[Senate Hearing 115-661]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 115-661

                    ENCOURAGING HEALTHY COMMUNITIES:
                  PERSPECTIVE FROM THE SURGEON GENERAL

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

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                                   ON

EXAMINING ENCOURAGING HEALTHY COMMUNITIES, FOCUSING ON PERSPECTIVE FROM 
                          THE SURGEON GENERAL
                               __________

                           NOVEMBER 15, 2017
                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions
                                
                  [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]                                

        Available via the World Wide Web: http://www.govinfo.gov


                              ___________

                    U.S. GOVERNMENT PUBLISHING OFFICE
                    
27-683 PDF                WASHINGTON : 2019


          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                  LAMAR ALEXANDER, Tennessee, Chairman
MICHAEL B. ENZI, Wyoming             PATTY MURRAY, Washington
RICHARD BURR, North Carolina         BERNARD SANDERS (I), Vermont
JOHNNY ISAKSON, Georgia              ROBERT P. CASEY, JR., Pennsylvania
RAND PAUL, Kentucky                  AL FRANKEN, Minnesota
SUSAN M. COLLINS, Maine              MICHAEL F. BENNET, Colorado
BILL CASSIDY, M.D., Louisiana        SHELDON WHITEHOUSE, Rhode Island
TODD YOUNG, Indiana                  TAMMY BALDWIN, Wisconsin
ORRIN G. HATCH, Utah                 CHRISTOPHER S. MURPHY, Connecticut
PAT ROBERTS, Kansas                  ELIZABETH WARREN, Massachusetts
LISA MURKOWSKI, Alaska               TIM KAINE, Virginia
TIM SCOTT, South Carolina            MAGGIE WOOD HASSAN, New Hampshire
               David P. Cleary, Republican Staff Director
         Lindsey Ward Seidman, Republican Deputy Staff Director
                 Evan Schatz, Democratic Staff Director
             John Righter, Democratic Deputy Staff Director

                                  (ii)

  


                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                      WEDNESDAY, NOVEMBER 15, 2017

                                                                   Page

                           Committee Members

Alexander, Hon. Lamar, Chairman, Committee on Health, Education, 
  Labor, and Pensions, opening statement.........................     1
Murray, Hon. Patty, Ranking Member, Committee on Health, 
  Education, Labor, and Pensions, opening statement..............     3

                                Witness

Adams, Jerome, Vice Admiral, M.D., MPH, Surgeon General of the 
  Public Health Service, Washington, DC..........................    12

                                 (iii)


 
                    ENCOURAGING HEALTHY COMMUNITIES:
                  PERSPECTIVE FROM THE SURGEON GENERAL

                              ----------                              


                      Wednesday, November 15, 2017

                               U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:05 a.m., in 
room SD-430, Dirksen Senate Office Building, Hon. Lamar 
Alexander, Chairman of the Committee, presiding.
    Present: Senators Alexander [presiding], Cassidy, Young, 
Murray, Casey, Franken, Bennet, Whitehouse, Murphy, Warren, 
Hassan, and Kaine.

                 Opening Statement of Senator Alexander

    The Chairman. The Senate Committee on Health, Education, 
Labor, and Pensions will please come to order.
    Today, we're holding a hearing with the Surgeon General, 
Dr. Jerome Adams, to hear his priorities on how to encourage 
people to lead healthier lives. Senator Murray and I will each 
have an opening statement. Then we'll introduce Dr. Adams. 
After his testimony, Senators will each have 5 minutes of 
questions.
    When Dr. Adams and I met before his confirmation hearing, I 
said to him that if, as Surgeon General, he threw himself into 
one important problem with everything he has, he could have a 
real impact on the lives of millions of Americans. At his 
confirmation hearing, he said, ``I would make wellness and 
community, and employer engagement a centerpiece of my agenda 
if confirmed. Our health starts in the communities where we 
live, learn, work, play, and go to school.''
    Dr. Adams has said his first Surgeon General's Report will 
focus on health and the economy. So it makes sense for that to 
be his focus, because there is a remarkable consensus that 
wellness--lifestyle changes like eating healthier and quitting 
smoking--can prevent serious illness and reduce healthcare 
costs. This is important because the United States spends about 
$2.6 trillion treating chronic diseases. This accounts for more 
than 84 percent of our healthcare costs--$2.6 trillion treating 
chronic diseases, 84 percent of our healthcare costs.
    Today, Dr. Adams will talk to us about what local 
communities, businesses, and other organizations can do to 
encourage people to live healthier lives, which will help 
reduce healthcare spending on chronic diseases. The Cleveland 
Clinic has said if you achieve at least four normal measures of 
good health, such as a healthy body mass index and blood 
pressure, and you see a primary care physician regularly and 
keep immunizations up to date, you will avoid chronic disease 
about 80 percent of the time.
    At a hearing we held last month on wellness, I said that it 
is hard to think of a better way to make a bigger impact on the 
health of millions of Americans than to connect the consensus 
about wellness to the health insurance that 178 million people 
get on the job.
    One of our witnesses last month, Steve Burd, talked about 
an employee wellness program he implemented while CEO of 
Safeway that has reduced the biological age of employees by 4 
years.
    He said, ``Given that 70 percent of healthcare spending is 
driven by behaviors, employers can have a powerful impact on 
both employee health and healthcare cost. Healthcare costs 
continued to decline by 9 percent per year as Safeway with no 
material changes to plan design. Safeway's health actuaries 
reported this continued cost reduction was due predominately to 
improved health status.''.
    Many employers have developed similar wellness programs to 
incentivize people to make healthier choices.
    These programs may reward behaviors such as exercising, 
eating better or quitting smoking, or offer employees a 
percentage off their insurance premiums for doing things like 
maintaining a healthy weight or keeping their cholesterol 
levels in check.
    Last month, we heard that while both employees and 
employers benefit from lower healthcare costs, both also can 
benefit in other ways when people live healthier lives.
    Michael Roizen, the Chief Wellness Officer at the Cleveland 
Clinic, told us, quote, ``The culture of wellness at the 
Cleveland Clinic has generated remarkable results that have led 
to shared benefits: healthier, happier employees, as well as 
lower costs for their self-funded insurance program, and lower 
costs for our employees and the communities and patients we 
serve.'' In other words, a healthier workplace translates to 
the greater community being healthier.
    In recent years, a growing number of organizations and 
communities have developed innovative programs to incentivize 
individuals to engage in healthy behaviors.
    For example, BlueCross BlueShield of Tennessee partnered 
with local, state, and private organizations to fund community 
level initiatives across the state, such as Fitness Zones in 
Chattanooga, programs in rural counties to promote healthy 
habits, and an interactive elementary school program to keep 
kids moving. An overall healthy community is more economically 
productive. There are fewer workplace accidents, less 
absenteeism, and a higher rate of engagement.
    At his confirmation hearing, Dr. Adams also said not all 
national problems should have a response from Washington, DC. I 
agree. We don't get any smarter flying to Washington each week. 
Dr. Adams' motto as Surgeon General is, quote, ``Better health 
through better partnerships,'' and I hope this Committee can be 
one partner going forward.
    I look forward to hearing how community level partnerships 
and engagement can lead to healthier individuals, higher 
quality healthcare, and lower healthcare costs.
    Senator Murray.

                  Opening Statement of Senator Murray

    Senator Murray. Thank you, Mr. Chairman.
    Before we begin today's conversation, I do want to comment 
on the decision by Senate Republicans to once again attempt to 
raise families' costs and take away their healthcare, this time 
to fund tax cuts for massive corporations and the rich, while 
using the bipartisan agreement that Chairman Alexander and I 
and Members of this Committee reached as nothing more than 
political cover.
    First, let's be clear about the policy. Tacking Alexander-
Murray onto the partisan Republican tax reform effort is like 
trying to put out a fire with penicillin. It will not do 
anything to help. The Alexander-Murray Bill was intended to 
lower costs and stabilize the market, but millions of people 
will still be left paying more and losing coverage if Senate 
Republicans sabotage families' healthcare to help millionaires 
and billionaires get more tax breaks they probably don't need.
    Second, the way this was done, by sneaking devastating 
healthcare changes into a partisan bill at the last minute, is 
completely counter to the bipartisan spirit in which we worked 
on this stabilization bill. Many of us agreed in the wake of 
the partisan repeal efforts earlier this year that jamming 
partisan policy through before anyone has a chance to see it is 
absolutely not the right way to get things done. It is 
especially disappointing to see this happen because in working 
on our bill and reaching an agreement, we proved that we can 
work under regular order and find common ground.
    Finally, Mr. Chairman, I've said many times before how much 
I appreciate your willingness to work across the aisle after 
Trumpcare failed in July to try to get a result that actually 
helps families rather than burdening them with higher costs and 
causing millions to lose coverage. think the work that we and 
this Committee are able to do together when we focus on what's 
best for patients and families is exactly what people want to 
see happening in Congress.
    What Senate Republicans are proposing now is the exact 
opposite and the wrong direction for families' health and 
financial security. It would be deeply disappointing for people 
who are looking to Congress for leadership, not partisanship, 
if this latest partisan Republican effort undermined both the 
policy and the spirit of the agreement that we were able to 
reach.
    Now, having said that, Dr. Adams, I do want to welcome you. 
It's good to see you again, and I want to focus on this 
hearing. As you know, several weeks ago, this Committee held a 
hearing focused primarily on supporting health and wellness 
through employee wellness programs. I, for one, was very 
encouraged by our discussion on workplace wellness, as well as 
on the importance of protecting workers' civil rights and 
privacy. I'm glad that we're continuing that discussion today 
by exploring the role of community prevention programs. Disease 
prevention and health promotion is a critical part of improving 
families' well-being, and we also know it can help yield better 
health outcomes and lower costs.
    Now, one thing I look forward to talking about more about 
is the diverse role that stakeholders have in supporting 
healthy communities. As I have said before, we all have an 
important role to play in supporting health and wellness. That 
means supporting public health at all levels, including 
initiatives that promote physical activity, increase access to 
healthy foods, expand on science-based ways to reduce tobacco 
use, and a lot more.
    Again, not only is this an important aspect of improving 
the health of families, but it's also our local economies that 
stand to benefit from the increased engagement of stakeholders 
and businesses in partnership with government at all levels in 
health promotion efforts.
    This is something I know that you, Dr. Adams, are very 
interested in, and I am encouraged that you are seeking input 
on how the business community can do more to contribute to 
community health.
    Now, as you know, many businesses are already working hard 
on this, and they are taking steps to invest in public health 
efforts. It's something I've seen in my home State of 
Washington, and I know it's happening in many states, where we 
have businesses searching for ways to better support the health 
and wellness of their workers, and where we have businesses 
reaching out to our most at-risk populations of all ages, as 
well as partnering with health departments and other partners 
in the health community.
    Needless to say, we want to encourage and build on these 
efforts.
    Now, I'm looking forward to today's discussion on how we 
can continue to bring communities together to prioritize public 
health. I am appreciative of your focus on this, Dr. Adams, and 
I stand committed to working with you and all of my colleagues.
    But I couldn't let a hearing about encouraging healthy 
communities take place without pointing out that, on the whole, 
it's hard to imagine what else the Trump Administration could 
be doing right now to undermine the health of our communities.
    I hope you agree that the following are all essential to 
supporting public health and well-being: first, investing in 
public health and prevention rather than slashing investments 
in the Prevention and Public Health Fund; helping women get the 
reproductive healthcare they need; supporting services that 
allow people with disabilities and aging adults to remain in 
their home and part of their communities; making sure people 
struggling with opioid use disorders get comprehensive 
healthcare coverage, including through Medicaid; and responding 
effectively to urgent threats of disease and unsanitary 
conditions in the wake of natural disasters like we've seen in 
Puerto Rico and nationwide. Unfortunately, the Trump 
Administration has failed profoundly in these areas and many 
others.
    As we move forward with these discussions, I want to be 
clear. I will continue to urge the Trump Administration to 
reverse its course and put the health and well-being of 
children, women, and families ahead of politics. That certainly 
includes any efforts to sabotage the bipartisan legislation 
many of us in this Committee worked so hard to agree on in 
favor of yet another partisan healthcare repeal effort that 
will leave families paying more and losing coverage.
    Mr. Chairman, before I close, I do want to submit a 
statement by the American Association for Family Physicians for 
the record. Thank you.
    [The information referred to follows:]
                                ------                                

    On behalf of the American Academy of Family Physicians 
(AAFP) thank you for the opportunity to submit this Statement 
for the Record for the U.S. Senate Health, Education, Labor, 
and Pensions Committee's hearing, Encouraging Healthy 
Communities: Perspectives from the U.S. Surgeon General.
    The AAFP appreciates the Committee's interest in examining 
health through the lens of community health. Consistent with 
the World Health Organization's definition, the AAFP believes 
that health is ``a state of complete physical, mental, and 
social well-being and not merely the absence of disease or 
infirmity.'' As the largest society of primary care physicians, 
we are committed to helping patients achieve health and in 
supporting initiatives that build healthy communities. It is 
also our view that community health does not occur by 
coincidence. Healthy communities develop through robust 
research as well as investments from citizens, community-based 
organizations, educational institutions, governments, and the 
private sector.

