was around 
immunizations, and one was around chronic care where we worked 
very--we have a model for that, how we worked with local public 
health and with the CDC. We have some ideas about how to do it.
    And third, it might be weird from a guy who worked in the 
South Bronx, but the Extension Service in Agriculture is also a 
vehicle in terms of extension agents that can be doing health 
prevention messages right there on the front line. I think that 
is also a potential.
    Senator Harkin. I never thought about that.
    Mr. Meit. And that is being done. I had previously been in 
Pennsylvania, and in Pennsylvania, the Cooperative Extension is 
very involved in health education throughout the State, and 
that is how a lot of health education happens in rural 
jurisdictions.
    Pennsylvania doesn't have a strong public health 
infrastructure in the rural jurisdictions. They have tried to 
identify other partners, and some of those partners have been 
Cooperative Extension, and they have been a very good partner.
    I think the only other thing I would add, I really like 
this idea of a marriage between public health and community 
health centers. It just needs to be about more than just 
access, though.
    One of public health's core functions is to ensure access 
to healthcare services. That is a core role of the community 
health centers. It needs to go wider and deeper than that so 
that the community health centers get involved in all aspects 
of public health, delivering broad messages to the community, 
conducting disease surveillance, helping to implement community 
policies.
    It is not just about making sure that everyone has 
accessible healthcare services. That is critical, but it goes 
wider and deeper than that.
    Senator Harkin. Dr. Mourey.
    Dr. Lavizzo-Mourey. I agree. One of the things that we are 
learning about improving the quality of public health services 
is that there is a tremendous variation in the quality of 
services across the country.
    Senator Harkin. Yes.
    Dr. Lavizzo-Mourey. The public health professionals 
themselves are calling for greater accreditation standards and 
improvement of those standards as time goes on to ensure that 
whether it is a community health center that is delivering the 
services or a public health department or at the county or 
State level, we are ensuring that the level of standards and 
the quality of public health being delivered is what it should 
be across the country.
    We know that the return on investment for delivering public 
health as opposed to medical care is tremendous. We have got to 
make sure that public health is being delivered, whether it is 
in a community health center or in some other venue.
    Senator Harkin. Dr. Iezzoni, I have been thinking. I 
mentioned earlier about the training of doctors in medical 
schools on prevention programs and approaches. Another thing 
that is lacking is for doctors and nurses and other health 
professionals to get adequate training in dealing with people 
with disabilities. They just have not----
    Dr. Iezzoni. OK. I will go anywhere at any time to talk to 
medical students about this, and you are absolutely right. They 
don't hear about it at all.
    Senator Harkin. They don't.
    Dr. Iezzoni. No. On Tuesday, I was teaching the second-year 
Harvard medical students in their Patient-Doctor II course, and 
I told them this will be the only hour in your 4 years at 
Harvard Medical School that you will hear about disability.
    Apparently, when I left the room, which I had to do because 
I had a van scheduled--and when you are disabled and the van is 
there, you have to leave--they sat around for a half an hour 
and talked to the course director and said absolutely that is 
true. They will not hear about this topic again.
    Now you had mentioned earlier about how do you get 
preventive services onto the agenda of medical schools? This is 
the phrase that I hear repeatedly, at least at Harvard, from 
the curriculum people. ``The real estate is really tight 
here.'' There are tons of people jockeying for space on the 
real estate, i.e., the curriculum at the medical school.
    There are the genomics people. There are the new imaging 
people. There is just so much fund of knowledge that today's 
medical student needs to become aware that the kind of push-
pull among different groups trying to get a hold of the 
students' attention is just really kind of dramatic at medical 
schools.
    And so, you are absolutely right. They do not hear about 
disabilities. They do not also hear the more general topic of 
functional assessments, which is the more general topic.
    Senator Harkin. Yes, right.
    Dr. Iezzoni. Yes.
    Dr. Hagan. In way of counterpoint, and I agree completely, 
I think efforts are certainly being taken in many medical 
schools. At the University of Vermont, our first-year students 
have a mandatory course called Medical Student Leadership 
