[Senate Hearing 112-871]
[From the U.S. Government Publishing Office]
S. Hrg. 112-871
THE STATE OF CHRONIC DISEASE PREVENTION
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HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED TWELFTH CONGRESS
FIRST SESSION
ON
EXAMINING THE STATE OF CHRONIC DISEASE PREVENTION
__________
OCTOBER 12, 2011
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
Available via the World Wide Web: http://www.gpo.gov/fdsys/
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
TOM HARKIN, Iowa, Chairman
BARBARA A. MIKULSKI, Maryland MICHAEL B. ENZI, Wyoming
JEFF BINGAMAN, New Mexico LAMAR ALEXANDER, Tennessee
PATTY MURRAY, Washington RICHARD BURR, North Carolina
BERNARD SANDERS (I), Vermont JOHNNY ISAKSON, Georgia
ROBERT P. CASEY, JR., Pennsylvania RAND PAUL, Kentucky
KAY R. HAGAN, North Carolina ORRIN G. HATCH, Utah
JEFF MERKLEY, Oregon JOHN McCAIN, Arizona
AL FRANKEN, Minnesota PAT ROBERTS, Kansas
MICHAEL F. BENNET, Colorado LISA MURKOWSKI, Alaska
SHELDON WHITEHOUSE, Rhode Island MARK KIRK, Illinois
RICHARD BLUMENTHAL, Connecticut
Daniel E. Smith, Staff Director
Pamela Smith, Deputy Staff Director
Frank Macchiarola, Republican Staff Director and Chief Counsel
(ii)
C O N T E N T S
__________
STATEMENTS
WEDNESDAY, OCTOBER 12, 2011
Page
Committee Members
Harkin, Hon. Tom, Chairman, Committee on Health, Education,
Labor, and Pensions, opening statement......................... 1
Roberts, Hon. Pat, a U.S. Senator from the State of Kansas,
opening statement.............................................. 3
Whitehouse, Hon. Sheldon, a U.S. Senator from the State of Rhode
Island......................................................... 15
Franken, Hon. Al, a U.S. Senator from the State of Minnesota..... 19
Mikulski, Hon. Barbara A., a U.S. Senator from the State of
Maryland....................................................... 20
Blumenthal, Hon. Richard, a U.S. Senator from the State of
Connecticut.................................................... 23
Witness--Panel I
Koh, Howard K., M.D., M.P.H., Assistant Secretary for Health,
U.S. Department of Health and Human Services, Washington, DC... 4
Prepared statement........................................... 6
Witnesses--Panel II
Brown, Nancy, Chief Executive Officer, American Heart
Association, Dallas, TX........................................ 26
Prepared statement........................................... 28
Seffrin, John R., Ph.D., Chief Executive Officer, American Cancer
Society, Atlanta, GA........................................... 33
Prepared statement........................................... 34
Griffin, John, Jr., J.D., Chairman, American Diabetes
Association, Victoria, TX...................................... 38
Prepared statement........................................... 40
Troy, Tevi, Ph.D., Senior Fellow, Hudson Institute, Washington,
DC............................................................. 45
Prepared statement........................................... 47
ADDITIONAL MATERIAL
Statements, articles, publications, letters, etc.:
Senator Enzi................................................. 65
(iii)
THE STATE OF CHRONIC DISEASE PREVENTION
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WEDNESDAY, OCTOBER 12, 2011
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The committee met, pursuant to notice, at 2:31 p.m., in
room SD-430, Dirksen Senate Office Building, Hon. Tom Harkin,
chairman of the committee, presiding.
Present: Senators Harkin, Mikulski, Franken, Whitehouse,
Blumenthal, and Roberts.
Opening Statement of Senator Harkin
The Chairman. The Senate Committee on Health, Education,
Labor, and Pensions will come to order.
Chronic disease presents one of the greatest challenges to
the public health of the American people. Research shows that
almost one out of every two adults has at least one chronic
disease. We also know that nearly one-fourth of individuals
with chronic disease have one or more daily activity
limitations. It's a staggering fact that 7 out of 10 deaths
among Americans are related to chronic illnesses.
Our Nation's fiscal well-being is also impacted by chronic
disease. Of the more than $2 trillion we spend on healthcare,
75 percent is accounted for by individuals with chronic
conditions. In the workplace, these conditions account for
nearly $1 trillion in lost productivity each year. Chronic
disease is a huge cost to both private and public sectors and a
major contributor to our deficits and our debt.
A major gap exists between what we know about chronic
disease prevention and what we're actually doing about it.
There are many examples of effective, evidence-based prevention
programs that we will hear about from our witnesses. We need to
apply these proven approaches to prevent chronic diseases from
developing in the first place, which will improve health and
restrain healthcare costs.
An important tool to address chronic disease is the
implementation of proven prevention programs in local
communities. Targeted, evidence-based community prevention
activities can have an enormous impact on chronic disease,
while at the same time being cost-effective. A study by the
Trust for America's Health titled Prevention for a Healthier
America found that investing $10 per person in proven
community-based programs to increase physical activity, improve
nutrition, and prevent tobacco use could save the Nation about
$16 billion annually within 5 years.
The Community Transformation Grant program and the
Affordable Care Act helps communities to implement evidence-
based strategies that prevent the development of chronic
diseases. Through this program, communities develop public-
private partnerships and collaborate to tailor health promotion
initiatives that meet the unique needs of their residents in
addressing chronic disease. This helps turn the environment in
which local residents live, work, play, and raise their
families into one that provides a greater array of healthy
choices, making the healthy choice the easy choice.
I've often said, it's easier to be unhealthy and harder to
be healthy, and shouldn't we turn that dynamic around?
Shouldn't it be easier to be healthy and harder to be
unhealthy? That's why the Prevention and Public Health Fund,
which I authored in the Affordable Care Act, is so fundamental
to addressing the gap that exists between what is and what can
be done to address chronic illness.
The Prevention Fund supports evidence-based health
promotion programs. However, this fund is only a small down
payment in comparison to the size of the problem. Some critics
have called the fund a ``slush fund.'' Well, that's nonsense.
Let me give just a few examples of investments made possible by
this fund to address chronic disease.
In Alabama, funding is being used to make Mobile County
smoke-free, and tobacco quit lines and media are helping
residents to live tobacco-free. Thanks to the fund, South
Carolina has started a statewide Farm-to-School program that
brings fresh fruits and vegetables to children in over 1,000
schools in South Carolina.
Another tool in addressing chronic disease is the use of
evidence-based clinical preventative services. We significantly
increased the availability of these critical activities in the
Affordable Care Act by requiring first dollar coverage of
recommended preventative services. Many Americans are already
benefiting from these important evidence-based preventative
services and wellness visits, which will help lower costs,
prevent disease, and save lives. Now, these services also make
great economic sense. For example, for every $1 we spend on the
full course of childhood vaccines we save $16.50 in future
healthcare costs.
Businesses have not traditionally been players in the field
of wellness and disease prevention. But this is rapidly
changing. I find this very, very encouraging, because corporate
America has the expertise, the resources, and the enlightened
self-interest to make a huge difference in the way we approach
healthcare in this country. That's why I included a provision
in the ACA that makes it easier for businesses to push more of
their healthcare investments upstream, helping employees to
stay healthy and stay out of the hospital.
Proven prevention efforts need to occur not only in the
doctor's office, but where people live and work and go to
school. American families also recognize the importance of
these services in preventing chronic disease. According to a
national survey conducted by Lake Research Partners, prevention
and wellness resonate with Americans on a core value level and
enjoy very broad support. People know that prevention saves
both lives and money.
I'm looking forward to the testimony of our expert
witnesses who approach this important issue from a variety of
perspectives, all with the goal of transforming our current
sick care system into a genuine healthcare system, one that
emphasizes wellness and prevention and public health. And so I
thank everyone for being here, and I am looking forward to the
testimony.
Now I'll yield to Senator Roberts for an opening statement.
Statement of Senator Roberts
Senator Roberts. Mr. Chairman, thank you so much for
holding this hearing today. I apologize for being late. That's
a chronic disease that I've had for some years. And thank you
for your leadership on this.
And I want to thank also all of our witnesses for appearing
before our committee and your continued commitment to
prevention and to public health. I think we all know the
statistics related to chronic disease. I know the chairman has
spoken of that. Billions and billions of dollars are spent each
year to treat these conditions and the efforts to prevent their
occurrence. I think that we all have a story of someone,
ourselves or a loved one, affected by a chronic disease.
If only wishing made it so, we would have prevented and
cured many of these conditions many years ago. Unfortunately,
we still struggle to prevent and treat chronic conditions. But
science has evolved our understanding of how chronic conditions
can be mitigated or avoided, which leads us to today's
discussion on the state of chronic disease prevention and the
implementation of the Prevention and Public Health Fund
authorized under the new healthcare law.
I do share some of my colleagues' questions about the
implementation of many parts of the law, including the fund,
and the current discussions on deficit reduction and spending
reductions continue to evaluate where this fund should fall
into the prioritization of Federal funding. But I am hopeful
that today's hearing and the testimony of today's witnesses
will help us better inform that assessment.
The reality of our current combination of public health
priorities and economic challenges leave us with no option. As
the saying used to be, just throw spaghetti at the wall and see
what sticks. That is to say any funding, especially Public
Health and Prevention Funding, must be very carefully
distributed and the outcomes clearly identified in order to
prioritize the few resources that are available. That's
unfortunate, but that's the way things are today.
Additionally, if we determine that the funding is a
priority, it is essential to ensure oversight of these dollars
to make sure that metrics are in place for measuring the
outcomes associated with public health and prevention programs
and that they are meeting and exceeding the minimum metrics. In
my opinion, this is the only way to ensure that we are reducing
costs yet saving lives and prioritizing Federal dollars
appropriately.
I look forward to hearing from our witnesses today and
again thank the chairman for his leadership in holding the
hearing.
The Chairman. Thank you very much, Senator Roberts, and I
agree with everything you said. I think it's got to be
evidence-based and make sure that we're getting a good return
on the dollar that we've invested.
Senator Roberts: Yes, sir.
The Chairman. We have two panels today, two great panels.
Our first panel will be just one witness, our Assistant
Secretary, and then we'll have the second panel.
Our first panel will be Dr. Howard Koh, Assistant Secretary
for Health at the Department of Health and Human Services. Dr.
Koh is a well-recognized expert in the field of public health.
Before being confirmed as the 14th Assistant Secretary, he
served as Professor at the Harvard School of Public Health,
Director of the Harvard School of Public Health Center for
Public Health Preparedness, and as Commissioner of Public
Health for the Commonwealth of Massachusetts. As Assistant
Secretary, Dr. Koh is dedicated to the mission of creating
better public health systems for prevention and care in the
United States.
Dr. Koh, we all know your wonderful background. Your
statement will be made a part of the record in its entirety.
And if you could sum it up in 5 to 10 minutes, we'd be
appreciative so we can get to questions and answers.
STATEMENT OF HOWARD K. KOH, M.D., M.P.H., ASSISTANT SECRETARY
FOR HEALTH, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES,
WASHINGTON, DC
Dr. Koh. Thank you so much, Chairman Harkin, Ranking Member
Roberts, and distinguished members of the committee. I'm Dr.
Howard Koh, the Assistant Secretary for Health. I want to start
by thanking you for holding this critical hearing on
prevention.
Promoting disease prevention is absolutely crucial to
reducing suffering and death in our country, improving the
health of our Nation, and addressing the enormous costs of
healthcare. The passage of the Affordable Care Act and with it
the creation of the Prevention and Public Health Fund
represents a pivotal action by Congress and the Federal
Government that will promote prevention and improve the overall
health and well-being of all Americans for the future.
I'd like to start by thanking you, Senator Harkin, for your
vital leadership on this important issue. You have been leading
the charge to promote prevention and wellness for your entire
career, and we are all deeply in your debt. And I also want to
thank all the committee members, because this is such a crucial
issue for our Nation's public health.
Today, our country is facing an epidemic of unprecedented
magnitude, that is, the overwhelming burden of chronic diseases
throughout our country. As you heard from the chairman, 7 out
of 10 deaths in the United States are due to chronic
conditions. Heart disease, cancer, and stroke account for more
than 50 percent of all deaths each year. Nearly half of all
adults in our Nation have at least one chronic illness. And we
need greater attention and commitment to prevention more than
ever before.
For example, rates of obesity in our country are increasing
with more than one in three adults in this category, as well as
almost one in every five children. As you can see from the
chart on the right, with the highest obesity rates in red, the
epidemic of obesity is engulfing our Nation over time.
Astoundingly, chronic disease is responsible for more than
75 percent of the more than $2.5 trillion we spend annually on
healthcare. Confronting the massive impact of chronic disease
on both our Nation's health and our economy is imperative to
saving lives and bringing down healthcare costs.
My own commitment to prevention began decades ago as I was
starting my career as a physician and clinician. As a young
physician, it was absolutely heart wrenching, starting then and
over the next three decades, to care for so many patients who
were suffering and dying preventable deaths. It was clear to
me, and I know to all of us, that as a country, we need a
better national approach to finding disease earlier or
preventing it in the first place. These are themes I've been
very committed to in my career as a researcher, physician,
State health commissioner, and now as the Assistant Secretary
for Health.
We know that preventing disease can save lives and reduce
suffering. And by focusing on the most prevalent chronic
diseases, such as heart disease, cancer, stroke, and diabetes,
and addressing behaviors that fuel these conditions, such as
tobacco use, poor diet, physical inactivity, and alcohol abuse,
we can make a profound impact on reducing the harm caused by
chronic diseases.
The economic argument for investing in prevention is also
compelling. Using evidence-based interventions can improve
health and prevent unnecessary suffering and also potentially
save money. One recent study in the journal, Lancet, just
published, estimates that an average 1 percent reduction in
body mass index, BMI, across the United States could
potentially avoid up to 2.4 million cases of diabetes, 1.7
million cases of cardiovascular disease, and up to 127,000
cases of cancer.
However, only an estimated 3 percent or less of all
healthcare dollars in the United States right now are dedicated
to these scientifically proven prevention strategies. This is
barely the proverbial ounce of prevention that we all have
talked about in the past. By investing in prevention, as the
Senator said, we can transition our current medical care system
from one of sick care to one that's based on prevention and
wellness.
We are grateful that the Affordable Care Act represents a
transformative opportunity to bring prevention to the forefront
of the Nation's priorities. And one of the most important
commitments in that Act is the creation of the Prevention and
Public Health Fund. The fund represents our most significant
investment to step up and scale up effective prevention and
public health measures in our Nation's history. And despite
only being in existence for 2 years, it's already making
positive impact in a broad range of areas.
The fund allows us to make targeted, high-priority
investments in areas of obesity, tobacco, HIV, immunization,
hospital-required conditions, substance abuse, behavioral
health, as well as build a stronger primary care workforce,
surveillance systems, and laboratories. And these investments,
along with Federal expertise and partnerships with State and
local leaders, can best address the needs of our communities
across the country.
As you know, the fund started in fiscal year 2010 with $500
million, a figure that rose, as required by statute, to $750
million in fiscal year 2011. And these funds are being used in
the statue, as noted in the language,
``to provide for expanded and sustained national
investments in prevention and public health programs,
to improve health, and help restrain the rate of growth
in the private and public sector healthcare costs.''
The fund has made strides in leaving a legacy to help make
the healthier choice the easier choice in communities. And just
as an example, recently, the CDC just announced over $100
million to be used for Community Transformation Grants. These
programs will help State and local communities address root
causes of poor health, improve prevention at both the clinical
and community levels so that Americans can lead healthier and
more productive lives.
The Affordable Care Act also mobilizes national partners in
prevention, such as a new National Prevention, Public Health,
and Health Promotion Council, a new National Prevention
Strategy, and brings together partners in 17 Federal agencies
to prioritize these efforts in public health in what we call a
Health In All Policies approach.
In closing, the burden and urgent threat of chronic disease
constitutes one of the major public health challenges of the
21st Century. We can prevent future death and suffering through
strong scientific approaches that incorporate evidence-based
and affordable population-wide interventions.
The Affordable Care Act and especially the Prevention and
Public Health Fund are helping us reach our goal of
transitioning our Nation away from being a sick care system to
one that prizes prevention and public health in the community.
We are committed to furthering this important work and look
forward to sharing more success stories with you in the future.
Thank you very much, and I'd be very pleased to take some
questions.
[The prepared statement of Dr. Koh follows:]
Prepared Statement of Howard K. Koh, M.D., M.P.H
Good afternoon, Chairman Harkin and Ranking Member Enzi. I am Dr.
Howard K. Koh, the Assistant Secretary for Health at the U.S.
Department of Health and Human Services. I would like to thank you for
holding this important hearing on the critical role of prevention in
improving the health of Americans and how the Prevention and Public
Health Fund that was created by the Affordable Care Act supports our
efforts to prioritize prevention across our programs and policies. The
passage of the Affordable Care Act and with it the creation of the
Prevention and Public Health Fund represents one of the most important
actions by Congress and the Federal Government to promote prevention to
improve the overall health and well-being of the American people. It
manifests an unprecedented commitment to ensuring that all Americans
are able to achieve their potential by realizing the highest standard
of health. Also, I would like to take this opportunity to thank you,
Senator Harkin, for your leadership on this important issue. You have
been leading the charge to promote prevention and wellness for your
entire career, and we are all indebted to you for your tremendous work
on this important topic.
As the Assistant Secretary for Health, I am tasked with advancing
prevention nationwide. Promoting prevention and its crucial role in
improving the health of individuals, and communities, has truly been a
life-long passion of mine. Before assuming my current position, I spent
more than 30 years as a physician, caring for patients. When I began my
career as a clinician, I set out to alleviate the pain and suffering of
my patients to the best of my ability. However, as I provided care for
more and more people facing serious medical problems, I came to realize
that a significant number of the problems my patients faced were
preventable. Thus, I became intensely interested in finding ways to
educate my patients about prevention so that they, and their loved
ones, could maintain healthy lifestyles and avoid unnecessary pain,
sickness and early death.
During my tenure as the Commissioner of Public Health for the
Commonwealth of Massachusetts, one of my key priorities was to promote
prevention efforts throughout the State. I worked with the health care
sector, the business sector, other government sectors, community-based
organizations and private citizens to raise awareness about community
prevention and preventive health care services. To support these
efforts, we worked closely with the Federal Government, including the
CDC, on many of these initiatives. The Federal Government has been a
partner for many years in promoting prevention, and I am committed to
accelerating these efforts as the Assistant Secretary for Health.
chronic disease and the united states
Today, the United States is facing an epidemic of unprecedented
magnitude: the sky-rocketing prevalence of chronic disease throughout
our Nation. Seven out of every ten deaths in the United States are due
to some form of chronic condition. Heart disease, cancer and stroke
account for more than 50 percent of all deaths each year. Nearly half
of all adults in our Nation have at least one chronic illness. Rates of
obesity are increasing, with more than one in three adults fitting the
clinical definition of obese, and almost one in every five children
being categorized as obese. Diabetes rates are also on the rise. If
current trends continue, one out of every three babies born today will
suffer from diabetes at some point in their life. Indeed, chronic
disease impacts all Americans, but not equally. Rates of chronic
disease among racial and ethnic minorities, and among lower-income
Americans, are higher than the national average and thus are of
particular concern. Racial and ethnic minority communities experience
higher rates of heart disease, stroke, cancer, obesity and diabetes.
Within the African-American and Hispanic demographic, nearly 40 percent
of children are overweight or obese.
Chronic disease impacts not only the health of the individual and
their families, but it has a broader impact on our communities and the
economy. Astoundingly, chronic disease is responsible for more than 75
percent of the more than $2.5 trillion we spend annually on health
care.\1\ Specifically, nationwide health care costs for all
cardiovascular diseases are $442 billion annually \2\; diabetes-
associated costs are approximately $174 billion annually \3\; obesity-
related costs are approximately $147 billion annually \4\; and lung
disease costs are approximately $154 billion annually.\5\ In fact,
cigarette smoking costs the Nation an astounding $193 billion in health
costs and lost productivity each year.\6\ Society--and business--also
incurs the indirect costs of these conditions, including absenteeism,
disability and reduced productivity.
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\1\ http://www.cdc.gov/chronicdisease/resources/publications/AAG/
chronic.htm.
\2\ AHA Policy Statement: Forecasting the Future of Cardiovascular
Disease in the U.S. (January 2011: http://circ.ahajournals.org/content/
123/8/933.full.pdf+html.
\3\ American Diabetes Association. Direct and Indirect Costs of
Diabetes in the United States. American Diabetes Association Web site.
Available at http://www.diabetes.org/diabetes-basics/diabetes-
statistics/.
\4\ Finkelstein, E.A., Trogdon, J.G., Cohen, J.W., and Dietz, W.
Annual medical spending attributable to obesity: payer and service-
specific estimates. Health Affairs 2009; 28:w822-w831.
\5\ National Heart, Lung, and Blood Institute. Morbidity and
Mortality: 2004 Chart Book on Cardiovascular, Lung, and Blood Diseases.
Bethesda, MD: National Institutes of Health, 2004.
\6\ http://www.cdc.gov/tobacco/data_statistics/fact_sheets/
fast_facts/.
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With employer-based health insurance covering almost 160 million
workers under age 65, preventing disease and improving health outcomes
is a financial imperative for many businesses. The Almanac of Chronic
Disease by the Partnership to Fight Chronic Disease documented that
chronic disease causes the loss of $1 trillion \7\ in economic output
annually. Furthermore, individuals serving as caregivers to loved ones
suffering from chronic disease also represent an undercounted economic
cost of chronic disease that runs into the tens of billions of dollars
annually. The Almanac of Chronic Disease, for example, estimates that
lost productivity associated with caregiving activities totals
approximately $91 billion annually. Confronting the massive impact of
chronic disease on our Nation's health, and our economy, is imperative
to bringing down health care costs and improving the lives of our
citizens.
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\7\ http://www.fightchronicdisease.org/sites/default/files/docs/
2009AlmanacofChronicDisease
_updated81009.pdf.
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preventing disease: value for health and the economy
Preventing disease can save lives and money. With health care costs
on the perpetual rise, investments that reduce costs and improve health
outcomes are critically important. By focusing on the most prevalent
chronic diseases (heart disease, cancer, stroke and diabetes) and
addressing behaviors that contribute to these conditions (tobacco use,
poor diet, physical inactivity and alcohol abuse), we can make a
profound impact on reducing the harm caused by chronic disease.
Here are just a few examples:
Health care costs for smokers, people who are obese, and
those who have diabetes are $2,000, $1,400, and $6,600 per year higher
for each person with these conditions, respectively. Health care costs
saved from preventing these diseases reduce health insurance premiums.
A proven program that prevents diabetes can save costs
within 3 years.\8\
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\8\ Rigorous economic models have demonstrated that structured
lifestyle interventions to prevent diabetes can be cost-saving within 2
to 3 years time if the direct costs of the intervention can be reduced
to $250-$300/participant/year. Ackermann, R.T., Marrero, D.G., Hicks,
K.A., Hoerger, T.J., Sorensen, S., Zhang, P., Engelgau, M.M., Ratner,
R.E., and Herman, W H. (2006). An evaluation of cost sharing to finance
a diet and physical activity intervention to prevent diabetes. Diabetes
care, 29(6):1237-41. And Ackermann, R.T., Finch, E.A., Brizendine, E.,
Zhou, H., and Marrero, D.G. (2008). Translating the diabetes prevention
program into the community. The DEPLOY pilot study. Am J Prev Med,
35(4):357-63.
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A 5 percent reduction in the prevalence of hypertension
would save $25 billion in 5 years.\9\
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\9\ Ormond, B.A., Spillman, B.C., Waidmann, T.A., Caswell, K.J.,
and Tereschchenko, B. Potential National and State Medical Care Savings
from Primary Disease Prevention. Am J Public Health 2011, 101(1): 157-
64.
The economic argument for investing in prevention is compelling.