         Primary Care is Associated With Healthier Communities

    The AAFP acknowledges that physicians play an important 
role in community health, both as clinicians, but also as 
community partners who understand that what takes place outside 
of the doctor's office (the social determinants of health) 
impacts patients' health and the health of a community. Still, 
primary care (comprehensive, first contact, whole person, 
continuing care) is the foundation of an efficient health 
system. It is not limited to a single disease or condition, and 
can be accessed in a variety of settings. Primary care (family 
medicine, general internal medicine and general pediatrics) is 
provided and managed by a personal physician, based on a strong 
physician-patient relationship, and requires communication and 
coordination with other health professionals and medical 
specialists. The benefits of primary care do not just accrue to 
the individual patient.
    Primary care also translates into healthier communities. 
\1\ For instance, U.S. states with higher ratios of primary 
care physician-to-population ratios have better health 
outcomes, including lower rates of all causes of mortality: 
mortality from heart disease, cancer, or stroke; infant 
mortality; low birth weight; and poor self-reported health. 
This is true even after controlling for sociodemographic 
measures (percentages of elderly, urban, and minority; 
education; income; unemployment; pollution) and lifestyle 
factors (seatbelt use, obesity, and smoking). \2\
---------------------------------------------------------------------------
    \1\  Shi L, Macinko J, Starfield B, Politzer R, Wulu J, Xu J. 
Primary Care, Social Inequalities, and All-Cause, Heart Disease, and 
Cancer Mortality in U.S. Counties, 1990. American Journal of Public 
Health. 2005a;95:674-80.
    \2\  Shi L, The relationship between primary care and life chances. 
J Health Care Poor Underserved. 1992 Fall; 3(2):321-35
---------------------------------------------------------------------------
    The dose of primary care can even be measured--an increase 
of one primary care physician per 10,000 people is associated 
with an average mortality reduction of 5.3 percent, or 49 fewer 
deaths per 100,000 per year. \3\ High quality primary care is 
necessary to achieve the triple aim of improving population 
health, enhancing the patient experience and lowering per 
capita costs. \4\
---------------------------------------------------------------------------
    \3\  Macinko J, Starfield B, Shi L. Quantifying the health benefits 
of primary care physician supply in the United States. Int J Health 
Serv. 2007;37(1):111-26.
    \4\  Shi L, Starfield B, Primary care, income inequality, and self-
rated health in the United States: a mixed-level analysis. Int J Health 
Serv. 2000; 30(3):541-55.
---------------------------------------------------------------------------
    Patients, particularly the elderly, with a usual source of 
care are healthier and have lower medical costs because they 
use fewer health care resources and can resolve their health 
needs more efficiently. \5\ In contrast, those without a usual 
source of care have more problems getting health care and more 
often do not receive appropriate medical help when it is 
necessary. \6\ Patients who gain a usual source of care have 
fewer expensive emergency room visits, unnecessary tests and 
procedures. They also enjoy better care coordination. \7\ We 
believe it is in the national interest to support programs with 
the potential to help improve patient access for this 
population.
---------------------------------------------------------------------------
    \5\  Gilfillan, R. J., Tomcavage, J., Rosenthal, M. B., Davis, D. 
E., Graham, J., Roy, J. A., & ... Steele, J. D. (2010). Value and the 
Medical Home: Effects of Transformed Primary Care. American Journal of 
Managed Care, 16(8), 607-615
    \6\  Ibid.
    \7\  Liaw, W., Jetty, A., Petterson, S., Bazemore, A. and Green, L. 
(2017), Trends in the Types of Usual Sources of Care: A Shift from 
People to Places or Nothing at All. Health Serv Res. doi:10.1111/1475-
6773.12753
---------------------------------------------------------------------------

     The Nation's Primary Care Shortage is a Community Health Issue

    The current physician shortage and uneven distribution of 
physicians impacts population health. A U.S. Centers for 
Disease Control and Prevention study indicated that patients in 
rural areas tend to have shorter life spans, and access to 
health care is one of several factors contributing to rural 
health disparities. \8\ The report recommended greater patient 
access to basic primary care interventions such as high blood 
pressure screening, early disease intervention, and health 
promotion (tobacco cessation, physical activity, healthy 
eating). \9\ The findings highlighted in the CDC's report are 
consistent with numerous others on health equity, including a 
longitudinal study published in JAMA Internal Medicine, 
indicating that a person's zip code may have as much influence 
on their health and life expectancy as their genetic code. \10\ 
Therefore, it is imperative that physician care is accessible 
for all.
---------------------------------------------------------------------------
    \8\  Moy E, Garcia MC, Bastian B, et al, Leading Cause of Death in 
Nonmetropolitan and Metropolitan Areas - United States, 1999 - 2014, 
MMWR, Surveil Summ, 2017; 66 (No.SS-1); 1-8. DOI: https://www.cdc.gov/
mmwr/volumes/66/ss/ss6601a1.htm
    \9\  MMWR, 2017
    \10\  Dwyer-Lindgren L, Bertozzi-Villa A, Stubbs RW, Morozoff C, 
Mackenbach JP, van Lenthe FJ, Mokdad AH, Murray CJL. Inequalities in 
Life Expectancy Among US Counties, 1980 to 2014Temporal Trends and Key 
Drivers. JAMA Intern Med. 2017;177(7):1003-1011. doi:10.1001/
jamainternmed.2017.0918
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    The current primary care physician shortage and its 
maldistribution remain significant physician workforce 
challenges. An Annals of Family Medicine study \11\ projects 
that the changing needs of the U.S. population will require an 
additional 33,000 practicing primary care physicians by 2035. A 
2017 Government Accountability Office (GAO) report indicates 
that physician maldistribution significantly impacts rural 
communities. \12\ The patient-to-primary care physician ratio 
in rural areas is only 39.8 physicians per 100,000 people, 
compared to 53.3 physicians per 100,000 in urban areas. \13\ 
According to GAO, one of the major drivers of physician 
maldistribution is that medical residents are highly 
concentrated in very few parts of the country. The report 
stated that graduate medication education (GME) training 
remained concentrated in the Northeast and in urban areas, 
which continue to house 99 percent of medical residents. \14\ 
The GAO also indicated that while the total number of residents 
increased by 13.6 percent from 2001 to 2010, the number 
expected to enter primary care decreased by 6.3 percent. \15\
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    \11\  http://www.annfammed.org/content/13/2/107.full
    \12\  U.S. Government Accountability Office, May 2017, GAO 17-411, 
http://www.gao.gov/assets/690/684946.pdf
    \13\  Hing, E, Hsiao, C. US Department of Health and Human 
Services. State Variability in Supply of Office-based Primary Care 
Providers: United States 2012. NCHS Data Brief, No. 151, May 2014
    \14\  GAO, 2017
    \15\  Ibid
---------------------------------------------------------------------------
    Primary care workforce programs, such as the Teaching 
Health Center Graduate Medical Education Program and the 
National Health Service Corp Program, are essential resources 
to begin to increase the number of primary care physicians and 
to ensure they work in communities that need them most. The 
THCGME program appropriately trains residents who then stay in 
the community. THCGME residents are trained in delivery system 
models using electronic health records, providing culturally 
competent care, and following care coordination protocols. \16\ 
Some are also able to operate in environments where they are 
trained in mental health, drug and substance use treatment, and 
chronic pain management. \17\ Residents who train in 
underserved communities are likely to continue practicing in 
those same environments. \18\
---------------------------------------------------------------------------
    \16\  Candice Chen, Frederick Chen, and Fitzhugh Mullan. ``Teaching 
Health Centers: A New Paradigm in Graduate Medical Education.'' 
Academic Medicine: Journal of the Association of American Medical 
Colleges 87.12 (2012): 1752-1756. PMC. available at https://
www.ncbi.nlm.nih.gov/pmc/articles/PMC3761371/
    \17\  David Mitchell, Residency Directors Tout Benefits of Teaching 
Health Center GME Program, AAFP News, (September 6, 2013), available at 
http://www.aafp.org/news/education-professional-development/
20130906thcroundtable.html
    \18\  Elizabeth Brown, MD, and Kathleen Klink, MD, FAAFP, Teaching 
Health Center GME Funding Instability Threatens Program Viability, Am 
Fam Physician. (Feb. 2015);91(3):168-170. Available at http://
www.aafp.org/afp/2015/0201/p168.html
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    American Medical Association Physician Masterfile data 
confirms that a majority of family medicine residents practice 
within 100 miles of their residency training location. \19\ By 
comparison, fewer than 5 percent of physicians who complete 
training in hospital-based GME programs provide direct patient 
care in rural areas. \20\ Thus, the most effective way to 
encourage family and other primary-care physicians to practice 
in rural and underserved areas is not to recruit them from 
remote academic medical centers but to train them in these 
settings. Similarly, the National Health Care Corps (NHSC) 
offers financial assistance to recruit and retain health care 
providers to meet the workforce needs of communities across the 
Nation designated as health professional shortage areas 
(HPSAs). The NHSC is vital for supporting the needs of our 
Nation's vulnerable communities. The AAFP believes building the 
primary care workforce is an important return on investment. We 
also believe that workforce programs help ensure high quality, 
efficient medical care is more readily available. By reducing 
physician shortages and attracting physicians to serve in 
communities that need them, these programs also help improve 
the way care is delivered and help meet the Nation's health 
care goals.
---------------------------------------------------------------------------
    \19\  E. Blake Fagan, MD, et al., Family Medicine Graduate 
Proximity to Their Site of Training, Family Medicine, Vol. 47, No. 2, 
at 126 (Feb. 2015).
    \20\  Candice Chen, MD, MPH, et al., Toward Graduate Medical 
Education (GME) Accountability: Measuring the Outcomes of GME 
Institutions, Academic Medicine, Vol. 88, No. 9, p. 1269 (Sept. 2013).
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                                ------                                


                Disease Prevention and Population Health

                 Mental Health and Substance Use Issues

    Family physicians have traditionally focused on treating 
the whole patient, and recognize the mind, body and spirit 
connection. Promotion of mental health, diagnosis and treatment 
of mental illness in the individual and family context are 
integral components of family medicine. Mental health is also 
fundamental for patient and health and community well-being. 
The AAFP believes that access to increased mental health and 
substance use funding is a national imperative. According to 
SAMHSA's 2014 National Survey on Drug Use and Health (NSDUH), 
an estimated 43.6 million (18.1 percent) Americans ages 18 and 
up experienced some form of mental illness. \21\ In the past 
year, 20.2 million adults (8.4 percent) had a substance use 
disorder. Of these, 7.9 million people had both a mental 
disorder and substance use disorder. \22\
---------------------------------------------------------------------------
    \21\  Substance and Mental Health Services Administration, https://
www.samhsa.gov/disorders
    \22\  SAMHSA, Substance Use and Mental Health Disorders
---------------------------------------------------------------------------
    Social factors, such as early life experiences, poverty, 
racial and ethnic minority status, and exposure to violence, 
put patients at greater risk of developing mental illnesses. 
Mental illness is associated with increased occurrence of 
chronic diseases such as cardiovascular disease, diabetes, 
obesity. \23\ Research found that among elderly patients with 
high depressive scores, the risk of coronary heart disease 
increased 40 percent while the risk of death increased 60 
percent compared with elderly patients with the lowest mean 
depressive scores. \24\
---------------------------------------------------------------------------
    \23\  AAFP, Mental Health Care Services by Family Physicians,
    \24\  Ibid
---------------------------------------------------------------------------
    The AAFP commends Congress mental health reform efforts, 
but there is still significant progress needed to fully 
implement the Mental Health Parity and Addiction Equity Act and 
to eliminate barriers for primary care and behavioral health 
integration. People with mental or substance abuse disorders 
were more likely to get treatment from a primary care 
physician/nurse or other general medical doctor. \25\ We urge 
continued progress to address this issue.
---------------------------------------------------------------------------
    \25\  Ibid
---------------------------------------------------------------------------
    The AAFP shares the administration's commitment to 
addressing the Nation's opioid crisis through public education, 
substance use treatment, overdose prevention, and improved 
prescription drug monitoring. In 2015, the AAFP joined partners 
in the public and private sector in announcing a unified effort 
to address the Nation's epidemic of opioid abuse and heroin 
use. The AAFP, along with the more than 40 stakeholder groups, 
pledged to increase opioid abuse prevention, treatment, and 
related activities. Over the next few years, medical and health 
stakeholders have committed to having more than 540,000 
physicians and health care professionals complete opioid 
prescriber training in the next 2 years; double the number of 
physicians certified to prescribe buprenorphine for opioid use 
disorder treatment--from 30,000 to 60,000--in the next 3 years; 
double the number of clinicians who prescribe naloxone; double 
the number of physicians and health care professionals 
registered with their State Prescription Drug Monitoring 
Programs in the next 2 years; and, reach more than 4 million 
physicians and health care professionals with awareness 
messaging about opioid abuse.

