[House Hearing, 117 Congress]
[From the U.S. Government Publishing Office]
EMPOWERED BY DATA: LEGISLATION TO ADVANCE EQUITY AND PUBLIC HEALTH
=======================================================================
HYBRID HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON ENERGY AND COMMERCE
HOUSE OF REPRESENTATIVES
ONE HUNDRED SEVENTEENTH CONGRESS
FIRST SESSION
__________
JUNE 24, 2021
__________
Serial No. 117-39
Published for the use of the Committee on Energy and Commerce
govinfo.gov/committee/house-energy
energycommerce.house.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
51-212 WASHINGTON : 2023
COMMITTEE ON ENERGY AND COMMERCE
FRANK PALLONE, Jr., New Jersey
Chairman
BOBBY L. RUSH, Illinois CATHY McMORRIS RODGERS, Washington
ANNA G. ESHOO, California Ranking Member
DIANA DeGETTE, Colorado FRED UPTON, Michigan
MIKE DOYLE, Pennsylvania MICHAEL C. BURGESS, Texas
JAN SCHAKOWSKY, Illinois STEVE SCALISE, Louisiana
G. K. BUTTERFIELD, North Carolina ROBERT E. LATTA, Ohio
DORIS O. MATSUI, California BRETT GUTHRIE, Kentucky
KATHY CASTOR, Florida DAVID B. McKINLEY, West Virginia
JOHN P. SARBANES, Maryland ADAM KINZINGER, Illinois
JERRY McNERNEY, California H. MORGAN GRIFFITH, Virginia
PETER WELCH, Vermont GUS M. BILIRAKIS, Florida
PAUL TONKO, New York BILL JOHNSON, Ohio
YVETTE D. CLARKE, New York BILLY LONG, Missouri
KURT SCHRADER, Oregon LARRY BUCSHON, Indiana
TONY CARDENAS, California MARKWAYNE MULLIN, Oklahoma
RAUL RUIZ, California RICHARD HUDSON, North Carolina
SCOTT H. PETERS, California TIM WALBERG, Michigan
DEBBIE DINGELL, Michigan EARL L. ``BUDDY'' CARTER, Georgia
MARC A. VEASEY, Texas JEFF DUNCAN, South Carolina
ANN M. KUSTER, New Hampshire GARY J. PALMER, Alabama
ROBIN L. KELLY, Illinois, Vice NEAL P. DUNN, Florida
Chair JOHN R. CURTIS, Utah
NANETTE DIAZ BARRAGAN, California DEBBBIE LESKO, Arizona
A. DONALD McEACHIN, Virginia GREG PENCE, Indiana
LISA BLUNT ROCHESTER, Delaware DAN CRENSHAW, Texas
DARREN SOTO, Florida JOHN JOYCE, Pennsylvania
TOM O'HALLERAN, Arizona KELLY ARMSTRONG, North Dakota
KATHLEEN M. RICE, New York
ANGIE CRAIG, Minnesota
KIM SCHRIER, Washington
LORI TRAHAN, Massachusetts
LIZZIE FLETCHER, Texas
------
Professional Staff
JEFFREY C. CARROLL, Staff Director
TIFFANY GUARASCIO, Deputy Staff Director
NATE HODSON, Minority Staff Director
Subcommittee on Health
ANNA G. ESHOO, California
Chairwoman
G. K. BUTTERFIELD, North Carolina BRETT GUTHRIE, Kentucky
DORIS O. MATSUI, California Ranking Member
KATHY CASTOR, Florida FRED UPTON, Michigan
JOHN P. SARBANES, Maryland, Vice MICHAEL C. BURGESS, Texas
Chair H. MORGAN GRIFFITH, Virginia
PETER WELCH, Vermont GUS M. BILIRAKIS, Florida
KURT SCHRADER, Oregon BILLY LONG, Missouri
TONY CARDENAS, California LARRY BUCSHON, Indiana
RAUL RUIZ, California MARKWAYNE MULLIN, Oklahoma
DEBBIE DINGELL, Michigan RICHARD HUDSON, North Carolina
ANN M. KUSTER, New Hampshire EARL L. ``BUDDY'' CARTER, Georgia
ROBIN L. KELLY, Illinois NEAL P. DUNN, Florida
NANETTE DIAZ BARRAGAN, California JOHN R. CURTIS, Utah
LISA BLUNT ROCHESTER, Delaware DAN CRENSHAW, Texas
ANGIE CRAIG, Minnesota JOHN JOYCE, Pennsylvania
KIM SCHRIER, Washington CATHY McMORRIS RODGERS, Washington
LORI TRAHAN, Massachusetts (ex officio)
LIZZIE FLETCHER, Texas
FRANK PALLONE, Jr., New Jersey (ex
officio)
C O N T E N T S
----------
Page
Hon. Anna G. Eshoo, a Representative in Congress from the State
of California, opening statement............................... 2
Prepared statement........................................... 3
Hon. Brett Guthrie, a Representative in Congress from the
Commonwealth of Kentucky, opening statement.................... 4
Prepared statement........................................... 6
Hon. Frank Pallone, Jr., a Representative in Congress from the
State of New Jersey, opening statement......................... 7
Prepared statement........................................... 8
Hon. Cathy McMorris Rodgers, a Representative in Congress from
the State of Washington, opening statement..................... 9
Prepared statement........................................... 11
Hon. Richard Hudson, a Representative in Congress from the State
of North Carolina, prepared statement.......................... 109
Witnesses
Karen B. DeSalvo, M.D., Chief Health Officer, Google Health...... 13
Prepared statement........................................... 15
Answers to submitted questions............................... 232
Romilla Batra, M.D., Chief Medical Officer, SCAN Health Plan..... 25
Prepared statement........................................... 27
Answers to submitted questions............................... 235
Beth I. Blauer, Executive Director, Johns Hopkins University
Centers for Civic Impact....................................... 34
Prepared statement........................................... 36
Answers to submitted questions............................... 240
Faisel Syed, M.D., National Director of Primary Care, ChenMed.... 42
Prepared statement........................................... 44
Answers to submitted questions............................... 243
Kara Odom Walker, Executive Vice President and Chief Population
Health Officer, Nemours Children's Health System............... 46
Prepared statement........................................... 48
Answers to submitted questions............................... 245
Submitted Material
H.R. 379, the Improving Social Determinants of Health Act of
2021\1\
H.R. 666, the Anti-Racism in Public Health Act of 2021\1\
H.R. 778, the Secure Data and Privacy for Contact Tracing Act of
2021\1\
H.R. 791, the Tracking COVID-19 Variants Act\1\
H.R. 831, the Health Standards To Advance Transparency,
Integrity, Science, Technology Infrastructure, and Confidential
Statistics Act of 2021\1\
H.R. 925, the Data to Save Moms Act\1\
H.R. 943, the Social Determinants for Moms Act\1\
H.R. 976, the Ensuring Transparent Honest Information on COVID-19
Act or the ETHIC Act\1\
H.R. 2125, the Quit Because of COVID-19 Act\1\
H.R. 2503, the Social Determinants Accelerator Act of 2021\1\
----------
\1\ The legislation has been retained in committee files and is
available at https://docs.house.gov/Committee/Calendar/
ByEvent.aspx?EventID=112817.
H.R. 3894, the Collecting and Analyzing Resources Integral and
Necessary for Guidance for Social Determinants of Health Act of
2021\1\
H.R. 3969, a bill to amend title XXVII of the Public Health
Service Act\1\
H.R. 4026, a bill to require the Comptroller General of the
United States to submit to Congress a report\1\
Statement of the March of Dimes by Stacey D. Stewart, President
and Chief Executive Officer, June 24, 2021, submitted by Ms.
Eshoo.......................................................... 110
Statement of AHIP, ``Medicare Advantage: Overcoming Barriers to
Good Health,'' March 2021, submitted by Ms. Eshoo.............. 114
Report by NORC at the University of Chicago, ``Spotlight on
Health: Analysis of COVID-19 Impact on Medicare Advantage and
Fee-for-Service Beneficiaries,'' May 18, 2021, submitted by Ms.
Eshoo.......................................................... 115
Letter of June 23, 2021, from Gary L. LeRoy, Board Chair,
American Academy of Family Physicians, to Ms. Eshoo and Mr.
Guthrie, submitted by Ms. Eshoo................................ 125
Letter of June 23, 2021, from Jennifer L. Ellis and Paul L.
Underwood, Cochairs, Policy and Advocacy Committee, Association
of Black Cardiologists, to Ms. Eshoo and Mr. Guthrie, submitted
by Ms. Eshoo................................................... 128
Statement of Aligning for Health, June 24, 2021, submitted by Ms.
Eshoo.......................................................... 131
Report by Anthem, ``Expanding Access to Care and Social
Supports,'' submitted by Ms. Eshoo............................. 134
Report of the Blue Cross Blue Shield Association, ``Social
Determinants of Health,'' June 16, 2021, submitted by Ms. Eshoo 138
Report of the Blue Cross Blue Shield Association, ``Improving
Black Maternal Care and Health Through Pregnancy and
Childbirth,'' submitted by Ms. Eshoo........................... 154
Report on behalf of the Better Medicare Alliance, ``Comparing the
Demographics of Enrollees in Medicare Advantage and Fee-For-
Service Medicare,'' by Milliman, October 2020, submitted by Ms.
Eshoo.......................................................... 159
Statement of Hon. Ayanna Pressley, a Representative in Congress
from the Commonwealth of Massachusetts, June 24, 2021,
submitted by Ms. Eshoo......................................... 176
Letter of April 30, 2021, from Representative Val Demings, et
al., to Secretary Xavier Becerra, Department of Health and
Human Services, submitted by Ms. Eshoo......................... 179
Letter of June 23, 2021, from Harold P. Wimmer, President and
Chief Executive Officer, American Lung Association, to Ms.
Eshoo and Mr. Guthrie, submitted by Ms. Eshoo.................. 181
Statement of the National Indian Health Board, June 24, 2021,
submitted by Ms. Eshoo......................................... 185
Statement of Dr. Jim Jirjis, Chief Health Information Officer,
HCA Healthcare, June 23, 2021, submitted by Ms. Eshoo.......... 194
Letter of June 17, 2021, from Senator Cory A. Booker, et al., to
House Speaker Nancy Pelosi and Senate Majority Leader Charles
E. Schumer, submitted by Ms. Eshoo............................. 197
H.R. ___, the Addressing Social Determinants in Medicare
Advantage Act of 2021, submitted by Ms. Eshoo.................. 205
Letter from Sinsi Hernandez-Cancio, Vice President for Health
Justice, National Partnership for Women & Families, to Ms.
Eshoo and Mr. Guthrie, submitted by Ms. Kelly.................. 208
News release of May 14, 2021, ``New Report Ends Corporate Media's
Favorite False Narrative About Florida's Successful COVID-19
Response,'' Executive Office of Ron DeSantis, Governor of
Florida, submitted by Mr. Bilirakis............................ 210
Report of the National Partnership for Women & Families and the
National Birth Equity Collaborative, ``Saving the Lives of Moms
and Babies: Addressing Racism and Socioeconomic Influencers,''
by Joia Creer-Perry and Sinsi Hernandez-Cancio, submitted by
Ms. Eshoo...................................................... 212
----------
\1\ The legislation has been retained in committee files and is
available at https://docs.house.gov/Committee/Calendar/
ByEvent.aspx?EventID=112817.
Report of AHIP, ``Social Determinants of Health and Medicare
Advantage: Policy Recommendations to Achieve Greater Impact on
Reducing Disparities & Advancing Health Equity for America's
Medicare Population,'' submitted by Ms. Eshoo.................. 218
Statement of J. Nadine Gracia, President and Chief Executive
Officer, Trust for America's Health, June 24, 2021, submitted
by Ms. Eshoo................................................... 223
Article of June 15, 2021, ``Ending sickle cell disease is a
matter of racial justice,'' by Brett P. Giroir, The Hill,
submitted by Ms. Eshoo......................................... 228
Letter of June 23, 2021, from Barbara Petee, Executive Director,
and Thomas Dorney, Director, The Root Cause Coalition, to Ms.
Eshoo and Mr. Guthrie, submitted by Ms. Eshoo.................. 231
EMPOWERED BY DATA: LEGISLATION TO ADVANCE EQUITY AND PUBLIC HEALTH
----------
THURSDAY, JUNE 24, 2021
House of Representatives,
Subcommittee on Health,
Committee on Energy and Commerce,
Washington, DC.
The subcommittee met, pursuant to call, at 10:30 a.m., in
the John D. Dingell Room 2123, Rayburn House Office Building,
and remotely via Cisco Webex online video conferencing, Hon.
Anna G. Eshoo (chairwoman of the subcommittee) presiding.
Members present: Representatives Eshoo, Matsui, Castor,
Sarbanes, Welch, Schrader, Cardenas, Ruiz, Dingell, Kuster,
Kelly, Barragan, Blunt Rochester, Craig, Schrier, Trahan,
Fletcher, Pallone (ex officio), Guthrie (subcommittee ranking
member), Upton, Burgess, Griffith, Bilirakis, Long, Bucshon,
Mullin, Hudson, Carter, Dunn, Curtis, Crenshaw, Joyce, and
Rodgers (ex officio).