The use of evidence-based interventions can improve health and prevent
unnecessary suffering, while at the same time, save money for both the
government and the private sector. According to the CDC, for example,
there is a $10 return on investment for every dollar spent on childhood
vaccinations. Vaccination of children and adolescents prevent
approximately 20 million cases of disease each year and save as many as
42,000 lives on an annual basis. Immunizing children born in the United
States each year costs about $7 billion and saves $21 billion in direct
costs and $55 billion in indirect costs \10\ In another example, the
implementation of CDC's guidelines for preventing blood stream
infections could potentially save $414 million annually in excess
health care costs and $1.8 billion annually estimated cumulative excess
health care costs prevents 25,000 infections from occurring; and saves
approximately 4,500 lives.\11\
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\10\ Preliminary results, updated from Zhou, F., Arch of Pediatric
and Adolescent Medicine.
\11\ http://www.cdc.gov/mmwr/pdf/wk/mm60e0301.pdf.
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Despite the indisputable wisdom of investing in prevention,
currently less than 1 percent of all health care dollars spent in the
United States are dedicated to these scientifically proven, effective
strategies. If we managed heart disease better, for example, by 2023 we
could reduce associated health care costs by $76 billion. And, if
stronger prevention and care management systems are implemented across
the Nation for the seven leading chronic diseases, our economy could
see $1 trillion in savings by 2023.\12\ By investing in prevention, we
can transition our current medical care system from a sick care system
to one based on prevention and wellness.
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\12\ http://www.fightchronicdisease.org/resources/almanac-chronic-
disease-0.
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prevention and the affordable care act
The passage of the Affordable Care Act was an historic moment that
represented a major commitment to ensure all Americans have access to
high quality and affordable health care while focusing on promoting the
health and well-being of communities. The Affordable Care Act is a
landmark law that grants individuals more control over their health
care, and brings down the cost of health care for both families and
businesses. At the same time, the Affordable Care Act also represents a
once in a generation opportunity to bring prevention to the forefront
of the dialogue about health care and the cost of care. Under the
Affordable Care Act, people in traditional Medicare as well as
individuals joining private insurance plans will receive recommended
preventive services with no cost-sharing requirements for patients. The
Affordable Care Act also provides States the option to provide these
services in Medicaid, with incentives for eliminating cost-sharing. The
law also requires new health plans to cover important services for
infants and children as outlined in the Bright Futures Guidelines and
preventive services for women across their life-span, included as part
of HRSA supported Guidelines for Women's Preventive Services, without
co-pays, co-insurance rates, or deductibles. So far in 2011, nearly
20.5 million people with Medicare reviewed their health status at a
free Annual Wellness Visit or received other preventive services with
no deductible or cost sharing this year, and as many as 41 million
Americans in new health plans are also benefiting from free preventive
services because of the law.
The Affordable Care Act, however, recognizes health goes beyond the
clinical setting. As such, the Affordable Care Act creates the National
Prevention, Health Promotion, and Public Health Council (National
Prevention Council) to provide coordination and leadership at the
Federal level and among all executive agencies regarding prevention,
wellness, and health promotion practices. It is composed of the heads
of 17 Federal agencies and chaired by Surgeon General Regina Benjamin.
The National Prevention Council released the National Prevention and
Health Promotion Strategy as a comprehensive plan for Federal, State,
local and private partners to work together to help increase the number
of Americans who are healthy at every stage of life. The Strategy
recognizes good health comes not just from receiving quality medical
care but from stopping disease before it starts. Good health also comes
from clean air and water, safe outdoor spaces for physical activity,
safe worksites, healthy foods, violence-free environments and healthy
homes. Prevention should be woven into all aspects of our lives,
including where and how we live, learn, work and play. Everyone--
businesses, educators, health care institutions, government,
communities and every single American--has a role in creating a
healthier nation. Investments in prevention across the life span
complement and support treatment and care. Prevention policies and
programs can be cost-effective, reduce health care costs, and improve
productivity.
The Strategy provides four broad strategic directions to improve
prevention and wellness in order to have a healthier America, including
building healthy and safe community environments; expanding quality
preventive services in both clinical and community settings; empowering
people to make healthy choices; and eliminating health disparities.
One of the most important commitments in the Affordable Care Act to
help HHS achieve such goals is the investment in public health and
community prevention programs made possible by the creation of the
Prevention and Public Health Fund (the Prevention Fund, or Fund). The
Fund represents our most significant investment to promote and scale up
effective public health and prevention measures in our Nation's
history. Despite only being in existence for 2 years, the Fund is
already making a positive impact on public health, prevention and
wellness across the Nation.
The Fund allows us to make targeted, high priority investments
across a spectrum of prevention and public health initiatives. Primary
prevention programs work at the community level, and they employ local
scientists, epidemiologists, laboratorians, and others to control
diseases before people end up in a hospital or acute care centers. Fund
investments represent a unique blend of Federal expertise, technical
assistance and data with State and local, on-the-ground experts who
best understand the needs of their respective communities. With the
Fund, we are supporting, expanding and accelerating our commitment to
innovative and effective prevention programs that impact people's lives
on a daily basis.
The Fund currently supports public health programs to prevent and
reduce obesity, tobacco use, heart disease, diabetes and cancer,
strengthen the public health workforce, modernize and improve vaccine
systems, and track outbreaks of disease across the country. Our
partners in health organizations across the Nation are having a real
impact that will be felt in both lives saved and costs avoided.
The Fund provided $500 million in fiscal year funding for critical
initiatives focused on the training of new primary care providers to
help meet the needs of a growing and aging population, and provide
essential primary and preventive care. Funding also is enabling us to
embrace smarter more strategic approaches within current programs. As
just one example, to further the goals of the National HIV/AIDS
Strategy for the United States which calls for improved coordination
across all levels of government, CDC used resources from the fund to
launch a pilot initiative in the 12 communities with the highest AIDS
prevalence to test and evaluate new approaches to integrating planning
for prevention and care services. In addition to the investment in
building our primary care workforce, our fiscal year 2010 investments
laid the groundwork for achieving three primary objectives:
Empower communities to reduce heart attacks, cancer,
stroke, injuries and more--the leading causes of disability and death.
Enhance State and local capacity to detect and respond to
disease threats and manage scarce resources.
Produce information for action--what prevention programs
work and performance of the health system--so we can increase the
health value of our health investments.
These objectives were the focus of our fiscal year investments,
when the size of the fund increased to $750 million, enabling HHS to
work with States, tribes and local governments to continue many of the
strategic investments made in the previous year, and at the same time
expand investments to support prevention and public health initiatives
at every level of government. In fiscal year 2011, the Fund continued
support for community and clinical prevention efforts, public health
infrastructure development, and research and tracking initiatives to
evaluate the efficacy of efforts related to the program. Initiatives
receiving funding include:
Community and State Prevention ($222 million). Implement
the Community Transformation Grant (CTG) program and strengthen other
programs to support State and community initiatives to use evidence-
based interventions to prevent heart attacks, strokes, cancer and other
conditions by reducing tobacco use, preventing obesity, and reducing
health disparities. Launch a consolidated chronic disease prevention
grant program.
Tobacco Prevention ($60 million). Implement anti-tobacco
media campaigns that have been proven to reduce tobacco use, telephone-
based tobacco cessation services, and outreach programs targeted toward
vulnerable populations, consistent with HHS' Tobacco Control Strategic
Action Plan.
Obesity Prevention and Fitness ($16 million). Advance
activities to improve nutrition and increase physical activity to
promote healthy lifestyles and reduce obesity-related conditions and
costs. These activities will implement recommendations of the
President's Childhood Obesity Task Force.
Access to Critical Wellness and Preventive Health Services
($112 million). Increase awareness of new prevention benefits made
available by the Affordable Care Act. Expand immunization and
strengthen employer participation in wellness programs.
Reduce the Impact of Substance Abuse and Mental Illness
($70 million). Assist communities with the coordination and integration
of primary care services into publicly funded community mental health
and other community-based behavioral health settings.
Public Health Infrastructure and Capacity ($92 million).
Support State, local, and tribal public health infrastructure to
advance health promotion and disease prevention and improve detection
and response to disease outbreaks by improving epidemiology and
laboratory capacity, information technology, public health workforce
training, and policy development.
Public Health Workforce ($45 million). Support training of
public health providers to advance preventive medicine, health
promotion and disease prevention and epidemiology in medically
underserved communities.
Health Care Surveillance and Research ($133 million).
Improve the evidence base for prevention and public health by improving
data collection and analysis (including on environmental health
hazards), and investing in rigorous review of evidence on the
effectiveness of both clinical prevention services and community
interventions.
Already, the Fund has made strides in prevention and public health
in a way that will leave a legacy of commitment and success for the
future. This year, we invested over $100 million of the Fund in
Community Transformation Grants (CTGs). This program provides direct
support to State and local communities to help tackle the root causes
of poor health so Americans can lead healthier, more productive lives.
The grantees will work to implement proven prevention activities and
build capacity in their community to support sustainable initiatives in
the future. Grantees will work to address the following priority areas:
tobacco-free living; active living and healthy eating; and quality
clinical and other preventive services, specifically prevention and
control of high blood pressure and high cholesterol. Grantees, who are
expected to have a direct impact on up to 120 million Americans, will
use these funds to improve where Americans live, work, play, and go to
school, and to reduce chronic diseases, such as heart disease, stroke
and diabetes, which account for a significant portion of the health
care costs in the United States.
By promoting healthy lifestyles, especially among population groups
experiencing the highest rates of chronic disease, these grants will
help improve health, reduce health disparities, and control health care
spending. Within the CTG program, there is a clear focus on addressing
health care disparities. More than half of the recipients intend to
target African-American and Latino populations, and over one in three
of the grantees will focus specifically on American Indians/Alaska
Natives. Almost all grantees will include initiatives focused on
children, and nearly 20 percent of the programs will include efforts to
improve the health of older adults. And consistent with the program's
authorization, at least 20 percent of grant funds are directed to rural
and frontier areas to help them address their unique health issues. The
CTG program is a direct investment of Prevention and Public Health Fund
dollars into our communities that will improve the health of our
society. CTGs will allow cities and States to innovate and implement
specifically tailored interventions in their own communities in order
to promote health, increase prevention and reduce the burden of chronic
disease throughout our Nation.
With funding recently awarded, communities across America are
initiating work to tackle critical health problems. Selected examples
include:
In Minnesota, the Hennepin County Human Services and
Public Health Department is implementing comprehensive tobacco-free
policies in public housing, and increasing daily physical activity in
school-settings by implementing a Safe Routes to School program and
adopting Active Recess systems at elementary and middle schools.
The Iowa Department of Public Health is improving school-
based nutrition and the quality and amount of physical activity in
schools. Iowa is also increasing health provider awareness of high
blood pressure and high cholesterol through new clinical tools and
systems.
The North Carolina Division of Public Health will work
toward increasing the number of convenience stores that offer fresh
produce, and increase the number of communities that support farmers'
markets, mobile markets, and farm stands. North Carolina will also
increase the number of healthcare organizations that support tobacco
use screening, referral and cessation.
The Sault Saint Marie Tribe of Chippewa Indians will
create a region-wide Food Policy Council to increase accessibility,
availability, affordability and identification of healthful foods in
communities; improve the quality and amount of physical education and
physical activity in schools; and support workplace policies and
programs that increase physical activity and work to increase bicycling
and walking for transportation and pleasure.
The West Virginia Bureau for Public Health is working with
the States' clinical sector to assure improvement in control of high
blood pressure and high LDL-cholesterol.
In addition to partnering with State and local governments, and
others working in communities across the United States, the Department
is committed to partnering with the private sector to promote
prevention and reduce the prevalence of chronic disease. At the end of
last month, the Department announced a workplace wellness initiative to
improve the health of workers and their families. The CDC recently
awarded a contract that will help an estimated 70 to 100 small, mid-
size, and large employers create and expand workplace programs aimed at
achieving three goals: reduce the risk of chronic disease among
employees and their families through evidence-based workplace health
interventions and promising practices; promote sustainable and
replicable workplace health activities; and promote peer-to-peer
healthy business mentoring. These efforts--focused on changing
programs, policies, benefits, environmental supports and links to
outside community prevention efforts--will help CDC learn about best
practices and replicable models that can be disseminated to the
business community to inform their efforts to adopt cost-saving
preventive measures.
The President included recommendations to the Joint Select
Committee on Deficit Reduction that would prioritize investments within
the Prevention and Public Health Fund. At the same time, the Federal
Government will continue to invest strategically in areas of national
importance, such as prevention. To this end, President Obama's recently
released deficit reduction plan would allow for significant investments
in prevention and public health activities of more than $6 billion over
5 years and $13.8 billion over 10 years, while providing $3.5 billion
in savings. Even with this reduction in the Fund's size, the Federal
Government will still be able to make significant investments in
prevention and tackle the urgent threat and challenge chronic disease
presents to our society. We, at the Department, look forward to
continuing to execute this important plan.
In addition to the Prevention and Public Health Fund, the Obama
administration has made a significant commitment to combating childhood
obesity so that children born today can grow up healthier and able to
pursue their dreams. The First Lady has already been successful in
bringing nutrition and healthy lifestyle messages to the forefront of
the national conversation through Let's Move!, a comprehensive
initiative dedicated to solving the challenge of childhood obesity
within a generation.
Building on the strong foundation of the Affordable Care Act, the
Department of Health and Human Services launched the ``Million
HeartsTM '' initiative with other Federal, State and local
government agencies, and a broad range of private-sector partners. The
goal of this program is to prevent 1 million heart attacks and strokes
over the next 5 years by implementing proven, effective, inexpensive
interventions. The Department is committed to developing and
implementing robust and multi-faceted approaches to prevention. By
coordinating the multiple initiatives focused on prevention and
wellness across the government, and joining with partners at the State
and local level, we can bring about fundamental change that ensures a
brighter and healthier future for all Americans.
conclusion
In closing, the burden and urgent threat of chronic disease
constitutes one of the major public health challenges of the 21st
century. The incidence and impacts of preventable diseases can be
largely reduced with an approach that incorporates evidence-based,
affordable population-wide interventions. The Affordable Care Act and,
especially, the Prevention and Public Health Fund, is helping us make
significant progress in our efforts to transition our Nation's health
care system away from being a sick care system. In the last 2 years,
the Department has used the Prevention and Public Health Fund to make
important strategic investments in promoting preventive health care and
community health, and to improving our Nation's public health
infrastructure. We are committed to continuing this important work and
look forward to sharing more success stories with you in the future.
Thank you. I am now happy to take questions.
The Chairman. Thank you very much, Mr. Secretary. We'll
start rounds of 5-minute questions.
Mr. Secretary, you've outlined in your testimony, which I
read last night, all the different things you're doing with
these funds. You say the fund allows us to make targeted, high-
priority investments across a spectrum of prevention and public
health initiatives. You list all of those.
Would you address what's been published and what some
people have said--they've just called this a slush fund. I'm
not certain what that definition is, but it doesn't sound good.
So how would you respond to someone saying it's just a slush
fund? What's your response to that?
Dr. Koh. First, Mr. Chairman, we have so many urgent
threats with respect to preventable conditions that we have all
already discussed in the opening minutes of this very important
hearing. We know that prevention works. We have science and
evidence that interventions can make a difference and save
lives and reduce suffering and begin to reverse these rising
healthcare costs.
But the challenge has been that we haven't had the
opportunity or the resources to make those interventions
available to community and local leaders so they can make a
difference around the country. So we are administering these
efforts according to strict guidelines. We are following the
directives of the statute passed by Congress and put into law.
We have strict adherence to accountability and to proper
uses of these funds so that we can support State and local
efforts. And we view this as a partnership where we help local
and State leaders move prevention and advance these evidence-
based interventions, and that's the whole theme of this effort.
The Chairman. I listened very closely to what my friend
from Kansas had to say, and I agreed with him that we want to
see evidence-based processes going forward. We want the
collection of data. Are you comfortable with that, the way
we're proceeding, that we will have good evidence-based
processes?
Dr. Koh: We have not only implementation of evidence-based
interventions, but also very strong and rigorous evaluation
strategies embedded with each grant. And we are committed to
seeing outcomes and strong evidence of what works and what
works even better with respect to prevention. So this is a
great investment in prevention, in public health, and in the
rigor of science. And that's what we're advancing with these
efforts.
The Chairman. Mr. Secretary, a number of times--and using
my own phraseology--runs have been made on this fund to take
money out of it to use it for something else. You mentioned
just one initiative that you started. You call it the Million
Hearts Initiative with other Federal, State, and local
governments. The goal was to prevent a million heart attacks
and strokes for the next 5 years by implementing proven,
effective, inexpensive interventions.
Could you just talk a little bit about that? If this fund
is cut down, what happens to that kind of an initiative?
Dr. Koh. We all understand that cardiovascular disease is
the leading killer in this country. We know that so much of
this is absolutely preventable. We know that a lot of heart
disease and stroke is driven by issues such as blood pressure
control, cholesterol control, and particularly tobacco
dependence.
If we set national goals, as has been done in this so-
called Million Hearts Initiative just unveiled several weeks
ago by the Secretary, and really galvanize national attention
on reducing those risk factors, we can see an even further
decline in cardiovascular disease deaths in the future than
we've had before. And we view this as a critical way of
reducing suffering and also reducing health disparities in the
country. There are major disparities with respect to
cardiovascular disease that we need to address as well.
The Chairman. Mr. Secretary, I'll bring this up at the next
panel because we have experts from different disease groups.
But on diabetes, could you address yourself to the looming
prospect of how many people are going to be getting diabetes,
young people? You mentioned it. Today, you said, one out of
every three babies will suffer from diabetes--even higher among
African-Americans and Hispanics, almost one out of every two.
How would this fund approach that? How are we going to
prevent that from happening?
Dr. Koh. The rising obesity rates are a tremendous societal
challenge right now. And the rising obesity rates fuel Type 2
diabetes, heart disease, stroke, even some forms of cancer. And
so we know that tackling the obesity challenge for children and
adults is a way of preventing diabetes and cancer and heart
disease as well.
For example, in these Community Transformation Grants that
have just been announced by the CDC, there are directives for
grantees to work on reducing obesity rates in their respective
communities through a Health In All Policies approach, and
that's prevention at its very best. And we expect to see big
payoffs in the future and reverse this trend, because
otherwise, the health of our country is greatly at risk.
The Chairman. Thank you, Mr. Secretary. My time is up.
Senator Roberts.
Senator Roberts. Thank you, Mr. Chairman, and Doctor,
several times over.
In discussing the special initiative on the funding from
the fund--and the chairman is exactly correct. Folks have been
using this fund as a bank, and that's not for what it was
intended. But you used statements that are very familiar to the
committee and to everybody here in the hearing room and the
Public Health Committee, like increased awareness, support
State and local public health infrastructure, advanced
activities.
I know that when we get to the challenges of the Super
Committee on what this committee and other committees are going
to have to recommend to the Super Committee, or vice versa,
they're going to ask with limited dollars, ``Can you specify
what each of these dollars were used for and detail the
pragmatic use of these funds?'' What would you advise us to say
in that regard?
Dr. Koh. Thank you for that question, Senator. When we look
at the challenge of public health in our country and see how
much suffering is due to illness that could be and should be
prevented, one has to reach the conclusion that we need more of
an emphasis on prevention as well as treatment. And we view
that new emphasis as one that makes our country stronger and
healthier and in the long run has the potential to reduce
healthcare costs as well.
The fund is a substantial accomplishment, and we're very
proud of that. And it's a great product of the Affordable Care
Act. But when you put it next to the fact that treatment of
chronic disease is contributing to over 75 percent of the $2.5
trillion in healthcare costs----
Senator Roberts. Doctor, I apologize for doing this, and I
shouldn't. But I've got about 3 minutes here. And that was part
of my opening comments, so I'm trying to buttress what you're
saying in my opening comments.
Dr. Koh. Thank you.
Senator Roberts. But we get down to the details of the
pragmatic use of the funds, and when you say proven prevention
activities that you're funding, are there any of them that are
experimental, or are they supported by scientific evidence? And
that's going to be key if we're able to save the funds for what
purpose they are intended.
So I don't expect you to list the whole laundry list of
things that you are doing with State and local officials. But
if you could be a little more specific on the pragmatic thing
rather than--we all know that wellness is the way to go and
prevention is the way to go if we're going to answer this
question.
Dr. Koh. If we can take the example of tobacco, Senator, we
know that tobacco dependence drives up cancer and heart disease
and so many other conditions. We know that these are
preventable illnesses. I'll give you the prime example. Lung
cancer, which is primarily driven by tobacco dependence, is the
leading cancer killer in our society. Without tobacco, that
would be a rare condition, and it should be a rare condition.
Senator Roberts. OK. I'll use South Carolina as an example
because the chairman brought it up. Specifically, what do you
do with State and local officials to achieve this goal?
Dr. Koh. The South Carolina example the Senator mentioned
was the Farm-to-School programs, where we're improving--or
they're improving, actually, options for healthier foods for
kids in schools so that those kids have a better chance of
growing up with a healthy weight and not obese.
Senator Roberts. No. I want to know about tobacco. I don't
smoke, by the way, but--only when I'm mad, Mr. Chairman. You
know, specifically on----
Senator Mikulski. And there's evidence of that.
Senator Roberts. Yes, that's true.
[Laughter.]
She knows. At any rate, what is your yardstick to know that
the programs and the fund really work? And specifically
tobacco--other than just saying it's a heck of a problem. Yes,
it is. It has been for years, but we are making some progress
on it.
Dr. Koh. Sure.
Senator Roberts. Is there going to be scientific evidence,
or is this experimental, or is it just advice and counsel, or
what?
Dr. Koh. In areas like tobacco, the evidence is
overwhelming.
Senator Roberts. No. In South Carolina, for the program,
what happened?
Dr. Koh. Senator, I don't have the specifics on South
Carolina tobacco control. But I can say in many States, the
themes are the same, that is, improving cessation opportunities
for smokers who want to quit, access to quit lines, making sure
that public places are smoke-free so that workers aren't
exposed to secondhand smoke in their work, education in schools
so that kids don't get dependent in the first place, and really
making this so-called Health In All Policies approach. And I'm
sure that applies to South Carolina as just about every other
State.
Senator Roberts. I'll leave it at that. I want to
underscore, the kind of competition we have here in terms of
funding for all the things we'd like to fund. And if you can't
have a yardstick to know what programs actually have worked and
get specific with our colleagues, we're going to have some
problems.
Dr. Koh. Senator, if I can just add--for each of those
components I mentioned, there are measureable yardsticks that
get followed and tracked over time. So we can provide all that
information for you.
Senator Roberts. I wish I had asked that first so he would
have said that first, and then I could have gone to the next
question. I'm sorry.
The Chairman. I have in order Senator Whitehouse, Senator
Franken, Senator Mikulski.
Senator Whitehouse.
Statement of Senator Whitehouse
Senator Whitehouse. If I may, I'd like to followup on
Senator Roberts' question. One can understand that,
hypothetically or from past experience, a tobacco cessation
program is, overall, a cost-benefit positive. But as we pursue
the prevention effort and as we push out into other areas, it's
going to be important to have a systematic, constant way of
making the cost-benefit determination. And you will be a lot
better off if we are all agreed that the numbers that you're
working with are real numbers.
We have to work with CBO, and although we hate it, it adds
a certain amount of order to the proceedings. What are the
metrics for determining the cost justification for prevention
plans right now? Do you have your own CBO? Do you have a shop
where that gets done?
Dr. Koh. We depend on the Science Center, and we want to
thank you for your commitment to getting good science and
particularly through electronic health records and other ways--
--
Senator Whitehouse. That's really not what I was getting
at. I think--it sounds like you're telling us that there isn't
a location within the Federal Government in which prevention
strategies get formally evaluated as to their cost-benefit
analysis and a rigorous and constant discipline is applied to
those questions.
Dr. Koh. Those themes--I would disagree, actually, Senator.
Those themes are aggressively pursued by agencies like NIH,
like CDC and LSAR, Agency for Healthcare Research and Quality.
And so the emphasis on scientific rigor, evaluation,
accountability is very, very strong, and we----
Senator Whitehouse. With respect to the cost-benefit
equation?