                            Chronic Diseases

    Chronic diseases are the leading causes of mortality and 
morbidity in the United States adult population. According to 
the CDC, the leading chronic conditions are heart disease, 
cancers, stroke, obesity, diabetes, and arthritis. \26\ As of 
2012, about half of all adults-117 million people-had one or 
more chronic health conditions. \27\ One in four adults had two 
or more chronic health conditions and seven of the top 10 
causes of death in 2014 were chronic diseases. \28\ Two of 
these chronic diseases-heart disease and cancer-together 
accounted for nearly 46 percent of all deaths. \29\ These 
conditions are mostly preventable; therefore, it is vital that 
as a country we invest in preventive health efforts.
---------------------------------------------------------------------------
    \26\  CDC, Chronic Diseases, https://www.cdc.gov/chronicdisease/
overview/index.htm
    \27\  Ibid
    \28\  Ibid
    \29\  Ibid
---------------------------------------------------------------------------
    Preventive health is essential for adults, especially with 
the aging of the U.S. population. By the year 2050, the number 
of people 65 years of age and older will nearly double 
increasing the population of Medicare patients, 82 percent of 
whom have chronic health conditions. \30\ As a country, we will 
only succeed at caring for this population by strengthening 
primary care, a specialty that is highly skilled in addressing 
the needs of patients with chronic diseases and multiple 
conditions. Better chronic care management is associated with 
fewer trips to the hospital and appropriate utilization of less 
expensive medical care. \31\ Making strides in this area will 
require a serious commitment to patient education, health care 
access, and community support.
---------------------------------------------------------------------------
    \30\  Tricia Neuman, Juliette Cubanski, Jennifer Huang, Anthony 
Dominco, Kaiser Family Foundation, Report, Rising Cost of Living Longer 
(January 2015), accessed online at:http://kff.org/medicare/report/the-
rising-cost-of-living-longer-analysis-of-medicare-spending-by-age- for-
beneficiaries-in-traditional-medicare/
    \31\  Reid B. Blackwelder, MD, Leaders Voices Blog, (October 2014), 
We're Doing Our Part to Keep SGR Issue On Congress' Radar, http://
blogs.aafp.org/cfr/leadervoices/entry/we--re--doing--our--part
---------------------------------------------------------------------------
    Programs, such as those that increase access to healthy 
foods and to increase opportunities to walk through 
improvements to the built environment have the capacity to help 
lower the risk of disease such as heart disease, stroke, and 
diabetes.
    Tobacco use is the single largest cause of preventable 
disease in the United States. Cigarette smoking kills more than 
480,000 Americans each year, with more than 41,000 of these 
deaths from exposure to secondhand smoke \32\ The AAFP supports 
these initiatives through its Tar Wars Program, a community-
based effort to encourage family physicians to educate school-
age youth about the dangers of smoking. The program began and 
has been particularly supportive of programs to reduce smoking 
and to increase access to cessation programs. The AAFP has also 
supported the Family Smoking Prevention and Tobacco Control 
Act's full implementation, including efforts to restrict 
adolescents from using tobacco programs. The AAFP supports 
restrictions on the sales of specialty and flavored tobacco 
products, regulations on electronic nicotine delivery devices, 
and prohibits on the sale of tobacco products for those under 
21 years of age.
---------------------------------------------------------------------------
    \32\  CDC, https://www.cdc.gov/tobacco/campaign/tips/resources/
data/cigarette-smoking-in-united-states.html
---------------------------------------------------------------------------

                  Immunization and Infectious Diseases

    Immunizations are a 21st century public health success, yet 
42,000 adults and 300 children in the United States die each 
year from vaccine-preventable diseases. \33\ A 2016 report 
published in Health Affairs indicates that the economic costs 
of vaccine-preventable disease for adults is between $4.7 
billion and $14 billion per year. \34\ Although vaccines are 
available in many different locations, such as pharmacies and 
in workplaces, primary care physicians play an important role 
as immunizers. The doctor-patient relationship can be 
instrumental in helping patients overcome their hesitancy or 
educating them when new immunizations are recommended.
---------------------------------------------------------------------------
    \33\  Office of Disease Prevention and Health Promotion, Healthy 
People 2020, https://www.healthypeople.gov/2020/topics- objectives/
topic/immunization-and-infectious-diseases
    \34\  Modeling The Economic Burden Of Adult Vaccine-Preventable 
Diseases In The United States. Health Aff (Millwood). 2016 Nov 
1;35(11):2124-2132. Epub 2016 Oct
---------------------------------------------------------------------------
    Doctors also understand patients' medical histories and 
risk factors. For example, primary care physicians can help 
diabetes mellitus patients understand how the condition 
compromises their immune system and why their vaccinations 
should be up-to-date. Health experts also agree that global 
cooperation is an important value, but it is also important 
note that infectious disease knows no boundaries. The AAFP 
supports programs that increase access to vaccines, such as the 
CDC's Section 317 Immunization Grant program. The program 
provides funding to states to immunize underserved populations. 
The AAFP also supports policies to improve immunization 
information system interoperability to allow physicians to 
access state data bases and to allow for better interstate 
communication.
    The AAFP recognizes the importance of addressing the spread 
of antibiotic resistant bacteria. AAFP has committed to 
reducing the use of unnecessary antibiotics in medicine, but 
there is still significant progress needed within animal 
agriculture. Currently, 70 percent of the antibiotics used in 
the US are used for food-producing animals. It is our hope that 
progress continues under the U.S. Food and Drug 
Administration's current initiatives to reduce the over-
utilization of antibiotics in animals.

                              Child Health

    Disease prevention is an import issue for pediatric 
populations. Children are not little adults, which means that 
their health needs are unique. Most children are healthy and 
spending on this population represents a small portion of 
overall healthcare investments, but supporting child well-being 
can ensure that our Nation has a healthier future. Initiatives 
that build health early in life include pro-conception care, 
home visiting, early nutrition, vaccine access, health care, 
child care, and early education. Medicaid is particularly vital 
for children because it provides coverage for such a large 
proportion of the child population (close to one in three US 
children are covered by Medicaid or CHIP). Child patients with 
Medicaid coverage are also entitled to any benefit that is 
``medically necessary,'' which includes hospital care, 
physician services immunizations and early, periodic, 
screening, diagnostic, and treatment (EPSDT) for those under 
the age of 21 \35\ Medicaid also covers family planning, and 
other maternal health services for women across the country. 
Medicaid is also the predominant source of health coverage for 
children in the foster care system. These are among the most 
vulnerable children in society because of their unique social 
and emotional needs.
---------------------------------------------------------------------------
    \35\  Kaiser, Medicaid Benefits, 1997, https://
kaiserfamilyfoundation.files.wordpress.com/2013/05/mrbbenefits.pdf
---------------------------------------------------------------------------
    Violence prevention is an important child health and 
lifespan issue. \36\ An estimated 702,000 children were 
confirmed by child protective services as being victims of 
abuse and neglect in 2014. \37\ At least one in four children 
have experienced child neglect or abuse (including physical, 
emotional, and sexual) at some point in their lives, and one in 
seven children experienced abuse or neglect in the last year. 
\38\ Children who have suffered abuse or neglect may develop a 
variety of short-or long-term behavioral and functional 
problems including conduct disorders, poor academic 
performance, decreased cognitive functioning, emotional 
instability, depression, a tendency to be aggressive or violent 
with others, post-traumatic stress disorder (PTSD), sleep 
disturbances, anxiety, oppositional behavior, and others \39\
---------------------------------------------------------------------------
    \36\  AAFP, Violence Position Paper, http://www.aafp.org/about/
policies/all/violence.html
    \37\  CDC, Child Abuse and Neglect, https://www.cdc.gov/
violenceprevention/childabuseandneglect/index.html
    \38\  Ibid
    \39\  Holbrook TL, Hoyt DB, Coimbra R, Potenza B, Sise M, Anderson 
JP. Long term trauma persists after major trauma in adolescents: new 
data on risk factors and functional outcome. J Trauma. 2005;58 (4):764 
-771
---------------------------------------------------------------------------
    According to the landmark Adverse Childhood Experience 
Study (ACES), children who are exposed to traumatic life 
experiences are more likely to experience adult diseases later 
in life. \40\ The Among those adults who had experienced the 
highest levels of childhood trauma and thus had the highest 
``ACES'' score, those individuals were: five times more likely 
to have been alcoholic; nine times more likely to have abused 
illegal drugs; three times more likely to be clinically 
depressed; four times more likely to smoke; 17 times more 
likely to have attempted suicide; three times more likely to 
have an unintended pregnancy; three times more likely to report 
more than 50 sexual partners; two times more likely to develop 
heart disease; and two times more likely to be obese. \41\
---------------------------------------------------------------------------
    \40\  Felitti VJ, Anda RF, Nordenberg P, et al. Relationship of 
childhood abuse and household dysfunction to many of the leading causes 
of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J 
Prev Med. 1998;14 (4):245 -258
    \41\  Jones R, Flahery EG. Clinicians' Description of Factors 
Influencing Their Reporting of Suspected Child Abuse: Report of the 
Child Abuse Reporting Experience Study Research Group. Pediatrics. 
2008;122(2):259-266
---------------------------------------------------------------------------
    Violence prevention is not only a child health issue, as 
many children survive violence in the home that has impacts 
across their lifespan. It is important to invest in initiatives 
that reduce violence and promote child well-being such as 
domestic violence prevention, parenting education, evidence-
based home visiting, and early childhood support. Furthermore, 
there is a growing movement within the medical community to 
address these issues, like toxic stress, and to help patients 
access mental health and trauma-informed services. In addition, 
gun safety policies have the potential to decrease accidents 
and violence that result in thousands of injuries, 
disabilities, and deaths each year. The AAFP supports research 
and common-sense policies, such as improved background checks, 
to reduce the risk individuals may pose to themselves or to 
others within their communities.

                       Equity and Health Barriers

    The mission of the AAFP is to improve the health of 
patients, families, and communities by serving the needs of 
members with professionalism and creativity. In their patient-
centered practices, family physicians identify and address the 
social determinants of health for individuals and families, 
incorporating this information in the bio psychosocial model to 
promote continuous healing relationships, whole-person 
orientation, family and community context, and comprehensive 
care. Social determinants of health are the conditions under 
which people are born, grow, live, work, and age. To that end, 
the AAFP established its Center for Diversity and Health Equity 
to provide opportunities to become a more thoughtful and 
visible leader for diversity and health equity.
    Race or ethnicity, sex, sexual identity, age, disability, 
socioeconomic status, and geographic location all contribute to 
an individual's ability to achieve good health. Experts agree 
that successfully achieving measurable outcomes is possible 
with a ``health in all policies'' strategy that examines the 
multiple factors that contribute to or detract from a patient's 
health. We must seek to understand how issues such as race, 
ethnicity, sex, age, disability, economic status, and 
geographic location influence health, but also acknowledge that 
access to housing, safe drinking water, and clean air also 
impact our patients.
    The AAFP believes Federal, state, and local policymakers 
should acquaint themselves with these social determinants of 
health and embrace equality as vital to community health. 
Policy makers should also eliminate barriers that prevent 
individuals from accessing the care, information, and social 
supports that they need to reach optimal health. One barrier 
that raises concerns for health equity is the persistent 
passage of Federal laws that interfere with the doctor/patient 
relationship. These efforts often manifest in policies that 
create barriers for women's ability to access contraception and 
abortion. The AAFP opposes legislative interference in the 
doctor/patient relationship its replacement of scientific 
evidence and its undermining of patient autonomy.
    The AAFP is also concerned about the state of Federal 
funding and the implications for patients' health, safety and 
access to care. Growing Federal funding cuts potentially create 
a domino effect of damage that ultimately will harm the health 
of America on both an individual and community-wide basis. 
Reducing funding for agencies that oversee the health care 
industry--17 percent of the U.S. economy--destabilizes the 
foundation of services on which patients depend. Damage to one 
agency can impact the viability and effectiveness of others. 
The system is only as strong as the agencies and programs that 
undergird it. The AAFP encourages Congress to ensure stability 
of programs that are foundational to an effective, efficient 
health care system.
    Health care access is also a significant barrier, 
especially for low-income individuals. The AAFP first adopted a 
policy supporting health care coverage for all in 1989. For the 
past 28 years the AAFP has advanced and supported policies that 
would ensure a greater number of Americans had health care 
coverage. The AAFP appreciates the bipartisan support for the 
Medicare Access and CHIP Reauthorization Act's (MACRA) landmark 
reforms that have the potential for improving patient care 
outcomes by emphasizing value over fee-for-service. We welcome 
the opportunity to work with policymakers to evaluate MACRA's 
implementation process. enactment and the potential to improve 
patient outcomes.
    It is also important to acknowledge that passage of the 
Patient Protection and Affordable Care Act represented a sea 
change for millions of patients. We are pleased the Committee 
has engaged in bipartisan hearings on how to improve individual 
market as well as proposals to maintain the cost-sharing 
reduction payments. Medicaid expansion and the law's Essential 
Health Benefits were particularly important for vulnerable 
populations. Medicaid assists the most vulnerable patients who 
are members of minority groups, homeless, formerly 
incarcerated, foster and former foster youth, mentally ill, 
addicted, and military families. Insurance coverage rates among 
minorities are lower than rates among the non-Hispanic white 
population. \42\ Minorities experience disproportionate rates 
of illness, premature death, and disability compared to the 
general population. \43\ In addition, virtually all of the 
estimated individuals nationally who are homeless could be 
eligible for Medicaid. Many in this population would benefit 
from the mental health and addiction treatment requirement 
included under the law. \44\ Forty percent of our Nation's 
veterans who are under 65 years of age have incomes that could 
qualify them for Medicaid under the ACA's expanded coverage. 
\45\ In general, family members of veterans are not covered by 
the Veteran's Administration, but may seek coverage through 
Medicaid or the marketplace. \46\ Many patients in this 
category are unaware that they qualify for health benefits.
---------------------------------------------------------------------------
    \42\  Center for Health Care Statistics (CHCS), Reaching Vulnerable 
Populations Through Health Reform, April 2014, available at--http://
www.chcs.org/media/Vulnerable-Populations--April-2014.pdf
    \43\  Center for Health Care Statistics, April 2014
    \44\  Id.
    \45\  Id.
    \46\  Id.
---------------------------------------------------------------------------
    A New England Journal of Medicine article indicates that 
the law's coverage expansion was associated with higher rates 
of having a usual source of care, greater access to primary 
care access, and, higher rates of preventive health screenings. 
\47\ Anecdotal evidence among family physicians also reveal 
that health care access is saving lives and improving patient 
health for those who are accessing much-needed care for chronic 
diseases or detecting conditions in the initial stages. Again, 
achieving optimal health does not occur by accident. Realizing 
the vision of healthy communities, like other national 
priorities, requires that we identify goals, invest resources, 
and eliminate barriers, especially for vulnerable citizens.
---------------------------------------------------------------------------
    \47\  Benjamin D. Sommers, M.D., Ph.D., Atul A. Gawande, M.D., 
M.P.H., and Katherine Baicker, Ph.D., N Engl J Med 2017; 377:586-593
---------------------------------------------------------------------------

                               Conclusion

    The AAFP appreciates the opportunity to share these 
comments on community health and welcomes the opportunity to 
work with policymakers to achieve positive outcomes on these 
and other policies. For more information, please contact Sonya 
Clay, Government Relations Representative, at 202-232-9033 or 
[email protected].
                                ------                                

    The Chairman. Thank you, Senator Murray. It will be 
included.
    I'm pleased to welcome the Surgeon General, Dr. Jerome 
Adams, to today's hearing. He oversees the U.S. Public Health 
Service Commissioned Corps, a group of over 6,500 public health 
professionals working throughout the Federal Government for the 
advancement of public health.
    Dr. Adams previously served as the Indiana State Health 
Commissioner. Before that, he served as Staff Anesthesiologist 
and Assistant Professor of Anesthesia at the Indiana University 
School of Medicine. He holds a B.S. in biochemistry, a B.A. in 
biopsychology from the University of Maryland, Baltimore 
County; a Master's in Public Health from the University of 
California at Berkeley; and an M.D. from the Indiana University 
School of Medicine, where he also completed his anesthesia 
residency.
    Welcome again, Dr. Adams. We appreciate you summarizing 
your testimony in about 5 minutes. That'll leave more time for 
questions.
    Welcome.