Staff present: Shana Beavin, Professional Staff Member;
Jeffrey C. Carroll, Staff Director; Waverly Gordon, General
Counsel; Tiffany Guarascio, Deputy Staff Director; Perry
Hamilton, Clerk; Zach Kahan, Deputy Director, Outreach and
Member Service; Una Lee, Chief Health Counsel; Meghan Mullon,
Policy Analyst; Joe Orlando, Policy Analyst; Michael Ovlin,
Health Fellow; Tim Robinson, Chief Counsel; Chloe Rodriguez,
Clerk; Kylea Rogers, Staff Assistant; Andrew Souvall, Director
of Communications, Outreach, and Member Services; Kimberlee
Trzeciak, Chief Health Advisor; Alec Aramanda, Minority
Professional Staff Member, Health; Sarah Burke, Minority Deputy
Staff Director; Theresa Gambo, Minority Financial and Office
Administrator; Seth Gold, Minority Professional Staff Member,
Health; Grace Graham, Minority Chief Counsel, Health; Nate
Hodson, Minority Staff Director; Peter Kielty, Minority General
Counsel; Emily King, Minority Member Services Director; Bijan
Koohmaraie, Minority Chief Counsel, Oversight and
Investigations Chief Counsel; Clare Paoletta, Minority Policy
Analyst, Health; Kristin Seum, Minority Counsel, Health;
Kristen Shatynski, Minority Professional Staff Member, Health;
Olivia Shields, Minority Communications Director; Michael
Taggart, Minority Policy Director; and Everett Winnick,
Minority Director of Information Technology.
Ms. Eshoo. The Subcommittee on Health will now come to
order. And due to COVID-19, today's hearing is being held both
remotely and in person.
For Members and witnesses taking part remotely, microphones
will be set on mute to eliminate background noise. Members and
witnesses, you will need to unmute your microphone when you
wish to speak.
Since Members are participating from different locations at
today's hearing, recognition of Members for questions will be
in the order of subcommittee seniority. So keep that in mind.
The documents for the record should be sent to Meghan
Mullon at the email address that has been provided to your
staff. All documents will be entered into the record at the
conclusion of the hearing.
The Chair now recognizes herself for 5 minutes for an
opening statement.
OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN
CONGRESS FROM THE STATE OF CALIFORNIA
``Underfunded and under threat.'' That was the Associated
Press and Kaiser Health News' indictment of the U.S. public
health system, based on their award-winning investigation last
year. The investigation found that, since 2010, spending for
State public health departments dropped by 16 percent per
capita, and spending for local health departments fell by 18
percent. At least 38,000 State and local public health jobs
have disappeared since the 2008 recession.
Our hollowed-out public health system explains why we have
seen COVID-19 cases tracked using fax machines and COVID-19
vaccines recorded on little white paper cards. These antiquated
methods are embarrassing for our country that once held a--had
a globally respected public health system. And our disarrayed
data collection has brought our--consequences for so many
Americans. It has allowed racial health disparities to flourish
without intervention. And as the common maxim goes, you can't
manage what you can't measure.
The 13 bills our subcommittee is considering today begin to
rebuild our public health systems beyond pen-and-paper data
collection and inconsistent definitions. Several of the bills
use data to help our health systems improve the overall health
and wellness of local populations rather than treat individual
sickness.
I am proud to colead, with Representative Peters, the
Health STATISTICS Act, which directs the CDC to develop
uniform, public health data standards for State and local
health departments.
Put simply, public health data is a mess. A striking
example is the incomplete and inconsistent COVID-19 case counts
and death tallies, which is addressed by bills authored by
Representatives Castor, Speier, and Bera.
Beyond COVID-19, inconsistent public health data have been
raised repeatedly as an issue before this subcommittee in
hearings. An example of this is that there is not a single
standard for how to define a gun death or maternal death. My
legislation with Representative Peters carries out several
recommendations from the GAO and the National Academies of
Science to make vital health statistics electronically
available and comparable.
Robust and accessible public health data is a critical tool
for State and local officials in their efforts to address the
social determinants of health that perpetuate the inequities in
our communities. Representative Barragan's Improving Social
Determinants of Health Act builds and complements the Health
STATISTICS Act by authorizing a new CDC program that would use
the improved and available health data to address structural
challenges, such as unsafe housing, poor transportation, or
food deserts.
The remaining bills work together to use public health data
to address health disparities starting at conception through
childhood, and into adulthood. I am proud that our subcommittee
is once again leading the charge in a bipartisan way to promote
health equity through evidence-based, data-driven policy.
Taken together, these 13 bills will make real and lasting
change to rebuild our public health system so we can address
both new health emergencies, like COVID-19, as well as the
systemic issues of poverty and inequality.
[The prepared statement of Ms. Eshoo follows:]
Prepared Statement of Hon. Anna G. Eshoo
``Underfunded and under threat.'' That was the Associated
Press and Kaiser Health News' indictment of the U.S. public
health system based on their award-winning investigation last
year.
The investigation found that since 2010, spending for state
public health departments dropped by 16% per capita and
spending for local health departments fell by 18%. At least
38,000 state and local public health jobs have disappeared
since the 2008 recession.
Our hollowed-out public health system explains why we've
seen COVID-19 cases tracked using fax machines and COVID-19
vaccines recorded on white paper cards.
These antiquated methods are embarrassing for a nation that
once had a globally respected public health system, and our
disarrayed data collection has broader consequences for many
Americans. It has allowed racial health disparities to flourish
without intervention. As the common maxim goes ``you can't
manage what you can't measure.''
The 13 bills our Subcommittee is considering today begin to
rebuild our public health systems beyond pen-and-paper data
collection and inconsistent definitions. Several of the bills
use data to help our health systems improve the overall health
and wellness of local populations rather than treat individual
sickness.
I'm proud to co-lead with Representative Peters, the Health
STATISTICS Act, which directs the CDC to develop uniform public
health data standards for state and local health departments.
Put simply, public health data is a mess. A striking
example is the incomplete and inconsistent COVID-19 case counts
and death tallies, which is addressed by bills authored by
Representatives Castor, Speier, and Bera.
Beyond COVID-19, inconsistent public health data have been
raised repeatedly as an issue before this Subcommittee in
hearings. An example is that there's not a single standard for
how to define a gun death or a maternal death.
My legislation with Representative Peters carries out
several recommendations from the GAO and the National Academies
of Science to make vital health statistics electronically
available and comparable.
Robust and accessible public health data is a critical tool
for our state and local officials in their efforts to address
the social determinants of health that perpetuate the
inequities in our communities.
Rep. Barragan's Improving Social Determinants of Health Act
builds on and complements the Health STATISTICS Act by
authorizing a new CDC program that would use the improved and
available health data to address structural challenges such as
unsafe housing, poor transportation, or food deserts.
The remaining bills work together to use public health data
to address health disparities starting at conception, through
childhood, and into adulthood.
I'm proud that our Subcommittee is once again leading the
charge in a bipartisan way to promote health equity through
evidence-based, data-driven policy. Taken together, these 13
bills will make real and lasting change to rebuild our public
health system so we can address both new health emergencies
like COVID-19, as well as the systemic issues of poverty and
racial inequality.
Ms. Eshoo. The Chair now is pleased to recognize our
ranking member of the subcommittee, Mr. Guthrie, for 5
minutes----
Mr. Burgess. Madam Chair? Madam Chair? This is Burgess. I
wonder if I could just ask for a point of personal privilege
before Mr. Guthrie is recognized.
Ms. Eshoo. Certainly.
Mr. Burgess. Several people on this subcommittee are old
enough to remember when we had a different subcommittee chair.
And it was at that time that I was assisted so ably by my young
staff.
Elizabeth Allen is going to be leaving my office now. She
has accepted a position at Boston College to get an MBA, and it
is quite a step--needless to say, quite a step up for her.
We have all benefited from her experience and her knowledge
over the time that she has been associated with the Health
Subcommittee's work. So I thought, if I could, I would just
like to acknowledge the service of Elizabeth Allen, and perhaps
we could give her a brief round of applause.
Ms. Eshoo. Absolutely, thank you.
[Applause.]
Ms. Eshoo. And we thank her for her wonderful service and
wish her well.
The Chair now recognizes the wonderful ranking member of
our subcommittee, Mr. Guthrie.
OPENING STATEMENT OF HON. BRETT GUTHRIE, A REPRESENTATIVE IN
CONGRESS FROM THE COMMONWEALTH OF KENTUCKY
Mr. Guthrie. Thank you. Thank you, Chair Eshoo, and thanks
to Elizabeth. And I always enjoyed working with her, as well.
So thank you for your hard work, and good luck at Boston
College.
And thanks for holding this important hearing today.
Before us today we have several bills pertaining to social
determinants of health, as well as collecting health data. I
look forward to hearing from the witnesses regarding these
bills.
As currently defined by the CDC, social determinants of
health are conditions and places where people live, learn,
work, and play that affect a wide range of quality-of-health
and quality-of-life risks and outcomes. I have seen and heard,
firsthand, the benefits that Medicare Advantage can do to help
address social determinants of health for seniors.
For example, a recent study showed that Medicare Advantage
plans continue to offer benefits that help Americans with their
social determinants of health. Specifically, the study found 27
percent of Medicare Advantage plans offered in-home services;
57 percent offered meal delivery; 57 percent offered
transportation services; and 11 percent offered home
modification. Additionally, they found that 94 percent of plans
now offer telehealth as a base benefit. These benefits can
continue without policy changes or site-of-service
restrictions, postpandemic.
Since 2015 I have led the bipartisan Member letter in
support of Medicare Advantage. In 2020 we had over 300 Members
sign the annual letter to HHS in support of the program. It has
been a bipartisan effort, and I want to take this opportunity
to thank Representatives Cardenas, Blumenauer, and Kelly for
all of their hard work on this letter.
Medicare Advantage has demonstrated how successful private
insurance plans can be, if given the proper flexibilities--that
is, if my colleagues do not force Medicare for All on all
Americans and take away this choice for nearly 29 million
beneficiaries--nearly half of the eligible Medicare population
that is--is estimated to choose MA for 2022. Medicare for All
would prevent Americans from choosing this option that provides
quality healthcare and supplemental services and helps address
social determinants of health.
Medicare for All will lead to worst-case scenario for
seniors, longer wait times, and diminished patient control over
their own healthcare.
Today we are considering several health bills--health data
bills. Useful health data is important, but some of the bills
before us today are too narrow in scope and are duplicative of
current efforts. In addition, it does not seem there is a
consensus on what--who needs to collect what data, how it will
be used, and who will have access to it, and how to do that in
a way that doesn't add more administrative expense.
COVID-19 shed light on the need for more public health data
infrastructure, and we must use lessons learned to prepare for
future pandemics rather than continuing to focus on COVID-19's
specific authorities and programs.
For example, H.R. 778 would establish new CDC grants to
States that choose to develop and use digital contact tracing
technology for COVID-19, which seems duplicative of programs
that have already been funded in response to the pandemic. CDC
has already received funds to do just that, and we should first
evaluate how those funds are being spent.
Additionally, H.R. 791, the Tracking COVID-19 Variants Act,
includes provisions that will require the CDC to issue guidance
regarding collaborations in data sharing for COVID-19
sequencing while further enacting a pilot program by expanding
existing data linkages. Data sequencing is already being done
on variants today.
Further, H.R. 976, the ETHIC Act, would retroactively
require States to report specific COVID-19 data to the CDC as a
condition on receiving certain COVID-19 funding. Currently,
States are already required to report some of this data.
I am looking forward to examining and building on ideas
like Mr. Curtis' bipartisan legislation, H.R. 3969, which would
allow spending on social determinants of health to be included
in health insurance plans' medical loss ratio calculation, so
to encourage Medicare Advantage and Medicare managed care
organizations to take further action to support social
determinants of health.
I support Dr. Burgess' bill, the Social Determinants of
Health Data Analysis Act, which would require GAO to report on
the actions taken by the Secretary of HHS to address social
determinants of health.
In closing, I hope we can work in a bipartisan way to
improve America's public health infrastructure so we are better
prepared and ready to address the next pandemic. As we continue
working, we need to ensure Americans' hard-earned taxpayer
dollars are being used efficiently and not on duplicate
efforts. I look forward to having a productive discussion today
on how to have better healthcare data and address social
determinants of health.
[The prepared statement of Mr. Guthrie follows:]
Prepared Statement of Hon. Brett Guthrie
Thank you, Chair Eshoo, for holding this important hearing
today.
Before us today we have several bills pertaining to social
determinants of health (SDOH) as well as collecting health
data. I look forward to hearing from the witnesses regarding
these bills.
As currently defined by the CDC, social determinants of
health are conditions in the places where people live, learn,
work, and play that affect a wide range of health and quality-
of life-risks and outcomes. I have seen and heard firsthand the
benefits that Medicare Advantage can do to help address social
determinants of health for seniors.
For example, a recent study showed that Medicare Advantage
plans continue to offer supplemental benefits that help
Americans with their social determents of health. Specifically,
the study found 27% of MA plans offered in-home services, 57%
offered meal delivery, 57% offered transportation services, and
11% offered home-modification. Additionally, they found that
94% of plans now offer telehealth as a base benefit. These
benefits can continue without policy changes or site of service
restrictions post-pandemic.
Since 2015, I have led the bipartisan member letter in
support of MA. Historically, we have had record numbers of
members join these efforts. In fact, in 2020, we had over 300
members sign the annual letter to HHS in support of the
program. It has been a bipartisan effort, and I want to take
this opportunity to thank Representatives Cardenas, Blumenauer,
and Kelly for all their hard work on this letter. Medicare
Advantage has demonstrated how successful private insurance
plans can be if given the proper flexibilities.
