[Senate Hearing 112-871]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 112-871
 
                THE STATE OF CHRONIC DISEASE PREVENTION 

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

                                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


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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

                              ----------                              


                      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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \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\
---------------------------------------------------------------------------
    \10\ Preliminary results, updated from Zhou, F., Arch of Pediatric 
and Adolescent Medicine.
    \11\ http://www.cdc.gov/mmwr/pdf/wk/mm60e0301.pdf.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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\
---------------------------------------------------------------------------
    \1\  The Global Economic Burden of Non-communicable Diseases. 
Prepared by the World Economic Forum and the Harvard School of Public 
Health (2011).
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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).
---------------------------------------------------------------------------
                      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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    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.]



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