Dr. Koh. Yes. We want to demonstrate return on investment,
and we have some that, actually, Chairman Harkin recited with
respect to vaccination return on investment and other areas.
Senator Whitehouse. All right. Let me shift to a different
topic and ask that I get a more complete--I think Senator
Roberts may be interested in it as well--a more complete answer
for the record, a written QFR on that point.
Dr. Koh. Sure.
Senator Whitehouse. Because I think it would be helpful if,
instead of sort of grabbing a cost-benefit analysis from here
and another one from there and something that turned up in the
literature somewhere else, you actually had your own program
for determining what made the cuts, what didn't, what was the
most cost benefit, what's the wisest place to deploy the
funding that we have, and so forth.
That's my focus. I'm not challenging that you don't do this
with any cost-benefit considerations being made. What I don't
see is a place where this gets done consistently, reliably, by
the same people, so you get a consistent body of expertise
built up.
Dr. Koh. Actually, I can respond to that, Senator.
Senator Whitehouse. I'd rather you not, because I have 2
minutes left. Do it in writing, OK, as I asked.
Dr. Koh. OK.
Senator Whitehouse. Would that be all right?
Dr. Koh. Yes.
Senator Whitehouse. What I'd like to use my last 2 minutes
on is to urge you--as you know, you're standing in for the
administration here. And so, I say this to everybody, so don't
take it personally. But the prevention changes that we need to
make in our healthcare system marry up with care coordination
changes that we need to make as improvements to our healthcare
system. And those marry up with quality reform improvements
that we need to make in our healthcare system, and they marry
up with payment reform improvements that we need to make to
improve our healthcare system.
They all stand on electronic health infrastructure that
needs to be the structure for evaluating and propagating all of
those other missions that we have to accomplish. And I want to
say again I am extremely frustrated that I see no apparent goal
setting by the administration in this area. If you look at
these things as not independent plans, but a strategy for
delivery system reform that has these different components and
that will reinforce one another--so you have to go forward
globally with all of them.
You've got a great law in the Affordable Care Act in terms
of the programs that were set up. You've got people like Don
Berwick who are fantastic at this, and you've got them
propagated throughout the administration. But what the
administration has not yet done is to set a goal for itself as
to what the end product of this exercise is going to be.
And I submit to you that the bureaucracy of this government
would work a lot faster and a lot more effectively if it were
working toward a specific, accountable outcome that the
administration should announce. And I don't want to hear
anybody tell me about bending the curve of healthcare costs.
That is the most unaccountable metric you can imagine.
If President Kennedy, facing the space deficit that we had,
had said he was going to bend the curve of space exploration,
we would not have put a man on the moon and the speech would
have been forgotten to history and justifiably so. And I want
to just re-emphasize here my call on this administration--put a
dollar figure and a date on the kind of savings you want to
accomplish, describe how they're going to be done, and get the
administration to work on those goals.
You cannot have the goals pursue the effort. You've got to
have the goals lead the effort, and I don't see those goals.
Dr. Koh. If I can respond, Senator, I think I have a lot to
share with you that will make you more supportive of what we're
trying to do here. We have a national goal setting process
called Healthy People, which you've probably heard about, that
gets updated on a regular basis. We just updated Healthy People
2010 and put out Healthy People 2020 goals. And then the
Affordable Care Act and the Prevention Fund helps us
tremendously to reach those goals, Senator, because we are
uniting both clinical prevention and community prevention.
There's an effort for a focus on community prevention
services that look at return on investment issues, such as
you've been talking about in your several questions to us. And
there has been a national quality strategy that's been required
by the Affordable Care Act that the department put out. Dr.
Berwick was one of the co-authors along with Dr. Clancy of
AHRQ.
With health IT in the middle of all that, we viewed this as
a way of integrating all these efforts to reach those goals,
make the country healthier, and, hopefully, make a difference
on healthcare costs as well. So I would like to think that
we're doing all the things you just described, Senator.
Senator Whitehouse. I would like to also.
The Chairman. If I might just interject one thing, Dr. Koh,
that there are two entities, one old and one new, I'd say to my
friend, that--we have the U.S. Preventative Services Task
Force, which has been in existence for a long time. They do
look at cost benefits. They do look at science-based, evidence-
based processes, and recommend those. So that's been there for
some time.
We, in the Affordable Care Act, also set up the Prevention
Council----
Dr. Koh. Yes.
The Chairman [continuing]. Where we have someone from 17
departments and agencies in the Federal Government. They are
then supposed to look at proposals that cut across the entire
Federal Government. I share your little frustration that they
have been slow and haven't been too active, but we're going to
look at that too. But that idea of being--what are the goals
that cut across Department of Agriculture, Department of
Defense, Department of Energy? What are the things that cut
across all the departments? And that's what the Preventative
Council is supposed to be doing.
Senator Whitehouse. And what is the overall goal--would be
my question--of the common exercise? How do you knit together
the electronic health record piece, the various prevention
councils, the quality reform efforts, the payment reform
efforts? What goal are they together pointed at by the White
House? That's what I can't determine.
The Chairman. I'd like to see that myself.
Dr. Koh. If I can respond to that, the overarching goals of
Healthy People--again, which has been such a foundation for our
work for 30 years--has been to improve quantity and quality of
life, to eliminate health disparities, to----
The Chairman. Well, you do have some specific goals. I
mentioned the Million Hearts Program, which is to reduce
cardiovascular disease and strokes by how much, by a million?
Dr. Koh. By a million in 5 years.
The Chairman. In 5 years. So that's one goal they have, one
goal, just on cardiovascular disease.
Dr. Koh. And if you want to get concrete on these
initiatives, Mr. Chairman, another one that's received a lot of
attention is Partnership for Patients, a goal to reduce
hospital re-admissions and hospital-required conditions over
the next several years. So these are programs where we try to
merge our resources, make them efficient, effective, and make
prevention really work.
The Chairman. And if I might just add one other thing, I'd
say to my friend that in the past, so many times we've set up
goals, and we never seem to achieve them. We set up this little
goal and that little goal and this little goal.
I think what we tried to do in the Prevention Fund and the
Affordable Care Act was to set up not so much a goal here and
there and there, but to set up a dynamic, a system whereby
there would be, as Dr. Koh said, this interrelationship between
the clinical services, the community-based services, the
workplace-based services, the school-based services that would
all be working together in a dynamic to change the inputs into
healthcare, so that over a period of time, you just have a
different structure.
You have a different systems approach, rather than saying,
``Well, we're going to work with everything we have, but we're
going to have a goal.'' Well, if you work with everything you
have and you have a goal, you're never going to get to the goal
because the systems don't work. We have to change the systems.
So I would just say that. But I agree that we do need goals out
there, again, but still we need to change the system and not
just have a goal for an unworkable system that we have now, I'd
say to my friend.
Senator Franken.
Statement of Senator Franken
Senator Franken. Thank you, Mr. Chairman. I'd like to
associate myself with the Senator from Rhode Island's remarks.
We do want an overarching integration of all of the approaches
that are being taken in the Affordable Care Act, because there
are those of us who believe that this will save us tremendous
amounts of money over the years and that we need to demonstrate
that in a way that's convincing and in a way that's real.
And let me bore down into one thing that you write about in
your testimony, which is the National Diabetes Prevention
Program. You remember that I had you over a year ago come to my
office?
Dr. Koh. Yes.
Senator Franken. We had people from NIH and CDC, and we had
United Health there. And this program started as an NIH
clinical trial, became a CDC pilot, and it's the most evidence-
based program to prevent the onset of Type 2 diabetes. I was
proud to work with Senator Lugar and to include it in the
healthcare reform.
Now, this program would cost $300 per individual. People
who are pre-diabetic get 16 weeks of training in exercise at a
Y, they get 16 weeks of nutritional training, and it reduces by
60 percent the number of pre-diabetics who became diabetic.
The significance of having United Healthcare, a private
healthcare--the largest private healthcare insurer in the
country--there was the woman from United Health who said, ``We
will cover anyone who's pre-diabetic that we're covering--we
will pay for this program, and you know why? We will save $4
for every dollar.'' And I'd love for Senator Roberts to hear
that, because this is a private healthcare company, a private
health insurance company, saying, ``We'll save $4 for every
dollar.''
Now, what I want to ask you is what would you say is the
best way to scale this program up?
Dr. Koh. Well, Senator, first of all, thank you for a
commitment to this area, because I can't think of a better
example of evidence-based intervention than this one.
Senator Franken. That's kind of why I brought it up. I just
wanted to get specific and bore down into it. One detail
thing--where United Health said, ``We'll save $4 for every
dollar we spend on this.''
Dr. Koh. It's a great example of excellent science, of an
intervention that makes a difference in the community. And we
are committed to disseminating this across the country, as you
are. A lot of this, of course, is constrained by resources, but
it's also another great example of public-private partnerships
in the role of the Y, and United Health Group has been
extraordinary, as you mentioned.
I do have some figures in front of me that this effort is
now available in some 44 cities across the country. Over 500
coaches have been trained to implement this with respect to
people at high risk for diabetes. So it's one thing to gain
evidence through excellent science, which has happened. It's
another thing to disseminate them into the community and really
make it come alive. So we're definitely on the second part of
that right now.
Senator Franken. I would just ask that you work with me to
expand this program more broadly. Would you do that?
Dr. Koh. Absolutely.
Senator Franken. Great. I wanted to go to one little piece
of--I've only got a minute left, so this is more a comment, and
then maybe you can respond a little bit. You write in your
testimony,
``Good health also comes from clean air and water,
safe outdoor spaces for physical activity, safe
worksites, healthy foods, violence-free environments,
and healthy homes.''
And in your testimony you also talked about disparities in
health, and I think nothing speaks to disparities in health
more than that sentence, because there are people who don't
have neighborhoods where there are outdoor spaces to run
around. There are people who don't have clean air and clean
water. There are people that don't have healthy foods, who live
in violent communities.
We need to do something about the healthcare disparities in
our country, and part of it can be in creating a society where
people have that, which I think should be every kid's right to
grow up in a neighborhood that will allow them to be healthy.
Dr. Koh. Thank you for a commitment to that. Environmental
health and environmental justice is a key part of reducing
disparities. And as you pointed out, Senator, health starts
where people live, labor, learn, play, and pray. It's not just
what happens to you in a doctor's office. So I completely agree
with your sentiments. Thank you.
Senator Franken. Thank you.
The Chairman. Senator Mikulski.
Statement of Senator Milkulski
Senator Mikulski. Thank you, Mr. Chairman.
Dr. Koh, we're just so glad to see you today and----
Dr. Koh. Thank you, Senator.
Senator Mikulski [continuing]. Thank you for all of your
work. And what you have here are people who really believe in
public health, have been strong advocates of prevention. And
during the healthcare debate, Senator Kennedy established three
task forces. One is on access to go over the rate of the number
of people uninsured; one on prevention that Senator Harkin
chaired and did a spectacular job. Many of the issues we're
discussing today were Harkin initiatives, and I had the quality
task force.
We found quality and prevention were intertwined. And it
goes to Senator Whitehouse's comments about delivery systems
and change there. And you know what? We just didn't want to
change access, which was a big issue in our country, we wanted
to be not only reformers, but we wanted to be transformers. And
I think what you're hearing today--and I'm going to be part of
this--is the rate of change and what are we doing that's
transformational.
And as much as we like to hear about evidence-based, which
we all support, the question is are we funding the status quo,
are we funding the stagnant quo, or are we getting a sustained,
synergistic effort that's transformative? And what do we mean?
Public health and prevention has to have the elements of a
social movement, that people take responsibility, they get help
and assistance often outside of a doctor's office, and so on.
Often what we feel, with the implementation of this
Affordable Care Act, is that the pace is slow. The White House
Office of Personnel is notoriously sluggish, inert. We don't
have all of our people in the Preventive Council. Senator
Harkin and I put forth names. It took me 18 months to get one
name through the White House in terms of the Preventive Health
Council, in terms of the Advisory Council. So we're frustrated.
So what I would like to ask in my question to you is two
things. First, what are you doing that's truly transformative
and that we wouldn't have read in public health textbooks 10
years ago? The second thing is this preventive task force that
Senator Harkin established so that every government agency
would take ownership for what they did that would improve
health outcomes for people.
Agriculture would be involved. Defense would be involved.
We would learn from military medicine. Health would be
involved. Education would be involved. Lisa Jackson--and they
would all be coming together. Then we had an Advisory Council
which we can't even get our names confirmed. So we're
frustrated, sir.
Could you share with us kind of where you are, and could
you shake up the Office of White House Personnel for us? That
would be transformative.
[Laughter.]
Dr. Koh. Well, Senator, thank you for your commitment to a
healthier society. We really respect and appreciate that. And
you're absolutely right. This is a transformative opportunity,
and I can give you the concrete examples you're asking for.
We've always funded prevention in Health and Human Services
and in government for years, and you've been a leader at that.
But establishing a dedicated fund, this Prevention Public
Health Fund, gives us a rare opportunity to offer innovative
new strategies, really step up commitment to prevention, really
make a difference at the community level, and then do it in
what we call a Health In All Policies approach, bringing in
broad partners, non-traditional partners. So we could not do
that without that fund. And so this is really an opportunity to
do something really new and cutting edge at the community
level.
The Health In All Policies approach is so key, because we
are working with EPA--and you mentioned Administrator Jackson--
with Housing, with Transportation. And this National Prevention
Strategy that got unveiled a number of months ago by the
Secretary--and Senator Harkin was at the unveiling--really
celebrates having 17 Federal agencies working together on
health. We often say that health is too important to be left to
the health sector alone. And that's a new way of looking at
health now than we ever had before.
So, Senator, I would like to think those opportunities are
tremendous and, hopefully, will outweigh the frustrations of
the day-to-day implementation. And I just want to thank you for
your patience.
Senator Mikulski. What about the Advisory Council to the
Preventive Council, to the council that's supposed to give us
advice?
Dr. Koh. I'd be glad to get back to you on that. I had not
heard the specifics on that. So I'd be pleased to do that. I am
at HHS and not at the White House, so--but I'd be glad to get
back to you.
Senator Mikulski. You know, that's what everybody says.
They're not here, but they're going to be there. Believe me,
you are a dedicated public servant and have dedicated your life
to improving the health of people.
Dr. Koh. Thank you, Senator.
Senator Mikulski. But we've got to get this going, because
there is doubt. People think this is a slush fund. The
President himself wanted to cut it. We've got this window, and
we have to show movement and momentum and the involvement of
people. And I think otherwise, we're going to lose the
opportunity.
Dr. Koh. Right. I really appreciate your commitment to
this, Senator. No one wants to get this done faster than we do
and I do. This is--and if I can say, Senator, and as I've
mentioned, I've been waiting my whole life for an opportunity
like this. And that's why to serve as the Assistant Secretary
now, at this rare historic opportunity, is really
indescribable, and we want to work closely with you and
everybody to make prevention a reality in this country.
Senator Mikulski. Thank you.
The Chairman. I have to buttress what Senator Mikulski just
said. When we get from OMB--and that's not your shop, that's
the White House. When I get from OMB their suggestions for
cutting this and shifting the monies, that doesn't set very
well with us, who wanted to see this as transformative. I think
Senator Mikulski has got the right word, transformative. And so
we get a little frustrated with that.
Senator Roberts.
Senator Roberts. Mr. Chairman, I had no idea that the
distinguished chairman of this committee and the distinguished
Senator from Maryland was having so much trouble with the White
House on appointments. It's been a very enlightening learning
process for me. If it took 18 months for you to get back on
one, think what would happen if that person was a Republican.
It would have taken 24 months or something, or maybe 24 years,
as the chairman has indicated.
Senator Mikulski. No. I think it would have happened
faster.
Senator Roberts. OK. But the----
Senator Mikulski. It's different with you because of that
smoking we talked about.
Senator Roberts. I'm disappointed that Senator Harkin did
not associate himself with our remarks, Mr. Chairman. I merely
opened the door and Sheldon beat it down. But I do want to work
with the Senator, and I think we are on the same track. And
I'll be very interested in that written response.
Let me give an example. Shawnee County, KS, is the home of
Topeka, KS, the capital of Kansas. All of a sudden, there was a
$1.2 million grant that sort of fell out of the sky to the
Shawnee County Commission. That's outside of the Topeka city
limits. And it was for educating senior citizens not to eat too
much salt, or, as a matter of fact, not to eat any salt, but
salt intake.
The county commissioners were not aware of this, but they
said they surely could use the money. But they were advised
that they had to use it for that particular program. Not to
worry; there were quite a few groups that wanted to come to
their assistance to do that.
But that's the kind of thing that I'm talking about that
could really hurt us in regards to the objectives of what we
all share. And to date, I still don't know the metrics of that.
I still don't know what happened to the $1.2 million, and I
still don't know how the Shawnee County Commission was going to
have a program of outreach to senior citizens in the county.
Now, they hit the county because it's more rural, of
course, in terms of access to professional healthcare
providers. Obviously, your doctor is going to say, ``Hey,
you've got to watch your diet and get your blood pressure
down,'' et cetera, et cetera. But I have yet to find out, how
we're doing this.
Now, that's going to be sort of along the lines here that I
was searching for in terms of a specific in these, as you say--
you were much more specific in the Million Hearts initiative. I
can't find my original commentary. But that's what I'm driving
at. Would you care to comment? Because that could be $1.2
million that we could have used that, in other ways, would be
more productive.
Dr. Koh. I would be happy to get you specifics on that
particular grant, Senator. I don't know the specifics on that.
But I can say, in general, that the grant awards are reviewed
very carefully by independent committees. The competition for
these awards is fierce. The Community Transformation Grant
example I just mentioned that was unveiled by the CDC a couple
of weeks ago--there were over 200 applications, and only 60 of
those or so got funded, so less than one in three got funded.
And for each of them, they are heavily scored, and the
measurement, the accountability, the outcomes, and the
evaluation is what really is key, because we want to show at
the end of these interventions that we've made a difference,
how much it makes a difference, and then what the return on
investment is, as Senator Whitehouse was asking about. So these
are issues that we put into every grant review process, and the
competition is very, very fierce.
Senator Roberts. I appreciate your response, and that's
exactly the kind of thing that I think the Senator and I would
like to have.
Dr. Koh. Thank you.
Senator Roberts. Thank you.
The Chairman. Thank you very much, Senator Roberts.
Senator Blumenthal. I recognize Senator Blumenthal.
Statement of Senator Blumenthal
Senator Blumenthal. Thank you, Mr. Chairman.
And thank you for being here, and thank you for your
terrific work as a member of the administration and
particularly on issues of prevention and, most particularly, in
areas of tobacco prevention and cessation, which remains a
really profoundly costly problem both in lives and dollars for
our society. And I appreciate the change in approach and
attitude of this administration as compared with previous ones,
and that is due largely to your leadership. So I commend and
thank you.
And in that connection, could you perhaps update us if you
have information about the so-called deeming regulation, what
its current status is within the FDA, if you know?
Dr. Koh. I'm sorry, Senator. The term again?
Senator Blumenthal. The deeming regulation that, in effect,
applies to tobacco control activities of the FDA. And if you're
not familiar with it, I'll move on.
Dr. Koh. OK. Senator, I'm not familiar with the term. I can
say, as you well know, the FDA has created a new Center for
Tobacco Products. They are committed to implementing the new
law that was signed by the President in June 2009. There are a
number of regulatory activities that are proceeding forward,
mostly to protect kids. New graphic warning labels have been
proposed for cigarettes to hit the market in the fall of next
year.
Through those efforts, we are asking all organizations that
have anything to do with tobacco, its manufacturing, its
distribution, its sale to be registered with the FDA Center for
Tobacco Products, and that has been completed. So these are,
again, historic efforts that we hope will make tobacco control
come alive. You know better than anyone, Senator, because
you've been such a leader, that the tobacco successes in terms
of reducing dependence has stalled in the last number of years.
And we need to make a difference now, and we want to use this
opportunity to get there.
Again, the Affordable Care Act and the Prevention Fund has
had dedicated funds for tobacco control efforts at the
community level. So have these so-called Community
Transformation Grants. So there are many, many ways we're
trying to tackle this. And this is all an area where there's
overwhelming evidence about what works. This is all evidence-
based, science-driven efforts, and the challenge has been we
have not been able to disseminate it and really make it come
alive. So we hope that this is our opportunity to do so.
Senator Blumenthal. And just so perhaps we have you on
record, what would you say works best in this area?
Dr. Koh. Well, it's a multi-pronged strategy to, obviously,
raise awareness and educate the public, especially young
people; to offer cessation services through quit lines and
other efforts; to promote the use of effective pharmaceutical
interventions when appropriate; raising the price has an effect
on lowering consumption; increasing smoke-free workplaces to
create a new social norm for tobacco. So these are all efforts
to create a healthier, tobacco-free society.
Senator Blumenthal. And in terms of cessation and the quit
line, has it been your experience--I think there's evidence for
it--that the best approach is really combined counseling,
pharmaceutical drug assistance, a sort of multifaceted
approach, rather than just relying on one or another?
Dr. Koh. Absolutely, Senator. We often stress in public
health that there's often not one magic bullet but multiple
ways of addressing problems that work together. And
particularly in tobacco, we need counseling, we need outreach,
we need education, and then creating a new norm, so to predict
the next generation. Those are all elements that work together
in this critical field.
Senator Blumenthal. And that fact applies to Medicaid and
Medicare patients as well as others.
Dr. Koh. Especially to Medicaid patients and Medicare
patients. And you know so well, Senator, that the smoking rates
in Medicaid populations is close to twice what it is in the
general population. So we need special attention there. And if
I can say to both you and the chairman that we have some
evidence in Medicaid interventions at the statewide level that
really improving outreach and cessation can make a difference
in terms of reducing prevalence and then saving money as well.
So that's very promising evidence-based work that can be active
prevention and also save money at the same time.
Senator Blumenthal. Thank you. And thank you for your very
important work in this area.
Dr. Koh. Thank you, Senator.
The Chairman. Dr. Koh, Secretary Koh, thank you very, very
much, unless you had some closing thing that you wanted to say.
Dr. Koh. We can followup with Senator Blumenthal on the
deeming regulation. I have heard it as substantial equivalents.
That's the term that I had in my head. So there are regulations
to deem non-cigarettes as tobacco products so the FDA can
regulate them. And the so-called substantial equivalents effort
that's ongoing--we can get you more information on that.
Senator Blumenthal. Thank you.
The Chairman. Thank you very much.
Dr. Koh. Thank you, Mr. Chairman.
The Chairman. Thanks for being here.
Now we'll move to our second panel. I will introduce them
as they come up to the table. First, we welcome Ms. Nancy
Brown. Ms. Brown is the chief executive officer of the American
Heart Association. As the CEO, Ms. Brown leads the AHA in
continuing their work as the world's largest voluntary health
organization dedicated to preventing, treating, and defeating
cardiovascular diseases and stroke.
We also have Dr. John Seffrin. Dr. Seffrin is the chief
executive officer of the American Cancer Society. Under his
leadership, the society has become the largest health
organization fighting cancer with significant resources to help
develop early detection methods and find cures. Dr. Seffrin
currently serves on the Advisory Group on Prevention, Health
Promotion, and Integrative and Public Health that is
responsible for advising the National Prevention Council on
prevention and health promotion. Those were established by the
Affordable Care Act.
Next we have Mr. John Griffin, Jr., chair of the board of
the American Diabetes Association, the Nation's largest
organization leading the fight to stop diabetes. Mr. Griffin
has a wealth of legal experience in diabetes as he serves on
the board of directors and chairs the Legal Advocacy
Subcommittee for the ADA. He serves on the Texas Diabetes
Council by appointment of the Governor of Texas and is managing
partner of his law firm in Victoria, TX. That's near Beeville,
TX. How would I know about Beeville, TX? I went through flight
training there.