That is, if my colleagues do not force Medicare for All on
Americans and take away this choice for the nearly 29 million
beneficiaries--nearly half the eligible Medicare population
that is estimated to choose MA for 2022. Medicare for All would
prevent these 29 million Americans from choosing this option
that provides quality healthcare and supplemental services that
help address social determinants of health. Medicare for All
will lead to worse care for seniors, longer wait times, and
diminish patient control over their own healthcare.
Today we are also considering several health data bills.
Useful health data is important, but some of the bills before
us today are too narrow in scope to address future pandemics
and are duplicative of current efforts. In addition, it does
not seem there is a consensus on who needs to collect what
data, how it will be used, and who will have access to it, and
how to do that in a way that doesn't add more administrative
expense to our costly healthcare system. COVID-19 shed light on
the need for more public health data infrastructure, and we
must use lessons learned to prepare for future pandemics rather
than continuing to focus on COVID-19 specific authorities and
programs.
For example, H.R. 778 would establish new CDC grants to
states that choose to develop and use digital contact tracing
technology for COVID-19 contact tracing program efforts, which
seems duplicative of programs that have already been funded in
response to the COVID-19 pandemic. CDC has already received
funds to do just that, and we should first evaluate how those
funds have been spent.
Additionally, H.R. 791, the Tracking COVID-19 Variants Act
includes provisions that would require the CDC to issue
guidance regarding collaborations and data-sharing for COVID-19
sequencing, while further enacting a pilot program by expanding
existing data linkages. Data sequencing is already being done
on variants today.
Further, H.R. 976, the ETHIC Act would retroactively
require states to report specific COVID-19 data to the CDC as a
condition of receiving certain COVID-19 funding. Currently,
states are already required to report some of this data.
I'm looking forward to examining Mr. Curtis' bipartisan
legislation, H.R. 3969, which would allow spending on social
determinants of health to be included in health insurance
plans' medical loss ratio calculation. I'm also interested in
hearing how we can build on ideas like H.R. 3969 to encourage
other insurance plans, like Medicare Advantage and Medicaid
Managed Care Organizations, to take further actions to support
social determinants of health.
I'm also looking forward to discussing Dr. Burgess' bill,
the Social Determinants of Health Data Analysis Act, which
would require the GAO to report on the actions taken by the
Secretary of HHS to address social determinants of health.
In closing, I look forward to working in a bipartisan way
to help improve America's public health infrastructure, so we
are better prepared and ready to address the next pandemic. As
we work on this, we need to ensure Americans' hard-earned
taxpayer dollars are being used efficiently and not on
duplicate efforts. I look forward to having a productive
discussion today on how to have better healthcare data and
address social determinants of health.
Mr. Guthrie. And I yield back my time.
Ms. Eshoo. The gentleman yields back. The Chair now is
pleased to recognize the chairman of the full committee, Mr.
Pallone, for his 5 minutes for an opening statement.
OPENING STATEMENT OF HON. FRANK PALLONE, Jr., A REPRESENTATIVE
IN CONGRESS FROM THE STATE OF NEW JERSEY
Mr. Pallone. Thank you, Chairwoman Eshoo.
Throughout the COVID-19 pandemic, Federal, State, and local
public health leaders have faced barriers to collecting and
discussing the data needed to fully respond to a public health
crisis. It is this vital data that provides government
officials and health leaders the critical insight needed to
develop the best guidance in response to public health crises.
And as a result of these barriers, public health departments at
all levels of government have, at times, lacked the information
they needed to better understand the significant impacts of the
pandemic on our most vulnerable communities.
Unfortunately, the U.S. public health surveillance
infrastructure was fragmented and inconsistent long before this
COVID pandemic. Insufficient funding, limited resources,
inadequate training, combined with differing State and county
laws and nonexistent data standardization procedures, are
several of the many factors that limit public health data.
The slate of bills we are considering today will make
targeted improvements across three key areas. First, we will
discuss establishing a uniform Federal strategic action plan,
as well as data standards and a data sharing policy. Second,
several of the bills we are considering will improve the
collection of public health data that reveals the drivers of
health inequities. And third, we will discuss proposals to
assist States in the creation of a public health data
infrastructure necessary to appropriately deploy resources and
essential interventions.
I want to commend the chair and the sponsors of these bills
for their leadership in advancing policy solutions for some of
our country's most pressing health policy concerns.
Public health data is essential to the health of our
country. It may not seem very interesting, but it is very
important. This data allows us to understand which communities
need resources, how many, and when. It allows us to better
target health inequities and address them accordingly. Public
health data also gives government and local leaders the ability
to make upstream policy changes and implement prevention work.
Now, many of the bills we will discuss today also address
the importance of better understanding and researching social
determinants of health to improve the overall health status of
the United States. These bills take steps to eliminate the
lingering health inequities that exist and burden some of our
most vulnerable communities.
Uniform data collection is imperative to better
understanding the inequities in our healthcare system and to
guide real change. To effectively adapt interventions designed
to advance health equity, we have to be able to standardize and
collect data related to key social conditions. We will hear
from the witnesses today about legislation that will help give
States the tools they need to design effective interventions to
address certain social determinants of health. These
interventions will also improve the health and well-being of
some of our most vulnerable populations, including by expanding
access to evidence-based tobacco cessation treatment through
the Medicaid program.
In finding comprehensive solutions to our fragmented public
health data is of the utmost importance. With resources that
Congress has provided through the COVID-19 relief packages,
including the CARES Act and the American Rescue Plan, we know
that data modernization is underway, and we must now continue
that work to ensure that research labs, providers, and public
health departments are working with real-time current data and
have a better understanding of social determinants of health.
So I look forward to hearing from our witnesses and working
together with our colleagues on these legislative proposals
today.
Chairwoman Eshoo, I just want to say to you and the ranking
member, you know, we are now--you know, the pandemic,
hopefully, is winding down. But the pandemic showed us that,
whether it was the public health infrastructure or the data
collection--you know, I am talking about State labs, the supply
chain, so many things that really showed that--need a lot of
work, and didn't work well during the pandemic.
And so I think that--I just want everyone to know that
myself and the members of this committee--and I know you, in
particular, Ms. Eshoo--we want to get to the bottom of this and
make sure that we are better prepared in the future, for future
pandemics. And that is going to mean a lot in terms of, you
know, things that maybe don't sound very interesting but are
important, like data collection, like infrastructure for public
health, like the State labs, like the supply chain. It is only
if we can improve those things that we can be better prepared
for future pandemics, and I just want to stress that today.
I don't know how much the media cares about this, but it is
very important, it really is, and that is what I wanted to
stress.
So thank you, I yield back.
[The prepared statement of Mr. Pallone follows:]
Prepared Statement of Hon. Frank Pallone, Jr.
Throughout the COVID-19 pandemic, Federal, State, and local
public health leaders have faced barriers to collecting and
accessing the data needed to fully respond to a public health
crisis. It is this vital data that provides government
officials and health leaders the critical insight needed to
develop the best guidance and response to public health crises.
As a result of these barriers, public health departments at all
levels of government have, at times, lacked the information
they needed to better understand the significant impacts of the
pandemic on our most vulnerable communities.
Unfortunately, the U.S. public health surveillance
infrastructure was fragmented and inconsistent long before this
pandemic. Insufficient funding, limited resources, inadequate
training combined with differing state and county laws, and
nonexistent data standardization procedures are several of the
many factors that limit public health data.
The slate of bills we are considering today will make
targeted improvements across three key areas. First, we will
discuss establishing a uniform, federal strategic action plan,
as well as data standards, and data sharing policies. Second,
several of the bills we're considering will improve the
collection of public health data that reveals the drivers of
health inequities. And third, we will discuss proposals to
assist states in the creation of the public health data
infrastructure necessary to appropriately deploy resources and
essential interventions.
I commend the Chair and sponsors of these bills for their
leadership on advancing policy solutions for some of our
country's most pressing health policy concerns. Public health
data is essential to the health of our country. This data
allows us to understand which communities need resources, how
many and when. It allows us to better target health inequities
and address them accordingly. Public health data also gives
government and local leaders the ability to make upstream
policy changes and implement prevention work.
Many of the bills we will discuss today also address the
importance of better understanding and researching social
determinants of health to improve the overall health status of
the United States. These bills take steps to eliminate the
lingering health inequities that exist and burden some of our
most vulnerable communities.
Uniform data collection is imperative to better
understanding the inequities in our healthcare system and to
guide real change. To effectively adapt interventions designed
to advance health equity, we must be able to standardize and
collect data related to key social conditions.
We will hear from the witnesses today about legislation
that will help give states the tools they need to design
effective interventions to address certain social determinants
of health. These interventions will also improve the health and
well-being of some of our most vulnerable populations,
including by expanding access to evidence-based tobacco
cessation treatment through the Medicaid program.
Finding comprehensive solutions to our fragmented public
health data is of the utmost importance. With resources that
Congress has provided through COVID-19 relief packages,
including the CARES Act and the American Rescue Plan, we know
that data modernization is underway. We must now continue that
work to ensure that research labs, providers and public health
departments are working with real-time, current data and have a
better understanding of social determinants of health. I look
forward to hearing from our witnesses and working together with
my colleagues on the legislative proposals before us today.
Thank you, I yield back.
Ms. Eshoo. Thank you, Chairman, and it is exactly why we
are bringing these 13 bills forward, and have the outstanding
witnesses that are with us today to give us their opinion,
given their background and experience.
The Chair now is pleased to recognize the ranking member of
the full committee, Congresswoman Cathy McMorris Rodgers, for
her 5 minutes for an opening statement.
OPENING STATEMENT OF HON. CATHY McMORRIS RODGERS, A
REPRESENTATIVE IN CONGRESS FROM THE STATE OF WASHINGTON
Mrs. Rodgers. Thank you, Madam Chair.
Social and economic conditions have a powerful influence on
our health and well-being. Dependable transportation, job
security, and access to healthy foods are all factors that make
a difference in the prevention and management of many
conditions like diabetes, heart disease, and obesity.
Today 9.3 million Americans are currently on the sidelines
and out of work. Unemployed individuals are more likely to
suffer from illnesses such as high blood pressure, stroke,
heart attack, and arthritis. Unemployment leads to worse health
outcomes, on average, for all workers, regardless of their
baseline measure of health. It is a cycle of despair that must
be broken to promote healthier families.
We need to get Americans back to work. People need hope and
a purpose. It means more than a job. It is about dignity and
the opportunity for a better life. And we are only at the
beginning of understanding the impact of the pandemic lockdowns
on mental health. This is a crisis. One hospital I talked to
said social isolation is the biggest concern for seniors, not
to mention the rise in mental health emergencies that we have
seen for our children.
For hope and real results, we should be looking to how the
private sector and communities are leading the way for
healthier futures. In my district, to help people without
transportation, Washington State University partnered with
Range Health to purchase a mobile health unit to provide
primary care, noninvasive procedures, and preventative
screenings for underserved, rural communities. Some ride share
apps are also allowing eligible patients to order rides to and
from doctors' appointments, often paid for by health insurance
companies. Meal delivery services are also helping seniors
access nutritional food. And Medicare Advantage offers coverage
options for these services.
According to a recent CMS report, 60 percent of Medicare
Advantage beneficiaries are enrolled in a plan that offers food
assistance. The number of seniors that choose Medicare
Advantage plans offering these supplemental benefits like food
assistance, housing, pest control tripled between 2020 and
2021. I look forward to listening to and learning more from our
witnesses today on how Medicare Advantage flexibilities are
helping address social determinants of health in our seniors
and what more that we can do to incentivize the private sector.
In 2021 Medicare Advantage plans covered 26 million people,
which is a little over 40 percent of the entire Medicare
population. Seniors from all walks of life are choosing these
private-run plans over government-run fee-for-service plans.
They are spending less and getting better preventative care
because of it.
I am extremely concerned by proposals from my Democrat
colleagues that would ban Medicare Advantage plans and move
everyone to a one-size-fits-all, government-run plan. The
Federal Government should provide incentives and enable the
private sector to tackle these social determinants in a way
that empowers local communities. However, as we look at data
policies, we need to be very clear with the American people
about who is collecting what data and how it will be used.
Some of the bills today authorize enormous sums of money
before we even have a clear understanding of what the private
sector, State, local, and Federal Government is already doing
and what is working. That approach may work in scoring some
political points, but it doesn't drive results.
I also have concerns continuing short-sighted, COVID-19-
specific legislation. I recently spoke with former CDC Director
Dr. Redfield. He said that the big pandemic is yet to come. We
don't know that it will be coronavirus, pandemic flu, or
something entirely new. We need to be working on preparing data
systems and public health for all threats, not just COVID, and
take into account where these systems are after the large
investment and lessons learned from COVID-19.
We should be empowering innovative methods that are backed
by trust--trusted data--to address social determinants of
health. Doctors, hospital, State and local governments,
communities groups, and health insurers are leading the way,
tackling social determinants of health. We need to enable their
continued leadership and success and remove any arbitrary
roadblocks.
[The prepared statement of Mrs. Rodgers follows:]
Prepared Statement of Hon. Cathy McMorris Rodgers
SOCIAL DETERMINANTS OF HEALTH
Thank you, Madam Chair.
Social and economic conditions have a powerful influence on
our health and well-being.