  STATEMENT OF VICE ADMIRAL JEROME ADAMS, M.D., MPH, SURGEON 
      GENERAL OF THE PUBLIC HEALTH SERVICE, WASHINGTON, DC

    Dr. Adams. Absolutely. Thank you so much. It is good to be 
here again. It's a little bit lonelier up here than what it was 
the last time I was here. But I'll tell you, it's good to be 
back. I'd like to thank Chairman Alexander, Ranking Member 
Murray, and Members of the Senate HELP Committee for hosting 
these very important hearings on the topic of wellness.
    I'm going to sidetrack just for a little bit and go over my 
time just for a bit, because I have to say to each and every 
one of you thank you so much for confirming me. Thank you so 
much for being willing to work with me, both to the Senators 
and to all of the staffers.
    I was coming in the building this morning and I was reading 
about Senator Dirksen. He was beloved by all of his colleagues, 
and I think that the HELP Committee really epitomizes the 
bipartisan--from my point of view, health is nonpartisan--
nature of how we need to look at problems. I want to say thank 
you so much for your support getting me here, and I look 
forward to your support moving forward.
    Back to my testimony. The United States is the undisputed 
global leader in medical research and medical care. However, 
despite spending over $3.2 trillion annually on healthcare, we 
continue to rank below many countries in life expectancy and in 
other important indicators of health. Chronic diseases like 
heart disease, cancer, diabetes, and lung disease are the 
leading causes of death and disability in the United States and 
among the most costly. Yet we know they are preventable.
    While there's been some stabilization in mortality from 
most chronic diseases, we are now facing an unprecedented 
number of lives lost due to suicides and drug overdoses largely 
involving prescription or illicit opioids. These so-called 
deaths of despair are affecting all Americans across the 
country and are brought on in part by a lack of hope and a lack 
of opportunity. This is why it is so important that the 
President called for the declaration of the opioid crisis as a 
public health emergency. At HHS, we are committed to using all 
possible resources to attack this epidemic head-on.
    Not only is the opioid epidemic impacting our families and 
communities, but it is also taking a significant toll on our 
economy. The economic burden of the opioid crisis is $78.5 
billion, with a B, in healthcare, law enforcement, and lost 
productivity.
    There is good news, however. Research showed that for each 
dollar invested in evidence-based prevention programs, up to 
$10 is saved in treatment costs. Furthermore, these prevention 
programs have also been shown to prevent high school 
delinquency, teen pregnancy, school dropout, and violence. We 
can turn the tide.
    Effective public health interventions and policies that 
target chronic diseases and deaths of despair lead to a 
healthier population with lower healthcare spending, less 
school and workplace absenteeism, increased economic 
productivity, and an improved quality of life. What's the key 
to effectiveness and efficiency? Well, scientists have found 
that the conditions in which we live, learn, work, and play can 
have an enormous impact on our health long before we ever see a 
doctor.
    A community suffering from poor health is all too often a 
home to local businesses with workforce shortages and work-
related illnesses and injuries. There are declines in 
productivity and issues with workforce recruitment and 
retention, which lead to decreased profitability. Productivity 
losses as a result of employees who don't come to work or who 
work while sick, cost U.S. employers more than $225 billion 
annually. This equates to almost $1,700 per employee per year 
due to our country's unwellness.
    As I travel around the country, I constantly hear that 
businesses are struggling to fill open positions because 
applicants are unable to pass a drug test. Businesses that 
recognize addiction as a chronic disease and help their 
employees access treatment avoid the high cost of termination, 
recruitment, and retraining new staff. Businesses that 
recognize the downstream cost of community inactivity, poor 
nutrition, and tobacco use demonstrate lower healthcare costs 
and boast larger profits.
    While the government must play a role in prevention and 
treatment, we cannot do it alone, as Senator Alexander 
mentioned. The business sector is a critical partner in helping 
achieve gains in the wellness of all Americans. The private 
sector pays for about half of total healthcare spending in the 
United States.
    But rather than viewing health merely as an insurance 
expense to be controlled, more companies are seeing the 
building of a community culture of health as a true business 
opportunity. Why? Because mental, physical, and economic health 
in communities are strongly and inextricably correlated. 
Healthier communities tend to be more economically prosperous, 
and more prosperous communities tend to be healthier.
    Improved community conditions for health, such as clean and 
safe neighborhoods, access to healthy food options, and 
opportunities for exercise and physical activity can help 
influence positive health behaviors and lead to a more 
productive and a more profitable workforce. While workplace 
wellness programs are fortunately becoming more prevalent 
amongst corporations--and a lot of the initial testimony that 
you had previously focused on those--the most innovative 
businesses are implementing initiatives that go well beyond an 
onsite focus on employees to incorporating community health as 
a whole.
    For example, Target is putting wellness at the center of 
its corporate social responsibility strategy, investing $40 
million in more than 50 nonprofits which focus on increasing 
the physical activity and healthy eating habits of local 
children and their families. GSK, Costco, Cummins, and many 
others have invested in their communities as a means of 
investing in their most valued asset, their employees.
    In closing, I'd say that recognizing the role of wellness 
in our country's safety, security, and prosperity is why I'm 
focusing my term as Surgeon General on better health through 
better partnerships. This means we will strengthen ties with 
existing public health and healthcare partners. But it also 
means we will forge new partnerships with the business, law 
enforcement, education, and defense sectors, as well as the 
religious, faith-based, and other community organizations and 
sectors.
    For this reason, my signature report will focus on the 
intersection between health and the economy, how businesses are 
able to thrive by investing in the health of their employees 
and communities. Achieving wellness at the community level is 
paramount to eliminating chronic disease, improving quality of 
life, reducing healthcare costs, and increasing life 
expectancy. By working together across the public and private 
sectors, I am confident that we will achieve HHS's goal of 
healthier people, stronger communities, and a safer Nation.
    With that, I'm happy to take your questions.
    [The prepared statement of Dr. Adams follows:]
                                ------                                



                 prepared statement of jerome m. adams


                           Value of Wellness

    I would like to thank Chairman Alexander, Ranking Member 
Murray, and Members of the Senate HELP Committee for hosting 
hearings on the topic of wellness.
    The U.S. is the global leader in medical research and 
medical care. However, there are reasons for concern. Despite 
spending over $3.2 trillion annually on healthcare--which is 
significantly more than any other country--we continue to have 
room for improvement when it comes to life expectancy and other 
indicators of health.
    Chronic diseases--like heart disease, cancer, diabetes, and 
chronic obstructive pulmonary disease (COPD)--are the leading 
cause of death and disability in the U.S. and among the most 
costly, yet these afflictions may be preventable. The World 
Health Organization reports that at least 80 percent of all 
heart disease, stroke, and type 2 diabetes and up to 40 percent 
of cancer could be prevented if people ate better, engaged in 
more physical activity and ceased to use tobacco. \1\
---------------------------------------------------------------------------
    \1\  Preventing chronic diseases: a vital investment, World Health 
Organization, 2005, http://www.who.int/chp/chronic--disease--report/
full--report.pdf;Noncommunicable diseases country profiles, World 
Health Organization, July 2014, http://www.who.int/nmh/publications/
ncd-profiles-2014/en/
---------------------------------------------------------------------------
    While there has been some stabilization in deaths from some 
chronic diseases, we are now facing unprecedented increases in 
deaths due to suicide, liver cirrhosis from alcohol 
consumption, and drug overdoses, largely due to overdose deaths 
involving prescription or illicit opioids. The President 
recently called upon Acting Secretary Hargan to declare the 
opioids crisis plaguing our communities a nationwide Public 
Health Emergency. These so-called deaths of despair are 
affecting all Americans across the country, and are brought on 
in part by a lack of hope and opportunity. The opioid epidemic 
impacts our families and communities, and it is taking a toll 
on our economy. The economic burden of the prescription opioid 
crisis is $78.5 billion in healthcare, law enforcement, and 
lost productivity. The good news is that research shows that 
for each dollar invested in evidence-based prevention programs, 
up to $10 is saved in treatment for alcohol or other substance 
misuse-related costs. \2\ These prevention programs go beyond 
preventing or lowering the risks of addiction--they also have 
been shown to prevent delinquency, teen pregnancy, school 
dropout, and violence. \3\
---------------------------------------------------------------------------
    \2\  Facing Addiction in America: The Surgeon General's Report on 
Alcohol, Drugs, and Health, Office of the Surgeon General, U.S. 
Department of Health and Human Services, November 2016, https://
addiction.surgeongeneral.gov/
    \3\  Facing Addiction in America: The Surgeon General's Report on 
Alcohol, Drugs, and Health, Office of the Surgeon General, U.S. 
Department of Health and Human Services, November 2016, https://
addiction.surgeongeneral.gov/
---------------------------------------------------------------------------
    Effective public health interventions and policies that 
target deaths of despair and chronic diseases lead to a 
healthier population with lower health care spending, less 
school and workplace absenteeism, increased economic 
productivity, and an improved quality of life.
    By investing in the prevention and treatment of the most 
common chronic diseases, one estimate shows the U.S. could 
decrease treatment costs by $218 billion per year and reduce 
the economic impact of disease by $1.1 trillion annually. \4\
---------------------------------------------------------------------------
    \4\  An Unhealthy America: The Economic Burden of Chronic Disease--
Charting a New Course to Save Lives and Increase Productivity and 
Economic Growth, Milken Institute, 2007, http://
assets1b.milkeninstitute.org/assets/Publication/ResearchReport/PDF/
chronic--disease--report.pdf
---------------------------------------------------------------------------
    Scientists have found that the conditions in which we live 
and work have an enormous impact on our health, long before we 
ever see a doctor. Wellness starts in our families, our schools 
and workplaces, in our playgrounds and parks, and in the air we 
breathe and the water we drink.

                    Wellness and the Business Sector

    Productivity losses as a result of employees who don't come 
to work, or work while sick, cost U.S. employers $225.8 billion 
annually, or about $1,685 per employee each year. For example, 
obesity and obesity-related illnesses, like diabetes, cost the 
Nation over $153 billion per year in lost productivity. \5\
---------------------------------------------------------------------------
    \5\  Stewart WF, Ricci JA, Chee E, Morganstein D. Lost productive 
work time costs from health conditions in the United States: results 
from the American productivity audit. J Occup Environ Med. 
2003;45(12):1234-1246
---------------------------------------------------------------------------
    As an administration, we are focused on the opioid crisis 
currently impacting our country, and with good reason. 
Prescription opioid addiction and non-fatal overdoses cost 
$20.4 billion in lost productivity in 2013. \6\ According to 
the National Safety Council, a worker with a substance use 
disorder is not as productive, is more likely to make a 
mistake, and may take twice as many sick days. Companies that 
recognize addiction and support their staff have found that 
employees in recovery have lower turnover rates, are less 
likely to miss work, and are less likely to be hospitalized and 
have fewer doctor visits.
---------------------------------------------------------------------------
    \6\  Florence, Curtis S., Chao Zhou, Feijun Luo and Likang Xu. 
``The Economic Burden of Prescription Opioid Overdose, Abuse, and 
Dependence in the United States, 2013.'' Medical Care 54 10 (2016): 
901-6
---------------------------------------------------------------------------
    A community with poor health results in local businesses 
with workforce shortages; absenteeism; presenteeism, when 
workers are on the job but are not fully functioning due to 
illness or other medical conditions; work-related injuries and 
illnesses; declines in productivity and profitability; and 
issues with workforce recruitment and retention. As I travel 
around the country, I have heard that businesses are now 
struggling to fill open positions because applicants are unable 
to pass their drug tests. Businesses that recognize addiction 
and help employees get into treatment allow employers to keep 
valued employees. Furthermore, employers also avoid the high 
costs of termination, recruitment, and retraining new staff.
    The business sector is a critical partner in helping 
achieve gains in the wellness of Americans. The private sector 
pays for about half of total healthcare spending in the United 
States. Rather than viewing health merely as an insurance 
expense to be controlled, more companies are seeing the 
building of a health culture as a business opportunity.
    After CVS removed tobacco products from store shelves and 
renamed itself CVS Health, new revenues more than made up for 
lost sales while also reducing the purchases of cigarette packs 
by at least 95 million at ``all retailers'' by at least 95 
million at ``all retailers.''by at least 95 million at ``all 
retailers.'' \7\ General Dynamics Bath Iron Works, a large 
full-service shipyard in Maine employing over 6,000 employees, 
extended a successful in-house diabetes prevention initiative 
into the wider community. It expects to cut participants' 
future healthcare costs over five years by 60 percent on 
average.
---------------------------------------------------------------------------
    \7\  CVS; Forbes, 2015
---------------------------------------------------------------------------
    The health and economy of communities are often strongly 
correlated. Healthier communities tend to be economically more 
prosperous and vice versa. Improved community conditions for 
health, such as clean and safe neighborhoods, access to 
healthful food options, and opportunities for exercise and 
physical activity, can help positively influence health 
behaviors and lead to a more productive workforce.
    Several businesses are implementing health initiatives that 
go beyond workplace wellness programs to support community 
health. For example, Target is putting wellness at the center 
of its Corporate Social Responsibility strategy, having 
invested $40 million dollars in more than 50 non-profit 
organizations around the U.S., which focus on increasing the 
physical activity and healthy eating habits of children and 
their families in local communities.