And Dr. Tevi Troy, our final witness, Senior Fellow at the
Hudson Institute. In his capacity, Dr. Troy consults on
healthcare and other domestic economic policy issues. Prior to
his position at Hudson, he served as the Deputy Secretary of
the Department of Health and Human Services from 2007 to 2009,
and also directed the White House Domestic Policy Council under
President George W. Bush.
Thank you for being here today, Dr. Troy.
Again, all of your statements will be made a part of the
record in their entirety. I ask--in order of introduction,
we'll just go from left to right--if you could sum up in 5
minutes or so, we'd appreciate it so we can get into a
dialogue.
Ms. Brown, welcome and please proceed.
STATEMENT OF NANCY BROWN, CHIEF EXECUTIVE OFFICER, AMERICAN
HEART ASSOCIATION, DALLAS, TX
Ms. Brown. Thank you, Mr. Chairman and Senator Roberts. I
want to thank you for this opportunity to discuss the
importance of prevention in the fight against cardiovascular
diseases and stroke.
Cardiovascular diseases are the deadliest and most
prevalent illnesses in our Nation. More than 82 million adults
in the United States have been diagnosed with some form of
cardiovascular disease and someone dies from it every 39
seconds. Along with the enormous physical and emotional toll
cardiovascular disease exacts, it is also America's costliest
illness, accounting for 17 percent of overall health
expenditures.
The direct medical costs of treating cardiovascular
diseases are estimated at $273 billion in 2010, and the annual
indirect costs, including lost productivity, come to $172
billion. All in all, that adds up to $445 billion. The future
looks even worse. We project that by 2030, two out of five
Americans, or 116 million people, or 40 percent of the
population, will have some form of cardiovascular disease. The
associated costs are staggering. Total direct and non-
direct costs are expected to exceed a whopping $1 trillion by
the year 2030.
However, there's hope in what could be characterized as a
sea change in how we view this deadly disease. Despite being
the No. 1 killer of all Americans, research has demonstrated
that cardiovascular disease is largely preventable. A report in
the New England Journal of Medicine found that 67 percent of
the decline in heart disease death rates in the United States
between 1980 and 2000 was due to reductions in cholesterol,
blood pressure, smoking, and physical inactivity. And to the
surprise of many, only about 7 percent was the result of bypass
surgery or angioplasty.
Prevention holds the key to changing the trajectory of
these projections if we're willing to take deliberate and
focused actions to prevent or delay the many forms of
cardiovascular disease. Studies estimate that people who reach
middle age with optimal cardiovascular health have only a 6 to
8 percent chance of developing cardiovascular disease in their
lifetime. And as I sit here today, although 39 percent of all
Americans believe they're in ideal cardiovascular health,
actually fewer than 1 percent are.
To do this, we must reorient our entire national approach
to promote healthy habits and wellness at an early age. We must
reach individuals before they actually become patients,
suffering a heart attack or any other acute cardiovascular
event. We have to get in the game earlier to influence the
final score and make a positive difference in people's lives.
We believe at the American Heart Association that we must
take a two-pronged prevention approach: first, what has been
referred to as primordial prevention and, second, primary
prevention. Both public and private prevention initiatives
present the largest opportunities to make a positive impact on
our Nation's physical and fiscal health, national security, and
workforce productivity. And research demonstrates that some
interventions can have a major impact on improving public
health and saving precious taxpayer dollars.
We have a paper published in circulation in July of this
year that provides the background for some of these statistics
I'm about to give you. For example, research in Massachusetts
showed that comprehensive coverage of tobacco cessation
services in the Medicaid program led to reduced
hospitalizations for heart attacks and a net savings of $10.5
million or a $3.07 return on investment for every dollar spent
in the first 2 years.
Comprehensive smoke-free air laws in public buildings bring
an estimated $10 billion in annual savings for direct and
indirect healthcare costs. And community-based programs to
increase physical activity, improve nutrition, and prevent
smoking show a return on investment of $5.60 for every dollar
spent within 5 years.
So why, then, might you ask, is prevention taking a back
seat to acute care and treatment? There are many complex
reasons for this and environmental barriers to overcome that I
discuss in my written testimony, but one overarching issue I'd
like to focus on. Like all pressing problems facing our Nation
today, there must be a shared responsibility when it comes to
preventing cardiovascular disease. That includes individuals
themselves, our government, and not-for-profit organizations
like the American Heart Association.
First of all, individuals must take more responsibility for
their health through lifestyle changes, such as eating better,
exercising, and not smoking. Unfortunately, we know from our
own research a vast majority of Americans are not in optimal
cardiovascular health, as I mentioned before, although 39
percent of them believe that they are.
Government can help by supporting policies that promote an
environment more conducive to positive health, encourage
healthier lifestyles, and reward businesses, healthcare
providers, and communities that provide quality preventative
care and healthier environments.
And we at the American Heart Association will continue to
promote awareness in the public and medical communities of the
need and importance of prevention. We'll also continue to
support research aimed at identifying new and better ways to
prevent the onset of cardiovascular disease and support
volunteer-led programs throughout the country that put this
knowledge into action. We will engage people as activists in
their own health, and we will continue to implement quality
improvement programs like the American Heart Association's Get
with the Guidelines program which has documented more lives
saved and lower healthcare costs in this country.
Thank you for the opportunity to present this information
today, and at the appropriate time, I'd be happy to answer any
questions.
[The prepared statement of Ms. Brown follows:]
Prepared Statement of Nancy Brown
summary
Mr. Chairman, I want to thank you for this opportunity to discuss
the importance of prevention in the fight against cardiovascular
diseases and stroke. Cardiovascular diseases are the deadliest and most
prevalent illness in our Nation. More than 82 million adults in the
United States have been diagnosed with some form of cardiovascular
disease, and someone dies from it every 39 seconds.
Along with the enormous physical and emotional toll cardiovascular
disease exacts, it is also America's costliest illness, accounting for
17 percent of overall health expenditures. The direct medical costs of
treating cardiovascular disease are estimated at $273 billion in 2010.
The annual indirect costs, which refer to lost productivity, come to
$172 billion. All in all, that adds up to $444 billion.
The future bodes even worse. We project that by 2030 two out of
five Americans--116 million people, or 40 percent of the population--
will have some form of cardiovascular disease. The associated costs are
staggering. Total direct and non-direct costs are expected to exceed a
whopping $1 trillion.
However, there is hope in what could be characterized as a sea
change in how we view this deadly disease. Despite being the No. 1
killer of all Americans, research has demonstrated that cardiovascular
disease is largely preventable. A report in the New England Journal of
Medicine found that 67 percent of the decline in heart disease death
rates in the United States between 1980 and 2000 was due to reductions
in cholesterol, blood pressure, smoking and physical inactivity--and to
the surprise of many--only about 7 percent was the result of bypass
surgery or angioplasty.
Indeed, prevention holds the key to changing the trajectory of
these projections if we are willing to take deliberate and focused
actions to prevent or delay the many forms of cardiovascular disease.
Studies estimate that people who reach middle age with optimal
cardiovascular health have only a 6 to 8 percent chance of developing
cardiovascular disease in their lifetime.
But to do so we must reorient our entire national approach to
promote healthy habits and wellness at an early age. We must reach
individuals before they actually become ``patients'' suffering a heart
attack or any other acute cardiovascular event. Let me put it a
different way. We have to get into the game earlier to influence the
final score and make a positive difference in people's lives.
We must take a two-pronged prevention approach. First, what has
been referred to as ``primordial'' prevention, which prevents the
development of risk factors.
Second is ``primary'' prevention which consists of interventions to
reduce worrisome risk factors like high blood pressure or high
cholesterol once they're present, with the goal of preventing an
initial acute event.
Both public and private prevention initiatives present the largest
opportunities to make a positive impact on our Nation's physical and
fiscal health, national security, and workforce productivity. And
research demonstrates that some interventions can have a major impact
on improving public health and saving precious taxpayer dollars. For
example:
Research in Massachusetts showed that comprehensive
coverage of tobacco cessation services in the Medicaid program led to
reduced hospitalizations for heart attacks and a net savings of $10.5
million or a $3.07 return on investment for every dollar spent in the
first 2 years.
Comprehensive smoke-free air laws in public buildings
bring an estimated $10 billion in annual savings for direct and
indirect healthcare costs.
Community-based programs to increase physical activity
improve nutrition and prevent smoking use show a return on investment
of $5.60 for every dollar spent within 5 years.
So why is prevention taking a back seat to acute care and
treatment? There are many complex reasons and environmental barriers to
overcome that I discuss in my written testimony. But let me focus on
the overarching issue.
Like all of the pressing problems confronting our Nation today,
there must be a shared responsibility when it comes to preventing
cardiovascular disease. That includes individuals, government, and non-
profits, such as the American Heart Association.
Individuals must take more responsibility for their health through
lifestyle changes, such as eating better, exercising, and not smoking.
Unfortunately we know from our own research that a vast majority of
Americans are not in optimal cardiovascular health--although nearly 40
percent believe that they are.
Government can help by supporting policies that promote an
environment more conducive to positive health, encourage healthier
lifestyles and reward businesses, health care providers, and
communities that provide quality preventative care and healthy
environments.
And we at the American Heart Association will continue to promote
awareness in both the public and medical communities of the need and
importance of prevention. We will also continue to support research
aimed at identifying new and better ways to prevent the onset of
cardiovascular disease and support volunteer-run programs throughout
the country that put this knowledge into practice. Our organization has
embraced an ambitious 2020 goal to improve the cardiovascular health of
all Americans and reduce deaths from cardiovascular diseases and stroke
by 20 percent.
But we can't do this alone--the problem is too large for any one
group to accomplish. The only way we can solve this problem is by
working together and we look forward to that opportunity.
I would be happy to answer any questions.
______
introduction
Chairman Harkin, Ranking Member Enzi and members of the committee,
I want to thank you for this opportunity to present the American Heart
Association's research and views on the importance of prevention in the
fight against cardiovascular diseases and stroke. Cardiovascular
disease (CVD) is the deadliest and most prevalent illness in our
Nation. More than 82 million adults in the United States have been
diagnosed with some form of cardiovascular disease, and someone dies
from it every 39 seconds.
Along with the enormous physical and emotional toll cardiovascular
disease exacts, it is also America's costliest illness, accounting for
17 percent of overall health expenditures. According to a recent
American Heart Association article/policy statement, ``Value of
Primordial and Primary Prevention for Cardiovascular Disease''
published in our journal Circulation (http://circ.ahajournals.org/
content/124/8/967.full.pdf+html?sid=2ea4c775-5912-4cf8-8c42-
13ab84042e2f ), the direct medical costs of treating cardiovascular
disease are estimated at $273 billion in 2010. The annual indirect
costs, which refer to lost productivity, come to $172 billion. All in
all, that adds up to $445 billion.
The future bodes even worse. We project that by 2030 two out of
five Americans--116 million people, or 40 percent of the population--
will have some form of cardiovascular disease. The associated costs are
staggering. Total direct and non-direct costs are expected to exceed a
whopping $1 trillion making this a critical medical and societal issue.
a sea change
However, there is hope in what could be characterized as a sea
change in how we view this deadly disease. Despite being the No. 1
killer of all Americans, research has demonstrated that cardiovascular
disease is largely preventable.
Indeed, we can change the trajectory of these frightening
projections if we as a nation are willing to take deliberate and
focused actions to prevent or delay the many forms of cardiovascular
disease. The facts speak for themselves and let me cite some of the
more prominent ones.
Studies estimate that people who reach middle age with optimal risk
levels have only a 6 to 8 percent chance of developing cardiovascular
disease in their lifetime.
It is estimated that if all Americans had access to recommended CVD
prevention activities, myocardial infarctions and strokes would be
reduced by 63 percent and 31 percent respectively in the next 30 years.
Men and women who lower their risk factors may have 79-82 percent
fewer heart attacks and strokes than those who do not reduce their risk
factors.
A recent review by the U.S. Preventive Services Task Force showed
that counseling to improve diet or increase physical activity changed
health behaviors and was associated with small improvements in weight,
blood pressure, and cholesterol levels.
And this is perhaps the most telling statistic of all.
Approximately 67 percent of the decline in U.S. age-adjusted coronary
heart disease death rates from 1980-2000 can be attributed to
improvements in risk factors including reductions in total blood
cholesterol, systolic blood pressure, smoking prevalence, and physical
inactivity--only about 7 percent was the result of bypass surgery or
angioplasty. However, these reductions were partially offset by
increases in the prevalence of obesity. It is much more difficult and
costly to reverse obesity and diabetes once they occur than to prevent
them from developing in the first place.
setting the stage for transformation
We as a nation must reorient our entire approach to promote healthy
habits and wellness at an early age. We must transform the current
healthcare delivery system that focuses on ``sick care'' to one that
better incorporates, coordinates, values and financially rewards
quality and prevention.
We must reach individuals before they actually become ``patients''
suffering a heart attack or any other acute cardiovascular event. Let
me put it a different way. We have to get into the game earlier to
influence the final score and make a positive difference in people's
lives.
We must take a two-pronged prevention approach. First is
``primordial'' prevention, which prevents the development of risk
factors.
Second is ``primary'' prevention which consists of interventions to
modify adverse risk factors once they're present, with the goal of
preventing an initial acute event.
To this end, the American Heart Association created ``Life's Simple
7'', which are seven key modifiable health factors and behaviors that
we believe are essential for successful prevention of cardiovascular
disease. They include regular physical activity, a heart healthy diet,
no smoking, weight management and control of blood pressure,
cholesterol and blood sugar. These are literally lessons for life.
a solid return on investment
These and other public and private prevention initiatives present
the best opportunities to make a positive impact on our Nation's
physical and fiscal health. In a time of tight budgets and limited
resources when the Administration and Congress are looking for a solid
return on investments, prevention is a proven winner.
Research already demonstrates that environment and policy change
can have a major impact on improving public health and saving precious
taxpayer dollars. For example, research in Massachusetts showed that
comprehensive coverage of tobacco cessation services in the Medicaid
program led to reduced hospitalizations for heart attacks and a net
savings of $10.5 million or a $3.07 return on investment for every
dollar spent in the first 2 years.
Community-based programs to increase physical activity, improve
nutrition, and prevent smoking and other tobacco use can show a return
on investment of $5.60 for every dollar spent within 5 years.
Moreover, comprehensive worksite wellness programs can lower
medical costs by approximately $3.27 and absenteeism costs by about
$2.73 in the first 12 to 18 months for every dollar spent.
And speaking of getting into the game earlier, robust school-based
initiatives to promote healthy eating and physical activity have shown
a cost effectiveness of $900-$4,305 per quality-of-life-year saved.
million hearts initiative
One other reason to be optimistic about the potential for a
heightened focus on prevention is the Department of Health and Human
Services' recently announced Million Hearts Initiative (Million
Hearts).
This new initiative will focus, coordinate, and enhance CVD
prevention in programs and activities across all HHS agencies with the
aggressive goal of preventing 1 million heart attacks and strokes over
the next 5 years (by 2016).
By pledging to partner with and work alongside healthcare
providers, nonprofit organizations, and the private sector, Million
Hearts represents an unprecedented commitment on the part of Secretary
Sebelius and the HHS to make preventing heart attacks and stroke a top
national health priority.
The American Heart Association not only applauds the launch of
Million Hearts but also is grateful for the opportunities we have been
provided to help inform, shape, and support the initiative. We look
forward to joining and partnering with Secretary Sebelius and the HHS
in implementing this initiative, which has the potential to advance the
mission and work of the American Heart Association dramatically and to
help us achieve our ambitious ``Impact Goal'' to improve the
cardiovascular health of all Americans and reduce deaths from
cardiovascular diseases and stroke by 20 percent by 2020.
Million Hearts represents a bold opportunity to bring CVD
prevention to the forefront of Federal healthcare policy. As the
leading voluntary health organization in the field of CVD, the American
Heart Association is committed to this initiative and welcomes an
opportunity to take a leadership role in its implementation.
In addition to working to help inform and shape the Million Hearts
initiative, the American Heart Association is prepared to partner with
the Centers for Disease Control and Prevention and other HHS agencies
on various activities, and is also committed to working with HHS to
hold ourselves collectively accountable for achieving its goals. This
includes evaluating and publicly reporting progress toward reducing 1
million heart attacks and strokes over the next 5 years. The Guideline
Advantage program--a jointly directed quality improvement program from
the American Cancer Society, the American Diabetes Association and the
American Heart Association--may help contribute to these surveillance
efforts. This program works with practices' existing EHR or health
technology platform to extract relevant patient data and quarterly
reports, and benchmarking on adherence to guidelines.
In addition to improving CVD prevention in the next 5 years,
Million Hearts aims to use the prevention of CVD as a model for how
health reform can work to make a dramatic, immediate, and sustainable
impact on the healthcare system to save lives and to prevent chronic
disease. The lessons learned from Million Hearts will inform
complementary implementation efforts addressing other chronic
conditions.
the state of prevention today
We are starting to place a greater emphasis on prevention. However,
we still have a long way to go to ``walk the talk'' as access to and
use of preventive services remain stubbornly low.
Indeed, let me share with the committee some very informative and
alarming statistics about CVD preventable risk factors and where we
stand today. They are clearly a call to greater action; millions of
lives are at risk.
There are tremendous gaps in clinical prevention: only 47 percent
of patients at increased risk of CVD are prescribed aspirin; one in
three Americans have high blood pressure, however, only 46 percent of
them have it adequately controlled; only 33 percent of people with high
cholesterol have adequately controlled low-density lipoprotein
cholesterol; and just 26 percent of those who want to quit smoking
receive adequate support services.
In addition, effective community prevention interventions, such as
eliminating exposure to secondhand smoke and decreasing sodium and
trans fat intake in the population, have been underused because of a
lack of a coordinated national effort to make these population
interventions available to reduce CVD.
Only 18 percent of U.S. adults follow three important measures
recommended by the American Heart Association for optimal health: not
smoking, maintaining a healthy body weight, and exercising at moderate-
vigorous intensity for at least 30 minutes, 5 days per week.
In 2009, adult obesity rates rose in 28 States and in more than
two-thirds of States, more than 25 percent of all adults are obese.
The number of overweight pre-schoolers jumped 36 percent since
1999-2000. Nearly 1 of every 6 children and adolescents ages 2-19 are
considered obese. Sadly, one study has shown that obese children's
arteries resemble those of a middle-aged adult.
The percentage of high school students who smoke decreased over 34
percent from 1999 to 2009. Still, over 3,800 children under 18 try a
cigarette for the first time each day. An estimated 6.4 million of them
can be expected to die prematurely as a result.
A sedentary lifestyle contributes to coronary heart disease.
However, moderate-intensity physical activity, such as brisk walking,
is associated with a substantial reduction in chronic disease. It is
estimated that $5.6 billion in heart disease costs could be saved if 10
percent of Americans began a regular walking program. Still, 33 percent
of U.S. adults report that they do not do any vigorous physical
activity.
At least 65 percent of people with Type 2 diabetes die from some
form of heart disease or stroke. Unfortunately, diabetes prevalence
increased 90 percent from 1995-1997 to 2005-2007 in the 33 States that
tracked data for both time periods.
About 25.4 million American adults have diagnosed or undiagnosed
diabetes and the prevalence of pre-diabetes in the adult population is
nearly 37 percent. Diabetes disproportionately affects Hispanics,
blacks, Native Americans and Alaskan Natives.
Approximately 44 percent of U.S. adults have unhealthy total
cholesterol levels of 200 mg/dL or higher. A 10-percent decrease in
total blood cholesterol levels population-wide may result in an
estimated 30 percent reduction in the incidence of CHD. Unfortunately,
fewer than half of the people who qualify for cholesterol lowering
treatment are receiving it.
If these statistics were not troubling enough, according to a new
Commonwealth Fund-supported study in the journal Health Policy, the
United States ranks last among 16 high-income industrialized Nations
when it comes to deaths that could potentially have been prevented with
timely access to effective health care. That is not a distinction we
should be proud of as a nation.
what we have learned so far
Although we are still in the early stages of the transformation
from ``sick care'' to preventive care, we have already learned some
valuable lessons that can help guide our future individual and
collective efforts.
Policy change makes the greatest impact when it optimizes the
environments where people live, learn, work and play--offices, schools,
homes, and communities, making healthier behaviors and healthier
choices the norm by default or by design, putting individual behavior
in the context of multiple-level influences.
Research continues to demonstrate that environment and policy
change have some of the greatest impact in improving public health,
providing the counter argument to those policymakers who argue that
government has no role, that health is determined solely by individual
responsibility.
Although there may not be significant cost-savings in the short-
term to society there is value in making an important investment in the
long-term health of our Nation.
The medical and research communities are challenged to further
clarify the effectiveness and sustainability of cost-effective
preventive cardiovascular services so that proven interventions can be
provided in home-, work-, school- and community-based settings to save
lives, money, and resources.
Finally, legislators, public health and planning professionals and
community representatives can help to facilitate this objective by
empowering localities to embrace a culture of lifestyle that
incorporates physical activity, healthy nutrition options, smoking
bans, and affordable access to health care for all Americans.
what is holding us back?
All of these findings and lessons learned beg the questions, ``Why
is prevention taking a back seat to acute care and treatment? Why
aren't more efforts and dollars being spent on prevention? '' The
answers are not easy and there are many barriers to overcome to get to
the solutions.
First, prevention is a long-term commitment; policymakers are
generally focused on a much shorter timeframe with tangible benefits
delivered in the near term.
Second, as a Nation, we have made a significant investment in acute
care and treatment which is much more impressive than prevention
efforts. Treatments like open heart surgery have the ``wow'' factor
that prevention lacks.
Third, the line of sight between preventive actions and results is
significantly longer and harder to reinforce. If a patient is admitted
with chest pains, a diagnosis is made and appropriate treatment is
started--usually that same day.
However, if someone who is overweight sees their doctor and loses
weight, the positive results of that weight loss may not be evident for
months, years or even decades later and may exhibit in less ``obvious''
ways such as reduced absenteeism from work.
And finally, prevention's attribute as a cost-saver has created the
unintended situation where it is necessary to justify spending
resources to prevent disease when we do not have to justify funding
focused on treating conditions that could have been prevented.
For these reasons, and others, prevention is ironically still an
afterthought to acute care and treatment. This is all backwards because
if you look at what's moving the needle and improving health, it is
prevention efforts.
Indeed, the only way to truly reduce healthcare costs in this
country is to have a healthier American population which will only come
if we can improve the health and health status through prevention.
There are certainly many other complex reasons and environmental
hurdles to overcome in the transformation to preventive healthcare and
ultimately a healthier and more productive society, but let me focus on
the overarching issue.
Like all of the pressing problems confronting our Nation today,
there must be a shared responsibility when it comes to preventing
cardiovascular disease. That includes individuals, government, and non-
profits, such as the American Heart Association, the American Diabetes
Association, and the American Cancer Society.
Individuals must take responsibility for their health through
lifestyle changes, such as eating better, exercising, and not smoking.
Government can help provide the tools to help them meet these goals,
such as incentives for businesses to create healthy work environments
and funding to test for risk factors.
And we at the American Heart Association will continue our role to
promote awareness in both the public and medical communities of the
need and importance of prevention. We will also continue to support
research aimed at identifying new and better ways to prevent the onset
of cardiovascular disease and support volunteer-run programs throughout
the country that put this knowledge into practice. In other words, we
are all in this together and the only way we can solve this problem is
by working together.
I would be happy to answer any questions.
The Chairman. Thank you, Ms. Brown.
Dr. Seffrin, welcome back to the committee. You've been
here before.
Mr. Seffrin. I have, Senator Harkin. Thank you. And by the
way, on behalf of the American Cancer Society--as part of the
record--you've been officially forgiven for taking Dan Smith
away from us.
[Laughter.]
The Chairman. And don't come trying to get him back,
either.
STATEMENT OF JOHN R. SEFFRIN, Ph.D., CHIEF EXECUTIVE OFFICER,
AMERICAN CANCER SOCIETY, ATLANTA, GA
Mr. Seffrin. Senator Harkin and Senator Roberts, I want to
summarize my formal written testimony in just a few words of
saying what do we know, what do we know for sure, and what do
we know works? And what we know is that the No. 1 health,
disease, and disability challenge of the 21st Century for
America will be non-communicable diseases, chronic disease--not
second, not third, No. 1. We know that to be the case.