Dependable transportation, job security, and access to
healthy foods are all factors that make a difference in the
prevention and management of many conditions like diabetes,
heart disease, and obesity.
Today, 9.3 million Americans are currently on the sidelines
and out of work.
Unemployed individuals are more likely to suffer from
illnesses such as high blood pressure, stroke, heart attack,
and arthritis.
Unemployment leads to worse health outcomes on average for
all workers, regardless of their baseline measures of health.
It's a cycle of despair that must be broken for healthier
families.
We need to get Americans back to work.
People need hope... and a purpose. It means more than just
a job. It's about dignity and the opportunity for a better
life.
And we're only just beginning to understand the impact of
pandemic lockdowns on mental health.
This is a crisis. One hospital I talked to said social
isolation is the biggest concern for seniors...
..not to mention the rise in mental health emergencies
we've seen for our kids.
For hope and real results, we should be looking to how the
private sector and communities are leading the way for
healthier futures. .
PRIVATE SECTOR
In my district, to help reach people without
transportation, Washington State University partnered with
Range Health to purchase a mobile health unit to provide
primary care, noninvasive procedures, and preventative
screening for underserved, rural communities.
Some rideshare apps are also allowing eligible patients to
order rides to and from doctors' appointments, often paid for
by health insurance companies.
Meal delivery services are also helping seniors access
nutritious food..and Medicare Advantage offers coverage options
for these services.
According to recent CMS data, 60% of Medicare Advantage
beneficiaries are enrolled in a plan that offers food
assistance.
The number of seniors that chose Medicare Advantage plans
offering these ``supplemental benefits,'' like food assistance,
housing, pest control tripled between 2020 and 2021.
I look forward to listening to and learning more from our
witnesses today on how Medicare Advantage flexibilities are
helping address social determinants of health in our seniors...
. what more we can do to incentivize the private sector.
In 2021, Medicare Advantage plans cover 26 million people,
which is a little over 40 percent of the entire Medicare
population. Seniors from all walks of life are choosing these
private run plans over government run fee-for-service plans.
They are spending less and getting better preventive care
because of it.
I'm extremely concerned by proposals from Democrat
colleagues that would ban Medicare Advantage plans and move
everyone to a one-size-fits all government run plan.
Concerns with Legislation
The federal government should provide incentives and enable
the private sector to tackle these social determinants in ways
that empower local communities.
However, as we look at data policies, we need to be very
clear with the American people about who is collecting what
data, and how it will be used.
Some of the bills today authorize enormous sums of money
before we even have a clear understanding of what the private
sector, state, local, and federal governments are already doing
and what is working.
That approach may work to score political points, but it
doesn't drive real results.
I also have concerns continuing short-sighted COVID-19
specific legislation. I recently spoke with former CDC Director
Robert Redfield.
He said the big pandemic is yet to come.
We don't know if that will be a coronavirus, pandemic flu,
or something entirely new.
We need to be working on preparing data systems and public
health for all threats, not just COVID, and take into account
where these systems are after the large investment and lessons
learned from COVID-19.
CONCLUSION
We should be empowering innovative methods--that are backed
by trusted data--to address social determinants of health.
Doctors, hospitals, state and local governments, community
groups, and health insurers are leading the way in fighting
social determinants of health.
We need to enable their continued leadership and success
and remove any arbitrary roadblocks.
I'm looking forward to today's discussion and I yield back.
Mrs. Rodgers. I am looking forward to today's discussion,
and I yield back.
Ms. Eshoo. The gentlewoman yields back. I thought I knew
just about everything in terms of benefits in Medicare
Advantage. I didn't know that pest control was one of them.
The Chair would like to remind Members that, pursuant to
committee rules, all Members' written opening statements will
be made part of the record.
I now would like to introduce our witnesses.
Dr. Karen DeSalvo is the chief health officer for Google
Health. She previously served as the Acting Assistant Secretary
for Health and the national coordinator for health information
technology at HHS.
Welcome, Dr. DeSalvo, we are thrilled to have you with us.
Dr. Romilla Batra is the chief medical officer for the SCAN
Health Plan, which is one of our Nation's largest not-for-
profit Medicare Advantage plans.
Welcome to you.
Ms. Beth Blauer is the assistant vice provost for public
sector innovation and the data lead for the Johns Hopkins
University's Coronavirus Resource Center.
Welcome to you. We look forward to your testimony.
Dr. Faisel Syed is the national director of primary care
for ChenMed, which is a fully capitated primary care practice
for seniors. He is also testifying on behalf of the America's
Physician Groups.
Welcome to you, and we all look forward to your testimony.
And Dr. Kara Odom Walker, who is the executive vice
president and the chief population health officer for the
Nemours Children's Health System.
So welcome to each one of you. The entire subcommittee is
very grateful that you have agreed to testify.
And Dr. DeSalvo, you have--you are recognized for 5 minutes
for your testimony, and please unmute.
STATEMENT OF KAREN B. DeSALVO, M.D., CHIEF HEALTH OFFICER,
GOOGLE HEALTH; ROMILLA BATRA, M.D., CHIEF MEDICAL OFFICER, SCAN
HEALTH PLAN; BETH I. BLAUER, EXECUTIVE DIRECTOR, JOHNS HOPKINS
UNIVERSITY CENTERS FOR CIVIC IMPACT; FAISEL SYED, M.D.,
NATIONAL DIRECTOR OF PRIMARY CARE, CHENMED; AND KARA ODOM
WALKER, EXECUTIVE VICE PRESIDENT AND CHIEF POPULATION HEALTH
OFFICER, NEMOURS CHILDREN'S HEALTH SYSTEM
STATEMENT OF KAREN B. DeSALVO, M.D.
Dr. DeSalvo. Thank you, Chairwoman Eshoo, Ranking Member
Guthrie, and distinguished members of the committee. I
appreciate the opportunity to appear today. My name is Dr.
Karen DeSalvo, and I am a physician and former local and
national public health official who has spent my career working
at the intersection of clinical care, public health, and
digital innovation to improve the conditions in America's most
vulnerable communities.
Currently I serve as the chief health officer at Google and
remain engaged in efforts to address the public's health
collaboratively, including through my role as coconvener of the
National Alliance to Impact the Social Determinants of Health
with former HHS Secretary, Michael Leavitt and as a member of
the Robert Wood Johnson Foundation National Commission to
Transform Public Health Data Systems.
Today's hearing takes place at an historic moment, as we
chart the road to recovery from the greatest public health
emergency in over a century. I applaud the subcommittee for
their leadership during the pandemic and for advancing a bold
vision for public health transformation that intersects with
data modernization and health equity. The vision recognizes how
COVID-19 pulled back the curtain on the structural failings
that contribute to inequities in our current public health
system: chronic underfunding, obsolete digital infrastructure,
and longstanding capacity gaps.
I have seen these shortcomings firsthand. That is why I
believe building resilient and equitable public health systems
begins with crosscutting solutions, a theory of change that is
captured in the Public Health 3.0 framework. I am excited that
many of the proposed bills in today's hearing share this ethos,
and offer the following recommendations to inform the
subcommittee's vital work.
First, while data analytics and IT infrastructure are
important, it is imperative that legislation and policymaking
focus on the systems that collect, exchange, and act on data,
rather than the data itself. Recently proposed legislation for
the Public Health Infrastructure Fund highlights the stable
foundation of resources that health departments will need, from
infrastructure upgrades to workforce investments and
operational design.
Second, public-private partnerships can maximize the value
of data for governmental public health. There are numerous
examples of such partnerships during COVID-19. To optimize
these beyond the pandemic, we need to develop data
infrastructure within public health focused on racial and rural
disparities like the ones proposed in the bills today.
Third, achieving equity requires expanding our
understanding of what data can be useful. Projects like our
Google COVID-19 Search Symptoms Trends show how public health
can leverage novel data signals in a privacy-preserving manner
to inform research and public health decision making, such as
where to dedicate more resources. In addition, data systems
aimed at addressing inequities should integrate sources from
the social and human services sectors.
Fourth, data systems need to be built to describe and
address inequities, not only at the individual level but at the
system level too. For example, knowing that kids in a certain
neighborhood are unhealthy is just one step. But understanding
where kids might not have access to sidewalks and playgrounds
could help communities take action.
Fifth and finally, the CDC's data modernization initiative
would benefit from incorporating the lessons learned from high
tech, the opportunities to do more than rewire the current 20th
century public health systems, but to reimagine it. 21st
Century Cures articulated such a vision by advocating the use
of open--standards and FHIR-based application programming
interfaces, or APIs, for the healthcare system. The same can be
used for public health.
We should also ensure that States and localities are not
rushed in spending the funds and that they have an
appropriately resourced workforce to maximize impact.
In closing, I want to reiterate my thanks for the
opportunity to testify and emphasize the critical importance of
the topics covered in today's hearing. I look forward to
working with the subcommittee on opportunities to strengthen
our Nation's public health infrastructure to achieve health for
all equitably. I look forward to your questions.
[The prepared statement of Dr. DeSalvo follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Eshoo. Thank you very much, Dr. DeSalvo.
Next, Dr. Romilla Batra, you are recognized for your 5
minutes of testimony.
STATEMENT OF ROMILLA BATRA, M.D.
Dr. Batra. Thank you so much. Good morning, Chairwoman
Eshoo, Ranking Member Guthrie, and distinguished members of the
Health Subcommittee. My name is Romilla Batra. I am a primary
care physician and chief medical officer of SCAN Health Plan.
Thank you for giving me the opportunity to address how SCAN
addresses social determinants of health, what supplemental
benefits we provide, and our recommendations. My remarks will
briefly cover who we are, how do we serve our members and our
communities, and our focus on the older adult population at
large.
SCAN stands for Senior Care Action Network. We were founded
in 1977, and we are a not-for-profit MA plan. We are a mission-
based organization, and our mission is keeping seniors healthy
and independent. And the true story is it was started by 12
angry seniors who truly believed there was more to health than
doctors and medications and nursing homes. They wanted to age
in place and live in their communities. They were the true
pioneers who knew why social determinants of health are so
important to be fulfilled.
And since then we have taken care of that population. We
have provided a special needs plan, and we are the only plan in
California to offer a fully integrated, dual-eligible special
needs plan. We serve about 220,000 beneficiaries in California,
and we have been consistently CMS-ranked a 4.5-star plan, so we
are really proud of the quality of care that we provide.
Addressing social determinants of health is really
important to improve health outcomes, as these factors
represent 70 percent of the drivers affecting a person's
overall health status. We see that in studies. We see that also
in our data. So our approach to addressing social determinants
of health is identifying what the social risks are, stratifying
the population so we can match them with programs and benefits,
serving our members and clients, measuring the impact, scaling
the programs, and, as a not-for-profit organization, running
our own community-based organization in the community that
serves older adults and their caregivers.
In terms of identification, we have consistently done
health risk assessment to gather not only health data but also
social needs data as well as demographic data. That is race and
language, including newly started sexual orientation and gender
identification data. We have data on 90 percent of our
population on their race and language, which really helps us
serving them better.
In terms of stratifying and serving them, we offer
different programs. I would like to quickly highlight one of
them. It is a member-to-member program, where we take our own
members, who then are our employees, train them in motivational
interviewing. They then engage with our members, help them
around social isolation, addressing their social needs, mental
health. Last year we were able to reach out to about 10,000 of
our members through this program. We had a very high adoption
rate of 50 percent, and saw a statistically significant
improvement in things like incontinence, falls, physical
activity, and social isolation.
On the other extreme, we also have programs like connecting
provider to home, where we have a social worker and a community
health worker from a community that addresses the needs of the
top 1 percent of our population who have high social burden and
high medical burden. A great story of Mr. M, who lived in a
mobile home, had a history of falling, did not have access to
food, did not have access to resources to pay for his utility
bills. A community health worker was going--was able to stop
in, helped with filling out forms for application for Medicare,
get assistance from community around utility payments, able to
connect them with benefits around food, as well as able to go
over the doctor's appointment to help with the DME. Those are
the kind of things that make a difference in terms of their
health outcomes.
We continue following our data to find where there are
unmet needs and addressing supplemental benefits to address
them. In terms of our supplemental benefits, we are very
grateful for the Congress for helping us do the flexibility.
Because of the flexibility, we are able to offer multiple
benefits. I will highlight one of them. It is called the Return
to Home Benefit, which addresses the needs of older adults
getting discharged to their home. We provide in-home
caregiving, meals, homemaking services, care coordination to
pick up that medication, as well as caregiving support.
Finally, my recommendation would be that, as a not-for-
profit MA plan with a long history of serving older adults,
these are very important needs. We ask that Congress include
SDOH such as food insecurity to the criteria for supplemental
benefits more broadly than only specific chronic conditions.
Finally, we recommend you consider supporting H.R. 2166,
Ensuring Parity in MA and PACE for Audio-Only Telehealth bill.
Wi-Fi access became a huge social determinant of health need
during the pandemic, and digital divides were huge, so we truly
believe this can make a difference.
There is also a Senate companion bill, Ensuring Parity in
MA Audio--for Audio-Only that we would love--like to recommend.
On behalf of SCAN, thank you for your ongoing commitment to
improving the care for older adults. We welcome the opportunity
to be a resource to members of this committee, if you can be of
service. Thank you again for the honor to speak before this
distinguished committee. Thanks.
[The prepared statement of Dr. Batra follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Eshoo. Thank you. Thank you, Dr. Batra.