                     Wellness and National Security

    As a United States Public Health Service (USPHS) 
Commissioned Corps officer and member of the uniformed 
services, I know that wellness is at the heart of the safety 
and security of our Nation. It is estimated that seven in ten 
youths (ages 17-24) would fail to qualify for military service 
due to obesity, educational deficits, or behavioral health 
issues/criminal history. \8\
---------------------------------------------------------------------------
    \8\  Unfit to Serve, CDC infographic; Ready, Willing, and Unable to 
Serve, Mission: Readiness Report, 2009
---------------------------------------------------------------------------
    In order to ensure a strong national defense, we need to 
ensure threats to service member recruitment, retention, 
readiness, and resilience are mitigated. As Surgeon General, I 
am working to bring awareness to this issue by publicizing my 
annual physical fitness test for the USPHS, which evaluates 
four key components of fitness: cardiorespiratory endurance, 
upper body endurance, core endurance, and flexibility. I will 
be working with members of the PHS Commissioned Corps, National 
Guard, and other Department of Defense reserves to work with 
local schools in order to implement evidence-based programs to 
increase physical fitness. Not just because our youth deserve 
to be healthy, but also for their educational benefit and the 
benefit of teachers and their classrooms as well. Research 
demonstrates that students who engage in physical activity have 
greater attention spans in class and higher test scores in 
addition to the health benefits.

                       Surgeon General Priorities

    Recognizing the role of wellness in our country's safety, 
security, and prosperity is the reason I will focus my term as 
Surgeon General on ``Better Health through Better 
Partnerships.'' This means we will strengthen ties with 
existing public health and healthcare partners, while forging 
new partnerships with the business, law enforcement, education, 
and defense sectors, as well as religious and faith-based, and 
other community organizations.
    It is for this reason I have decided my signature Surgeon 
General's report will focus on the intersection between health 
and the economy, and how businesses are able to thrive by 
investing in the health of their employees and communities. By 
partnering with non-traditional sectors and helping them 
recognize their role in wellness at the community level, we 
allow everyone to have a fair chance for good health and 
opportunities for better health choices. Achieving wellness at 
the community level is paramount to eliminating chronic 
disease, improving quality of life, reducing healthcare costs, 
and increasing life expectancy. By investing in communities, we 
can ensure the U.S. Department of Health and Human Services' 
goal of healthier people, stronger communities, and a safer 
Nation.
                                ------                                