We are faced with a virtual tsunami of chronic disease if
we don't intervene. If we knew when the next real tsunami would
hit, and we knew what to do about it and didn't do anything, I
would suggest we'd passed up a moral imperative to act. So when
it comes to non-communicable diseases, like cancer and heart
disease and diabetes and others, if we're really serious about
reducing human suffering and premature death from cancer and
other NCDs and, over time, reducing overall healthcare costs,
we have to understand four things.
No. 1, prevention is the best policy. No. 2, prevention is
the best buy. No. 3, prevention is the best cure. And No. 4,
prevention is best for the economy of America and, indeed, the
world. A word or two about each of those.
First, Prevention is the best policy because it works.
Prevention works as Dr. Koh said it works. We are saving 350
more lives each and every day from cancer today than we were in
1991 when Dan came to work for us--350 per day more than we
were saving then. The lion's share of that is from effective
prevention interventions--people either not starting to smoke
or being able to quit or get the proper screening they need.
Second, prevention is the best buy. We now have good
documentation that the prevention efforts that work, the
interventions that work to forestall or to prevent chronic
disease can be implemented from $1 to $3 per person per year--
not a bad buy, it would seem to me.
Third, prevention is the best cure. One of the things a lot
of people don't realize is that of the 1.4 million Americans
who were diagnosed with cancer this year, 60 percent of them
could have been prevented with what we already know to do
today. A third would disappear almost overnight if we just got
rid of tobacco.
Fourth, prevention is the best for the economy. To give you
some sense of the proportionality, the global cost of cancer is
$895 billion per year, three times as much as HIV/AIDS and
tuberculosis and malaria combined. And yet, interestingly,
cancer isn't on the G-8 health agenda, the G-20 health agenda,
and so forth.
Or let me explain it a different way. If we choose not to
intervene, globally, in the next 20 years, we will have lost
economic output of $47 trillion globally--lost economic--I'm
not talking about the healthcare cost of treating sick people
or disabled. I'm talking about the economic lost productivity--
$47 trillion. That's more money than I can conceptualize, so
I'll put it this way. That's 75 percent of the global GDP in
2010. Or put still another way, it's enough money to eliminate
$2 a day poverty to the 2.5 billion inhabitants of planet earth
that are on $2 a day poverty for a century.
So let me just sum up by saying I think it's extremely
important for Americans to better understand, but especially
policymakers to understand that unless we make prevention the
centerpiece of our healthcare system, we're going to miss an
opportunity to become the healthiest Nation. Prevention is the
best cure.
[The prepared statement of Dr. Seffrin follows:]
Prepared Statement of John R. Seffrin, Ph.D.
summary
We are facing a tsunami of chronic disease in this century. Cancer
and other non-communicable diseases (NCDs) represent a new frontier in
the fight to improve our Nation's health. While we have made great
strides over the past two decades in reducing the rate of death from
cancer, we are in danger of falling behind previous generations.
Although we have cut in half the percentage of regular tobacco users,
20 percent of the population still smokes, and the rate of childhood
obesity due to bad diet and lack of physical activity has reached
epidemic proportions. For the first time in our Nation's history our
children could on average live shorter lives than their parents.
We know that half of cancer deaths are preventable. Much of the
suffering and death from cancer that occurs today, and the substantial
cost we incur of treating advanced disease, could be reduced through
evidence-based prevention. That means more systematic efforts to reduce
tobacco use, improve diet and physical activity, reduce obesity,
develop and deliver preventive vaccines, and expand the use of
established early detection screening tests.
It is important to note that throughout history prevention has been
the key to bringing known diseases under control. It has been
prevention in the public health sphere that has virtually eliminated
epidemics of plague, cholera, yellow fever, measles and polio from our
shores. This is what we need to do to prevent the next epidemic of
cancer, heart disease and diabetes. We must go on the attack against
childhood obesity and tobacco use and other causes of these diseases
now or we will be overwhelmed by the cost of treating them later.
Spending on prevention, particularly in the area of cancer, is an
important down payment to improve the health of our communities and
families. But we still need to do more.
Today, we know more about cancer than ever before, but while we
continue to make important progress, we have not yet realized the true
potential we already have to save lives and reduce suffering from this
terrible disease. The simple truth is that while more Americans were
saved from cancer last year than ever before, it is also true that
millions of Americans still suffer and die from cancer. It doesn't have
to be this way.
We don't need a magic bullet to control cancer, what we need is the
will and courage to do the right things. If we do, we can and will
significantly hasten the day when cancer is no longer a significant
public health threat in America and around the world.
______
Good afternoon, Mr. Chairman, Senator Enzi, and distinguished
members of the committee. Thank you for the opportunity to testify
today about the importance of prevention. I am Dr. John Seffrin, chief
executive officer of the American Cancer Society (the Society) and the
American Cancer Society Cancer Action Network (ACS CAN). On behalf of
the millions of cancer patients and survivors in America today, I want
to thank you for holding this hearing and for your continued leadership
in the fight against cancer.
the burden of cancer in america and worldwide
Cancer and other non-communicable diseases (NCDs) represent a new
frontier in the fight to improve global health. Because of rising
incidence rates worldwide, NCDs are now responsible for more deaths
than all other causes combined. In 2008, 36 million people died from
NCDs, representing 63 percent of the 57 million global deaths that
year. By 2030, deaths from NCDs are projected to grow to 52 million
people each year.\1\ This epidemic is fueled by a combination of
growing risk factors, including continued tobacco use, unhealthy diets,
and insufficient physical activity. NCDs pose obvious harm to families
and communities as individuals get sick and die but they are also an
increasing drag on the U.S. economy and on economies worldwide. Recent
research from Harvard University suggests a cumulative economic output
loss of $47 trillion over the next two decades from cardiovascular
disease, chronic respiratory disease, cancer, diabetes and untreated
mental health illnesses.\1\
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\1\ The Global Economic Burden of Non-communicable Diseases.
Prepared by the World Economic Forum and the Harvard School of Public
Health (2011).
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In the United States this year, cancer is projected to drain nearly
$21 billion from the economy due to lost productivity, cause an
additional $102 billion in direct medical costs and create another $140
billion in losses as a result of premature death.\2\ While we have made
great strides over the past two decades in reducing the rate of death
from cancer, we are in danger of falling behind previous generations.
Although we have cut in half the percentage of regular tobacco users,
20 percent of the population still smokes,\3\ and the rate of childhood
obesity due to bad diet and lack of physical activity has reached epic
proportions. For the first time in our Nation's history, our children
could live shorter lives on average than their parents. I urge you, as
our Nation's leaders, not to let that happen.
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\2\ American Cancer Society. Cancer Facts and Figures 2011.
Atlanta: American Cancer Society, 2011.
\3\ American Cancer Society. Cancer Prevention and Early Detection
Facts and Figures 2011. Atlanta: American Cancer Society, 2011.
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Every day, nearly 4,000 young people try their first cigarette and
approximately 900 become addicted daily smokers. The percentage of
children aged 6 to 11 years old in the United States who were obese
increased from 7 percent in 1980 to nearly 20 percent in 2008.
Similarly, the percentage of adolescents aged 12 to 19 years old who
were obese increased from 5 percent to 18 percent over the same period.
Obese children and adolescents are likely to be obese as adults and are
therefore more at risk for adult health problems such as heart disease,
type 2 diabetes, stroke, cancer and osteoarthritis. Furthermore,
inadequate access to preventive care and primary health care in
minority and low-income populations continues to result in disparities
in health outcomes, and the unfortunate result of that will continue to
intensify as our country becomes more diverse over time.
As a Nation, we spent more than $2.5 trillion for health care in
2009. We spent far more than other countries in the developed world,
yet we delivered a quality of care that ranked below them in life
expectancy, infant mortality, and other key indicators. The number of
seniors aged 65 and older is projected to increase to 18.5 percent of
the total population by 2025, a factor that will help drive health care
spending from 16 percent of GDP in 2007 to 25 percent of GDP in 2025,
and potentially to 37 percent in 2050.\4\ Despite the advances we have
made in successfully discovering and treating cancer, the actual number
of cancer deaths will increase in the coming years because of the
significant growth of the elderly population. In the absence of urgent
action, the rising financial and economic costs of chronic disease will
reach levels that are beyond our capacity to deal with them.
---------------------------------------------------------------------------
\4\ Congressional Budget Office. The Long Term Budget Outlook
(June 2010).
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prevention is the real cure
So what is the answer? How do we as a nation deliver high-quality
care to an aging population at a cost we can afford? Certainly, a large
part of the answer is through prevention. We know that 50 percent of
cancer deaths in America today are preventable. Much of the suffering
and death from cancer that occurs today, along with the substantial
cost we incur of treating advanced disease, could be reduced through
evidence-based prevention. That means more systematic efforts to reduce
tobacco use, improve diet and physical activity, reduce obesity,
develop and deliver preventive vaccines, and expand the use of
established early detection screening tests. Proper utilization of
established screening tests and cancer vaccines can prevent the
development of certain cancers and premalignant abnormalities.
Screening tests can also improve survival and decrease mortality by
detecting cancer at an early stage when treatment is more effective.
Throughout history, prevention has been the key to bringing known
diseases under control. Prevention in the public health sphere has
virtually eliminated epidemics of plague, cholera, yellow fever,
measles and polio from our shores. Clean water, mosquito and rodent
eradication, and the development of oral and intravenous vaccines--
these are all preventive measures. We are able to keep our communities
safe through conscious action to prevent diseases from occurring.
This is what we need to do to prevent the next epidemic of cancer,
heart disease and diabetes. We must go on the attack now against
childhood obesity, tobacco use and other causes of these diseases, or
we will be overwhelmed by the cost of treating them later. Today we
spend just 3 to 4 percent of our health care dollars on prevention.\5\
That's not enough.
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\5\ Woolf, SH. The Power of Prevention and What It Requires. JAMA.
2008;299(20):2437-2439.
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investing in strategies that work
A large portion of NCDs are attributable to modifiable risk
factors--things we can do something about, such as tobacco use, diet
and exercise, and compliance with proven early detection
recommendations. So, while we don't expect these diseases to disappear
entirely in the near term, here at home and around the world we have
opportunities to substantially reduce the risk of these diseases and
catch them at an earlier more treatable stage simply by encouraging
people to act on what we already know and what is proven to work. This
would bring down costs for medical care, lost productivity, and other
associated costs.
For example, communities with comprehensive tobacco control
programs that include cessation services for a wide scope of their
population experience faster declines in cigarette sales, smoking
prevalence, lung cancer incidence and mortality than States that do not
invest in these programs. Tobacco quitlines can increase cessation
success by more than 50 percent. In the United States, quitlines reach
only about 1 percent of the country's 46 million adult smokers each
year.\6\ Researchers estimate that with adequate funding and
promotional activities, quitlines could reach 16 percent of smokers
annually.\7\ This could increase the number of tobacco users receiving
relatively inexpensive cessation assistance services to 7.1 million
smokers per year.\7\
---------------------------------------------------------------------------
\6\ SE Cummins, L Bailey, S Campbell, C Koon-Kirby, SH Zhu. (2007).
Tobacco Cessation Quitlines in North America: A Descriptive Study.
Tobacco Control;16 (Suppl I):i9-i15.
\7\ North American Quitline Consortium. (2009). Tobacco Cessation
Quitlines: A Good Investment to Save Lives, Decrease Direct Medical
Costs and Increase Productivity. Phoenix, AZ: North American Quitline
Consortium.
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Screening for breast, cervical and colorectal cancers enables
doctors to catch these diseases in their early stages, and even to
prevent them entirely in the case of colon cancer. Unfortunately,
screening rates are far below optimum levels nationwide, resulting in
higher costs and worse health outcomes. Colorectal cancer screenings in
the United States remain low, with only about half of the population
aged 50 and older receiving their recommended tests. Consequently,
colorectal cancer takes a significant toll on the Medicare population,
both in terms of lives affected and staggering treatment costs. Of the
140,000 people diagnosed with colorectal cancer in 2011, nearly two-
thirds were within the Medicare population. In addition, with the
introduction of biologics, oncolytics and other targeted therapies,
Medicare faces ever increasing costs to treat advanced colorectal
cancer with state-of-the-art therapy.
By increasing colorectal cancer screening rates in the population
aged 50 to 64, we would reduce suffering, save lives, and reduce cancer
costs in Medicare. A recent study by the American Cancer Society found
that increasing colorectal screening rates in the pre-Medicare
population could reduce subsequent Medicare treatment costs by $15
billion over 11 years.\8\ The earlier and sooner regular screening
begins, the larger the benefit to Medicare in terms of cancer treatment
costs avoided. Investing in screening is a wise use of limited health
dollars.
---------------------------------------------------------------------------
\8\ National Colorectal Cancer Roundtable. Increasing Colorectal
Cancer Screening--Saving Lives and Saving Dollars: Screening 50 to 64
year olds Reduces Cancer Costs to Medicare. September 2007.
---------------------------------------------------------------------------
Mammogram screening provided under the National Breast and Cervical
Cancer Early Detection Program has detected 52,000 breast cancers over
the past 20 years and saved countless lives. Last week I had the honor
of attending an event a few blocks away at the Capital Breast Care
Center celebrating both National Breast Cancer Awareness Month and the
10 millionth cancer screening administered under the program. These are
the kinds of things we are doing now, but we could be doing so much
more.
now is the time
We must elevate prevention into standard practice and policy
nationwide, and I believe we have begun to do that with passage of
health reform legislation in 2010. Some people suggest that patients
must have ``skin in the game'' in the form of out-of-pocket costs to
prevent them from overusing health care services. But we know from the
evidence that co-pays, deductibles and other out-of-pocket costs
actually deter people from seeking preventive care.\9\ Patient cost-
sharing for preventive services is penny-wise and pound-foolish. This
is especially true for those with lower incomes because even a small
copay has been shown to discourage getting a simple prevention
service.\9\
---------------------------------------------------------------------------
\9\ Trivedi AN, Rakowski W, Ayanian JZ. Effect of cost sharing on
screening mammography in Medicare health plans. N Engl J Med
2008;358:375-83.
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I have the honor of serving on the national Advisory Group on
Prevention, Health Promotion, and Integrative and Public Health, which
is charged with providing recommendations on how best to integrate the
prevention efforts of the Federal Government and coordinate all
prevention and wellness services nationwide. The advisory board helped
to develop the first ever National Prevention Strategy to ensure that
health and prevention are part of all of our policies and health
programs. This comprehensive cross-sector strategy will help us achieve
a healthier nation. And I believe the Prevention and Public Health Fund
is an important down payment on prevention and wellness. I asked my
staff to compile a few examples of how the Prevention and Public Health
Fund is helping to reduce cancer risk factors and save lives, and I'll
illustrate a few of them here.
In West Virginia, the Department of Health was awarded $1 million
in fiscal year 2010 to help improve wellness and prevention efforts.
The grant will help combat obesity by evaluating changes in community-
level variables (such as changes in cafeteria foods), and the impact on
body mass index and related biometric measures. Through this project we
will begin to identify effective strategies that can be employed at the
community level, which is where it counts.
In another project in Wyoming, $127,000 was allocated over 2 years
from the fund to enhance tobacco cessation quitlines. This is a
solution to smoking addiction that we know from the evidence works and
simply needs to be adequately resourced. I assure you that fewer people
in Wyoming will smoke as a result of this investment of tax dollars.
Just last month, the Department of Health and Human Services
awarded more than $103 million through its Community Transformation
Grants program. Sixty-one private and public organizations in 36 States
and one territory will receive funding to promote healthy living and
prevention locally over the next 5 years, reaching 120 million
Americans. In Washington State, $3.3 million will be used to address
five strategic objectives: tobacco-free living; active and healthy
eating; high impact evidence-based clinical and other preventive
services, specifically prevention and control of high blood pressure;
social and emotional wellness; and healthy and safe physical
environments. The Maine Department of Health and Human Services
received a $1.3 million implementation award to build on existing
initiatives like a tobacco helpline and physical activity program for
elementary school children, who as we know are otherwise experiencing
fewer hours of physical activity in school every year.
conclusion
Today, we know more about cancer than ever before, but while we
continue to make important progress, we have not yet realized the true
potential we already have to save lives and reduce suffering from this
terrible disease. The simple truth is that while more Americans were
saved from cancer last year than ever before, it is also true that
millions of Americans still suffer and die from cancer. It doesn't have
to be this way.
We don't need a magic bullet to control cancer, what we need is the
will and courage to do the right things. If we do, we can and will
significantly hasten the day when cancer is no longer a significant
public health threat in America and around the world.
The Chairman. Thank you very much, Dr. Seffrin, for that
very forceful and poignant testimony.
Mr. Griffin, please proceed.
STATEMENT OF JOHN GRIFFIN, JR., J.D., CHAIRMAN, AMERICAN
DIABETES ASSOCIATION, VICTORIA, TX
Mr. Griffin. Thank you, Chairman Harkin, Senator Roberts.
It's my privilege, and thank you for allowing me to testify on
behalf of the American Diabetes Association and the 105 million
Americans with diabetes and pre-diabetes.
Every 17 seconds, a child or an adult is told in this
country, ``You have diabetes.'' If current trends continue, we
know that one in three children will develop diabetes in their
lifetime, and in minority communities where I come from, one in
two children will have diabetes in their lifetime.
It is an economic tsunami for our country--diabetes. The
complications are severe. Today, 328 Americans will have an
amputation. Another 120 will enter end stage kidney problems,
dialysis problems. Another 48 will be blind, all because of
diabetes. Diabetes also takes a vengeance on our wallets. The
monetary cost of diabetes was almost $220 billion a year in
2007.
Consider this: one in five healthcare dollars in this
country and one in three Medicare dollars in this country are
associated with diabetes. We know these costs will overwhelm
our healthcare system if we don't intervene with prevention. We
can do it. For too long, we've acted only when full blown
diabetes is present, or act for an amputation or kidney
dialysis or eye surgeries instead of preventing.
While we applaud the great prevention work being done at
HHS and at the Division of Diabetes Translation, the Federal
investment at this point is too small. Among the many facets of
the Affordable Care Act is its focus on prevention and its
creation of the Prevention and Public Health Fund. We know Type
2 diabetes is preventable, and the best evidence of this is
those who live free of diabetes because we prevented it.
Taylor David of the Klamath tribe in Oregon knows
prevention works. She had pre-diabetes, but, luckily, the
Klamath Diabetes Prevention Program helped her lose more than
38 pounds. She no longer has pre-diabetes. She runs 5Ks now,
because she was one of 36 clinical demonstration projects for
Native Americans based upon a successful clinical trial at NIH.
The proof is there.
The clinical trial found that intervention resulted in
weight loss, resulted in more exercise, and caused those to
delay--a 58 percent delay in diabetes and prevent diabetes in
its participants. Seventy-one percent of seniors reduced their
risk for diabetes. Follow up studies show that this
intervention can be replicated in community environments for
less than $300 a participant, and compare that to an amputation
or eye surgery.
The reality is that we can save $190 billion over 10 years
if we scale these to a national level. This is not complicated
math. Congress actually had this success in mind when it
authored the National Diabetes Prevention Program. Thanks to
Senator Franken and Senator Lugar for being a leader on this.
Recently, the Appropriations Committee proposed funding the
program through the Prevention and Public Health Fund.
This represents the best comprehensive national effort to
invest in prevention and rein in healthcare costs. The NDPP is
the prime example of results we've proven we can get. This is
exactly how we should be using taxpayers' resources. We asked
scientists to develop a program to prevent diabetes and avoid
complications, and they did it. And then they road tested it,
and it delayed half the cases of diabetes. These are otherwise
people who will be in the circle of diabetes who will
ultimately get complications and be a drag on our healthcare
dollars.
Then we asked healthcare experts: Can we do this in our
communities and cut the costs? And you know what? They did it.
Y's are doing it. In the face of this tsunami of exploding
diabetes, we found something that actually works and keeps
people away from diabetes. We cannot cut the Prevention and
Public Health Fund. We simply can't afford not to stop
diabetes.
It's not only the ADA and others working on this. As you
mentioned, United Healthcare is working on this. They figured
it out--a private health insurer. They're saving money by doing
proven--clinically proven prevention programs. It was the
partnership like that with United Health and the Y that
Margaret Hutchinson of Mound, MN, managed to stop diabetes in
its tracks.
Margaret had an elevated blood glucose. She was in the zone
of danger for diabetes. She got a note that said she was in the
danger zone. She got into a Y program--allowed her to lose 13
percent of her body weight, and now she is diabetes-free.
However, these programs are not everywhere. They're proven to
work, but they're not everywhere and they need to be.
We all want, in this room and other places, to make a
difference in the health and financial stability of our
country. This committee here has demonstrated a focused
commitment to chronic disease prevention, because diabetes and
complications are bipartisan. Using the Prevention Fund to
invest in programs like the NDPP is an important step.
The American Diabetes Association and the other 26 million
children with diabetes, like I've had for 15 years, are
standing ready to work with you to make our country healthier
and more committed to preventing disease and producing more
stories like Taylor's and Margaret's. We can together change
the trajectory of the human and financial crisis that diabetes
is inflicting on our country, if only we will attack it with a
thoughtful and concerted effort that relies on approaches we
know work. It is to those approaches that we commend you this
afternoon.
Thank you for allowing me this time to be able to share
this about diabetes.
[The prepared statement of Mr. Griffin follows:]
Prepared Statement of John Griffin, Jr., J.D.
executive summary
Prevention is our Nation's greatest untold healthcare story. For
far too long we have acted once disease is present in the body rather
than supporting efforts to prevent chronic disease. But, with the
passage of the Patient Protection and Affordable Care Act (PPACA,
Public Law 111-148), prevention became front and center to our efforts
to fight disease, encourage healthy living, and rein in costs.
Every 17 seconds somebody is diagnosed with diabetes in the United
States. Already nearly 26 million Americans have diabetes, and another
79 million Americans have prediabetes and are at increased risk for
developing type 2 diabetes. According to the Centers for Disease
Control and Prevention (CDC) one in three adults will have diabetes by
the year 2050 if present trends continue. This number is even greater
for minority populations with nearly one in two minority adults
expected to have diabetes in 2050.
In addition to the physical toll, diabetes also attacks our
wallets. The total cost of diabetes to the United States was $218
billion in 2007. Approximately one out of every five health care
dollars is spent caring for someone with diagnosed diabetes and nearly
one-third of Medicare expenses are associated with treating diabetes
and its complications. If we do not work to prevent diabetes, this
epidemic will bankrupt our healthcare system.
Despite these grim statistics, we know that type 2 diabetes is
largely preventable. Sedentary lifestyles and unhealthy diets
contribute greatly to the burden of diabetes and being overweight or
obese is a leading modifiable risk factor for type 2 diabetes. Other
risk factors include physical inactivity, family history of the
disease, being a member of a high-risk population, advanced age and
impaired glucose tolerance or impaired fasting glucose. With tens of
millions of Americans at risk for diabetes it is crucial that we work
to prevent new cases of the disease. Indeed, due to rising healthcare
costs, we can't afford not to. A 2008 study by Trust for America's
Health found that investment of $10 per person per year in proven
community prevention programs could save the country more than $15.6
billion per year within 5 years--a return on investment of $5.60 for
every dollar spent.
Individuals at risk for diabetes can prevent the disease through a
specific evidence-based lifestyle intervention aimed at diabetes
prevention. The Diabetes Prevention Program (DPP), a multicenter
clinical research trial funded by the National Institutes of Health's
National Institute of Diabetes and Digestive and Kidney Diseases
(NIDDK), found that modest weight loss through dietary changes and
increased physical activity can prevent or delay the onset of diabetes
by 58 percent in participants with prediabetes. Further studies of the
DPP by the CDC have shown that this groundbreaking intervention can be
replicated in community settings for a cost of less than $300 per
participant. With this in mind, Congress authorized the National
Diabetes Prevention Program as a part of the PPACA. This program allows
CDC to expand these evidence-based lifestyle intervention programs
across the country and into communities. For this program to truly
thrive across the Nation, we need a strong Federal investment to
develop the infrastructure necessary to ensure access to this proven
approach, to develop more community-based sites, and to provide public
education efforts.