Groups, where they meet every week and they talk about 
doctoring, not just about medicine.
    The most popular week that I have with my preceptees is 
when the parent of a child with special healthcare needs comes 
in to talk about what it is like to have a disabled child. As 
your students' response was, it is dramatic. That is always the 
week that they highlight most in the course.
    I can't speak for what happens in medicine, but I can say 
that when our students come into pediatrics, wherever they are 
rotated, whether it is on the floor or in the clinic, they are 
seeing children with special healthcare needs.
    The model is the medical home model. The model is care 
management. The model is working collaboratively. It is a whole 
lot better than when I was trained, and it is not--I mean, UVM 
isn't Harvard. I agree. I think that there is room in the real 
estate, and I think it has to do with when we teach them 
genomics and we teach them radiology, how do we integrate that 
into the care of patients?
    Dr. Iezzoni. Oh, I agree. I can only speak to where I am 
and what I know the most about. I do hear about programs around 
the country in other places, the University of Florida and the 
University of Pennsylvania in Philadelphia, have, again, an 
hour on it. You know, an hour.
    I think it is wonderful that the parent with the kid comes, 
and I agree that that would be a very evocative something that 
the students will probably remember all their entire lives. I 
remember that from my medical school days of a given patient 
that I will remember now 30 years later.
    But, I just think that the kind of continuity of looking 
across the lifespan at functioning, the fact that disability is 
not a minority issue. It is something that we all will face at 
some point in our lives. Kind of the lifespan context of that, 
I think, has not really been conveyed in medical schools in the 
way that might be most powerfully done.
    Senator Harkin. Again, a lot of times when we talk about 
people with disabilities, we think of someone that uses a 
wheelchair or has a physical disability. How about people with 
intellectual disabilities?
    Senator Sanders. Or mental health issues?
    Senator Harkin. Or mental health disabilities, kind of two 
other groups that have trouble accessing and getting adequate 
primary care in our system.
    And again, I have talked to dentists--I don't know why I 
focus on dentists, but they just don't have any training at all 
in how to deal especially with kids that have intellectual 
disabilities, a Down Syndrome kid or something like that, and 
how you deal with them. They don't know.
    Dr. Hagan. The pediatric dentists, the Board of Pediatric 
Dentists are actually trained. How well I don't know, but I 
think the children certainly in Burlington are well served with 
special needs kids because we have a core of pediatric dentists 
there.
    But, I think you are right. I think it is broader than just 
the so-called obvious disabilities. We know that one in five 
children from the beginning of middle school to the end of high 
school will have a diagnosable mental health condition. They 
are underserved. They have a chronic problem for a period of 
time.
    Senator Harkin. Yes. Well, we just had that in a hearing 
the other day about that, about how--first of all, a lot of 
physical ailments that we have in our society are traceable 
back to mental illnesses that people have. Those mental 
illnesses kind of go back a lot of times, back to youth, back 
to grade school, high school.
    When they don't get treated early on, they fester, and they 
grow and they fester. They get worse and worse as they get to 
18, 19, 20, 22 years old. Now they have physical ailments as a 
result of that. And so, you are right on point on getting more 
mental health in pediatrics, for kids in school, in high 
school.
    Some of these kids come from tough homes, tough 
neighborhoods. They have tough lives. Yet they are trying to 
struggle with it and cope with it, and they have absolutely no 
help or support whatsoever in that. That is just another area 
that we have got to think about in terms of primary care.
    Dr. Lavizzo-Mourey. And frankly, prevention. One of the 
programs that has been very exciting for us is one that 
actually trains people in schools--teachers, counselors, and 
the like--families, and people in communities to recognize the 
symptoms of serious mental illness before it becomes a full-
blown psychotic event and to begin to structure the environment 
in a way that you can actually prevent some of these terribly 
debilitating and lifelong problems.
    Having the services in the schools to treat is important. 
Even more important, I think, is beginning to train people to 
recognize these symptoms before they become psychotic problems 
or real disabilities.
    Senator Harkin. You know, everybody talks about change. We 