I think that it would be really helpful if the witnesses--
because this is a legislative hearing--and with the
extraordinary experience and background that you all have, if
you could weave into your comments if you think we are hitting
the mark with any one of these bills. Any suggestions,
critiques, comments about them, I think, would be most helpful
to the members of this subcommittee.
Next, Ms. Blauer, it is a pleasure to welcome you again.
Thank you. And you are recognized for your 5 minutes of
testimony.
STATEMENT OF BETH I. BLAUER
Ms. Blauer. Thank you very much, Chairman Eshoo, Ranking
Member Guthrie, and members of the subcommittee. Thank you for
inviting me to participate in today's hearing and for
dedicating your time to an examination of the role of data and
health outcomes.
My first job in the public sector was nearly two decades
ago, when I worked as a juvenile probation officer for the
State of Maryland. I left the State after leading an ambitious,
cross-government data initiative that was credited with
significant outcomes for residents, ranging from market
reductions in infant mortality, nation-leading school
performance, and record low crime rates. Since 2015 I have led
a center at Johns Hopkins University focused on building the
capacity of local leaders to use data to improve outcomes. And
for the last 17 months, I have been the data lead for the Johns
Hopkins University Coronavirus Resource Center. I have seen the
very best and the very worst of data use.
The bills that are the subject of today's hearings go a
long way to realign Federal resources with interventions that
are proven, measurable, and focused on ending multigenerational
health and well-being disparities.
In the last 18 months, governments at all levels did
something incredibly remarkable. They built data collection
efforts, shared data, and made real-time decisions based on
near-time data. Never before has the Nation endeavored to
realize a coordinated effort around data sharing, data-informed
decision making, and collective outcome measurement at such
scale. Local and State governments used every possible lever to
stall the spread of this disease, including the very difficult
decisions of closing businesses and schools.
What has this last year taught us about using data to
collectively solve problems? At the Johns Hopkins Coronavirus
Resource Center, we became a trusted resource for millions of
viewers worldwide. Over the course of weeks, JHU developed a
methodology for scraping public data and encouraged State and
local governments to share their data in standardized ways. JHU
data scientists set up an internal governance and articulated
standard collection methods under the guidance of public health
and medical experts. We openly shared the entire process with
the public.
By January 2021 we had accrued more than a billion views.
Our audience included news outlets, local governments, and
everyday people that were making deeply personal decisions
about how they would navigate their public lives. The backdrop
to our entire pandemic experience was and continues to be a
hunger for sound, publicly available data.
This Congress has an opportunity to capitalize on the
public demand for data, the financial investments we have
already made in data infrastructure, and the newly minted
analytic skill that has emerged across government during COVID-
19, and improve upon the systems to provide accountability,
accessibility, consistency, equity, and sustainability. But
there are some lessons that I can offer that have been helpful
over the course of my public-sector career.
First, we need data standards. The first instinct when you
consider strengthening a data practice is to think about IT
modernization or tools. But the truth is, one of the most
important elements of a strong data practice is actually in the
governance and the alignment of creating a common language and
rules around how and why data is collected and applied to
problem solving. This will not be solved by one agency. This is
an interagency dilemma that requires a centralized
administrative focus.
Second, we must invest in better demographic data
collection. State and Federal demographic data does not align.
Inconsistencies and categorization between States, and even
within States, make data incomparable and can obfuscate the
disproportionate effects that the pandemic--and, in reality,
all programs--targeted, entrenched social determinants of
health have had on people of color. Without standards there is
no way to analyze available data to locate vulnerable
populations, and appropriately intervene.
Finally, whenever possible, we must make data public. While
I applaud that many of these bills require data collection in a
manner that is anonymized, disaggregated, and stratified, they
do not at all provide a plan for public dissemination. These
data will be high quality, high resolution, and in high demand.
Government will not be able to turn the tide on social
determinants of health alone. It will require deep coordination
and public engagement in the most intimate of ways. Our centers
at JHU continue to work to build the capacity of local leaders
to use more data as they examine their practice, and architect
on-the-ground strategies to deliver better outcomes for people.
But they need the support of our partners within the Federal
Government to have the greatest impact.
I am so thankful to be included in the hearing today, and I
look forward to fielding any questions. Thank you.
[The prepared statement of Ms. Blauer follows:]
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Ms. Eshoo. Well, we are very thankful to you. Your
testimony was highly instructive.
Next it is a pleasure to once again welcome and thank Dr.
Faisel Syed for--and you are now recognized for your 5 minutes
of testimony.
STATEMENT OF FAISEL SYED, M.D.
Dr. Syed. Thank you, Chairwoman Eshoo, Ranking Member
Guthrie, and members of the subcommittee. I am Dr. Faisel Syed,
and I am honored to testify on behalf of America's Physician
Groups.
APG is a national professional organization that represents
over 300 physician groups and 195,000 physicians who provide
care to nearly 45 million patients. APG member organizations
share a vision to transition from a fee-for-service system to a
value-based system, where physician groups are accountable for
the cost and quality of care.
I always wanted to be a doctor. I was appalled that people
died because they had no access to medical care. I joined one
of the largest FQHCs in the country because they treated
everyone the same, regardless of their ability to pay. Today I
am the national director of primary care for ChenMed. We are a
fully capitated primary care practice for senior citizens. But
I am also a son. And today's hearing is about my dad.
Dad was an inventor, but then he got sick: heart disease,
diabetes, chronic low back pain, and memory loss. Dad saw five
specialists but not a PCP. None of them spoke with each other.
Dad was taking pills for side effects from other pills. I
convinced him to sign up for a Medicare Advantage plan, where a
PCP would coordinate his care. Today Dad's heart function is
normal, his diabetes is under control, his back pain and memory
loss are gone, and he is on very few meds. So when we talk
about Medicare Advantage, I think about Dad and people in this
country like him, who are older and medically complex.
My patients are over 70 years old, suffer from 5 or more
chronic medical conditions, and live on fixed incomes. These
people fought in wars and marched for civil rights. Today they
are some of the most underserved in America.
We claim to have the world's best healthcare system, and if
you have money, the care you get is remarkable. But the color
of your skin, the balance in your bank account, and the diploma
hanging on your wall have more to do with staying healthy than
pathophysiology. We cannot improve healthcare for everyone if
the access to healthcare or healthy lifestyles are beyond
someone's means. Low-income and minority populations in the
United States don't live as long as more affluent Americans.
There are ZIP Codes in New Orleans where life expectancy is
only 54 years old. In more affluent ZIP Codes a few miles away,
life expectancy is close to 80.
Medicare Advantage is the great equalizer and plays an
instrumental role in the transformation of our Nation's
healthcare system. It rewards physicians who participate in
high-risk contracts for the value of their services. The
Medicare Advantage value-based payment arrangement creates
three distinct advantages: a team-based primary care delivery
system; incentives for delivering primary care in the right
setting; and a holistic approach that addresses the patient's
mental health, behavioral health, and home environment needs.
Medicare Advantage acknowledges that 70 percent of medical
outcomes are based on patient lifestyle.
I can offer tailored solutions to people with food and
housing insecurities, health literacy, and transportation
issues. Because we are fully capitated, I can focus on
prevention and early intervention. I invest the time it takes
to build trust and influence patient behavior. Thanks to
Medicare Advantage, I can offer exercise classes to patients
who are afraid to take a walk through their neighborhoods, on-
site medication pickup to patients who have no way to get to a
pharmacy, social services to help patients eat healthier. And I
can see patients as often as needed to prevent little problems
from becoming big ones.
I had a patient once who was an uncontrolled diabetic. He
refused to take insulin. Medicare Advantage gave me the time to
get to know him. He told me about living on a fixed income and
not having enough money to buy groceries. I earned his trust.
He drank six to nine sodas every day. I made a deal with him. I
wouldn't bug him about the insulin if he cut back on the soda.
I suggested he drink seltzer with artificial sweetener. It
turns out he liked the fizz more than the soda. Within a few
months we got his blood sugar under control without a single
shot of insulin. That is the beauty of Medicare Advantage.
At ChenMed we practice a high-touch preventative model. Our
patients have 35 percent fewer emergency room visits and 51
percent fewer hospitalizations than the average Medicare
beneficiary. We did a survey, and 94 percent of our patients
said they were highly satisfied with the care they received.
Our model fulfills the promise of Medicare Advantage and
restores the sacred doctor-patient relationship. Let's
prioritize what is working and make it better. Thank you.
[The prepared statement of Dr. Syed follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Eshoo. Thank you, Doctor. Maybe it will come up during
the questions from Members, but I want to remind the witnesses
that this hearing is about public health agencies in the
country. It is wonderful to hear about how wonderful Medicare
Advantage is, but we have 13 bills that we are examining in
this legislative hearing today, so I hope that those that are
not speaking to those, that your experience will be probed by
Members as to what is before us, and that is the 13 bills that
we are examining today, to see if we are on the mark or off the
mark, and if we can do better, and what is missing, and all of
that.
So it is a pleasure to recognize Dr. Kara Odom Walker, and
you are recognized for your 5 minutes of testimony. And thank
you again for being willing to be a witness.
STATEMENT OF KARA ODOM WALKER, M.D.
Dr. Walker. Thank you so much. Good morning, everyone, and
Chairwoman Eshoo, Chairman Pallone, Ranking Members McMorris
Rodgers and Guthrie, and distinguished members of the
committee. My name is Dr. Kara Odom Walker, and I am executive
vice president and chief population health officer at Nemours
Children's Health, and I am honored to testify to get--today,
and hope to speak to some of those questions.
Nemours is one of the Nation's largest and--pediatric
health systems, including 2 freestanding children's hospitals
and a network of nearly 80 primary and specialty care practices
across 5 States. We seek to transform the health of children by
adopting a holistic health model that utilizes innovative,
safe, and high-quality care while also caring for the health of
the whole child beyond medicine.
Decades of research demonstrate that substantially reducing
disparities requires a multigenerational approach, starting in
the early years of a child's life, and with the help of the
mother. We know that children who live in the most economically
disadvantaged counties in America die at rates up to 5 times
those of their peers in the--and are 3 times more likely to
lack regular access to healthy food--times more likely to drop
out of high school.
If effectively implemented and designed in consultation
with those they intend to serve, numerous policy approaches can
substantially reduce disparities and improve health. Nemours is
appreciative that the subcommittee is considering legislation
to advance these aims.
Nemours supports the Caring for Social Determinants of
Health Act and commends Congresswoman Lisa Blunt Rochester and
Congressman Gus Bilirakis for introducing this bill. It would
require the Secretary of Health and Human Services to update
guidance to State health officials regarding strategies to
address social determinants of health in Medicaid and CHIP.
This bill would ensure that, as new bright spots and approaches
emerge, they are disseminated to States to spread what works.
Nemours also appreciates the subcommittee's consideration
of the Quit Because of COVID-19 Act introduced by Congresswoman
Lisa Blunt Rochester and Congressman Brian Fitzpatrick. This
bill would expand coverage of comprehensive tobacco cessation
services for individuals--Medicaid and CHIP. One of the many
benefits of increased access to cessation services and
decreased tobacco use is the potential for reduced secondhand
smoke exposure in infants and children. This would also help
address disparities. Despite similar or lower smoking rates
compared to other racial and ethnic groups, African Americans
have the highest rates of tobacco-related cancer and are more
likely to die from the disease. As a family physician, I am
strongly supportive of H.R. 2125.
Nemours also supports the Improving Social Determinants of
Health Act and the Social Determinants Accelerator Act, which
would invest in Federal, State, local, and organizational
capacity to address the social determinants of health. One
social factor of particular importance to the health of
children is the health of their mother, which is why Nemours
supports the Data to Save Moms Act and the Social Determinants
for Moms Act. We believe these bills are a very important step
in addressing maternal health outcomes.
Another important opportunity relates to data sharing
across sectors. In my prior role as the secretary of health and
social services in Delaware, I saw firsthand that, with the
right data and technology systems, it was possible to better
identify high-risk populations, reveal where disparities exist,
and implement targeted interventions at the individual and
population level.
We are seeing pockets of innovation across the country and
making exciting progress in Delaware--the Delaware integrated
data system in order to integrate data across multiple agencies
that provide services to families. We in Delaware are launching
a screening tool to help identify special needs, partnering
with Delaware 211, and creating a central resource.
To catalyze and spread this needed innovation, Nemours
supports the LINC to Address Social Needs Act, which would also
support public-private partnerships to develop or enhance
integrated, cross-sector solutions. We believe that--for
delivery and payment models, and you have heard a bit about how
that can happen. So pairing with work to advance and
incentivize valuable payment and delivery models can
incentivize health.
The COVID-19 pandemic laid bare the inequities that exist
across so many domains. Out of this historic challenge is an
opportunity to rethink the way we deliver healthcare, starting
with pediatrics. We encourage the subcommittee to build on this
tremendous legislative work stemming from today's hearing to
facilitate and incentivize--and family health models--the data.
We look forward to continuing to work with you to advance
equity and help create the healthiest generations of children.
[The prepared statement of Dr. Walker follows:]
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Ms. Eshoo. Thank you very much for your testimony, Dr.
Walker.
We will now move to Member questions, and the Chair
recognizes herself for 5 minutes.
To Dr. DeSalvo, you were the health commissioner of the
City of New Orleans. Describe for us, please, the public health
data that was available to you in that position. How old was
it? How was it collected? Was there the ability to share with
other community-based organizations?