The Prevention and Public Health Fund, which the Senate
Appropriations Committee has proposed as a funding source for the
National Diabetes Prevention Program, is a monumental national
investment in prevention and public health programs. It represents the
best comprehensive effort to date to prevent disease and improve the
quality of life for millions of Americans. Funding efforts to prevent
diabetes is essential to reining in our Nation's ballooning healthcare
costs. This year there have been numerous efforts to cut or eliminate
the Prevention and Public Health Fund, but doing so would only set our
country back in its efforts to rein in health care costs and trim
budget deficits.
Physical activity and proper nutrition are essential to reduce the
risk for diabetes in children and adults. That's why the Association
supports legislative efforts like the FIT Kids Act, last year's
Healthy, Hunger-Free Kids Act, and PPACA provisions that require menu
labeling in chain restaurants.
The HELP Committee has consistently demonstrated a commitment to
chronic disease prevention and the Association is grateful for those
efforts. We know we all want to make a difference in the health and
financial stability of this Nation. Using the Prevention and Public
Health Fund to make a dedicated investment in proven chronic disease
prevention programs, including the National Diabetes Prevention
Program, is the first step. The Association stands ready to work with
Congress toward making America a nation committed to preventing disease
rather than acting only to treat disease.
______
Chairman Harkin, Ranking Member Enzi and members of the committee,
thank you for providing me the opportunity to testify today before the
Committee on Health, Education, Labor, and Pensions (HELP) on behalf of
the American Diabetes Association (Association) and the nearly 105
million American children and adults living with diabetes and
prediabetes, including myself.
The state of chronic disease prevention is an important topic.
Prevention is our Nation's greatest untold healthcare story. For far
too long we have acted once disease is present in the body, and often
only to mitigate an acute episode, rather than believing in and
supporting efforts to prevent chronic disease. But, last year, with the
passage of the Patient Protection and Affordable Care Act (PPACA,
Public Law 111-148), prevention became front and center to our efforts
to fight disease, encourage healthy living, and rein in costs. The
inclusion of preventive services as a required benefit, the development
of the National Prevention Strategy, and the establishment of the
Prevention and Public Health Fund, are major steps to put our country
on the right track to prevent chronic diseases like diabetes. In my
testimony, I will present the facts about prevention, but I will also
tell the stories behind it that prove prevention works and we all have
a role to play in promoting it.
Every 17 seconds somebody is diagnosed with diabetes in the United
States. Already nearly 26 million Americans have diabetes, but this
number is expected to grow to 44 million in the next 25 years if
current trends continue. Another 79 million Americans have prediabetes
and are at increased risk for developing type 2 diabetes. For these
millions of Americans, the complications of diabetes are severe. Two
out of three people with diabetes die from heart disease or stroke.
Today 238 Americans will undergo an amputation; 120 will enter end-
stage kidney disease programs; and 48 will become blind--all due to the
devastating effects of this disease. In fact, diabetes is the leading
cause of kidney failure, adult-onset blindness and non-traumatic lower-
limb amputation, as well as a major cause of cardiovascular disease and
stroke.
According to the Centers for Disease Control and Prevention (CDC)
one in three adults will have diabetes by the year 2050 if we do not
take action. This number is even greater for minority populations with
nearly one in two minority adults expected to have diabetes in 2050.
In addition to the physical toll, diabetes also attacks our
wallets. A study by the Lewin Group found that in 2007 the total cost
to our country of diabetes and its complications, along with
gestational diabetes, undiagnosed diabetes and prediabetes, was $218
billion. Medical expenditures due to diabetes totaled $116 billion,
including $27 billion for diabetes care, $58 billion for chronic
diabetes-related complications, and $31 billion for excess general
medical costs. Other costs included $18 billion for undiagnosed
diabetes, $25 billion for prediabetes and $623 million for gestational
diabetes. Indirect costs resulting from increased absenteeism, reduced
productivity, disease-related unemployment disability and loss of
productive capacity due to early mortality reached $58 billion.
Approximately one out of every five health care dollars is spent caring
for someone with diagnosed diabetes. Further, one-third of Medicare
expenses are associated with treating diabetes and its complications.
Clearly, if we do not work to prevent diabetes this epidemic will
bankrupt our healthcare system.
Diabetes is a chronic disease that impairs the body's ability to
use food for energy. The hormone insulin, which is made in the
pancreas, is needed for the body to change food into energy. In people
with diabetes, either the pancreas does not create insulin, which is
type 1 diabetes, or the body does not create enough insulin and/or
cells are resistant to insulin, which is type 2 diabetes. In
individuals with prediabetes, blood glucose levels are higher than
normal and the risk for developing type 2 diabetes is elevated. If left
untreated, diabetes results in too much glucose in the blood stream.
The majority of diabetes cases, 90 to 95 percent, are type 2 diabetes.
Additionally, an estimated 18 percent of pregnancies are affected by
gestational diabetes, which occurs when a mother's blood glucose levels
are too high during pregnancy, which can harm both the mother and her
baby. In the short term, blood glucose levels that are too high or too
low (as a result of medication to treat diabetes) can be life
threatening. The long-term complications of diabetes are widespread,
serious--and deadly.
Despite these grim statistics, we know that type 2 diabetes is
largely preventable. Being overweight or obese is a leading modifiable
risk factor for type 2 diabetes. In addition to obesity, there are
several known risk factors for type 2 diabetes, including physical
inactivity, unhealthy diets, family history of the disease, being a
member of a high-risk population, advanced age and previous impaired
glucose tolerance or impaired fasting glucose. Although some of these
factors are not subject to change, changing one's lifestyle can often
help prevent type 2 diabetes.
With tens of millions of Americans at risk for diabetes it is
crucial that we work to prevent new cases of the disease. Indeed, given
rising healthcare costs, we can't afford not to. A 2008 study by Trust
for America's Health found that investment of $10 per person per year
in proven community prevention programs could save the country more
than $15.6 billion per year within 5 years--a return on investment of
$5.60 for every dollar spent. Investing in prevention programs will
save money and improve the health and quality of life of Americans, two
outcomes that, as a Nation, we cannot afford to ignore.
national diabetes prevention program
Research has shown that over half of the individuals at risk for
diabetes can prevent the disease through a specific evidence-based
lifestyle intervention aimed at diabetes prevention. The National
Diabetes Prevention Program, included in the Patient Protection and
Affordable Care Act (PPACA), authorizes CDC to expand its work in
translating a successful National Institutes of Health (NIH) clinical
trial to the community setting for individuals with the highest risk of
developing diabetes.
The Diabetes Prevention Program (DPP), a multicenter clinical
research trial funded by the NIH's National Institute of Diabetes and
Digestive and Kidney Diseases (NIDDK), found that a structured
lifestyle intervention given in a clinical setting that produced a
modest weight loss (about 5-7 percent of body weight) through dietary
changes and increased physical activity was able to prevent or delay
the onset of diabetes by 58 percent in participants with prediabetes--
those at the highest risk for diabetes. The results were even greater
among adults aged 60 years or older, who reduced their risk by 71
percent. Further studies of the DPP by the CDC have shown that this
groundbreaking intervention can be replicated in community settings for
a cost of less than $300 per participant, about a fourth of the cost of
the original clinical intervention. With this in mind, Congress
authorized the CDC to operate the National Diabetes Prevention Program.
This program allows CDC to build the infrastructure to expand these
evidence-based lifestyle intervention programs to reach communities
across the country. Bringing this program to scale is the key to
prevention for many of the 79 million Americans with prediabetes.
Researchers have continued to follow clinical trial participants.
Ten years later, the Diabetes Prevention Program Outcomes Study found
that the rate of developing diabetes was still reduced. Moreover,
individuals aged 60 years or older still showed the greatest overall
reduction, proving that the results of this program continue in the
long term.
The National Diabetes Prevention Program supports the creation of
community-based sites where trained staff will provide those at high
risk for diabetes with cost-effective, group-based lifestyle
intervention programs. Local sites will be required to provide an
approved curriculum and trained instructors and will be rigorously
evaluated based on program standards and goals. Thus, implementation of
the National Diabetes Prevention Program will ensure availability of a
low-cost, highly successful diabetes prevention program in communities
across the country.
The National Diabetes Prevention Program will do more than just
prevent diabetes and its devastating complications. Contrary to
arguments that prevention does not save money, the National Diabetes
Prevention Program shows that prevention programs are a wise investment
that yields significant savings. In 2009, the Urban Institute estimated
that a nationwide expansion of this type of diabetes prevention program
will produce an estimated $190 billion in savings to the U.S.
healthcare system over 10 years. Because the burden of chronic disease
falls disproportionately on seniors and the poor, the Urban Institute
also estimated that 75 percent of the total savings would be to Federal
health programs like Medicare and Medicaid. Without a concerted effort
at prevention that cost will only grow. Because the National Diabetes
Prevention Program focuses on individuals at the highest risk for the
disease, the return on investment is certain and it is realized early.
One need only look to the numerous stories of how prevention has
changed lives to know that prevention works. Taylor David of the
Klamath tribe in Oregon knows that prevention--the Diabetes Prevention
Program in particular--works. Taylor was diagnosed with prediabetes.
But luckily for her, the Klamath Diabetes Prevention Program was one of
the 36 federally funded demonstration projects to translate the DPP
clinical trial to meet the cultural needs of tribal organizations.
In 2004, Congress mandated the Indian Health Service (IHS) use
additional funding provided through the Special Diabetes Program for
Indians (SDPI) to implement the latest scientific findings to prevent
diabetes. This resulted in 36 IHS tribal and urban Indian health
programs receiving funding to translate the DPP into common prevention
education programs in Native American communities. Taylor successfully
participated in the program and changed the course of her path to
diabetes. She lost over 38 pounds and she no longer has prediabetes. In
fact, last year she participated in her first 5k ever and learned how
to snowboard. She is healthier, more active, and diabetes free and she
states she would not have had the courage, knowledge or ability to make
these crucial lifestyle changes were it not for the Klamath Diabetes
Prevention Program.
While the National Diabetes Prevention Program has been authorized,
it has yet to receive dedicated Federal funding. On September 21, 2011,
the Senate Appropriations Committee passed their fiscal year (FY) 2012
Labor, Health and Human Services, and Education Appropriations bill,
providing $10 million in funding to the National Diabetes Prevention
Program through the Prevention and Public Health Fund. The Association
thanks the committee and hopes that Congress and the Administration
maintain this funding as the fiscal year 2010 appropriations process
continues. Despite the lack of Federal funding needed to fully scale
this program, CDC, the Y-USA and UnitedHealth Group have partnered with
great success to administer this program in 170 sites in 23 States.
This is a start, but it leaves most of the 79 million Americans at risk
for diabetes without access to this program, and doctors with nowhere
to refer patients with prediabetes. For this program to truly thrive
across the Nation, it needs a strong Federal investment to develop the
infrastructure necessary to ensure access to this proven approach, to
develop more community-based sites, and to provide public education.
This year the Administration released the National Prevention
Strategy, which promises the Federal Government will ``promote and
expand research efforts to identify high-priority clinical and
community preventive services and test innovative strategies to support
delivery of these services.'' This is a laudable goal, but in the case
of the National Diabetes Prevention Program, the research has been
done, the results already exist and the Federal Government is poised to
take the next step. That next step is a commitment to bringing the
results of this successful, federally funded research to communities
across our country.
Funding will lead to more stories like Margaret Hutchinson from
Mound, MN. Last year at Margaret's annual check-up, she found out her
blood glucose levels were elevated. Not having a family history of
diabetes she didn't think much about it, until she received a letter--
and a wake-up call--from her insurer telling her that she had
prediabetes and was eligible for the Diabetes Prevention Program at her
local Y.
Margaret started the program in November of last year, attended
weekly classes with a small group and a lifestyle coach who taught the
participants about proper nutrition and physical activity. The class
tracked their diets, activities and weight on a weekly basis to
decrease their risk for diabetes. Margaret far surpassed the goal to
lose 7 percent of her body weight, dropping 13 percent plus an
additional 10 pounds after the weekly classes ended. Her blood glucose
levels no longer indicate prediabetes. She is now much less likely to
develop type 2 diabetes and to seek treatment for its dangerous and
costly complications.
Indeed, this program is exactly how we should be using taxpayer
funds. We asked our scientists to develop a program to prevent
diabetes. They did so and they tested it in the doctor's office. It
prevented or delayed over half of the new cases of diabetes. Then we
asked our public health experts to see if we could move this great
program into the community and slash the price. They did it. In the
face of the tsunami that is diabetes, we found something that works! To
discontinue the Federal investment in prevention by eliminating the
Prevention and Public Health Fund would be a slap in the face of the
success we have achieved as a nation.
prevention and public health fund
The Prevention and Public Health Fund, which the Senate
Appropriations Committee has proposed as a funding source for the
National Diabetes Prevention Program, is a monumental national
investment in prevention and public health programs. We applaud the
great work being done regarding prevention at HHS and specifically at
the Division of Diabetes Translation, but recognize that the Federal
investment just hasn't been adequate. The Prevention and Public Health
Fund represents the best comprehensive effort to date to prevent
disease and improve the quality of life for millions of Americans.
Additionally, funding efforts to prevent chronic diseases, like
diabetes and its complications, is essential to reining in our Nation's
ballooning healthcare costs.
In this time of tight budgets and drastic proposed funding cuts it
is important that Congress protect the Prevention and Public Health
Fund. The $218 billion annual price tag of diabetes alone is enough to
demonstrate that a concerted effort at chronic disease prevention is a
prudent investment. This year, there have been numerous efforts to cut
or eliminate the Prevention and Public Health Fund, but doing so would
only set our country back in its efforts to rein in health care costs
and trim budget deficits. Billions of dollars a year are spent through
Federal Government programs to treat acute illnesses and chronic health
problems. However, until the creation of the Prevention and Public
Health Fund, there was no parallel investment in wellness and chronic
disease prevention that could alleviate the existing burden to Federal
health programs. Even the CDC's efforts to prevent disease have been
hampered by budget cuts and flat funding despite the excellent work
they do toward disease prevention. But, with the Prevention and Public
Health Fund we are finally seeing that investment. States and
communities are using these funds for tobacco cessation, behavioral
health, obesity prevention and to strengthen the public health
workforce
physical activity
We know that with healthy diets and active lifestyles, people can
reduce their risk for type 2 diabetes. The Physical Activity Guidelines
for Americans recommend that adults get 2\1/2\ hours of moderate
exercise every week to achieve health benefits and reduce the risk of
type 2 diabetes, heart disease, stroke and high blood pressure. The
guidelines also recommend children be active for at least 1 hour per
day to achieve similar health benefits. Our education system must take
our children's physical education as seriously as training their minds
if we hope to change the prediction that one in three children (and one
in two minority children) born in the year 2000 face a future with
diabetes.
This is why the Association supports S. 576, the Fitness Integrated
in Teaching (FIT) Kids Act of 2011 sponsored by Chairman Harkin. The
FIT Kids Act requires State and local education agencies to include
information on health and physical education programs on their annual
agency report cards. Requiring this reporting will make school programs
more transparent and encourage improved physical education curriculums.
This legislation also promotes professional development and training
for physical education teachers and emphasizes the importance of
promoting healthy lifestyles for students. We ask that the HELP
Committee include this legislation in the upcoming reauthorization of
the Elementary and Secondary Education Act.
Physical activity can help adults at high risk for the disease
prevent type 2 diabetes. Christie Lussoro of the Nez Perce tribe in
Idaho has a history of diabetes on both sides of her family. She was
concerned about developing diabetes so she joined the Nimiipuu Health
Diabetes Program to begin an exercise program and reduce her risk. She
worked closely with program staff to develop a customized plan and
increased her physical activity level. Over time, Christy lost 31
pounds and her children have joined her at the fitness center to help
reduce their own chances of developing type 2 diabetes.
nutrition
Access to a healthy diet is essential for all Americans and perhaps
can be seen most acutely in children like Ahni. Since moving to the
United States from China about 10 years ago, Ahni has adopted a western
diet--full of fast foods, processed foods and high-calorie snacks. Even
at school, Ahni eats meals that are high in fat, sugars and calories.
Moreover, Ahni's school is one of the many that has cut physical
education programs. Unfortunately, unless Ahni's family makes drastic
changes in their lifestyle and diet, Ahni has a high probability of
developing diabetes. Asian Americans are already acutely susceptible to
type 2 diabetes, developing the disease at lower weights than people of
other races, so Ahni's sedentary lifestyle and high-calorie diet put
her even more at risk.
Ahni should be eating healthier meals, especially in school where
she spends much of her time. In the 111th Congress, the Association
supported passage of the S. 3307, the Healthy, Hunger-Free Kids Act of
2010 (Public Law 111-296). This legislation is a tremendous step
forward in improving the nutritional value of foods served at schools.
The U.S. Department of Agriculture is moving forward with regulations
that will make meals under the Federal school lunch and school
breakfast programs healthier and we will soon see improved nutrition
standards for foods sold in vending machines, a la carte lines, and
school stores as well. In order to curb obesity and the related chronic
diseases, like diabetes, it is essential to provide young students with
healthy meals and snacks that are low in calories and fat. We ask that
Congress oppose any efforts to roll back provisions of this law and
allow the relevant Federal agencies to proceed with implementation so
our young students can benefit from healthier meals as soon as
possible.
The Association also looks forward to final regulations from the
Food and Drug Administration implementing the PPACA requirement for
chain restaurants to include calorie counts on their menus and menu
boards. This information will help people make more informed choices
about the food they choose in restaurants. Choosing lower calorie
options when dining in restaurants and fast food establishments will
help consumers manage their weight and reduce their risk of type 2
diabetes or better manage existing diabetes.
american diabetes association activities
The Federal Government is not in this alone. The American Diabetes
Association is also doing its part to promote prevention and improve
lives. We are engaging in continuing education for clinicians, ensuring
that providers are familiar with the preventive tools that are
available to them so that they can provide the best options for at-risk
patients. For individuals, the Association provides information about
diabetes and its seriousness, education on how to lower their risk for
diabetes as well as inspiration and programs in communities across the
country. Between PSA campaigns to make sure people know their risk for
diabetes and education on how to lower that risk, we are getting the
message out that it is crucial to stop diabetes.
Additionally, along with the American Cancer Society and the
American Heart Association, we have established the Preventive Health
Partnership (PHP). The PHP is a coordinated effort between our three
organizations to raise public awareness about what Americans need to do
to live healthier lives and to provide information and motivation about
how better nutrition and regular exercise can prevent type 2 diabetes,
heart disease and some forms of cancer.
conclusion
We all want to make a difference in the health and financial
stability of this Nation. The HELP Committee has consistently
demonstrated a commitment to chronic disease prevention and the
Association is grateful for those efforts. Your leadership in combating
the growing epidemic of diabetes is critical. It is clear that in order
to stop diabetes and rein in healthcare costs, we must support efforts
to prevent chronic disease and the complications associated with
chronic disease.
Using the Prevention and Public Health Fund to make a dedicated
investment in proven chronic disease prevention programs, including the
National Diabetes Prevention Program, is the first step. As we sit here
today, there are patients in our Nation's hospitals awaiting a horrific
amputation or waiting in line at the clinic for their turn at kidney
dialysis. Let's work together to clear those waiting rooms and,
instead, have more stories like Taylor and Margaret. The Association
stands ready to work with Congress toward making America a nation
committed to preventing disease rather than acting only to treat
disease. Thank you again for allowing me to testify before the
committee today.
The Chairman. Mr. Griffin, thanks for a very clear and very
forceful presentation. We appreciate that.
Dr. Troy, please proceed.
STATEMENT OF TEVI TROY, Ph.D., SENIOR FELLOW,
HUDSON INSTITUTE, WASHINGTON, DC
Mr. Troy. Mr. Chairman, thank you very much for this
opportunity.
And thank you as well to Senator Roberts and Senator
Franken, before whom I've had the privilege to testify in the
past.
I think we can all agree after today's conversation that
obesity is a problem, chronic diseases are a problem. I like to
talk about it from three specific perspectives. One is from a
health concern, and we've talked about it already a great deal
today. But two-thirds of Americans are overweight or obese.
Over 60 million people have diabetes. And Type 2 diabetes, as
we've discussed, is both preventable but also a terrible
condition.
From an economic perspective, and specifically from an
employment perspective, I cite in my testimony, which I
appreciate you putting in the record, that obesity has
employment costs equivalent to about 1.8 million workers per
year at $42,000 each. But when we think about it in times of
consistently high unemployment rates--and the rate was just 9.1
percent last week--we should really think about the employment
costs of obesity and chronic diseases.
And then I'm also very worried from a national security
perspective. The Army did a study that found that 27 percent of
Americans, age 17 to 24, are too overweight to serve. And the
Pentagon spends about a billion dollars a year trying to deal
with obesity in members of the armed forces.
So recognizing that this is a problem, the question is how
to approach it. And I commend the committee today for asking a
lot of the right questions, because while I agree that
prevention works, that doesn't mean that all prevention
programs work. In fact, I cite in my testimony some CBO
statements that suggest that sometimes prevention programs lead
to higher utilization and higher medical spending. So we have
to be very careful about it.
So, therefore, I lay out a number of ways to do this in the
right way, in the ways that will actually use the Federal
dollars in the best way and make sure that we are addressing
the problem. So I think to the extent we have Federal programs
for this and that dollars need to be discretionary, they need
to be done in a budget conscious way, recognizing our $1.4
trillion deficit and our $14 trillion debt.
I also think it needs to be targeted, accountable--and I
appreciate all the questions today about accountability and the
need for metrics to make sure that to the extent we do have
programs, that they are measured and that they are working. And
they also should be done in a competitive and a political
process. And also, Senator Roberts mentioned that they need to
be done in a cooperative process. It doesn't really help a
county if they get a grant and they are not prepared for the
grant and don't know what to do with the grant.
I also think that from the perspective of public health
advocates who recognize the importance of prevention, you need
to think about the optics of it as well. If prevention dollars
are wasted or ineffective, that can set back the cause of
prevention funding for everybody who's concerned about this
area.
I also think it's important that we look at private sector
solutions. And I'm glad that some of those private sector
solutions, such as employee wellness programs, were mentioned.
I believe Senator Franken said there was a four-to-one benefit
ratio. I cite some programs that have a three-to-one benefit
ratio. Four-to-one is better than three-to-one, but both are
good.
I think it's important that we get an incentive-based
approach to this, to get individuals involved in their own
health and that they have their own incentives to get fit and
to engage in prevention activities on their own. I suggest some
other possibilities, private sector possibilities, such as
health savings accounts, which help build a consumer-driven
health system, and also differential premiums--which I know the
Senate has done some work on this here, which I appreciate. So
I think all those are helpful.
I also think to the extent that we encourage the private
sector to engage in this, we need to be careful not to
micromanage private sector activity and make sure that it can
develop organically and in the most efficient and effective
way.
So in sum, I think preventative medicine can prove to be a
prudent investment. But in order to be effective, as I said, it
must take place within the limits of our significant fiscal
challenges and must be done in such a way that the services
eligible are not too broadly defined and narrowly targeted. And
it must take place within the context of a strong commitment to
rigorous program evaluation.
Mr. Chairman and other members of the committee, thank you
for your time and for your devotion to this issue.
[The prepared statement of Dr. Troy follows:]
Prepared Statement of Tevi Troy, Ph.D.
Mr. Chairman, Mr. Ranking Member, members of the committee, chronic
diseases cost this country more than $750 billion annually, and present
a serious challenge to the United States from a health, economic, and
national security perspective:
Health concerns: Two thirds of Americans are overweight or
obese; over 16 million people have diabetes, and type 2 diabetes is a
preventable condition.
Economic concerns: Obesity has employment costs equivalent
to about 1.8 million workers per year at $42,000 each.