have got to change this, and there is a lot of talk about 
change. There is one thing that hasn't changed in several 
hundred years, 300 years, I don't know. The concept of school, 
that a classroom is a bunch of kids sitting out there and a 
teacher up in front. It has been that way forever. Is that the 
best model? Is that the only model?
    You know, it used to be that kids with disabilities were 
shunted aside, were not incorporated. Many sent to special 
schools, schools for the deaf, schools for the blind, schools 
for this, schools for that. Now we are trying to integrate 
them. Maybe we have got to change the way we think about the 
classroom.
    Since society is evolving, maybe we have got to think about 
that classroom as not just a teacher who is teaching a subject 
to the kids, but there is a teacher teaching a subject. There 
is a child psychologist dealing with kids and their emotional 
and mental health problems. There is a nutritionist/dietician 
dealing with their food intake and what they eat.
    There is a Physical Ed teacher teaching them how to 
exercise and how to be healthy. Maybe this whole concept of one 
teacher sitting in front of all of those kids is old. Maybe we 
have to change the way we think about a classroom in America 
today and how kids are educated since they do spend so much of 
their daily lives in school.
    Again, I don't want to fall in the trap of saying, ``When I 
was young, things were great,'' you know? That is a definite 
sign of old age when you start talking about that.
    [Laughter.]
    It is true. When I was young in school, I mean we did 
exercise. We had an hour a day--a half hour at lunch, 15 
minutes in the morning, 15 minutes in the afternoon. We had to 
leave the building. We had to go outside. Well, maybe if it was 
20 below, maybe we didn't. But most of the time we had to.
    We had that, and we had everybody exercise, girls and boys 
together. I mean, we had softball teams that were made up of 
girls and boys together. I see today that doesn't happen 
anymore.
    And in terms of nutritious meals and stuff, I think our 
meals were much more nutritious. I was in grade school when the 
school lunch program started, and I can remember as a kid 
thinking this is great. This is really something getting fresh, 
just getting fruit and vegetables and high protein, good 
quality meats, things like that. Now it is all junk food.
    I don't know why I got off on that tangent, but just the 
idea that schools need to be more than just that one teacher 
teaching a bunch of kids. Anyway, that is just my thought for 
the day. I don't know if it is worth anything or not.
    Did you have anything else?
    Senator Sanders. Well, I just wanted to pick up on Dr. 
Iezzoni's point about medical curriculum, and it just occurs to 
me, my thought of the day, is that a society which ignores, to 
a significant degree, primary care, by definition, the medical 
schools are going to go where the money is. If the money is in 
high-tech tertiary care, that is where they are going to train 
the physicians.
    Meanwhile, 50 million Americans don't have access to any 
doctor at all, and schools don't have access to nutritionists, 
et cetera, et cetera.
    I think what we are really looking at is a revolution, 
which will eventually filter down to the medical schools as 
well, when we begin to say that long term, as Tom just 
indicated, we have got to pay attention to the kids. We have 
got to make sure that we do a much better job in terms of 
nutrition, in terms of exercise, and keeping people healthy.
    I think once we make that revolution, which probably will 
start here, it will filter down to the medical schools because 
that is where people will be working in those areas. Does that 
make sense to you?
    Dr. Iezzoni. I would like that to happen.
    [Laughter.]
    Senator Harkin. I have to go. Do you want to stay any 
longer or not? I have to go to an Appropriations Committee. I 
already announced it.
    Senator Sanders. Senator Harkin has to go and has asked me 
if we want to prolong the meeting. Are there any other issues 
that have not been discussed that you would like to bring 
public? If there are, I am happy to stay. If not, no. Or do you 
think we have covered the terrain?
    Senator Harkin. I thought this was a great discussion.
    Senator Sanders. I agree.
    Senator Harkin. Of course, this was right up my alley. Why 
wouldn't I think it would be a great discussion? You are all 
really experts in your fields, and you are all on the right 
track on this.
    Again, I just want to ask all of you to be available to our 
staff for further input and consultation as we move ahead.
    Thank you all very much. I know some of you came a great 
distance in bad weather, and I appreciate it very much.
    Senator Sanders. Thank you all very much.
    Senator Harkin. Thank you. The committee will stand 
adjourned.
    [Additional material follows.]