    The Chairman. Thank you, Dr. Adams. We'll now begin a 5-
minute round of questions, and I'll start.
    Senator Murray mentioned the tax bill, and I'll briefly 
comment on that before I go to wellness. Senator Murray knows 
how much I respect her leadership and the work we did most 
recently on the Alexander-Murray legislation, which has growing 
support in both the Democratic and Republican sides of the 
Senate and I think the House, and, hopefully, eventually with 
the President.
    But it's in a different bill in a different committee. It's 
in the Tax Reform Bill, and it cannot--the Alexander-Murray 
proposal, under the rules of the Senate, cannot be made a part 
of the Tax Reform Bill. It has to stand on its own. It'll be 
considered separately and must be considered separately. I 
imagine there will be other provisions in the Tax Reform Bill, 
as it makes its way through the Finance Committee today, that 
Democratic Members of the Senate don't like, and they'll have a 
chance to vote against those provisions.
    No. 2, the Tax Reform Bill is moving through committee. 
It's being amended this week, or amendments are being offered. 
It will go to the floor, where there'll be an unlimited number 
of amendments that can be offered.
    No. 3, it's true that if the individual mandate is repealed 
in 2019, the Congressional Budget Office has said that rates 
could go up 10 percent in that year, but that the markets would 
be stable during the decade. The Congressional Budget Office 
has also said that, quite aside from that, if we don't pass 
Alexander-Murray with the cost-sharing provisions that we'll 
have a 20 percent increase in rates this year, and that 
increase will go up to 25 percent in 2020.
    I know there are differences of opinion about what the 
Finance Committee is doing. My only point is that's a different 
committee, a different bill, and the work we did on Alexander-
Murray can't be considered as a part of the Tax Reform Bill 
under the rules of the Senate.
    Senator Murray. Mr. Chairman, could you just yield to a 
question?
    The Chairman. Sure.
    Senator Murray. Do you agree with me that the Alexander-
Murray Bill was not designed to deal with the disruption in the 
marketplace, though it increased costs by 10 percent, as you 
just identified, where more people lose their coverage under 
the individual mandate repeal?
    The Chairman. Well, it was designed to deal with disruption 
in the marketplace. The CBO found that repealing the individual 
mandate will not create instability in the market. It will 
raise rates 10 percent.
    Senator Murray. But our bill was never designed--we did not 
have hearings, we did not have input, we did not have any 
discussion about what the marketplace would look like if the 
individual mandate was repealed.
    The Chairman. Well, no, we didn't, because the individual 
mandate is a tax, and that's not in our jurisdiction.
    Senator Murray. Yes. My point is that our bill was not 
designed to----
    The Chairman. It's in the Finance Committee's jurisdiction.
    Senator Murray.----deal with the current provision that's 
being proposed.
    The Chairman. Well, our bill is in this Committee, and it's 
one set of issues, and if it doesn't pass, we'll have a big 
increase in premiums, the CBO has said. The Finance Committee 
is working on another bill, which our bill can't be a part of 
under the rules of the Senate.
    Dr. Adams, in our last wellness hearing, someone suggested 
that there might be a wellness program for the Department of 
Health and Human Services since it has 80,000 employees and 
millions of people work across all the Federal agencies. Would 
such a pilot program--does one exist, a wellness program now 
for HHS? Would it be possible to have one?
    Dr. Adams. Well, I certainly appreciate that question, 
Chairman, and I can tell you that the Department of Health and 
Human Services has a number of wellness programs for their 
employees. We offer free gym memberships. We offer free flu 
shots. We have a variety of healthful food options. When you go 
to the cafeteria, and when you're wearing the uniform, and you 
walk in----
    The Chairman. But I mean the kind that the Cleveland Clinic 
has, where it's a structured program, where employees are given 
incentives and opportunities to have reduced--some benefits for 
an improved lifestyle. Do you have that?
    Dr. Adams. Well, I certainly think that Cleveland Clinic is 
the ideal, and there's an opportunity for us to grow at HHS and 
to become even better at incentivizing healthy behaviors. The 
answer to your question, very directly, sir, is we have a 
number of programs, but we could do better, and we need to look 
at examples such as the Cleveland Clinic, and then take that to 
all of our corporations and businesses across the country.
    The Chairman. Well, models and pilot programs sometimes set 
good examples. The bully pulpit is a good way to lead, rather 
than mandates from Washington sometimes. Another example of 
that is the Malcolm Baldrige National Quality Improvement Act 
of 1987 that was created to encourage businesses, nonprofits, 
and others to compete for performance-based awards to improve 
the quality of what they were doing.
    I knew David Kearns very well. I recruited him to be the 
Deputy Secretary of the Department of Education in 1991. He was 
the CEO of Xerox, and Xerox is one of the companies that had 
gone through the Baldrige competition and won it. Companies all 
over America signed up for that and improved their quality 
without any Federal orders to do it. That was the incentive, 
the honor of it all.
    I wondered if you had ever considered a Baldrige type award 
for wellness for employers who want to improve the lifestyle of 
their employees.
    Dr. Adams. Senator, I think that is a wonderful idea. The 
states that have been really innovative in this arena have had 
awards sponsored by their local chambers of commerce to 
recognize businesses that are not only doing onsite workplace 
wellness but also reaching out into the communities. I think 
the more we can highlight those programs, the more we can 
applaud folks for doing what we know is the right thing, the 
better. I think that's wonderful idea.
    The Chairman. Thank you, Dr. Adams.
    Senator Murray.
    Senator Murray. Your testimony speaks to the critical role 
that employers can have in supporting the health and well-being 
of their communities and employees. Now, as you know, the Trump 
Administration recently took the extreme action of allowing 
practically any employer or university to claim a religious or 
morale exemption to avoid covering birth control for their 
employees without ensuring they have an alternative source of 
coverage.
    Rather than promoting the health of their workers, that 
would actually allow employers to prevent female employees from 
having coverage through their employer sponsored insurance that 
is required today under the ACA, taking away, actually, 
healthcare options for millions of women nationwide and 
undermining their economic well-being. I wanted to ask you, do 
you agree that having access to birth control is critical to 
the health of women across our country?
    Dr. Adams. Senator, I believe that women's health and 
family planning are extremely important parts of health and 
wellness in our communities, and I hope that the folks here in 
this room can come together and help institute reasonable laws, 
and at HHS, we're always searching to come up with reasonable 
compromises that are acceptable to communities and states to be 
able to emphasize women's health.
    Senator Murray. Do you believe that's an appropriate way 
for employers to influence healthcare decisions of their 
employees?
    Dr. Adams. I'm sorry, believe what is appropriate?
    Senator Murray. The new mandate--or the new rule from the 
Administration that pretty much says any employer or university 
can opt out. Is that an appropriate way if employers opt out?
    Dr. Adams. I certainly appreciate the question, Senator, 
and when I am talking to folks about health, there's the 
science, but the science has to be implemented as one variable 
into a complicated policy equation. What I've found is that 
mandates rarely are accepted by the community and by the people 
who we're trying to help. As Surgeon General, what I want to do 
is make sure folks understand the science, and I believe what 
we're trying to do is give corporations the flexibility to 
determine what is best for their employees. I want to make sure 
I'm there to help them understand what the science says.
    Senator Murray. Thank you. My point is that if we are 
telling employers that they can decide how a woman's healthcare 
can be covered, and in a hearing where we're talking about 
employers helping the well-being of their employees, that seems 
really at odds with me.
    Now, as you've heard today, there are many promising 
examples where private sector engagement can improve both 
health and economic growth at local levels. We've seen that in 
some of the most successful initiatives that involved efforts 
where the private sector investments complement our Nation's 
public health backbone. One great example of that is in my home 
State of Washington where child care providers, public water 
system operators, residential property managers, and others are 
working with their state health department to eliminate 
childhood lead exposure.
    Now, this would not be possible without state and local 
public health departments, which provide the services and 
infrastructure to protect kids from lead poisoning, which is 
why the private sector can't and should not be expected to go 
it alone. Whether we're talking about lead poisoning prevention 
or combating heart disease, our public health system really 
depends on sustained Federal funding from CDC and others. Yet 
time and again, we have had to fight back proposals from this 
Administration that would slash Federal funding for public 
health.
    In your written testimony, you spoke to the value of 
investing in prevention. Do you think Federal funding for CDC 
supported state, local, tribal, and territorial public health 
programs is adequate?
    Dr. Adams. Ma'am, as a public health advocate, I always 
want more money for public health. I also realize that tax 
revenues that come in from increased businesses in a society 
also can contribute to state and local funding for public 
health, and I think that's a complicated policy equation that 
doesn't fall under my purview.
    What I want to do is make sure folks understand we need to 
invest in prevention and public health. We need to make sure 
that that total number continues to increase, and that's going 
to come from private, that's going to come from Federal, that's 
going to come from state. But, ultimately, it does need to 
increase if we're going to lower our costs in the long term.
    Senator Murray. Okay. I just have a half a minute left. But 
we all know the opioid epidemic is going to take long-term 
sustained investments in prevention and treatment and recovery. 
As Surgeon General, I know you're less directly involved with 
on-the-ground response to the opioid epidemic than you were as 
a state health commissioner. But you do have a unique ability 
to speak to the country about how community stakeholders must 
come together.
    I wanted to ask you how you're using your role as Surgeon 
General to help communities overcome some of the divisive 
issues, like needle exchange, so they can really address the 
opioid crisis.
    Dr. Adams. Well, thank you so much for that question. One 
of the things that I've already done is participated in a forum 
for the HHS Neighborhood and Faith-Based Partnerships Division. 
I'm reaching out to those communities and helping folks 
understand that sometimes controversial interventions that are 
scientifically based can and should be considered in the 
toolkit when you're looking at how to respond to the opioid 
epidemic.
    I met with Chief Justice Loretta Rush just last night, the 
Chief Justice of Indiana. She's heading up the Judicial Opioid 
Task Force, and we're looking at ways to bring in the judicial 
community for diversion programs or pre-trial programs. We've 
also reached out to the police and the law enforcement 
community. I was in Atlanta last week and met with the sheriff 
down there, and we talked about ways to decrease violence by 
making sure folks get access to treatment.
    That's why, again, my motto is better health through better 
partnerships. Einstein said the definition of insanity is doing 
the same thing and expecting a different result. We've got to 
break out of our siloes. We've got to start speaking languages 
that resonate, including the language of business, including 
the language of the faith-based community, and an understanding 
for where they are, and we've got to meet people where they 
are.
    Senator Murray. Thank you very much.
    Dr. Adams. Thank you to you and your staff. You have been a 
tremendous help. Please share with me your examples from 
Washington, because we want folks to know you all are doing 
some great work out there.
    The Chairman. Thank you, Senator Murray.
    Senator Cassidy.
    Senator Cassidy. Hey, Dr. Adams.
    Dr. Adams. Hello.
    Senator Cassidy. I'm going to follow-up on what Senator 
Murray just said, because you're also a pain doc.
    Dr. Adams. I am.
    Senator Cassidy. If there's something that unites us, it's 
we've got to do something about opioids. It appears that 
overprescribing by physicians and dentists is part of what's 
driving the opioid epidemic. This may be in your current 
position, or it may be in your state position, or it may be in 
your pain doc position. But is there anything that we could do, 
legislatively, that you could specify that would help with this 
opioid epidemic, from any of the hats you have worn?
    Dr. Adams. I certainly appreciate that. I want to highlight 
one of the things we're doing at HHS, and that's the Committee 
on Alternatives for Pain Management, and we're going to have 
our first meeting either in late December or early January. 
Thank you all for giving us the opportunity to come up with 
those opioid alternatives.
    But something that all of you can do--you can invite me to 
your communities to help speak about wellness and the economy. 
Why does that matter, and why is that an answer to your 
question? Because I framed these in my opening testimony as 
deaths of despair. If you ultimately want to get upstream, 
we've got to make sure communities are more prosperous so that 
people don't lose hope. If they can see that there's an 
opportunity to go to something else besides self-medicating, 
ultimately, that's the most upstream that we can go.
    Senator Cassidy. That Princeton study by Anne Case, the 
Death of Despair--from Despair, specifically, middle-aged white 
males, but now also other groups--if you will, tracing that 
opioid epidemic back to if the folks have no vision, they 
despair.
    Dr. Adams. Absolutely. As I said, a healthier community is 
more prosperous, and a more prosperous community is, in turn, 
healthier and is not going to suffer as much from the opioid 
epidemic or cancer or diabetes or what-have-you.
    Senator Cassidy. We actually address opioids not 
collaterally, but as part of an overall approach. Now, we spoke 
beforehand about some of the stuff you've done--were involved 
with in Indiana----
    Dr. Adams. Yes.
    Senator Cassidy.----and with some of the preventive 
programs that we previously heard about from business have been 
implemented for folks who are not--through business. Can you 
elaborate on that? Again, what can we take as guidance from 
what you all have done successfully to bring better health to 
groups who, statistically, are more likely to suffer from 
chronic illness?
    Dr. Adams. Well, we know a lot of our folks who suffer from 
chronic illness, who suffer from infant mortality, who suffer 
from the opioid epidemic are covered by Medicaid. I don't want 
to go too far down the rabbit hole here, but I will say that in 
Indiana, with our Healthy Indiana plan, we've been able to 
incentivize wellness and healthier behaviors----
    Senator Cassidy. How did you do that, may I ask?
    Dr. Adams. Well, we have a health savings plan, and folks 
pay a deductible each year. They get a discount on their 
deductible if they participate in wellness activities that have 
been scientifically validated, like getting your colon cancer 
screening, like getting your breast cancer screening, like 
participating in immunizations.
    We found that by having a program that gave the state the 
flexibility to experiment--you mentioned pilot programs, sir--
to be able to do that in an innovative way, giving the state 
the flexibility, we've been able to increase the participation 
in wellness initiatives by folks who people did not believe 
would do it. I can tell you I lived through it. Folks didn't 
believe it was going to work.
    Senator Cassidy. Just to put a point on it--because my 
experience as a physician was working in a hospital for the 
uninsured, which just socioeconomically tended to be poor--
there's always a kind of bias that folks such as you and I are 
speaking of who are not sophisticated enough to respond to such 
incentives or otherwise have obstacles which do not allow it, 
and you're saying, absolutely, they will respond appropriately 
in their self-interest in a way which isn't mandated, because 
I'm not--believe me, the American people hate to be told to do 
anything, but they love being incentivized, and they responded 
to incentives.
    Dr. Adams. You said two things there, sir, that I want to 
draw out. You said that people believe that they can't or 
they're not sophisticated enough to do it. That is absolutely 
false. If we set up a program that incentivizes them, they will 
respond to those----
    Senator Cassidy. By the way, the same incentives as I would 
have through the workplace incentive program.
    Dr. Adams. Exactly. There's something else you said, too, 
though, that I think is very important. You mentioned 
obstacles. If we're going to do this, we need to make sure 
folks are aware of the real obstacles people face in terms of 
being healthier. I talk about my kids all the time. I live in a 
nice neighborhood. We've got sidewalks. We've got--nobody 
smokes. There's grocery stores right down the street. That's 
very different than the community where I work. I work in a 
hospital with a lot of people who are uninsured.
    Again, it's not as easy as saying go out and exercise when 
there's not complete streets. It's not as easy as saying eat 
healthy when there's only fast food restaurants. We have to 
take those obstacles into account, and there are a lot of great 
programs that mesh the two, and I hope that that's what you all 
can do as Senators from some very different ways of thinking. I 
hope you all can come together, and we can help promote the 
best practices.
    Senator Cassidy. Thank you, Doctor, and I yield back.
    The Chairman. Thank you, Senator Cassidy.
    Senator Warren.
    [No verbal response.]
    The Chairman. Oh, she's not here.
    Senator Hassan.
    Senator Hassan. Thank you, Mr. Chair, and thank you, 
Ranking Member Murray, and welcome, Doctor.
    Before I get to my questions, I do want to say how 
disappointed I am about reports that Republicans are now 
threatening to use their tax bill to pursue a partisan goal of 
repealing health coverage. The Trump Administration's sabotage 
attempts are already raising healthcare premiums and squeezing 
hard-working people in New Hampshire and across the country, 
and this partisan plan would cause healthcare premiums to rise 
an additional 10 percent a year in the individual market and 
about 10 percent through most of the budget window that the tax 
bill deals with, all to give tax breaks to corporate special 
interests and the wealthiest few.
    Instead of raising costs, we should be working together to 
pass the bipartisan stabilization package led by Senators 
Alexander and Murray that would lower costs. If Republicans 
move forward with their plan on the tax bill, the efforts of 
the Alexander-Murray Bill are for naught, because we are going 
to destabilize it in a different committee, in a different 
room, while also taking away health insurance, according to the 
CBO, from approximately 13 million people, which gets me to the 
point of this morning's hearing, which is it is very hard to 
promote wellness when people can't get primary care because 
they don't have insurance coverage, or where Medicaid expansion 
is threatened, and it's very hard to talk about wellness when 