National Security concerns: The Army found 27 percent of
Americans aged 17 to 24 too overweight to serve. The Pentagon spends $1
billion a year dealing with obesity.
Ad campaigns, such as those done by the Bush and Obama
administrations, are nice, but not working. We need a more serious
strategy, so it makes sense to be talking about prevention of the
problem.
Prevention is important, but must be done the right way. Prevention
dollars should be discretionary, targeted, accountable, and go through
a competitive and apolitical process. In addition, we must remember
that prevention does not always lead to cost savings. In addition,
labeling a project ``prevention'' does not mean it will be cost-
effective. Wasteful or ineffective prevention spending is not helpful
from a messaging standpoint, and is particularly problematic at a time
when we have an enormous budget deficit and face a $14 trillion--and
growing--debt.
We also need to look at private sector solutions: employee fitness
programs, Health Savings Accounts, differential premiums, and other
forms of incentive-based approaches. To be successful in our prevention
efforts, we need to unleash the power of incentives and move toward a
more consumer-driven system, one that will encourage individuals to
make healthy choices for themselves and their families. At the same
time, we should encourage the private sector in this effort without
micromanaging.
In sum, preventive medicine can prove to be a prudent investment in
the future of our country, but in order to be effective it must: take
place within the limits of our significant fiscal challenges; be done
in such a way that the services eligible are not too broadly defined;
and take place within the context of a strong commitment to rigorous
program evaluation.
Mr. Chairman, Mr. Ranking Member, members of the committee, I thank
you for your time and your efforts to fight chronic disease.
______
Mr. Chairman, Mr. Ranking Member, members of the committee, my name
is Tevi Troy, and I am a senior fellow at Hudson Institute, and a
former Deputy Secretary of the U.S. Department of Health and Human
Services, as well as a former senior White House Domestic Policy Aide.
In both capacities, I was involved in the Bush administration's efforts
to combat obesity and promote preventive behaviors.
I come here before the committee to talk about the important issue
of prevention, particularly prevention of chronic diseases, treatment
of which costs this country more than $750 billion annually.
I support the use of funds for appropriate preventive healthcare
measures. As Benjamin Franklin wisely put it, ``An ounce of prevention
is worth a pound of cure.''
I also recognize that there is a lot to prevent. The current State
of healthcare in America is well past due for its ``ounce of
prevention.'' I recognize that the concept of ``prevention'' addresses
multiple concerns, including smoking, but I will focus here on the
rising obesity epidemic as an illustrative example. Currently, two-
thirds of Americans are overweight or obese. This number is increasing
at an annual rate of 1.1 percent, or by about 2.4 million new obese
adults each year. As you well know, obesity increases the likelihood
for several other co-morbidities, including hypertension, type II
diabetes, coronary heart disease, and stroke, each with its own range
of associated costs and health complications. With respect to diabetes
alone, CDC has found over 16 million people have this terrible, and
often preventable, condition.
From an economic perspective, estimates of the cost of obesity to
America range from $150-$250 billion annually. $3.9 billion alone
stemmed from lost productivity due to obesity, reflecting 39.2 million
lost days of work. In addition to increased absenteeism, another study,
in the Journal of Environmental and Occupational Medicine, found
presenteeism--decreased productivity of employees while at work--to be
a significant cost-driver as well. Specifically, the cost of obesity
among full-time employees was estimated to be $73.1 billion--``roughly
equivalent to the cost of hiring an additional 1.8 million workers per
year at $42,000 each, which is roughly the average annual wages of U.S.
workers.'' At a time of consistently high unemployment, which was 9.1
percent in the most recent report, we need to look at the costs of
obesity and those costs' potential impact on U.S. employment levels.
Obesity is no longer solely an economic or a health issue, although
it is a serious concern in those areas. Obesity has become an issue of
national defense as well; the Army found 27 percent of Americans in
prime years for military recruitment--17 to 24--were ``too overweight
to serve in the military.'' The Pentagon alone spends nearly $1 billion
each year coping with weight-related challenges. Retired Rear Adm.
James A. Barnett put the issue starkly, warning that ``[o]ur national
security in the year 2030 is absolutely dependent on reversing the
alarming rates of child obesity.
And yet, we must remember that Dr. Franklin's maxim was aimed at
promoting cost-effectiveness, which is a value we must keep in mind
throughout this conversation. While I am passionate about the need to
address obesity and other issues that lead to preventable health
conditions, I am not convinced that the government has all of the
answers to this problem. In the administration for which I worked, HHS,
then led by Secretary Mike Leavitt, worked with the Ad Council and
Dreamworks on a public service announcement with characters from the
movie Shrek encouraging kids to ``Be a Player. Get up and play an hour
a day.'' The Obama administration has followed suit in this regard,
making combating obesity one of First Lady Michele Obama's signature
initiatives. In February 2010, she launched ``Let's Move!,'' a campaign
designed to end obesity in a generation. While the Bush White House did
its PR partnership with Shrek, Obama opted for New York Yankee star
Curtis Granderson, who said kids should play fewer video games and
engage in more outdoor activities. Neither admittedly well-intentioned
effort is going to stem the obesity tide. So going forward, we need not
just good intentions, but also strong principles to guide us, such as
the need for the right process, a recognition of our dire fiscal
situation, a need for focused and not vaguely defined programs, and a
recognition that many so-called prevention savings never materialize.
From a process standpoint, prevention dollars should be
discretionary and go through the normal and rigorous appropriations
process. As you all well know, spending on the mandatory side of the
budget is harder to adjust than discretionary spending because it does
not have to compete against other priorities in the annual
appropriations process. This means that cost-savings must come
disproportionately from the discretionary side of the budget. At a time
when both Social Security and Medicare are facing severe funding
challenges, when we have a $1.4 trillion deficit and $14 trillion debt,
putting more dollars in mandatory accounts lessens the sacrosanct
status of mandatory spending writ large, and also will put more
pressure on our discretionary accounts to find needed cost savings. The
irony here is that increased mandatory spending could increase the
pressure to cut discretionary spending on prevention, even if such
spending has been shown to be effective.
Another important principle is focus. Programs or studies eligible
for funding should not be too broadly defined. Laxity of definition may
lead to spending in areas that are not directly related to prevention.
Already there has been criticism around one program authorizing Federal
funding for the construction of sidewalks and jungle gyms. Programs
should be targeted so as not to incur such criticism, which can damage
the prevention ``brand.'' Furthermore, since money is fungible,
governments facing severe fiscal constraints could potentially use
poorly targeted money for ancillary purposes.
In addition, I recognize the importance of rigor in the review
process to get the best results. In order to have maximum
effectiveness, dollars should be distributed via a competitive process.
Policymakers should keep in mind the risk posed by the spending of
Federal dollars with inadequate supervision or the ability to correct
abuses. A single flawed project can be subject to ridicule--as we have
seen with the Solyndra project--and therefore harm the entire endeavor
by creating the perception that the program misuses taxpayer dollars.
Prevention funding must be targeted so that we are dedicating enough
resources to make an impact that actually reduces childhood obesity in
the long run. We currently fund over 300 different obesity programs,
which suggests an insufficiently focused approach and increases the
risk of duplicative or ineffective spending. We must ensure that
prevention dollars are spent wisely, and not used to fund parochial
projects that do not advance the prevention goal.
In addition, it is important to remember that the ``prevention''
label itself does not necessarily lead to cost savings. As Robert
Gould, president of Partnership for Prevention, has said, ``Some
preventive services save money and some don't.'' Just labeling
something a ``preventive'' service does not mean that it prevents
anything, or that it will save money. A recent letter by Congressional
Budget Office Director Douglas Elmendorf underscores this point.
According to Elmendorf, ``the evidence suggests that for most
preventive services, expanded utilization leads to higher, not lower,
medical spending overall.'' This is because, as Elmendorf noted,
doctors, whatever their skill level, are not prophets: ``[I]t is
important to recognize that doctors do not know beforehand which
patients are going to develop costly illnesses.'' As a result,
insufficiently targeted ``preventive services'' end up adding to total
costs because they are too often used on those who will not develop
expensive conditions. We need personalized medicine to play a role
here. If we can target those with the greatest risk, we will be more
likely to have cost-effective interventions.
Even beyond CBO, a recent study by Rutgers University Professor
Louise Russell found ``that contrary to common belief, prevention
usually increases medical spending.'' The same study found that ``Less
than 20 percent of the preventive options (and a similar percentage for
treatment) fall in the cost-saving category--80 percent add more to
medical costs than they save.''
Dr. Russell, does, however, open her study with some positive words
on preventive spending: ``Careful choices about frequency, groups to
target, and component costs can increase the likelihood that
interventions will be highly cost-effective or even cost-saving.'' I
fully agree. We must find an alternative approach to this very real
problem. With this in mind, I would like to highlight one type of
program that has proven to be both effective and cost efficient:
employee fitness programs. Both Motorola and PepsiCo received at least
a $3:1 return on investment from their employee fitness programs. These
are private sector initiatives that do not cost the government money,
but do help reduce obesity and other preventable conditions. We should
encourage these initiatives and let them develop without
micromanagement, as maintaining autonomy in employer-sponsored wellness
programs is imperative. Government intervention in the design and
administration of these programs will likely discourage employers from
engaging in this worthy endeavor. In addition, consumer-driven health
care, promoted by programs such as Health Savings Accounts, will give
individuals additional financial incentives to take the steps necessary
to pursue prevention on their own initiative. I would also like to see
the Senate continue to work to give the private sector flexibility to
promote prevention in the workplace, including the use of differential
premium costs to encourage healthy behavior.
I believe a new focus on preventive medicine can prove to be a
prudent investment in the future of our country. While doing so, we
must not forget the severe fiscal challenges that other important
government programs such as Medicare or Social Security already face.
We must ensure that the services eligible are not too broadly defined,
and that we maintain a strong commitment to rigorous program
evaluation. Most importantly, we must proceed in a cost-effective
manner, targeting those areas that are both the safest and most cost-
effective. And we should unleash the power of incentives and try to
move toward a more consumer-driven system, one that will encourage
individuals to make healthy choices for themselves and their families.
As I have tried to show in my testimony, there is so much at stake in
getting this right.
Mr. Chairman, Mr. Ranking Member, members of the committee, I thank
you for your time here today, and for your efforts on behalf of
prevention.
The Chairman. Thank you very much, Dr. Troy, again for your
very forceful presentation. Appreciate it very, very much.
We'll begin a round of 5-minute questions here.
Ms. Brown, you talked about some--you all had statistics
that are frightening. You pointed out, Ms. Brown, that the
number of preschoolers who are overweight jumped 36 percent
just in the last 10 years, and that is just frightening. And so
we have to get at these things early in life, early in life.
But one of the things that--you asked a question in your
testimony. You said that all of the findings that we have and
lessons learned beg the questions: Why is prevention taking a
back seat to acute care and treatment? Why aren't more efforts
and dollars being spent on prevention? You say, well, the
answers aren't easy. You say prevention first is a long-term
commitment policy, long-term. And most of us around here are
interested in short-term fixes.
But that's true of human nature. People want to be able to
live their lives however they want to live, and I want that
pill. I want that magic pill that will make it all right--clean
me all up again and start me over again, and all that kind of
stuff. So it's kind of human nature.
That's why we look for systems approaches, and that's why I
keep emphasizing that we need it early on, and it's got to be
broad-based--early on, childhood, preschool settings,
neighborhoods, communities, schools, certainly in the homes,
but also in the workplace. And that's one place where I have
found in the past some private sector employers have been way
ahead of the curve on this.
I have examples that go back 25 years of employers in my
State that decided to put in wellness programs in their plants,
prevention, cut down on smoking. They gave incentives to
workers, benefits--some of them pretty nice benefits--if they
would see an in-house nutritionist, dietician, something like
that, and cut down on smoking. And what we found was that in
these early days, their productivity shot up.
See, you always look at the cost, but their productivity
went up, turnover rates went down, absenteeism went down.
Workers would stay overtime just to make sure everything was
right. Nobody was rushing to the door. We know these things
work. But why aren't more employers doing it?
We know they work. We know they're cost-effective. As I
said, there are some employers that have really done great jobs
in this. But how can we--let's face it. We spend most of our
days at work. How can we get more employers involved in
wellness and prevention?
Ms. Brown. Well, thank you for that question. Certainly,
one of the priorities of the American Heart Association and our
partners, the American Cancer Society and the American Diabetes
Association, is to get more workplaces to promote the workplace
as a location for promoting positive health. We recognize, as
you've said, Senator, that people spend a good majority of
their day in the workplace.
And if we can encourage employers to offer positive
reinforcement for a healthier workplace--so serving healthier
foods in the workplace, offering time for individuals in the
workplace to get physical activity, helping to promote tobacco
cessation programs, and other activities--all very important.
So we need to have an environment where employers are provided
incentives for doing that in their workplace. And that
certainly is a priority for the AHA.
The Chairman. Dr. Seffrin, what do we need to get more
employers--do we need tax benefits? Do we need credit? What do
we need to do?
Mr. Seffrin. I think the answer, in addition to what Nancy
has said, is get specific engagement. We have a program in the
American Cancer Society called CEOs Against Cancer. We just had
a meeting 3 weeks ago in New York chaired by Glenn Tilton, the
former CEO of United Airlines, now the Chairman of JP Morgan
Chase.
When they recruit their colleague CEOs and get together and
talk, it bypasses a level of strata in the corporation and they
can begin to talk about we do care about our employees, and we
know a healthier workforce is a more productive workforce. The
data are very clear on that.
We've done analyses showing that if a company develops what
we call the CEO gold standard on cancer and they provide to
their employees the kinds of tests--if they need age
appropriate tests--that if they have a stable workforce over 5
years, it becomes budget neutral and then saves them money. So
I think it's engagement at the top level. But I see more and
more companies being willing to sit down and talk and do
something about it.
The Chairman. Mr. Griffin.
Mr. Griffin. We also at the ADA have relationships with
CEOs in large businesses. But part of this is awareness. And we
talked about United Health. It's just one carrier, but the
message is there. I also want to stress with my friends that up
here on the stage we have what we call the Preventive Health
Partnership. We found that these organizations together--more
than 100 million Americans in our constituency--when Heart,
Cancer, and Diabetes stands for these sorts of wellness and the
costs that they will save in the long run in terms of
prevention that we're learning, we pack a pretty good punch
when these three organizations join together, which we are
doing now.
The Chairman. Dr. Troy.
Mr. Troy. Yes, thank you. Two things, one on a positive
side--I think that government officials and senior officials
can help encourage this. Mrs. Obama, the First Lady, talks
about wellness so that she can help encourage CEOs. Similarly,
President Bush did programs like that.
But I also think you want to keep employers in the game.
Former CBO director, Douglas Holtz-Eakin, has suggested that
the Affordable Care Act will lead to a lot of employer dumping,
in which employers will no longer have responsibility for the
healthcare of their employees. They will put them into the
exchanges. To the extent that happens, you'll have employers
less interested rather than more interested, and I'm worried
about that.
The Chairman. Very interesting. I've got to look at that.
Thank you very much. My time is well over.
Senator Roberts.
Senator Roberts. Dr. Seffrin, how many of those CEOs that
you met with on prevention have taken the PSA test for prostate
cancer? Most of them?
Mr. Seffrin. I suspect so.
Senator Roberts. Well, the USPSTF has just come out with a
recommendation to downgrade PSA screening, if not to get rid of
it, for early detection of prostate cancer, recommending that
men should no longer need or get the PSA test. It goes by age,
and most of the Senate would be interested.
At any rate, you talk prevention, prevention, prevention.
Would you like to comment on what the recommendation of the
USPSTF is--I know it isn't in final form yet, but it's been
leaked out. Any comments?
Mr. Seffrin. I'd make a couple of comments. One is that the
de-rating clearly discourages its use, and they're basing that
on reviewing a number of studies and two--including two
randomized controlled trials which failed to demonstrate a
benefit and, indeed, indicate some risks associated--serious
risks associated with it.
So when you talk evidence-based--and you mentioned it
earlier, Senator Roberts, and, certainly, you did, Senator
Harkin--you have to--if that's going to be the standard, you
have to pay attention to it. The data are the data.
The American Cancer Society says things a little
differently. We feel that there is a test, and, unfortunately,
it's the only test of its kind. It's imperfect, to be sure, but
everyone knows that some lives have been saved because the test
has been used. We just don't know who those people are. We also
know some people have been hurt because they used the test and
it was positive and they followed up and even in some cases
died because of the treatment.
So we say that it's important that the clinician and the
patient talk about this, that they be informed a test does
exist, but there are definite risks and definite benefits. And
at the end of the day, it should be between the doctor and his
or her patient as to whether that test is used or not.
Senator Roberts. Thank you very much. I appreciate that. In
your former role as Deputy Secretary at HHS, Dr. Troy, you
oversaw the development and approval of regulations, all
regulations, and significance guidance. That's a hell of a job.
Can you speak to the use of interim final rules to implement
specific policy priorities and comment on the use of an IFR to
implement prevention priorities? And I'm very worried about
IFRs becoming final without any comment period down the line,
which I think is absolutely essential.
Mr. Troy. Thank you, Senator. IFRs, interim final rules,
are an important tool in the tool chest of regulators. But they
are a tool to be used sparingly. So to the extent that it is
something----
Senator Roberts. Give me an example.
Mr. Troy. Well, if there's a national security concern, if
you have to get a regulation out very quickly, that might be a
good time to use an IFR. I think we may have used them in terms
of bioterror or biopreparedness regulations. So it is not
something that should be forbidden. It's in the APA, the
Administrative Procedures Act.
But there should not be an over-reliance on IFRs, because,
as you say, they do circumvent what you call in the Senate
regular order, and so I am very worried about using them too
much. And there has been a concern with the Affordable Care Act
about the use of IFRs to get regulations out faster and to not
get the notice and comments that's required.
Senator Roberts. So the IFR used to seek the end result of
an agenda would not be helpful. In a specific instance where it
obviously--you have to act in haste--then you would recommend
that. I am just worried about IFRs being used too many times.
I yield back, Mr. Chairman.
The Chairman. Senator Whitehouse.
Senator Whitehouse. Thank you, Chairman.
First, let me thank the Heart Association and the Cancer
Society and the Diabetes Association for the work that you did
as we were preparing for the Affordable Care Act with the joint
statement that we worked on on healthcare delivery system
reform. I think that when the three of you and the other
illness advocacy groups get together, you can have very, very
powerful effects. And I appreciate that you put the weight of
your credibility and your energy as entities behind that
effort. So let me just begin by thanking you.
You heard the questions that Senator Roberts and I had for
Secretary Koh. I think you've got a very friendly audience here
in terms of the wisdom and merit of prevention investment. But
in order to get from being friendly into having real programs
that really support this effort, we have to go through a fairly
rigorous process of scoring and trying to work through that
this actually will save money and trying to figure out when.
It strikes me that supporting that kind of initiative would
be very valuable infrastructure for you in order to make these
arguments more effective and allow us to deploy this more
effectively as we go forward. I don't doubt for a moment that
you're right and, frankly, we're all right about this subject.
But when you get to the details of which should be rolled
out first, which will have the most immediate effect, which
will have the most pronounced effect, how do you tell one from
the other, where is the best way to put a fixed number of
dollars, I think more rigor would advance all of our causes.
And I'm interested in each of your thoughts on what you think
the best mechanism would be for establishing that kind of cost-
benefit rigor. And do you agree that if we had that improved,
that would, in turn, improve our ability to get legislation and
funding through this institution?
Ms. Brown first.
Ms. Brown. Certainly, the point, Senator, is an excellent
point. We at the American Heart Association believe that
demonstrated outcomes is really critical for all of the work
that we do. And I might mention, as one example, Dr. Koh was
asked about the Million Hearts Initiative. We're very closely
working with the Department of Health and Human Services and
all of the agencies on Million Hearts.
And as a matter of fact, we'll be together, harmonizing the
data so that the program of the American Heart Association,
Cancer Society, and Diabetes Association, called the guideline
advantage, can be used to collect data in communities to show
the return on investment and value in investing these dollars
of the Federal Government in saving a million heart attacks and
strokes in the next 5 years. And so measurement and evaluation
is a key part of that program.
One of the reasons we published a paper in circulation in
July of this year looking at the cost-effectiveness of
prevention is exactly to the kinds of questions that we've
heard asked today. We get asked those questions all the time at
the AHA as well, because we operate on donor dollars, and
donors want to understand, just as the Federal Government does,
that their dollars are being used to prevent heart disease and
stroke.
And so in our paper we were able to demonstrate a number of
ways that we can look at measuring the cost-effectiveness of
prevention, and we'd be happy to share that.
Senator Whitehouse. Dr. Seffrin.
Mr. Seffrin. I would certainly be appreciative of that
point of view, and I think it's extremely important, and we
should be as rigorous as we can be. I would only offer a
cautionary note. If you look at the entire spectrum of
interventions from primary public health to major league
intensive care and treatment and medicines, you might be
surprised how little rigor has been in some of those things
that have been funded heavily over and over and over again. But
I'm not arguing against rigor. I'm just saying that let's not
be harder on prevention than we are on other areas with respect
to health promotion.
The second point I would make----
Senator Whitehouse. Particularly when you're only 1 to 4
percent of the healthcare dollar, with all the gain that can be
made.
Mr. Seffrin. Exactly.
Senator Whitehouse. I understand that.
Mr. Seffrin. Exactly.
Senator Whitehouse. But this is less about the relative
merits of one strategy versus another than it is about being
able to move stuff through Congress----
Mr. Seffrin. Yes.
Senator Whitehouse [continuing]. With the kind of cost
justification that makes it easy to go rather than creating a
quarrel over whether the cost justification is there or not.
Mr. Seffrin. There are some things, though, that I think
about the breast and cervical cancer early detection program
and the limited funding for that. We've been able to
demonstrate and prove and publish literature of earlier
detection and saving of lives. And the disparity issue--that
would be an area that policymakers could invest a lot more
money and get a tremendous return on that investment.
I think you can look at things that you know will be
guaranteed, that will work. You can look at the Federal excise
tax on tobacco and increase it by $2 a pack. I think that was
recommended a number of years ago and never looked at
seriously. You do that--you're going to get results, and it'll
pay off.
Let me make one more point. I predict that within 24 to 36
months, the American Cancer Society will announce for the first
time in the history of the republic a 20 percent reduction in
age standardized cancer mortality rates in America. It's never
happened before in the world, in any country.
Senator Whitehouse. Repeat that again.
Mr. Seffrin. I predict that in 24 to 36 months, we'll be
announcing a 20 percent reduction in age standardized cancer
mortality rates in America. We already can show you that
900,000 people will have a birthday this year because they
didn't die of cancer, that would have if the cancer death rates
had stayed the same as they were in 1991. So that's why we say
we're the official sponsor of birthdays.
Now, my point in all that, a very important point--we know
that when we announce that, that is a $10 trillion economic
yield to the American public. So it's not just about the cost
of the program and what you get. It's also about the economic
value of intervening and keeping people healthier longer.
So aging is a global phenomenon. And in 20 years we know
precisely we're going to be 20 years older if we're still here.
And we're either going to be 20 years older and productive or
disabled, and if we're disabled, we've got a real economic
problem on our hands.
Senator Whitehouse. Mr. Chairman, my time has expired. I
thank you.
The Chairman. Thank you, Senator Whitehouse.
Senator Blumenthal.
Senator Blumenthal. Thank you, Mr. Chairman, and thank you
for holding this hearing on a topic that I think we all agree
is profoundly important, crucial to the future of healthcare
and the health of our Nation.
I want to thank all of you for your very good work in this
area.
Mr. Seffrin, I had a question about--and, by the way, thank
you for your longstanding and continued work on tobacco
cessation and prevention, which we began some years ago
together when I was attorney general. I was interested in a
statistic that you cited. I don't have it in front of me, but I
believe it's that cessation quit lines could reach 16 percent
of smokers annually.
Obviously, that's a lot better than 1 percent, but I was
curious as to why it's not 50 percent or 60 percent, why it's
only 16 percent. Maybe I misunderstand the statistic.