And also, describe the ideal for public health data for
local health officers. Would it be real-time? Would it be
accessible? Would it be shareable?
And any comments, recommendations, critiques you have of
the bills that are being considered today?
Dr. DeSalvo. Thank you, Congresswoman. Yes, I had the great
honor of serving the people of New Orleans. It was at a time
when data systems were even more nascent than they are now. And
we had to do a lot of work to just understand what was on the
minds of the people in our community, through coffees in
community centers or in church halls. And it was an inefficient
and incomplete way to really understand the health of our
community.
I had to do that kind of work, in addition to the
quantitative data I had, because, to your question, a lot of
the data and information local health officers even have now is
stale, old, a couple of years, often. So I am--I was looking in
the rearview mirror and didn't have a good sense of what was
happening in the now for my community, much less how to
forecast what might be happening in the future.
There were--when you are a local health officer, you also
have this sense, Congresswoman, that you are swimming in data
all around you, but you don't have access because it is in
silos, whether that is in electronic health records or in--even
public health data systems. And it isn't designed or built to
be interoperable and give you the answers that you need about
inequities, for example.
So the ideal systems are really ones that are, by design,
thinking about data harmonization, and the committee is looking
at some bills like H.R. 2503 that talk about the important need
to, by design, build open standards that are interoperable so
all these systems talk to each other.
We have good standards that we can draw from that we began
to build for the healthcare system. So a different use, it is
in public health, but basically it is a way to measure things
like blood pressure consistently and record that.
The same thing for an important public health challenge
like maternal mortality, which you mentioned.
So we have to be able to have a standard way that
communities can collect and then act on the data.
I would say the other important component of the data
systems is to feel more comfortable using novel signals. This
is the imperative in the 21st century. And there is work that,
for example, using information on public sentiment, or in our
case we have made available a search symptoms trends data that
can give information about what is on the community's minds.
And the way I used to go into the church hall and talk to
folks, it is another way to get more quantitative information
that is anonymized and private to augment other data systems.
And it is more timely, actionable, granular than the kind of
data that most public health has right now.
Ms. Eshoo. That is fascinating. Let me ask Ms. Blauer and
Dr. DeSalvo. In both of your written testimonies you say that
hospital data is some of the most reliable data.
And Dr. DeSalvo, I was especially struck by your point that
hospital records are what enabled health officials to sound the
alarm about the Flint water crisis. So my question is, why is
hospital data so reliable, and how can we make this data more
widely available to local health departments?
I am assuming that there isn't interoperability between the
public agency and the hospitals.
Dr. DeSalvo. Congresswoman, in the HITECH Act we invested
resources to digitize healthcare. So now we have relatively
reliable data in the healthcare systems that we have already
shown can be used for public health crises like identifying
Flint. There is a system in New York City that can identify
chronic disease. And in Massachusetts there are also systems
that can look for communicable disease outbreaks.
So--but there are some examples where we know that that
data is helpful in identifying public health challenges. The
reality is, also, that in HITECH public health wasn't resourced
to be able to receive that data and anonymize it and make use
of it in the way that Dr. Blauer has, for example, in some of
the work that she has done to create dashboards that really--
they can be useful to the community and to the country. So it
is an untapped resource that--but there are some great
examples.
I might even call out Oklahoma, another State that has been
using EHR data to look for public health challenges. But it
needs to be scaled. We need to do more to make sure that those
systems are interoperable. And this is an historic opportunity
in the bills that you have before you to begin to move in that
direction, to really think about designing with a standardized
approach and being able to make that information useful, not
just for individuals but also for the public's health.
Ms. Eshoo. Yes, most helpful, most helpful. Thank you.
The Chair now recognizes our wonderful ranking member, Mr.
Guthrie, for your 5 minutes to question.
Mr. Guthrie. Thank you, Madam Chair. I appreciate that. I
appreciate the recognition.
Actually, if you look at Mr. Curtis' bill, he is looking at
changing the medical loss ratio to incentivize spending on
social determinants of health, such as Medicare Advantage plans
do and I think Medicaid managed care does, as well. And Dr.
Burgess' bill looks at collecting data on social determinants
of health so that we can use this information.
I think what Medicare Advantage does is important in order
to lay out what private health insurance plans, if they had the
flexibility, would do. And I have a couple of questions.
One, Dr. Batra and Dr. Syed, if you could address this--you
know, and I know the reality of it, but one of the criticisms,
which I think is inaccurate, is that, if you have Medicare
Advantage plans, they cherry-pick--you cherry-pick who is in
your plan. And therefore, obviously, if you are a health
insurance company, you would, if you could cherry-pick, pick
healthy and not people with other conditions. But it is quite
the opposite with the flexibility incentives that Medicare
Advantage has, and I think, Dr. Syed, you talked about that in
your testimony, and Dr. Batra.
So you talk about--just kind of reemphasize, given the
flexibility you have in Medicare Advantage plans to spend money
on social determinants of health, one, that you are bringing in
people that are--that have chronic conditions, that are sick.
And not only are you bringing them into your program, but you
are giving them far better services than they get in the
Medicare fee-for-service plans. Could you address that, one,
that the criticism of cherry-picking, if you do, which I don't
think that you do, and the other one is how your plans are
structured that are so much better for people with chronic
conditions, like Mr. Curtis' bill is trying to allow health
insurance companies to do with their medical loss ratio
flexibility.
So, Dr. Batra, if you would, go first.
Dr. Batra. Sure. So we serve about 15,000 duals, you know,
so that tells you, out of a 220,000 population, 15,000 are on a
fully integrated dual eligible special needs plan.
We also serve folks who are low-income subsidy folks. We
serve folks who are in social vulnerability index four and
five. So we serve all throughout the population.
If you look at the social HRA that I spoke about, about 10
to 15 percent of our people have indicated, when we do their
initial HRAs, that they have food insecure. We have 2 or 3
percent of people who say they are housing insecure, many
people who say--who are transportation insecure. So they are
people from all backgrounds.
In terms of how we address their needs, it is through our
supplemental benefits. We offer in-home benefits that include
meals. We have a third of our population that complains of
living alone and falling. We have benefits where we send up
occupational therapists in their homes, so they can help with
safety and be able to mobilize better within their own home
setting.
So those are two very high-level examples. Transportation
is a big issue if you are an older adult, especially during the
pandemic, when you wanted to get vaccinated, you wanted to have
access to that ride that would take you to where you needed to
get the vaccine. That is the other benefit that we bring
across.
Ninety percent of our membership, more or less, use
medication, and 90 percent of that membership takes a zero-
dollar medication. So that is what we also bring, is that
affordability to them, so they can really--you know, and those
are the people who can use that benefit. So we do serve people
from all walks of life.
Mr. Guthrie. Thank you.
And Dr. Syed?
[Pause.]
Dr. Syed. Thank you.
Mr. Guthrie. If you would like to address it--OK, thanks.
Dr. Syed. Yes. ChenMed goes where the need is. And my
biggest challenge, ever since I completed residency training,
has always been access. And I have learned with Medicare
Advantage that Medicare Advantage opens the door. I mean, I am
able to give my patients and their families my cell phone
number. They call me if they are feeling, like my wife likes to
say, a little icky. And if I need help getting a patient to
stick to a treatment plan, I am able to call the kids and
grandkids for backup.
My team texts my patients daily about health, simple
messages like reminding them to get a flu shot or staying
hydrated on a hot summer day. We even call our patients weekly.
We call them love calls. Even if our patients feel good, they
make them feel better, just by saying hello. And I am able to
see my patients at least on a monthly basis. This is how we are
able to prevent little problems from becoming big ones.
I--food--when I think about the social determinants, I
think about food insecurity and----
Mr. Guthrie. Unfortunately, I only have about 18 seconds
left.
Dr. Syed. Oh, sure, sorry.
Mr. Guthrie. So I apologize.
Dr. Syed. Sure, sorry.
Mr. Guthrie. I just wanted to kind of summarize and tie
this to the legislative hearing that--H.R. 976, giving private
insurance plans flexibility within their medical loss ratio,
will allow other plans like Medicare Advantage to social
determinants of health spending that are important to the
healthcare, even though it may not be directly to--through
their healthcare spending, but the things that matter on people
being healthy. And that is why I think this is an important
discussion.
So thank you very much. And I appreciate it, and I yield
back my time.
Ms. Eshoo. The gentleman yields back. The Chair now
recognizes the chairman of the full committee, Mr. Pallone, for
your 5 minutes of questions.
Mr. Pallone. Thank you, Chairman Eshoo, and thanks to the
witnesses for being with us.
As we know, robust public health data plays a critical role
in improving public health. And I wanted to start with Dr.
DeSalvo.
You have worked firsthand both in the Federal Government
and in industry on improving the collection and sharing of
health data, and know well how these investments can help
improve health outcomes. For example, you played a leading role
in implementation of the HITECH Act. In your testimony you
noted that CDC's data modernization initiative would benefit
from the lessons of HITECH. So let me ask you, can you discuss,
Doctor, further what lessons learned from HITECH should be
incorporated into the policies that we are considering to
improve public health data collection, if you will?
Dr. DeSalvo. Thank you, Congressman. It is an important
opportunity for the country to, of course, recognize that we
have created a digital infrastructure for healthcare. On the
other hand, we now are about to embark on something like that
for the public health infrastructure. And I do very much
appreciate your comments that this could be boring for some
people, but it is vitally important to the health of our
communities.
The specific areas where I think the country learned some
lessons from the implementation of HITECH include, first,
around data and standards. That means, as we design the system
going forward, what we should reflect on is that, rather than
allowing each information technology system to develop its own
proprietary standards, its own special way of doing things, we
should create an open opportunity where there's shared
standards. There's already--we don't have to invent many of
those. There's organizations called standards bodies that are
already working with the CDC and public health officials around
the country to identify and clarify which standards we can use
as the foundation, so the building blocks all talk to each
other, and we start with interoperability as the base case.
The second is to make certain that we are thinking about
the uses. What is the end that we have in mind? And, as the
committee is articulating in a number of the bills, equity has
to be a part of how we design this system. Yes, we need the
system to be able to identify infectious diseases, and track on
communicable disease for communities, but we also need to do
that in a way that allows us to know where the resources need
to be applied most. So building into that design, understanding
of what are data systems that have to tell the story around
equity, or around important public health challenges like
maternal mortality.
The last thing I would say is timing. We pushed out the
funding for HITECH, and the system stood up. There was some
training for workforce, but it delayed a little bit behind when
the systems were actually up and running. And I think what we
all know is that it takes humans, it takes people to not only
work those systems but to interpret the data and the public
health--for the public's health, and work with community
organizations to put it to good use to make change on the
ground.
So we have to make certain that our workforce efforts are
not only focused on COVID, but thinking more broadly about the
infrastructure of public health and how to make that a durable,
longstanding opportunity to make good use of the data to
improve health and equity in communities.
Mr. Pallone. Let me ask about resources, because, you know,
Congress has provided funding for public health data and
modernization in the CARES Act and Rescue Plan appropriations.
But these were one-time investments. And you said that health
departments need stable resources.
So the LIFT America Act, which was introduced by Energy and
Commerce Democrats, has this core public health infrastructure
program to help fund public health needs such as facilities or
equipment upgrades, workforce capacity, health info systems.
Can you just comment on this program?
In your view, what further steps should the Federal
Government be taking to help improve public health data
collection?
Dr. DeSalvo. Well, I--Congressman, I first want to just say
thank you to Congress for recognizing how important the issue
is. The public health community, of which I am a member, really
is appreciative of the opportunity to meet the needs of the
public.
However, I think you are raising the important point, that
it--data doesn't happen in isolation, it requires a system,
which means we not only need to have strong data systems
upgrades initially, but they have to be durable and
sustainable, so that the health departments can refresh the
computers they have, or the--refresh the IT security systems
that they have over time. So it is an ongoing commitment that
they would need to make, to make sure they can meet the
population's needs.
They also need workforce, they need partnerships, they need
basic infrastructure to keep the lights on every day. I mean,
it is really--would be hard to explain for many people in
America how underresourced and challenged many health
departments in America are. I used to say when I was health
commissioner, we do our work with two nickels and some friends,
and we are really thankful for a lot of our friends.
This is an opportunity in this pandemic, a learning moment,
that we have a critical infrastructure that has been struggling
to meet the needs of the population's health, is ready to do
more. And I think, through partnership, we certainly can think
about investing in the whole system, not just the data systems.
But I think we are on a good path, as a country.
Mr. Pallone. All right. Thank you so much.
Thank you, Madam Chair.
Ms. Eshoo. The gentleman yields back. The Chair is now
pleased to recognize the ranking member of the full committee,
Mrs. McMorris Rodgers.
You have 5 minutes for your questions.
Mrs. Rodgers. Thank you, Madam Chair.
Dr. Syed, we are talking a lot about the need for more
data. I wanted to ask, based upon your experience working at a
FQHC and at ChenMed, can you just further elaborate on the role
of the doctor-patient relationship in addressing social
determinants of health?
Dr. Syed. Thank you. It is so important for doctors to know
about every emergency room visit. I was shocked when, during my
time at the FQHC, that half of all medical care in the City of
Tampa was delivered in the emergency room setting, and then
even further shocked, when I joined ChenMed, that in the United
States, at least pre-COVID, half of all medical care was
delivered in the emergency room setting. So doctors must know
about every emergency room visit. They must know about things
like when a patient doesn't fill their prescription refill.