                          ADDITIONAL MATERIAL

                 Prepared Statement of Senator Kennedy

    Millions of Americans are struggling today with the burden 
of rising health costs and inadequate health insurance. Our 
health is affected not only by our access to affordable care 
but also by our living conditions, healthy foods and safe 
environments. Children, seniors and persons with disabilities 
often have the most pressing health needs but also face the 
greatest barriers to health. It's estimated that at least 40 
million Americans live with some level of disability, including 
6 percent of children nationwide. Overall, American children 
lag behind almost all industrialized nations on key health 
indicators for children.
    Increased risk for poor health may result from chronic 
illness, age, lack of insurance, or poverty. By 2030, one in 
every five Americans will be aged 65 and older. Although 
physical activity has multiple proven health benefits, only 21 
percent of adults age 65 and older engage in regular leisure-
time physical activities. Programs that increase seniors' 
knowledge of the health benefits of physical activity and help 
them include it in their daily lives have been shown to work 
and need to be strengthened.
    In the years ahead, the increasing number of older 
Americans and their growing diversity will create unprecedented 
demands on public health, aging services, and the Nation's 
health care system. As our country ages, greater investments in 
prevention efforts are essential not only to protect the health 
and quality of life for older adults, but also to control the 
costs of health care.
    Individuals have the responsibility to eat well and stay 
active, but Federal programs can remove obstacles that make it 
difficult for individuals to make healthy choices. This point 
is especially true for high-risk persons. People with 
disabilities face significant barriers in obtaining preventive 
services, with only 48 percent reporting access to local health 
facilities and wellness programs. These barriers may include 
lack of transportation and affordable housing, higher rates of 
unemployment, and inadequate knowledge of the health risks they 
face.
    Initiatives such as the Making Healthy Connections Program 
in Boston address the specific needs of young people with 
disabilities as they move into adulthood and develop greater 
independence. In partnership with Boston Medical Center, the 
program educates youths and parents on how to obtain adult 
health services and develop independent living skills. Topics 
covered include personal care assistance, preparing for jobs 
and college, assistive technology and transportation options. 
This type of comprehensive care model will strengthen the 
connection between health services and other community 
resources, and reduce health costs by increasing access to care 
and preventing chronic disease. By adopting successful models 
of care for those with complex health issues, we can improve 
the health of millions of Americans.
    A key factor for successful programs for high-risk 
populations is to meet people where they live, work and play, 
in places such as schools and community health centers. 
Prevention efforts focused on children are essential, since 
health risks accumulate a person's lifespan.
    An impressive example is ``Shape Up Somerville: Eat Smart 
Play Hard'' a CDC-funded environmental approach to obesity 
prevention targeting 1st-3rd graders in Somerville, MA. 
Parents, local restaurants and after-school programs are each 
involved in increasing physical activity, and spreading healthy 
eating messages. It's clear that congressional action on health 
reform must encourage such successful initiatives for high-risk 
communities that cut across traditionally disjointed systems of 
care and services.
    Those at highest risk have the most to gain from effective 
public health and preventive clinical programs, and the most to 
lose if these programs are not a central part of health reform. 
By investing in proven preventive services and proven public 
health programs, we can reduce health care costs by increasing 
longevity, improving quality of life, and preventing chronic 
disease.
    An annual investment of $10 a person each year in effective 
community-based programs to increase physical activity, improve 
nutrition, and reduce tobacco use could save the country more 
than $16 billion annually within 5 years and would be of 
particular benefit to those at the highest risk of poor health 
outcomes.
    I commend Senator Harkin for highlighting the issues of 
high risk populations and emphasizing that effective strategies 
to reduce the risk of disease must be a central part of health 
reform. I look forward to the testimony of today's witnesses, 
and I wish I could be there for this important hearing.

                  Prepared Statement of Senator Coburn

    The Federal Government is engaged in extensive efforts to 
promote prevention and wellness, particularly for high-risk 
populations, and we must continue to examine ways in which our 
prevention dollars can be spent more effectively. The Centers 
for Disease Control and Prevention (CDC), the Nation's 
prevention agency, has an $8.8 billion budget to address 
infectious and chronic disease prevention, and the National 
Institutes of Health (NIH) spends $6.74 billion. The Substance 
Abuse and Mental Health Services Administration (SAMSHA) spends 
about $1.8 billion on prevention and treatment, and the Health 
Resources and Services Administration (HRSA) spends roughly 
$809 million primarily for underserved populations. For elderly 
Americans, the Administration on Aging spends $779 million for 
nutrition and preventive health services.&
    I appreciate the opportunity to hear from today's witnesses 
about how our health care system can better allocate resources 
to help those in need, and I look forward to working with my 
colleagues to change the paradigm in health care to prevention. 
The most effective way to achieve prevention is for individuals 
to have ``skin in the game.'' Our current health care system 
insulates individuals from the costs of their health care. We 
must realign incentives so that individuals see cause and 
effect from their lifestyle decisions. Rather than naively 
expand costly government programs and slap on onerous new 
mandates, we must emphasize the need for personal 
responsibility. In promoting behavior change, there are also 
appropriate roles for the Federal Government, States, and the 
private sector. The Federal Government doesn't need to 
implement a one-size-fits all solution for prevention--or in 
any other component of health care reform.&
    Access points for underserved communities, such as 
community health centers, are helpful safety nets for many 
across the country but are not the solution to our larger 
health care problems. Instead, we must pursue fundamental 
reforms of our health care system that allow market forces to 
make health care more affordable and tailored to each 
individual's needs. Our health care system should work for 
every patient, every time.

    [Whereupon, at 10:46 a.m., the hearing was adjourned.]


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