Mr. Seffrin. Well, it's resources, basically. We have a
call center in Austin, TX, that we can answer your calls 24
hours a day, 7 days a week, and on all holidays. We have a quit
line, but the key is that we can only service as many people as
we have funds for. So there's no question in my mind that 16
percent could be doubled or tripled if the resources were there
to pay for the service. As it turns out, quit lines are not
particularly inexpensive.
Senator Blumenthal. Well, I'm glad you clarified that,
because I had understood that part of your testimony to
indicate that that was the maximum, even with adequate funding,
that could be covered. But I think that's important to
recognize, that the only real limit is funding.
In fact, that was the experience in Connecticut. We had a
quit line with pharmaceutical drugs. There was a reluctance to
fund it, and it was exhausted within 30, 60 days. It was
supposed to last for a year. So people want to quit, don't
they?
Mr. Seffrin. Absolutely.
Senator Blumenthal. That is really across the board the
most enthusiastic anti-tobacco crusaders. Many of them are
smokers who want to quit and have tried again and again and
again and need some help to do so.
Mr. Seffrin. Absolutely correct.
Senator Blumenthal. Dr. Troy, if I can ask you, I
understand you have reservations about some of the anti-obesity
efforts, the reliance on Shrek and on Curtis Granderson by the
present administration. Do you have the same sorts of
reservations about anti-
tobacco efforts, that is, promotional and educational efforts
aimed at young people to try to stop them from beginning to
smoke?
Mr. Troy. Thank you for the question. I actually don't
really have that many reservations about Shrek and Curtis
Granderson. I happen to be a Yankee fan, and I'm all fine with
that. I just don't think that they're that effective broadly.
But, they don't spend that much government money, either, so
they're not a big problem. I like the idea of using role models
to help discourage kids from smoking, kids from overeating, and
encouraging them to exercise.
Senator Blumenthal. And, in fact, some of the most
effective role models are used in so-called spit tobacco or
chewing tobacco, as it's commonly known, where some of the
sports stars who have used it and who have suffered or seen
others suffer are, in effect, brought in front of classes or
groups of young people and are tremendously effective in that
regard, certainly much more effective than, I should say, even
a U.S. Senator or an Attorney General lecturing them and
preaching and so forth. But those role models are very
important, aren't they?
Mr. Troy. I'm a big fan of the use of role models, and
especially--I mean, it's tragic when you have these sports
stars who have done that. Babe Ruth, for example, died of
throat cancer from smoking too many cigars. It's tragic when
you have that happen. But it is important if we can leverage
these tragedies into getting good effects.
Senator Blumenthal. Thank you very much.
Thank you to all of you for your great work in this area
and thank you for being here today.
Thank you, Mr. Chairman.
The Chairman. Senator Franken.
Senator Franken. This is for anyone on the panel. Is a hot
workplace beneficial?
[Laughter.]
Mr. Seffrin. I don't think so.
Senator Franken. OK.
Senator Blumenthal. He didn't ask about hot air.
[Laughter.]
Senator Franken. Mr. Griffin, I want to----
Senator Roberts. Would the Senator yield? Are you talking
about this sauna bath we're in here or----
[Laughter.]
Senator Franken. Yes, I was, I was.
Thank you, Mr. Griffin, for talking about the National
Diabetes Prevention Program as a strong example of primary
prevention. In your experience, what elements of this program
make it so successful, and why should we be using limited
Federal dollars to fund it?
Mr. Griffin. Well, it answers Senator Whitehouse's question
and Senator Roberts, because it's built on actual dollars. It's
built on actual outcomes. These programs started with the NIH,
with actual clinical trials, translated into community-based
programs that led to the legislation that you and Senator Lugar
proposed. The cost, as we shared, is $300 per person to keep
them out of the circle of those with diabetes or full-blown
diabetes, part of the 26 million.
Senator Franken. I think the average to treat someone with
diabetes a year is about $6,000. Is that about right?
Mr. Griffin. That's right. And within that $6,000 are
countless, needless surgeries, hours of kidney dialysis, and
amputations within that. We know from the Urban Institute by
taking that $300--when we talk about cost-effectiveness, that
$300 keeps a third of those folks out of the diabetes
community--that we save $190 billion over 10 years. Those are
inevitable surgeries. Those one out of three Medicare dollars
are going for surgeries, eye surgeries, amputations that are
very expensive, and they are human tragedies as well as
financial ones.
This is one area where Congress has required scientific
rigor in the clinical trials at NIH and demonstrated it in a
community setting on a trial basis. Our only problem is that if
we could replicate it--not just in YMCAs where they are now,
the Y's. If we get them around the country, that's where that
$190 billion savings can be actually attained and procedures
averted that are otherwise going to overwhelm the healthcare
system. We cannot afford in the next 25 years to take care of
complications in that expensive manner.
Senator Franken. I want to thank you for sharing the story
of my constituent, Margaret Hutchinson. It's really inspiring
to see these folks go through this program and come out with
weight loss and with just a better life. I was talking with
General Shinseki, the Veterans Affairs Secretary. He visited
Minnesota in August. And I learned that diabetes affects more
than 1 million veterans.
You, obviously, share the belief that we should make this
more accessible to veterans and the elderly, and the elderly
have a higher success rate, actually, with the National
Diabetes Prevention Plan. Right?
Mr. Griffin. Seventy-one percent, even more than the 60
percent of others. That's right, Senator.
Senator Franken. I have one question for Dr. Troy, which
is, Do you know what the experience has been in Massachusetts?
Mr. Troy. I believe you had more companies covering. But
the structure is slightly different. And there was a study in
the Wall Street Journal that showed that AT&T, for example,
spends about $2.2 billion annually on covering its workers----
Senator Franken. Do you know the number of companies
covering?
Mr. Troy. I don't know the exact number, although I can
send it to you after, if you want, although I still don't know.
Senator Franken. Well, I do. It's the highest in the
country. Seventy-six percent of Massachusetts companies now
cover their employees. In fact, I believe it's the only State
since 2006, when their mandate went into effect, where
companies have increased--in every other State in the country,
it has gone down.
So I don't understand, did the Wall Street Journal have a
study or an editorial?
Mr. Troy. It was a statistic cited in the Wall Street
Journal.
Senator Franken. Cited where in the Wall Street Journal?
Mr. Troy. It was on the editorial page--an op-ed.
Senator Franken. On the editorial page.
Mr. Troy. It was an op-ed.
Senator Franken. OK. It was an op-ed----
Mr. Troy. Yes.
Senator Franken [continuing]. in the Wall Street Journal.
Mr. Troy. Yes.
Senator Franken. That's interesting.
Mr. Troy. But the statistic remains accurate.
Senator Franken. Thank you, Mr. Chairman.
[Laughter.]
Mr. Troy. May I respond?
Senator Franken. Yes, you can respond to that. Sure.
Mr. Troy. I just wanted to say what the statistic was,
which was that about $2.2 billion is spent by AT&T on providing
healthcare for its workers, and they calculated that it would
cost $600 million for them to dump their employees and pay the
penalty. Now, I personally don't think that AT&T might make
that calculation, because they're heavily in the public eye.
But other companies might look at--less prominent companies
might look at that spread, that $1.6 billion spread----
Senator Franken. Oh, I'd love to respond to your comment on
that statistic, because the point is--the same is true in
Massachusetts. These companies easily could have dropped their
employees and saved money. What they discovered was that to
keep valuable employees, they wanted to cover them, and it
became expected for companies to cover them.
Mr. Chairman.
The Chairman. Listen, I have a couple more questions I
would like to followup on.
Mr. Griffin, you've talked about the Diabetes Prevention
Program. Why do you think this program is more cost-effective
at the community level than similar programs that use a one-on-
one physician-patient approach? Why is that different?
Mr. Griffin. The primary care system is ill-equipped to
help a person who is in the zone of danger for diabetes.
Patients that--the physicians, even diabetes educators--we do
not have enough of them. They are not in the mainstream of
people's lives in our communities in our country.
The Y, for example, in most communities is a well-respected
organization with good standards. They're science-based. People
are comfortable. It works. We know that physicians--if they
could take one or two out of three of their patients who are
pre-diabetic and take them outside the zone of danger, they
would, but they can't. We know the Y has done a better job in a
patient's own community at keeping them outside the circle of
diabetes. That's where we want to keep them.
And we know--everybody at this table agrees we want people
more fit--better nutrition, more exercise and physical
activity. These programs work to do just that. They begin more
physical activity. They lose weight. Their blood glucose goes
down. The corresponding benefits are hypertension is lowered in
those populations. We've proven both in the science, in the
clinical part of it, that it works.
It's been translated into community-based programs, which
have been funded on a trial basis by this Congress in a
bipartisan way. It works. It works in a myriad of ways, and it
needs to be nationwide.
The Chairman. Let me focus on one other thing. Dr. Troy had
an interesting thing in his testimony. He said that the Army
found that 27 percent--you mentioned that--of its recruits were
unfit, too overweight to serve in the military.
``Retired Rear Admiral James Barnett put the issue
starkly, warning that our national security in 2030 is
absolutely dependent on reversing the alarming rates of
child obesity.''
OK. I want to know how--how do we do this? Do you have any
thoughts, any ideas you can share with us on how we get--
especially in the minority communities that we know--and
Hispanics. Well, how do we help there? How do we do that? Or do
we just throw up our hands and say it can't be done? What do we
do?
Mr. Griffin. Well, the association--what we've done is gone
around to school campuses, getting those sugar sweetened
beverages out of those campuses and encouraging--or not just
encouraging--actually, in some States, mandating that schools
have healthy choices available for those kids. We also know
from our experience with the Diabetes Prevention Program that
those parents who are educated as to nutrition and fitness--
they are going to take that to the next generation of children.
My sister is a pediatrician. She sees obese kids. When the
parents get the training on nutrition, when they get community-
based training, they can help with the next generation as well.
But, clearly, that is a problem.
And we are fortunate--as one of my colleagues just said
this--that the First Lady, in terms of making that a priority
in large companies, Wal-Mart, other places where she's worked,
as well as on school campuses--that is a way to intervene,
because children don't have any choice--the kinds of beverages
that adults put in front of them when they're small.
The Chairman. Well, we know one of the successes--the
success of public health in America has been through outreach
and community involvement. It seems like in the past we've done
a good job with that in terms of certain specific
interventions, immunizations, things like that.
But we haven't done a very good job of it in terms of
broad-based interventions in terms of diet, exercise--well,
we've done some on smoking. Some good interventions have been
done on smoking. But just diet and exercise--for example, what
kids should be eating, how parents can reinforce one another to
have healthy meals in schools. I've been fighting for years. In
the 1996 Farm bill, I first introduced an amendment to get
vending machines taken out of schools, and you see I was a
spectacular failure at that one.
But we have made progress. We're now getting the sugary
drinks out and the candy and stuff like that out. We're finally
getting there on that. But we need better thoughts and better
ideas on how we involve the community. And I'm thinking now of
the community of Hispanics and Latinos in this country, the
African-American community--for interventions and self-
reinforcement in that community. And I'm just open for thoughts
and suggestions on how we do that.
Ms. Brown.
Ms. Brown. To follow Dr. Koh's earlier testimony, two of
the important components of the Prevention Fund are the
Community Transformation Grants and the communities putting
prevention to work. And one of the really spectacular
components of those programs are that communities themselves
are looking at the issues that they're facing, whether it's a
high ethnic minority population or a more affluent population,
whatever their situation might be.
And they are identifying needs, coming together with
multiple stakeholders in a community, creating innovative ideas
and submitting them for funding that go through this very
rigorous peer review process that Dr. Koh identified. Therein
we will find many solutions that we can replicate in other
communities throughout the country. That's one thing that I
would mention.
The other thing I would say--several years ago, the
American Heart Association co-created the Alliance for a
Healthier Generation, which is focused on the issue of
childhood obesity, with the Clinton Foundation. And we have
worked in low-income schools throughout this country and
demonstrated with data collection a reduced rate of obesity in
kids, more physical activity, and it certainly helps to
incorporate families, teachers in creating a full environment
that promotes optimal health at a young age.
The Chairman. I'm just seeing if there's any other thoughts
on these community-based involvements.
Dr. Troy.
Mr. Troy. Yes. This is a real challenge, what you raised
about childhood obesity and how to address the questions when
children are obese, because you cannot apply economic
incentives there, and it's very hard to get in the home and
tell parents what to do. One study I found in my research on
this--and it was not in the Wall Street Journal, although I
think it's a perfectly legitimate place for studies. But this
was a study at the University of Illinois that found that a
college graduate is 12 to 28 percent less likely to be obese
than a similar person with just a high school degree.
So that goes across demographic groups. It's not just
within one demographic group or one class. So I'm not saying
that everybody needs to go to college or everybody can go to
college. But there is something about that higher education
that seems to promote lower obesity rates, and I was wondering
if we could study that and see what about the socialization you
get in higher education that we could apply to the parents who
would then hopefully apply it to their children.
The Chairman. I would wonder how much correlation there is
in that data with income, where they fall on the poverty-wealth
scale.
Mr. Troy. Right. And the key point is that--than a similar
person with a high school degree. So it applies across groups.
Now, obviously, people with a higher education do skew
wealthier. But what this study was comparing is people across
groups--people of lower income who get a college degree to
people of lower income who get just a high school degree.
The Chairman. It's just that people of low income tend to
have bad diets. Now, why do people of low income have bad
diets? As Michael Pollan pointed out in his book, he began to
think about that. And he went in the grocery store and found
out that poor people buy with food stamps, the SNAP program and
others. They tend to buy foods that are high in sugars, fats,
and starches.
Why do they do that? Because they're the cheapest. Why are
they the cheapest? Because we subsidize those the most in
agriculture, not fruits and vegetables. We don't subsidize
those, but we subsidize starches, fats, and sugars, so they're
cheap, and so people go and buy them. If you're pinching
pennies, you don't go to the fresh fruit and the fresh produce
counter. You buy packaged products. They're very cheap--high in
sodium, too, by the way, very high in sodium.
So we're trying some things. We tried some things in the
last Farm bill to try to get more fresh fruits, fresh
vegetables to those food deserts, as they say in the inner
cities and things. But, again, it seems to me that this is a
public health problem. No question it's a public health
problem. And why shouldn't we be approaching it that way?
Dr. Seffrin.
Mr. Seffrin. We should, and you're absolutely correct. The
most sobering thing for me in my life--because we know the
association between obesity and cancer, not one cancer but many
cancers. But the other point that's been made is how much it
involves all three of these major diseases, heart disease,
diabetes, and cancer.
The most sobering thing and why I say, prevention is the
best policy, is that we have very little evidence that we can
do much about morbid obesity once it occurs. When the best
thing you can do is cover gastric surgery at $25,000 a pop--and
one State, California, has over a million people who would
qualify under Medicare to have that--that's a pretty sobering
reality about what we know to do.
On the other hand, over 90 percent of our neonates are born
healthy.
The Chairman. Say that again.
Mr. Seffrin. Over 90 percent--in America, in this great
country, over 90 percent of newborn babies are born healthy.
And neonatal birth weights have not changed in over 300 years.
So we know this is an environmental problem and a policy issue.
We have to look at some of the good old days. You know, we used
to have exercise in school classes and physical education and
health education.
What I'm saying is I think it's complex and we don't have
exact answers, because we haven't been very effective at
controlling it. But it is a threat to this Nation's future
economic and public health stability. And policies need to be
developed to change the environment so kids are encouraged to
stay healthy.
Over 90 percent of those neonates are born healthy, and
most--not all--most are genetically programmed to stay healthy
for a normal human life span. And we need to create an
environment that encourages the kind of behaviors and practices
that would make that come true.
Mr. Griffin. There's been a thoughtful discussion, Senator,
among these three organizations and others about increasing the
percentages of children's diet that is--the sugar they get is
close to a third, just from sugar sweetened beverages. That's a
third of all of their sugar just from that one source. It's a
problem.
So there is a thoughtful discussion about taxing the heck
out of them. I mean, we have a task force at the ADA right now
studying sugar sweetened beverages and how do we lower its
consumption by young people, because that's why they are obese.
The Chairman. That's right.
Mr. Griffin. On the other hand, we know through the
programs that Congress has supported, through the Special
Diabetes Prevention Program, that when people can get
counseling on nutrition and fitness in their own communities
where they live and play, it works. And it covers more than one
generation, because once they've been sensitized to that fact
that we just talked about, that a fourth of calories that are
from those beverages alone contributing to obesity and cancer
and heart disease, we can make a difference. And so we have to
eliminate barriers to people having a good understanding of
both fitness and nutrition in their home neighborhood.
The Chairman. I appreciate you saying that. That was the
thought processes and the discussion that went on in setting up
these Community Transformation Grants--not that the government
has all the answers. We don't--but providing some framework for
communities to get together and discover their own ways of
doing things and coming--a lot of times, people say, ``Well,
what you're talking about is common sense.''
Well, yes, it's common sense, but until you get people
together in groups and have these supporting elements in
communities, where they recognize it's a community problem,
common sense kind of goes out the window, because people are
sort of by themselves out there, and they don't know what they
need to do. But with the Community Transformation Grants, you
encourage them to come up with their own solutions.
Mr. Griffin. That's right, but outcome-based. Like the
programs at the Y.
The Chairman. I want it outcome-based, and I want to know
which ones work best.
Mr. Griffin. Right. Exactly.
The Chairman. I diverge a little bit from some of my
colleagues who said we don't want to put money in anything
that's not proven. Well, I'd like to test some theories out.
I'd like to see maybe if somebody's got some ideas, if some
communities have an idea out there on doing something that
hasn't been done before. OK. Let's see if it works.
Maybe somebody's got a better idea out there. And why
should we be constrained by just the narrow things of what we
know that works? Maybe there are other things out there that
will work. So that's why I've been very promotive of getting
communities to come up with new ideas and new approaches on
this.
Well, it's been a great discussion. I'm sorry, Senator
Roberts. I yield to you.
Senator Roberts. Your recommendation is we increase taxes
on sugar products in regards to the soft drink industry and
also on tobacco? Is that correct?
Mr. Griffin. Dr. Seffrin has already talked about the
increase in cigarette prices, in terms of the decrease in the
use. Yes, there are plenty of studies that show that there will
be decreased consumption of sugar sweetened beverages if the
price goes up.
We have a task force currently that will--by gosh, at the
end of my term as chair of the board, we will have a policy by
the end of the year come hell or high water. But we are
currently studying the precise ways in which we can decrease
consumption.
Two of those methods being considered is allowing the
States to tax at a higher rate sugar sweetened beverages, and
also a subject that's on the table--very controversial--people
are thinking about it--is whether the SNAP program ought to be
adjusted so as participants in that program would not be able
to utilize the food stamp dollars to purchase those sorts of
beverages.
Senator Roberts. Now, that's an argument that's been going
on for some years.
Mr. Griffin. It has. But as long as our children are obese,
we are going to continue to have that discussion----
Senator Roberts. Or more obese.
Mr. Griffin. Or more obese--until that trajectory goes the
other way. And there is a sense of--how should I put this--
restlessness in the American people, at least in the 26 million
people in my community, and I'm sure it's the same in Cancer
and Heart. We want to make a dent in that. We want that dent to
happen sooner rather than later.
Senator Roberts. I don't know. Maybe it's because I come
from a--very fortunate. I didn't think so at the time--being
raised in a small community. And so there was mandatory gym in
high school, I think, when we were there, Mr. Chairman. Maybe
not. Maybe we have an age difference I'm not aware of.
But at any rate, there was mandatory gym. YMCA--we took a
bus down to Topeka and learned how to swim. It was mandatory.
I'm not quite sure why it was mandatory or who said it was
mandatory, but that's what we did. I learned how to swim. It's
a very easy process. They throw you in the deep end and say,
``Swim.'' That was a little harsh, but you do dog paddle back
to the side. And, of course, you probably fear water after
that, but that's beside the point.
There are a lot of activities that were going on in the
small town where I grew up during that era.
Mr. Griffin. That was a whole different era.
Senator Roberts. I understand that. And I have no trouble,
some of the time, thinking is this really the Federal
Government's responsibility to suggest--and it is suggest, not
coerce or mandate--local communities to do X, Y, or Z. I don't
think that's the answer. I think it is to try to network and
say, ``All right. This works. This doesn't. Why don't you give
this a try, et cetera, et cetera''--leave it up to the States
and the local communities.
But I was just interested in your recommendations on tax
policy. Does that come in on the 9-9-9 program, or is that----
[Laughter.]
All right. I'm sorry. I'm not behaving.
Mr. Griffin. We're not at Dartmouth anymore, Senator
Roberts.
Senator Roberts. Thank you.
Mr. Griffin. I'm just teasing.
Senator Roberts. Thank you all for your commentary and the
work you're doing. Thank you so much.
The Chairman. Thank you all. It was a great panel and great
testimony. I think we had a great exchange here. I request that
the record be kept open for 10 days until all Senators submit
statements and questions for the record.
Again, thank you all very much for this, and thank you for
all the work you do on the outside too.
[Additional material follows.]
ADDITIONAL MATERIAL
Prepared Statement of Senator Enzi
I would like to thank the Chairman for his continued focus
on chronic disease prevention. Our Nation has a problem with
obesity and chronic diseases, like cardiovascular disease,
diabetes, and cancer. The numbers speak for themselves--
according to CDC, 7 out of 10 deaths among Americans each year
are from chronic diseases.
Equally alarming is the rate of childhood obesity, which
has tripled in the last 30 years. The military is reporting
problems with recruiting because people don't qualify on the
fitness exams. Given these daunting statistics and accounts, it
is imperative that we come together to address these problems.
I fear the costs, both economic and otherwise, if we do not.&
What we need are solid, evidence-based proposals that
encourage people to take their health into their own hands. We
all know that individual behaviors and lifestyle choices can
have an impact on either preventing these diseases from
occurring or reducing their severity. Wellness programs are an
excellent way to incentivize healthy behaviors. Employers have
been looking to such programs to improve the health of their
employees and keep costs down. Safeway's CEO, Steven Burd, has
testified before this committee about the successes his company
has with its wellness program. I am encouraged by these kinds
of innovative ideas, and I look forward to hearing about more
ways that we can address this problem.&
What we don't need is to continue spending billions of
dollars to fund initiatives that restrict our ability to make
our own decisions. I'm concerned that in a time of record
deficits, we see the Secretary accepting recommendations for
coverage without cost sharing--without any analysis on what the
effect will be on the budget. In the past, CBO has said that a
number of preventive services add cost rather than savings. I
am not saying the recommendations are with or without merit--
simply that to not even consider the impact on the budget is
irresponsible.
Actions like this increase my concerns about the use of the
billions of dollars in the prevention fund. With little to no
accountability, this massive fund provides the Secretary with
unprecedented ability to dispense funds at her discretion. The
lack of accountability is alarming. In this budget environment,
we have to make careful decisions about how and where we
prioritize funding. The Fund allows the Secretary to fund
programs and initiatives over and above the amount Congress
deliberated over and allocated money for.
I am looking forward to hearing from Dr. Koh about how the
Fund is being used, and how it has improved health and reduced
public and private health care costs. We've got to make sure
that spending on prevention programs is evidence-based and
targeted with clear metrics on success.&
No one is denying that chronic disease is an issue on a
massive scale, and I anticipate that our witnesses will provide
sobering testimony on the state of chronic disease in the
United States. Scientists, medical professionals, public health
workers, policymakers, and even economists have been working to
prevent and treat chronic diseases. I commend them for their
tireless devotion to this problem facing our country.&
I have been working on ways to fix our broken healthcare
system for well over a decade now. One of the chronic problems
I've encountered time and time again is proposals that do
nothing to lower health care costs and instead, in fact,
dramatically increase health care spending. We can't keep doing
things the Washington way, passing the buck, literally, to the
next generation. The American people are calling for us to look
at spending, look at the debt, and do something about it. We
can, and should do better. I look forward to hearing from our
witnesses, and thank them for taking the time to be here today.
[Whereupon, at 4:41 p.m., the hearing was adjourned.]