They must know about every referral when the patients are being
referred to specialists.
It is so important for doctors to also understand the costs
of healthcare. You know, doctors should be more concerned about
the medical complexity of their patient, rather than the
medical complexity of the charting, which, unfortunately, is
what we see in the fee-for-service healthcare system.
Mrs. Rodgers. Thank you.
Dr. Batra, on Capitol Hill right now there's a number of
Members, Democrats, that have been promoting the Medicare for
All proposal. And the effect of Medicare for All would be to
ban private health insurance plans, including Medicare
Advantage plans.
When you look at who is leading the way right now in
addressing social determinants of health, it is really
private--it is the private sector--by the work that SCAN is
doing. I wanted to ask, are there specific programs that you
would like to highlight, as far as the success that could be
implemented by employer or individual health insurance plans?
Dr. Batra. Absolutely. Thank you for giving me the
opportunity. I think one of the programs that I highlighted,
I--we call it the peer-to-peer program, and I think that has
played a key role for us.
I absolutely agree with Dr. Syed. Physicians are busy,
physicians really want to build that trust, but we also know
that trust can be built with peers. So we have been utilizing
our own members to engage with members in a way they can relate
to in the way they can empathize, in the way that they can
understand around barriers that are big for this older adult
population. Social isolation: 30 percent of our members tell us
they feel lonely all the times or more than half the time.
Similarly around incontinence and falls, so our peer-to-
peer program, which extends the reach of the physician team,
has been able to do that. So I think that is a very key
program.
The other program I would quickly like to highlight is our
community health worker program. If we truly want to address
health outcomes in an equitable manner, we need to recruit
people from the community that have the trust of the community,
that can build on the trust of the community, that can not only
help them navigate this very complex healthcare system for our
members but also be able to connect them to community-based
resources if they are not available, let's say, with an MA
plan, in terms of benefits and programs.
We have a very successful program we just published in a
very well-reputed Journal of Geriatric Society. And that is
exactly what that program does, is it takes the physician's
care plan and makes the care plan really happen where the
patient wants it, in their home setting, in the community
setting, versus in the ER, in the hospital.
Mrs. Rodgers. Thank you. Thank you.
Dr. DeSalvo, the CDC has received over $1 billion from
COVID relief packages to update, modernize public health
infrastructure at the State, local, and Federal level. I wanted
to ask, what are the metrics that you would recommend that we
use to determine whether or not those dollars are being spent
wisely and driving results?
Dr. DeSalvo. Congresswoman, thank you for the question. And
I think we can learn a lot from what has already worked on the
ground. I will begin there.
In States like Washington State, particularly a community
like Spokane, that has a lot of historic work that it has done
in partnership with community to address the public's health--
it was one of our Public Health 3.0 communities that I visited
when I was in the administration, and learned from--and what
you learn from that is begin with the end in mind.
And as a country, if we want to address inequities in top
public health issues, there are bills before us today, for
example, about maternal mortality and the disparities in it for
Black women, in particular. We could begin with what--we call
that--and then work backwards, and say--then we need data that
is going to inform actions at the community level to drive
change.
I will particularly call out, though, I think the
importance of what was asked for in the data modernization
initiative by Congress, and that was for CDC to develop a
strategic plan, and because that will be essential to have
clarity about what needs to happen by when and by whom. Those
are the use cases. And then, rather than just collecting data
for data's sake, it must be done with the intention of
improving the public's health, going forward. So a strategic
plan, led by CDC, which is called for.
And I think, in addition, I would just call out Congressman
Burgess' bill to think about what is already happening at HHS,
and this opportunity to do an assessment inside of the
government of what are the levers that could be used. Once we
understand from the data the challenges that need to be solved,
how can we act on that to improve health equitably and address
social determinants, because there are many--probably already
underway, and it would be good to not be duplicative, but to
make sure that we are being as efficient as possible, because
the public is counting on it.
Ms. Eshoo. The gentlewoman's time----
Mrs. Rodgers. Thank you all.
I yield back.
Ms. Eshoo [continuing]. Has expired. It is a pleasure to
recognize the gentlewoman from California, Ms. Matsui, for your
5 minutes of questions.
Ms. Matsui. Thank you very much, Madam Chair, and I--this
is a terribly important hearing we have today, with much
legislation.
You know, last week we examined the importance of
increasing vaccinations to improve public health. And I would
ask the witnessed how we can help providers and public health
systems modernize Immunization Information Systems to help
support this goal.
And may I say this? Public health is so important. Public
health involves the whole community. It involves people who
don't have access easily to health systems. And I really feel--
I have got a huge health system in my district, four major
hospital systems. I really--I also have a great string of
community health centers too. And I really have a wonderful
public health center too. But I must say this, that we have not
funded public health in the way we should be. And I think every
time we get some sort of pandemic or some sort of crisis, we go
back again and say, well, this is what we should have been
doing. We can't do that any longer.
So I really feel hearings like this are so important
because, you know, we look at the social determinants data, and
that exacerbates health disparities. And the bills today we are
examining can provide a range of solutions to capture these
central data that is important to ensure that people don't fall
through the cracks as they did this time, as we promote health
and mitigate disparities beyond healthcare, including access to
healthy food, education, housing, and transportation.
So I am really interested in exploring how we can
strengthen public health reporting by leveraging both clinical
and public health data. And a lot of this data is not just in
the health arena, either, it is in schools and education
systems. It is in--just as somebody said before, just listening
to people, encouraging conversation. Those kinds of data are
really important to actually understand fully what is
happening.
Ms. Blauer, you highlighted the need for robust data
collection and reporting systems at the local and State levels.
And this on-the-ground expertise is really important. So, as we
build out our health data utility infrastructure, how can we
coordinate more on the State-level health information exchanges
and other clinical data sources?
I know there is a lot of conversation that goes on with our
community health centers and the public health area, but how
can we facilitate this even more, so that it goes up--so that
we can actually capture the data, understand what is happening
throughout not only the State itself but throughout the
regions?
Ms. Blauer?
Ms. Blauer. Thank you, Congresswoman, for the question.
There are--one of the things I have learned in my
experience in the public service is that there are some of the
most important thinkers and subject matter experts across the
board in government. We have some of the smartest thinkers, but
we need to invest in the skills of subject matter experts to
actually use data to solve hard problems.
So there is one part where--we need to start investing in
the capacity of people who are actually charged with leading
programs on how they can use data.
The health information exchanges are also incredibly rich
resources that exist that have great data and great data
skills, but there is a disconnect between the exchanges and
those people on the ground who are responsible for delivering
programs. And so we need to start thinking about how can we
build the capacity so that we are scoping our problems, that we
are thinking about our problems in a way that elicit the right
kinds of data responses, and that we have the skills to
actually take that data and apply it to solutioning.
Ms. Matsui. OK, well, thank you.
Dr. DeSalvo, we are talking about structural racism here.
It is a public health crisis. And I thank you for drawing
attention to this in your testimony. This was a huge issue
after Hurricane Katrina. And 15 years later, what has the COVID
pandemic revealed about the structural racism in the digital
infrastructure?
Dr. DeSalvo. Thank you for raising the issue. It has been
such an important conversation in the pandemic. But as you say,
it is not a new conversation in many circles. We saw it very
clearly after Hurricane Katrina. I saw it personally, as I was
on the streets delivering care to people, that where you live
matters so much.
It was described by another witness: a 25-year gap in life
expectancy in New Orleans, a whole generation, based upon where
people live. And where people live is not just about a choice,
it is also about structural systems that cause redlining and
other factors that make a difference in the access you have to
food and education and economic opportunity.
It has really motivated many of us in public health to
focus on this as a public health issue. In fact, in a recent
National Academy of Medicine report I had the chance to
coauthor with Bob Hughes from Missouri, we talked specifically
about how, coming out of the pandemic, equity and racism will
have to be priorities for public health and that the data
systems that are built will have to be capable of providing
information not only about individuals and how their health is
different--predicated on things like the color of their skin,
or race and ethnicity--but also, what are the structural
systems supporting them? What are the school food programs?
What is the access to sidewalks, so kids can walk to school?
So it is a double-layer system, not just--that looks at
people, but also at the context in which they live.
Ms. Matsui. So thank you very much. I have gone way over my
time. And thank you very much for your testimony.
And thank you, Madam Chair, and I yield back.
Ms. Eshoo. he gentlewoman yields back. It is a pleasure to
recognize the gentleman from Michigan, Mr. Upton, for your 5
minutes of questions.
Mr. Upton. Well, thank you, Madam Chair. Thanks for this
hearing today.
The ability to access and use information is certainly
critical to many aspects of healthcare and health system
operations. And the further embrace of real-world data and
evidence, including SDOH data, can all help improve the facets
on healthcare.
The 21st Century Cures Act included provisions to improve
data sharing through reforms to the statute created by the
HITECH Act that established the Office of the National
Coordinator, ONC. However, as we know, this issue is bigger
than ONC. How we use the data today is negatively impacted by a
number of things, including how we regulate data use, or how
capable the agencies of HHS are using the data well.
Representative DeGette and I released a discussion draft
earlier this week that we are calling Cures 2.0 to help solve
some of the issues that we are discussing. I would like to
focus on two of those provisions.
Ms. Blauer, section 304 of Cures 2.0, entitled ``Increasing
Use of RWE,'' builds on FDA's efforts by requiring HHS to
outline approaches to maximize and expand the use of RWE, and
establish a task force to develop recommendations on ways to
encourage patients to engage in RW data generation. So as we
consider ways to improve data access and use--in use for many
in health, how important is the patient participation in data
access for the FDA or other healthcare operations?
Ms. Blauer. Thank you, sir, for your question.
So I want to start by saying that I think a lot about
resident engagement and patient engagement in data across the
board. I think we need to be incredibly comprehensive as we
think about how we reflect the realities of life in a way that
we collect data, and patient information is at the center of
that consideration.
So we have to, obviously, make sure that we include all of
the protections and the privacy and advocacy that is required
to keep people's personal information safe, and make sure that
they are informed significantly in order for the safe
collection of that qualitative contribution to data collection,
but also to really understand why it is important to have
individual information as part of a consideration for data
collection.
Mr. Upton. Thank you.
Dr. Walker and DeSalvo, my staff over the years has
communicated with CMS and other agencies about the current
capabilities of their computer systems. Generally speaking, the
feedback has not been terrific.
One provision of Cures 2.0 would begin the process of
Congress working with HHS to update CMS and other computer
systems with the goal of helping these agencies use the data
better. So as we consider the bills before us today, I am
curious to your thoughts on whether improving CMS data
capabilities through modern computing approaches can help
support our goals.
[Pause.]
Dr. Walker. Thank you. I will go first, and I really
appreciate the opportunity.
From a State perspective, we certainly would appreciate
having additional support for CMS to update systems, to allow
for us to work together as States try to engage and leverage
data that is available. I think, as we learn more about the
impacts of social determinants of health, there are models that
can test how we support payment strategies and delivery system
innovation.
For example, the CMMI's Integrated Care for Kids model and
the maternal opioid use model, as well as other programs like
Medicaid waivers, really allow you to look at how you are
investing in the earliest years of life. But the challenge is
understanding what is working, and you need data to do that
programmatic evaluation and assessment.
We know, at Nemours, as we try to deploy value-based
services and new types of care delivery, we absolutely need
opportunities to work with CMS to develop demonstration models
to invest in the data and really figure out how to implement
value-based care.
Dr. DeSalvo. I will just maybe add a related issue, if I
could, Congressman, which is to--first of all, I am not an
expert in the CMS data systems, though my appreciation is that
they are in need of some upgrade. And I think, as Dr. Odom
Walker is describing, that opportunity there has to do with
making sure that we can meet the needs of the population's
health, using data that can support value-based care models or
global health models.
But I particularly wanted to call out that in Cures 1 there
was a push towards open APIs, FHIR-based systems, which I know
you and your team are familiar with, those same models can be
applied to public health. And as we think about modernizing the
public health data infrastructure, and because of 21st Century
Cures, there has been a movement in the field with public
health and the digital world to create that kind of an
interoperable system, so we don't repeat any of the mistakes
the country made with HITECH. So thank you for that direction
envisioning.
Ms. Eshoo. The gentleman's time has expired, and I thank
him.
It is a pleasure to recognize the gentlewoman from Florida,
Ms. Castor, for your 5 minutes.
And I want to remind Members that questions are being--
those that are--I am sorry. We are calling on Members in the
order of subcommittee seniority, OK? Just as a reminder.
Ms. Castor, you are on.
Ms. Castor. Right. Thank you very much, Madam Chair. Thank
you for calling this very important hearing, and thank you for
including my bill with Congresswoman Underwood, the Ensuring
Transparent, Honest Information on COVID Act, the ETHIC Act.
Colleagues, this committee, Democrats and Republicans, have
really shined the light on the lack of transparency and the
consistency around COVID-19 data during the pandemic. And I
think there are three main issues: one, many local communities
and States did not have the modern data reporting systems in
place; two, there was a troubling pattern in a number of places
of withholding COVID-19 data, censoring of data, whether it is
nursing home infections and deaths or overall mortality rates,
or testing, very serious issues there; and then three, of
course, we don't have the Democrat--demographic data we need on
health disparities, and we are--we have to do better on that.
Communities, businesses, public health experts need this
consistent and transparent health information to help keep
families safe, and to implement effective measures, and do it
efficiently.