people can't afford care and can't get care.
    I hope very much that the group that is crafting this tax 
bill will decide not to try to repeal the individual mandate 
and cause premiums to go up and rip care away from people.
    I do have a number of questions about wellness efforts. But 
I did also want to just comment a little bit on the discussion 
that we've already had on the opioid epidemic, because I 
appreciate your work very much. You know that New Hampshire has 
been one of the hardest hit states in the country. We all share 
a bipartisan commitment to addressing the opioid crisis.
    I was encouraged by the President's commission's 
recommendations. There are a number of things that are 
evidence-based that a lot of us have been doing in our states. 
But we are still waiting for the Administration to actually 
identify what implementing those recommendations is going to 
cost, and then identifying a number that we could all work to 
appropriate to get treatment and prevention efforts and 
recovery efforts out into our community.
    I hope very much that you will urge the Administration to 
actually identify what it would cost. Some of us have a bill 
that says let's start with $45 billion, which was an amount 
that friends on the other side of the aisle agreed would be an 
appropriate start this summer, and I think we really need to 
focus on getting resources to our communities. With an epidemic 
of this scope, this size, it does not seem to me that not 
spending additional dollars on it is going to do the trick.
    So I hope very much that you will be a voice for that. Can 
I have your commitment to helping the Administration identify 
real resources?
    Dr. Adams. You absolutely do. HHS has its foot on the gas, 
and we are not taking it off until we start to see some 
progress. I promise you that.
    Senator Hassan. Thank you. One other quick point that I 
would just ask you to think about, going back to Senator 
Murray's discussion on coverage for birth control. I cannot 
imagine that if an employer told male employees that they could 
not have certain kinds of healthcare that men would tolerate 
it.
    I really do believe that it is totally inappropriate for 
any employer to tell any employee how they can spend or apply 
healthcare coverage. That should be between the employee and 
her doctor, and if she needs access to birth control, and she 
is working and getting the benefit an employer-sponsored health 
insurance coverage, she should be able to make healthcare 
decisions without interference from her employer, and I just 
hope you will take that position into account.
    Dr. Adams. Thank you very much for that, Senator. Again, 
family planning is critically important to wellness. We also 
have to factor in the employers and the faith-based community, 
where some of those objections come from. I can promise you I 
will always be there to tell folks about the science, and the 
science says family planning is an important part of wellness.
    Senator Hassan. Thank you. Birth control also treats women 
for conditions other than family planning.
    Last issue--we are seeing in the annual sexually 
transmitted disease surveillance report that STD rates have 
increased by more than 2 million cases in 2016. What can 
communities do to address the rising rates of STDs and how 
should the Federal Government assist with these efforts?
    Dr. Adams. Well, HHS is focused on that. The CDC is focused 
on that. I was just down there last week talking with 
individuals. But it all, again, comes back to wellness. There 
are folks who are engaging in activities that are leading to 
increased transmission of sexually transmitted diseases for 
reasons due to lack of education, lack of opportunity.
    I think that if we can invest in wellness from both a 
Federal and a private point of view, you will see lower STD 
rates. You see that in communities that are more prosperous, 
the STD rates are lower. How can we engage businesses to 
participate in what we know are proven public health 
interventions and are a definite health problem.
    Senator Hassan. Thank you, and thank you, Mr. Chair, for 
your indulgence, and thank you Dr. Adams.
    The Chairman. Thank you, Senator Hassan.
    Senator Young.
    Senator Young. Dr. Adams.
    Dr. Adams. Hello.
    Senator Young. I enlisted in the United States Navy as a 
Seaman Recruit. It took me a decade in the military. I finally 
became an O3, a Captain in the U.S. Marine Corps, and here you 
sit as a Vice Admiral in the Navy, and I couldn't be happier. 
You're going to be a great Surgeon General.
    I'd like to ask you some questions related to evidence-
based prevention programs. You touched a bit on it earlier--the 
Indiana model with respect to our Medicaid program, targeting 
people of modest means. There's certainly some evidence-based 
prevention programs that were put to use there.
    But you've indicated in your testimony that for each dollar 
invested in some of these programs, we can see $10 saved in 
treatment on mental health issues, on alcohol abuse challenges. 
What specific programs would you like to bring to light in this 
Committee and all who are watching, whether it's in the public 
realm or in the private sector, that you think have been 
incredibly impactful and ought to be scaled up nationally?
    Dr. Adams. Well, I certainly appreciate that question, and 
again, it's partnerships. It's collaboration between the 
private and the public entities. We know that in South 
Carolina, Nikki Haley, when she was Governor there, shepherded 
a program that was a public-private partnership to address 
infant mortality, and they've seen their infant mortality 
metrics improve.
    Senator Young. Was that the Nurse-Family Partnership?
    Dr. Adams. That was involving Nurse-Family Partnership, 
absolutely, and we've invested in Nurse-Family Partnership in 
Indiana also under my tenure as Health Commissioner there. We 
know that every $1 invested in biking and walking trails can 
return benefits up to $12, and for every $1 invested in food 
and nutrition, there's a $10 return in healthcare costs.
    How do we get companies to invest in community building? 
We've seen this, and again, in Indiana--as Health Commissioner, 
I keep referring back--we built bike trails there throughout 
the city, and it actually improved the economy, and it also 
improved the health of individuals because they were able to 
participate in physical activity.
    Senator Young. Now, the things you mentioned--they strike 
me as powerful. They intuitively seem to advance health and 
wellness. Have they been rigorously evaluated? For example, you 
cite bike trails. Do we know that bike trails increase health 
and wellness, or is there just a correlation between the 
existence of bike trails and healthy persons who live in the 
surrounding area, which is not causal, per se?
    Dr. Adams. Well, there's two things I would say there. 
There is a fair amount of evidence that investing in wellness 
increases prosperity. The web-based diabetes prevention program 
lowers 5-year risk for diabetes by 30 percent, stroke by 16 
percent, and heart disease by 13 percent, and that's a program 
that Costco actually put in place. HEB Supermarket chain did 
research on their investments in wellness and found that their 
healthcare costs were less than half of the national average.
    There is evidence out there. But what I want to say to you 
all is that's why it's so critically important that I'm able to 
do the Surgeon General's Report on health and the economy, 
because we want to compile the evidence that exists showing the 
links between health and the economy, and we want to give the 
businesses and the public health entities in your state the 
tools to be able to say, ``This is evidence-based. We want to 
replicate this in our communities.''
    Minnesota is doing a great job, and Senator Franken didn't 
show on me again, so you tell him I miss him. Tell him he's got 
to get here next time. They're doing some great work there with 
Target and with the other businesses in their communities to 
promote health and wellness.
    Senator Young. It's great that you're looking nationally, 
clearly, at various examples in the private realm and also in 
the public sector. I think it's really important as you compile 
your Surgeon General's Report that we ensure--we indicate the 
level of certainty we have about the effectiveness of these 
different interventions and policy approaches. That is, have 
things been studied using the gold standard of evaluation, 
randomized control trial across multiple sites, or, instead, do 
we just have sort of a decent level of confidence, based on 
some longitudinal study that something is working well?
    If we have a very high level of confidence, I think those 
are the programs we're more inclined, as government officials, 
to invest in and to scale up. I say, we, meaning not just the 
Federal Government, but also state and local authorities. They 
need to begin maybe stepping up in a health prevention and 
wellness way that they haven't in the past.
    The last point I'd like to make, with the Chairman's 
indulgence, is some of the answers here may lie in behavioral 
science. If we can change the choice architecture people have, 
if we can organize our policies and also perhaps even our 
physical environment in a way that makes people more inclined 
to make individual choices in furtherance of the health 
outcomes that they want, then that could be very, very 
powerful. I hope you'll be consulting with behavioral 
scientists as you put together that report and work with this 
Committee.
    Thank you.
    Dr. Adams. Behavioral scientists, health economists--we 
want to make sure we bring everyone into the fold. To your 
point about the evidence, that is why it is so critical that I 
have your support for the Surgeon General's Report, because 
that's what we want to do. We want to look at it and say, 
``This is top tier. Go with it.'' This one, maybe not so.
    At HHS, in regards to the opioid epidemic, with your 
indulgence, sir, we're evaluating 42 different evidence-based 
programs to respond to the opioid epidemic, because right now, 
folks are throwing spaghetti at the wall to see what sticks, 
and we want to make sure we're funding the most evidence-based, 
the best programs, in order to be able to most efficiently and 
effectively tackle the opioid epidemic.
    Senator Young. I look forward to working with you, Vice 
Admiral. Thank you.
    Dr. Adams. Thank you.
    The Chairman. Thank you, Senator Young.
    Senator Murphy.
    Senator Murphy. Thank you very much, Mr. Chairman.
    Good to see you, Dr. Adams, again.
    Mr. Chairman, you're hearing our frustration about the way 
in which this tax bill has turned into a healthcare bill in the 
last 48 hours. I was so proud of this Committee when we held, I 
think, three or four hearings to study how we could stabilize 
the individual market and so proud of how you and Senator 
Murray worked together to develop that plan.
    But the impact of Alexander-Murray, should it pass, or had 
it passed, will be dwarfed by the impact of repealing the 
individual mandate, and it is potentially going to come up for 
a vote in the U.S. Senate without a single hearing in this 
Committee, maybe a markup in the Finance Committee, but no 
serious attempts to understand what the impact is.
    CBO admitted that it's very hard to understand what happens 
when the mandate disappears. It could be catastrophic in the 
sense that if you keep the requirement that plans continue to 
price without respect to medical acuity, but you don't require 
that people buy insurance, the rational individual would not 
buy insurance until they become so sick that they need care, 
knowing that they'll never pay any more for it. A rational 
healthy person simply would not buy insurance with the 
protection in place and no mandate. At the very least, CBO says 
that premiums are going to go up 10 percent compounding, year 
over year, simply because of the piece of legislation that the 
Senate is potentially going to pass.
    The reason I say that this bill is becoming a healthcare 
bill instead of a tax bill is because from what we understand, 
the individual income tax relief, which will help about two out 
of every three middle class families, is temporary. It 
disappears in 7 years, and by 7 years from now, premiums will 
have doubled, according to CBO, because of the repeal of the 
individual mandate.
    7 years from now, an average family will get almost no 
individual income tax relief, because their tax cuts will have 
expired, and their premiums will be potentially $10,000 higher 
than they are today, according to CBO. Seven years from now, a 
doubling of annual premiums for the average family will mean an 
increase in cost of $10,000.
    To most middle class families, yesterday, this bill stopped 
being a tax bill and started being a healthcare bill, and this 
Committee, again, is not reviewing it.
    Dr. Adams, thank you for being here. I have one question 
for you. Dangerous neighborhoods are not healthy neighborhoods. 
What we know about the biology of trauma and toxic stress is 
that if you're walking to school every day fearing for your 
life, if you live in a neighborhood in which gun shots are your 
bedtime music, as is the case in a lot of neighborhoods in this 
country, your brain is bathed in adrenalin and cortisol, which, 
from what I understand, fundamentally alters the way in which 
your brain works.
    As we're talking about trying to build healthy communities, 
how important is it to make sure that we're building safe 
communities? Because if kids fear violence, if they fear gun 
homicides, then all of the work we do to build resources and 
healthcare equity doesn't really matter because their brains 
have been altered. I know you've thought a lot about this, have 
done a lot of work around this issue. Talk about the connection 
between safe communities and healthy communities.
    Dr. Adams. Thank you so much for bringing up that point, 
because community safety is a critical part of wellness. I'll 
give you a quick example. I was in Atlanta last week, and the 
East Lake Community in Atlanta had some of the highest high 
school dropout rates, some of the worst crime, some of the 
lowest employment rates in the Nation.
    They brought together multiple different sectors, different 
partners, around the idea of economic wellness and 
productivity, and now, they are above the state average for 
high school completion, their crime rates have gone down, and 
they've become a more prosperous and a safer community, which 
leads back to the point that I originally made that health and 
the economy are intimately connected, and embedded in that is 
safety. If you're a more prosperous community, you're going to 
be a safer community and a healthier community, and vice versa.
    Senator Murphy. When we talk about gun violence, we tend to 
think of the impact as being on the victims and on the victims' 
immediate close set of friends and family. But the fact of the 
matter is the impact in these neighborhoods is felt by everyone 
who has this fight or flight mechanism that sets off in their 
brain. It's a public health issue, and I appreciate your 
comments on that.
    Thank you, Mr. Chairman.
    Dr. Adams. Thank you, sir.
    The Chairman. Thank you, Senator Murphy.
    Senator Warren.
    Senator Warren. Thank you, Mr. Chairman. I echo my 
colleague's concerns about yesterday's decision by the Senate 
Republicans to use their tax bill to rip healthcare coverage 
away from 13 million Americans. Republicans have apparently 
decided that it is not enough for their tax bill to raise taxes 
on millions of middle class families. Now it will also raise 
insurance premiums on millions more and take away healthcare 
coverage from people who desperately need it.
    Insurers, doctors, hospitals, patient groups--they have all 
been crystal clear. This will destabilize the insurance market, 
and it will hurt people, plain and simple. Republicans should 
not use their tax bill as a way to take away people's health 
insurance.
    Dr. Adams has come here to talk about an important topic, 
and I want to take an opportunity to ask him some questions 
about this. When it comes to health outcomes in this country, 
there are some really clear patterns. Life expectancy is lower 
for black Americans than for white Americans, lower for people 
without a high school degree than for those who complete 
college, lower for people at the bottom of the income 
distribution than those at the top. Because where we live is 
often segregated by these same factors, one recent study found 
a 20-year difference between counties with the highest and 
lowest life expectancies in America. That is deeply shocking.
    Dr. Adams. We've seen that even in Indiana.
    Senator Warren. That is deeply shocking in America. These 
disparities are persistent, but for decades, the story has been 
that all groups are living longer. Unfortunately, we're seeing 
some worrying new trends on that front. The CDC recently 
reported that the death rate so far in 2017 is up compared with 
last year, and research suggests that death rates are flat or 
even increasing for middle-aged white Americans who have not 
graduated from college.
    Dr. Adams, what do we know about what might be driving this 
troubling shift in mortality rates in America?
    Dr. Adams. Well, again, we had a discussion earlier about 
deaths of despair, and the reality is that when you look at the 
communities where those death rates are going up for middle-
aged white Americans, there is a lack of hope and there is a 
lack of opportunity.
    Hello, Senator Franken. How are you, sir?
    Senator Franken. Very good. How are you?
    Dr. Adams. I'm well.
    What we want to do is we want to make sure we're engaging 
the business sector, the faith-based community sector, the 
people in those communities who can provide that hope and 
opportunity, because that's the only way we're going to turn 
this around. We're not going to turn it around simply by 
looking at it as a medical problem or a health problem. We've 
got to look at it as a hope and an opportunity problem.
    Senator Warren. I see this as health and economic security 
go hand in hand, that having a good job with decent pay and 
health insurance means that if somebody gets sick, they can 
still go to the doctor and they can have a few months cushion 
until they get back on their feet. If addiction hits someone in 
the family, there's a better chance of accessing treatment.
    But if someone is injured on the job because their employer 
isn't following the law, or they can't get a hernia surgery 
because they don't have health insurance, or their paycheck 
barely covers their monthly rent, then--I'll be blunt about 
this--their chances of staying healthy and free from chronic 
pain simply aren't as good.
    Dr. Adams. They're a higher cost to their employers often.
    Senator Warren. That's exactly what I want to go to. Do you 
agree that improving health outcomes in this country and 
addressing these disturbing trends that we're talking about is 
going to take economic policies as well as public health 
policies?
    Dr. Adams. I think it's going to take economic policies, 
both in the private and the public sector, and I think that as 
public health advocates, we need to do a better job of helping 
corporations and businesses understand that connectivity so 
that they invest in their communities and their employees up 
front instead of paying on the back end for workplace 
accidents, for higher healthcare costs, for retraining people 
when they've got to fire the person who doesn't show up for 
work, or they just don't come back anymore.
    Senator Warren. Good. Well, I really appreciate your 
comments on this. These are very serious problems, literally 
life and death, and we're not going to solve them with any one 
hearing or any one policy. But we need to underline that a 
person's chances of growing up healthy or staying healthy or 
getting help when they need it should not depend on their zip 
code, and help should not be reserved for the wealthy few and 
the well connected. It means we have to be willing to fight for 
fair economic policies and an effective safety net as well as 
good public health programs.
    Dr. Adams. That's not just on the Federal level, but it's 
got to be on the private and on the state level also to make 
sure we have a comprehensive package of policies that put 
people in the best position for better health and communities 
in the best position for economic prosperity.
    Thank you.
    Senator Warren. Thank you.
    The Chairman. Thank you, Senator Warren.
    Senator Whitehouse.
    Senator Whitehouse. Thank you, Mr. Chairman.
    Welcome, Dr. Adams.
    Dr. Adams. Good to see you again.
    Senator Whitehouse. Good to see you again. First of all, 
thank you for mentioning CVS in your testimony. CVS is 
headquartered in Woonsocket, Rhode Island, and we're very proud 
of that company, and we're particularly proud of that company's 
decision to take cigarettes out of its stores, all of its 
stores, and indeed, they quit the United States Chamber of 
Commerce when it was discovered that the United States Chamber 
of Commerce was attacking tobacco regulations around the world. 
They have really dialed in on the health concerns about 
tobacco, and I think your recognition of that is a very nice 
thing for them and for Rhode Island. I appreciate that.
    Dr. Adams. Even though they took an initial hit, they 
actually are more profitable because they made a healthy 
decision. I think that's important for folks to understand. 
This wasn't just something that benefited the health of folks 
and it wasn't just a philanthropic endeavor. It was something 
that actually made economic sense for them to do in the long 
run, and that's what we want folks to understand and why the 
CVS story is so powerful.
    Senator Whitehouse. You also mentioned the discrepancy 
between the amount we pay for healthcare in this country and 
the outcomes that we get. You mentioned life expectancy, but 
there are plenty of metrics. I always have in my mind the graph 
of the OECD countries that shows the chart of them measured by 
life expectancy and by per capita cost, and America is like way 
out here, highest per capita cost by a ton over all of our 
competitors, and yet for all that extra money we're not getting 
gains. We're below the midpoint of the pack, as I recall, lined 
up with Croatia and Greece for life expectancy.
    What's interesting to me about that is that it suggests 
that there's real opportunity for good bipartisan work to be 
done here in this Committee to try to cure that problem, and, 
instead, we seem to be in this relentless groundhog day horror 
fight trying to undo healthcare for Americans, and to hell with 
the collateral damage in individual Americans' lives, and it's 
frustrating because I think we could be much more productive 
than this endless repeal and replace zombie that keeps coming 
out of the grave to no good that anybody can identify other 
than the political good, I guess, of putting the Affordable 
Care Act up as a sort of political trophy for the big 
Republican donors. The whole thing is very frustrating.
    But I want to focus on one particular area, because you 
spoke with a lot of passion about this when you and I met in my 
office, and that is the area when people are getting to the end 
of their life, when they have very advanced illnesses. As you 
know, there's a group called CTAC, the Coalition of Transformed 
Advanced Care, that is engaged with a lot of the business 
community, big business community leaders, to try to provide a 
better way of managing that time.
    In Rhode Island, we've done a lot of work that I told you 
about to try to take better care of people who are in that 
period of their lives. Very often, what we see, tragically, is 
that somebody who wants to be treated a certain way doesn't get 
that choice honored, partly because we haven't actually 
documented what their choice should be well enough and partly 
because the healthcare machinery just grabs them and grinds 
them along, and by the time you've been able to intervene, it's 
too late and they've had procedures they didn't want, and 
they've been in the ICU when they didn't want to be, and they 
weren't at home where they did want to be, and all of those 
things have gone wrong.
    In many respects, I think, the way we pay drives the care 
we get, and I encourage you to continue looking at ways that 
you can be an advocate for people suffering advanced illness in 
their last months of life who, I think, are very often 
casualties of our healthcare system because their voices simply 
aren't heard. I'd renew my invitation to you to come up to 
Rhode Island and let me show you what we're doing. You said you 
were interested in doing that when we met, and I renew the 
invitation today. If you could respond to that point.
    Dr. Adams. Absolutely, sir. I'm looking forward to coming 
up there. I've been in touch with your health commissioner 
constantly.
    By focusing on end of life care, we will be able to save 
tremendous dollars in terms of healthcare costs. But I'm going 
to show you an amazing display of message discipline. I'm going 
to show you how that fits into wellness. Folks who are 
healthier, who live a lifestyle of wellness, are going to not 
only live longer, but they're going to live healthier, they're 
going to have less healthcare cost, and they're not going to 
spend that much money on end of life care.
    But as you mentioned, just as importantly, part of wellness 
is having a plan for how you want to die. If it's going in and 
talking to your primary care physician about what you want and 
making sure it's documented in a way that folks understand and 
that can be communicated when the time actually comes. Even 
this, when you move upstream, comes back to focusing on 
wellness and making sure we're concentrating on that as a 
community instead of waiting until someone gets that terminal 
illness and then trying to sort it all out on the back end 
financially and philosophically.
    Senator Whitehouse. My time has expired. Thank you, Mr. 
Chairman.
    The Chairman. Thank you, Senator Whitehouse.
    Senator Kaine.
    Senator Kaine. Thank you, Mr. Chair, and thank you, Dr. 
Adams.
    Dr. Adams, Indiana, under the Affordable Care Act, chose to 
expand--to embrace the Medicaid expansion designed in its own 
way. Isn't that correct?
    Dr. Adams. We got a waiver to actually accept the Medicaid 
expansion funding through the ACA to expand our Healthy Indiana 
plan.
    Senator Kaine. Has the uninsured rate in Indiana come down 
fairly significantly because of that and also because of 
Obamacare subsidies that Indianans have been able to avail 
themselves of?
    Dr. Adams. We've been able to increase access to over 
400,000 people, and it's important to understand that the 
Healthy Indiana plan was also a partnership between the public 
and the private entities, which is why I keep saying 
partnerships are so critically important----
    Senator Kaine. Do you know, sitting here, what the 
reduction in the uninsured rate was, like pre-Affordable Care 
Act, and post-Affordable Care Act, when you include both the 
Obamacare subsidies to Indianans and the expansion of Medicaid 
that Indiana did?
    Dr. Adams. I can get you those specific numbers.
    I know I worked at a county hospital, and our uninsured 
rate went down significantly, and again, 400,000 is the number 
of folks who we've been able to increase access to coverage to.
    Senator Kaine. In your opinion, is Indiana a healthier 
community? The title of this hearing is Investing in Healthy 
Communities. Is Indiana a healthier community because fewer 
people are uninsured today?
    Dr. Adams. Indiana is a healthier community because we were 
given the flexibility to be able to design our own state 
program and actually implement it in a----
    Senator Kaine. Which many states have done under the 
Affordable Care Act. Correct?
    Dr. Adams. Yes, sir.
    Senator Kaine. You do believe that Indiana is a healthier 
community today as a result of both the Medicaid expansion that 
you designed and other aspects of the Affordable Care Act?
    Dr. Adams. I believe we're a healthier community today, 
sir.
    Senator Kaine. Would you say, generally, for purposes of 
the report that you're doing, looking at what makes a healthier 
community, that, all things being equal, as a general matter, 
the lower percentage of people who are uninsured, the healthier 
the community is?
    Dr. Adams. Yes, I would agree with that.
    Senator Kaine. You might find an exception here or there. 
But as a general matter, reducing the uninsured rate would be 
one sign of a community that is likely to be a healthier 
community.
    Dr. Adams. I would agree with that, sir.
    Senator Kaine. There's surveys every year that get put out 
by groups like United Health Association that rank the 
healthiest and least healthy states in the United States. In 
the most recent version that I've seen, the 10 healthiest 
states in the United States all have done the Medicaid 
expansion, and of the 10 least healthy states in the United 
States, only four have done the Medicaid expansion, and I think 
that's additional evidence of the proposition that you're 
testifying to today.
    I'll just add my own concern about what's happening in the 
Finance Committee now. If, as you testify and as the statistics 
would seem to suggest, one evidence of being healthier is 
reducing the percentage of uninsured, why would we want in a 
tax bill to do something that would increase the number of 
uninsured? It suggests that tax is more important than people's 
health. A tax break to some at the top is more important than 
people's health.
    It's kind of a left hand-right hand problem. We're here in 
the HELP Committee trying to do things that improve people's 
health, and you're testifying about healthy communities with 
some great testimony, and it would seem from the statistics and 
Indiana's own experience that if you reduce the uninsured rate, 
you're going to have healthier communities. That's the purpose 
of the hearing. But in the Finance Committee today, there's 
going to be an action taken that would reduce the number of 
people in this country by potentially 13 million who have 
health insurance. I just don't get it.
    Let me ask you this, switching gears. We had a hearing 
about 2 weeks ago, and we had a number of witnesses, including 
Francis Collins from NIH, a really great leader, a Virginian--
I'm a little proud of him for that reason--and I asked him this 
question, and I would be curious as to your answer about this 
question.
    If we were to set a goal as a Nation, like a big goal, and 
say we want to be addiction free by 2030, is the state of our 
knowledge about addiction, is the state of our treatments and 
technology such that we could make that kind of a bold 
statement, like John F. Kennedy said we're going to be on the 
moon at the end of the decade? Could we make that kind of a 
bold commitment if we really put our minds to it? Do you, as 
Surgeon General of the United States, think we can meet that 
goal?
    Dr. Adams. I wouldn't only say that we can. I would say 
that we must. We never would have gotten to the moon, even 
though folks didn't believe it was possible, unless JFK 
declared that we were going to do so. We are not going to solve 
this crisis unless we are definitive that it's an absolutely 
must that we achieve that goal, and I'm confident that we can 
if we work toward better partnerships.
    If I may, to your point earlier, I don't want to debate 
your point. It's clear that higher insurance rates correlate 
with healthier communities.
    Senator Kaine. Higher percentages of people with insurance.
    Dr. Adams. Yes. But there is primary, secondary, and 
tertiary prevention, and you're talking about tertiary 
prevention. As a public health advocate, I would be remiss if I 
did not say that we can focus all we want on healthcare, but as 
long as we're over-consuming it because of a lack of wellness, 
we aren't going to solve the problem.
    The states that you mentioned that are in the top 10 and 
the states that you mentioned that are in the bottom 10--they 
were in the top 10 and the bottom 10 before the Affordable Care 
Act. Why? Because they are states who invested in wellness and 
health and had their communities--Senator Franken and I talked 
a lot about Minnesota before you came, doing a great job there 
of engaging the corporations and the businesses in health, and 
Minnesota has been in that top in terms of health outcomes. I 
think it's important that we always remember we need to focus 
on wellness and that healthcare and health insurance coverage 
is one part of the equation, but it's not going to solve the 
problem if we don't focus upstream and keep----
    Senator Kaine. But you would agree with me, though, that 
the percentage of people with health coverage is a pretty 
important component of the health of a community.
    Dr. Adams. I would agree with you that the science shows 
that in communities that have higher rates of coverage, they 
tend to be healthier than ones that don't.
    Senator Kaine. Right. Thank you very much.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Kaine.
    Senator Franken.
    Senator Franken. Yes, I definitely agree with that, and in 
Minnesota, we have--we cut in half the numbers that were 
uninsured. I'm glad that you brought up the National Diabetes 
Prevention Program in your testimony or at some point earlier. 
I'm sorry----
    Dr. Adams. I was giving you shout-outs left and right, 
Senator.
    Senator Franken. That's what I understand, including 
mentioning that I didn't show on you again. Let me explain. I 
really wanted to be at your confirmation hearing. The day of 
that confirmation hearing, I was at Arlington Cemetery speaking 
at--I spoke at the funeral of Captain Luis Montalvan, who was 
an inspiration to me on--he had a dog, a service dog, and we 
can talk about the service dog program at some point. But I'm 
really sorry I wasn't able to be there, but I was doing 
something else.
    Dr. Adams. No, thank you for that. One of the honors of my 
life was marching in the New York City Veterans Day parade this 
past weekend. It's extremely important that we honor our 
veterans for their service, and thank you for that.
    Senator Franken. He was a friend of mine.
    I do want to mention this, in the finance bill, this idea 
of taking away the mandate. We know what the results of that 
would be, and it would be antithetical to what you're talking 
about. The more people insured, the healthier we are. We know 
that. We saw a survey study in JAMA about the benefits of 
more--that we've had because of the Affordable Care Act and 
more people insured.
    To me--and another thing that that does, which is inserting 
that into a tax bill, I think is just--it's not helpful. It 
poisons the well on cooperation on healthcare and the wonderful 
compromise that the Chairman and the Ranking Member came up 
with. I just would hope that the--we've been shut out of so 
many things, and it hasn't--there hasn't been a good result 
because of that. The best results, to me, are when we do things 
in a bipartisan way, which the Chairman does.
    But I want to move on to something that we do in Minnesota. 
You highlight that in the U.S., we spend more on healthcare 
than any other country, around $3.2 trillion each year, and in 
many cases twice the amount that other countries that cover 
everybody, and yet there's so much more that needs to be done 
to improve our outcomes. It's estimated that 50 percent of 
costs are used by just 5 percent of the population, and 
according to a piece in the Journal of the American Medical 
Association, an overwhelming portion of these top healthcare 
users are poor and housing insecure.
    Recognizing the connection between housing and health, some 
healthcare organizations have begun working to address housing 
needs in order to improve the overall health of their patients. 
In Minnesota, Hennepin Health, an accountable care organization 
in the Twin Cities, developed a program that paired healthcare, 
housing, and social services. Just 1 year after participants in 
the program were placed in supportive housing, Hennepin Health 
saw significant reductions in emergency room visits, 
hospitalizations, and psychiatric care.
    A study on a similar program in Los Angeles found that 
government spending was 79 percent lower for people in 
supportive housing than for people who were homeless.
    Vice Admiral Adams, what will you do to encourage 
healthcare providers and other stakeholders to work together to 
deliver healthcare interventions that are paired with housing 
and other social supports?
    Dr. Adams. Senator, thank you so much for that question. I 
have been in touch with Secretary Carson. I think we have a 
tremendous opportunity having a physician as head of HUD, and 
he and I both firmly believe housing is health. We know one of 
the No. 1 predictors of whether or not you're going to be 
successful in recovering from addiction is whether or not 
you've got permanent supportive housing to go back into.
    We know that you're not going to take your diabetes 
medication or your hypertension medications or get your 
screenings if you're worried about where you're going to sleep 
that night. Housing is absolutely health, and I think that the 
folks who represent the housing community need to be at the 
table when we're discussing how we build a healthier community.
    With a bit of your indulgence, Senator Alexander, I would 
be remiss if I did not say that I detected an insinuation from 
several folks that the current administration is against 
coverage for folks. I do agree that there is a direct link 
between the health of a community and the number of people who 
are insured. The administration is not against people being 
insured. We have a different mindset about how we can achieve 
that.
    I can tell you that in Indiana, folks did not believe we 
would be able to increase coverage to people through our 
Healthy Indiana plan. Folks didn't believe it. We were able to 
expand coverage to over 400,000 people. This administration is 
not anti-coverage. It's about giving states the flexibility to 
decide how that coverage is going to be delivered, and I think 
that's an important distinction without going too far down that 
rabbit hole, because, again----
    The Chairman. We need to wrap up, Dr. Adams.
    Senator Franken. Can I just respond to that in one little 
way?
    The Chairman. Yes.
    Senator Franken. In Indiana, you took Medicaid expansion, 
didn't you?
    Dr. Adams. Sir, we got a waiver to actually expand our 
Healthy Indiana plan utilizing funds that were made available 
through the Affordable Care Act by a waiver.
    Senator Franken. Exactly. I mean, funds were made available 
through the Affordable Care Act. You got a waiver, which was 
part of the structure of the Affordable Care Act. When--you 
can't have it both ways.
    Dr. Adams. But the administration's plans for healthcare 
reform that have been put out here so far--each of them--and I 
know because I'm in touch with the Governor of Indiana--would 
still allow us to continue our Healthy Indiana----
    The Chairman. We're well over time, and I have to go to a 
markup with----
    Senator Franken. I know, but every plan offered by the 
administration and by the Republicans--CBO has scored every one 
of them for, in many cases, tens of millions of Americans--
fewer having insurance, and you know that. You have to know 
that.
    Dr. Adams. I know we need to focus on wellness, and I look 
forward to working with all of you all to focus on wellness 
because----
    Senator Franken. That was not responsive to what I just 
asked you.
    The Chairman. Okay. Thank you, Senator Franken.
    Dr. Adams, thank you for being here for the hearing and for 
your suggestions and for your service to our country.
    Senator Murray, do you have other things you'd like to say?
    Senator Murray. Well, Mr. Chairman, I do want to just say 
that if you don't have access to insurance because the 
insurance market has collapsed, that's no healthcare coverage 
for a lot of people. That is why we are deeply concerned on 
this side.
    But, Dr. Adams, I do want to thank you for your hearing 
testimony today. We want to work with you on healthy outcomes, 
lower healthcare costs for families. We are concerned about and 
deeply opposed to the proposal because it will increase costs, 
and when it increases costs, then people don't have access. I'm 
very deeply concerned about this administration's long-time 
activity to actively undermine the healthcare of our 
communities, and we will continue to focus on that.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Murray.
    The hearing record will remain open for 10 days. Members 
may submit additional information for the record within that 
time if they would like.
    Thank you for being here. The Committee will stand 
adjourned.
    [Whereupon, at 11:27 a.m., the hearing was adjourned.]

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