So through the bipartisan--as Chairman Pallone said,
through the bipartisan emergency relief packages, this
committee really helped direct huge new investments in--to
update data reporting at the CDC. But we are going to need to
provide additional direction. And in addition to the bills that
get to it through standards, which is very important, the ETHIC
Act also will do this through transparency and data reporting.
One, it will require States, local communities, Tribal and
Territorial governments to report COVID-19 data, including
demographic information to the CDC; and two, make sure that it
is all reported up to the public.
And then, too, we are going to--we need to tap the
expertise of the National Academy of Sciences Engineering and
Medicine to review the current system and provide us with
additional recommendations on public health data,
infrastructure, and reporting.
So for Ms. Blauer, thank you so much for your longtime and
very important work to improve health outcomes using data, but
especially for your work and that of Johns Hopkins, the
Coronavirus Resource Center, over the last year. In your
testimony you say that consistency across States is going to be
vitally important. You highlight the ETHIC Act--thank you very
much--but can you also talk about how--what do you see that we
need to do to ensure dependable, transparent data for the
public, for communities, for businesses going forward?
What else do we need to be doing?
Ms. Blauer. Thank you, Congresswoman, for the question. I
can say with great authority that there is a hunger at the
State and local levels for standards, for this common language
that actually can help guide the way that we collect and think
about data across our States and our cities.
We had, over the course of our managing the Coronavirus
Resource Center, daily calls with mayors, with Governors, with
people from local communities, from health departments that
were seeking advice on how they should collect this data, how
they should express this data to the public, how they should be
thinking about letting this data support their decision making,
and they were searching for support and validation of their
approaches.
So, again, while the systems that collected this data were
often shoestring operations in some cases, started with manual
collections that did mature over time, I think the reality is
that these organizations across the board in State and local
communities were really seeking that kind of high-level
validation that what they were collecting and how they were
using this data was the right path forward.
And they also wanted to be able to look at their neighbors
and say, ``I see that you are having better experience in
managing this part of the pandemic. I want to learn from you.''
And with--in the absence of those standards and that common
language, it became very difficult to do apples-to-apples
comparison across the geographies.
And so the role of Federal Government here could really be
let's create that common language, let's provide those
standards, and then let's provide the support for the State and
local communities who are going to be navigating these health
challenges in a way that they can learn from each other, they
can learn from their wins, they can learn from their failures,
but then they can also think really critically about how they
are applying that data to the policy levers that have been so
critical to the way we have navigated the pandemic. Thank you
again.
Ms. Castor. Thank you very much.
And I yield back.
Ms. Eshoo. The gentlewoman yields back. It is a pleasure to
recognize the gentleman from Virginia, Mr. Griffith.
Mr. Griffith. Thank you very much, Madam Chair. I am very
happy to follow Congresswoman Castor talking about ensuring
transparent, honest information on COVID-19.
Ms. DeSalvo, it is being reported that there are financial
ties between Google and EcoHealth Alliance, a company that was
collaborating with the Wuhan Institute of Virology to conduct
bat coronavirus and other virus research. As donors to
EcoHealth Alliance, do you support its lack of cooperation with
my request and the requests of other members of this committee
as we seek information about the origins of COVID-19?
Dr. DeSalvo. I appreciate the question, Congressman. I
don't have all the details of that report, but I believe the
reporting has been inaccurate. The one-off grants that were
received by that researcher were years ago and predate the
pandemic. So my appreciation is they are not related.
Mr. Griffith. Well, and they certainly predate the
pandemic, as far as the base research. But the data indicates
that there was a 2010 study on that bat flaviviruses that was
listed as being supported by Google. There is also a 2014 study
on--if I am pronouncing it correct--henipavirus, which infects
fruit bats and micro bats. And that was in--on the spillover.
And then a 2018 EcoHealth Alliance paper entitled, ``Serologic
and Behavioral Risk Survey of Workers with Wildlife Contact in
China.'' That was made possible with the contributions of
Google.
So it is--it clearly predates the coronavirus outbreak, but
this research has been going on for over a decade. And the real
question is, does Google support or condemn EcoHealth Alliance
that they donate to?
Do they support or condemn the stonewalling of Members of
Congress who are trying to get information about what happened
with COVID-19, and what the origins really are, whether it was
a wet market situation or was it a lab leak?
Dr. DeSalvo. With respect to the--to this particular
investigator, or set of investigators, as I said, I haven't
seen the reports, and I am not intimately familiar with the
work.
What I can submit to you is that we will work with you and
your office and come back with answers that you may have--and
see that we have the right people who have more intimate
knowledge of the situation.
Mr. Griffith. And I appreciate that. I would also
appreciate any conversations, emails, et cetera, that Google
may have had from EcoHealth Alliance that may have indicated to
them information about COVID-19, since you all were involved in
earlier studies related to bat viruses that Mr. Daszak of
EcoHealth Alliance was one of the authors of, saying that this
was clearly coming from wet markets and from bats, and you all
were involved in that. Any conversations you all might have had
in 2019, 2020, or 2021 regarding that, if you could get me that
information, that would be greatly appreciated. And can you
commit to working with us to get that information?
Dr. DeSalvo. I certainly commit to working with you all,
and I will have the right people follow up with your office.
Mr. Griffith. I appreciate that greatly. You know, it is
important that, as we talk about having an honest and
transparent discussion about these items, that we move forward
working together. And is Google prepared--because it has been
criticized in the past for failing to demonstrate a commitment
to fostering open debate on scientific issues such as this--is
Google prepared to commit to such an open debate?
Dr. DeSalvo. I tell you, Congressman, I very much
appreciate you asking that, because, as a physician, the debate
about the medical treatments and origins and even the diagnosis
of COVID has been a rich and complex environment for the past
year and a half, and not only for the medical community and the
public health community, but the community at large has been
involved in trying to understand, as we learn on the journey,
what works, what doesn't work, how should we be protecting
people in communities, how should we treat our patients in the
hospital or at home.
So as that information has evolved, we have relied on
trusted authorities like the CDC or the World Health
Organization outside of the U.S. to provide authoritative
content, so we can lean on the group of scientists that build
consensus statements from those authoritative groups. And then
we use that to inform policies that we apply to information,
not only to raise up important quality information that we want
people to have, people--to protect themselves and their
families, but also----
Mr. Griffith. Yes, ma'am.
Dr. DeSalvo [continuing]. Harmful misinformation.
Mr. Griffith. And I appreciate that. And I think we should
go forward working together. And I hope that Google will have
an open policy on scientific discussion, because the EcoHealth
president has recently been taken off of or left the WHO study,
and it is now becoming clear that they are somehow involved. We
don't know exactly how, because they are stonewalling us. And
all we want here are answers to the American people.
I yield back.
Ms. Eshoo. The gentleman yields back. It is a pleasure to
recognize the gentleman from Vermont, Mr. Welch, for his 5
minutes of questions.
Mr. Welch. Thank you very much. I want to thank all the
witnesses for being here. And I want to bring up Congresswoman
Bustos' Social Determinants Accelerator Act, and I am a
cosponsor, and it is really important in Vermont.
In--the Vermont housing needs assessment in 2020 showed
that more than 19,000 Vermont households face housing quality
issues. It includes homes with coal or limited heating sources,
40-year-old mobile homes, incomplete plumbing, and so on. And,
unfortunately, too many Vermonters do live in these conditions.
Dr. Walker, you mentioned the Social Determinants
Accelerator Act in your testimony. And the bill, as you know,
would create a program at CMS to provide grants to State and
local governments to develop plans to combat social
determinants of health that are resulting in negative health
outcomes. The--are you aware of any cities or States who have
developed a strong model to improve housing and health outcomes
at the same time?
Dr. Walker. Thank you, Congressman. I think there are a
variety of examples that are critically important, not only
around housing, but also around nonmedical transportation,
home-delivered meals, and educational services. And some States
have incorporated waivers into their Medicaid program. I think
a few examples exist, including North Carolina, where they are
incorporating this into their value-based payment. Maryland is
certainly implementing a program to support individuals with
developmental disabilities. And there are others--Minnesota's
waiver that looks at the provision of housing stabilization for
individuals who are at risk for homelessness.
I think using these examples and innovations are helpful.
They also allow us to invest in families with long-term impacts
on the health and wellness and mental health and well-being of
children and adolescents. And so having these examples is
helpful, but encouraging it across our Nation could be a
tremendous health impact.
Mr. Welch. Thank you, Dr. Walker.
And Dr. DeSalvo, you also discussed the need to address
social determinants of health, housing being one of them. How
can investment in updated health data systems, including the
use of qualitative data, which you mentioned, help improve
public health and build up our communities suffering from
systemic health inequalities?
Dr. DeSalvo. Thank you, Congressman, for the question, and
I will answer it. I do want to first give a shout-out to
Vermont, who has done some great work, particularly for
populations with substance use disorder, in understanding how
to blend and grade resources to address social determinants of
health, including housing--housing being, for people, probably
the most important social determinant of health. We saw that
firsthand after Katrina, and we see that every day in
communities. So I also appreciate you raising a really
important foundational structure for individuals.
Two particular points. One is that data is--has to be
timely, actionable, and granular. It has to be not only
quantitative, because you need anonymous population-level
information that you can map to direct intervention, but you
also need the voice of community. Some of the bills today
include that concept, that there have to be community advisory
voices, particularly those bills--the bill about maternal child
health.
But that is true in every context. And that can be done
manually, if you will, human to human, and that is important.
It can be augmented by additional data sources. I mentioned
information that Google has made available to public health on
the open repository, including search symptoms trends. Again,
this is anonymized data that is at the population level that
could be useful to augment that important data that public
health needs to take action.
Final point, these bills, many of them speak to this idea
of community collaboration and partnership. I think you will
find threads throughout many of the successful projects in
communities that it is really about everyone coming together to
create the conditions for health, not any one sector alone. So
public health with business, faith-based and others.
I will just--for your information, and for your staff,
particularly, the NASDOH, the National Alliance for the Social
Determinants of Health, has a report on their website that
talks about some great examples across the country and a
playbook for how communities can do this, including what the
data needs might be.
Mr. Welch. Thank you very much.
Madam Chair, I yield back.
Ms. Eshoo. The gentleman yields back. The Chair is now
pleased to recognize Dr. Bucshon from Indiana for your 5
minutes of questions.
Mr. Bucshon. Thank you, Madam Chairwoman, and thank you for
having this hearing. This is really important.
Social determinants of health are critical in today's
healthcare system to improving health outcomes and better
understanding why social situations that people in our society
are in actually have a substantial effect on their ability to
lead healthy lives and to get good outcomes.
But it is a very complicated subject. I have worked on--a
lot on maternal mortality and maternal health. And, you know,
we have had testimony from physicians from Parkland Hospital in
Dallas, for example, which--that is a public hospital for the
underserved, and many of their patients are on Medicaid, and
their health outcomes were outstanding as it relates to
maternal health. And then we heard testimony from other areas
of the country that also service underprivileged and primarily
Medicaid patients, where their data wasn't quite as good.
So we really need to know why this is, and why that--and I
think part of that is because Parkland Hospital has data-driven
protocols to how they take care of patients, at least in the
maternal health. But this is also across our healthcare system.
It is all about innovation, I think, in healthcare.
Innovation and better-collected data help promote a more value-
based system that, in my view, helps lead to better outcomes,
because we are able to determine why the outcomes are poor in
one area that serves a similar population but outstanding in
another area of our society.
One area I want to focus on was the provider's role in
gathering and collecting of data. As we know, doctor burnout is
at an all-time high. Most of the time, the main reason, in my
view, for this is due to the burdensome paperwork and
duplicative administrative tasks that a lot of physicians don't
feel they signed up for. They want to take care of people. All
of this has doctors spending more time doing paperwork and less
time with their patients. While I think data is important and
should be incentivized, I am cautious not to put more of a
burden on doctors and other providers who already need more
time with their patients.
In that vein, Dr. Syed, it is my understanding that there
are existing ICD-10 codes for social determinants of health
that most doctors aren't collecting at the moment. In order to
properly advance social determinants of health policies,
someone will have to be responsible for reporting the data
collected. In your experience, who is responsible for
collecting the data needed for better social determinants of
health?
And whose responsibility would it be if some of these bills
considered today would become law?
Dr. Syed. Thank you. In my past life at the--in the FQHC
world, it was in the fee-for-service system. It wasn't in a
value-based system like I am currently in with Medicare
Advantage. So I was forced to focus on sick care. I have always
felt like I was two steps behind. I remember I was always
reacting to problems that were already out of control. See, in
the Medicare Advantage environment, practicing preventive
medicine keeps all of us--not only the doctors, the nurses, all
of our care team members--many steps ahead. And that is when
you are able to notice the small changes before they really
become the big ones.
So it should be the primary care doctor being at the center
of the care delivery system.
Mr. Bucshon. Yes, well, I appreciate that, and I think, you
know, that does add some administrative burden. But I do agree
that there has to be someone--the primary care doctor, you
know, is kind of the captain of the ship. And so I just want to
make sure whatever we do doesn't unnecessarily burden
providers.
And so I want to talk a little bit more about your
experience with--in Medicare Advantage. Why do you think it is
more of the--that more of the Federal Government and State
governments are so hesitant to embrace the existing approach
that gives plans and providers a risk-adjusted amount of money
that lets them decide which social determinate interventions
need to take place without adding more burden-inducing
reporting and box checking?
Because what you just described sounds better to me than
maybe the system that you had experience with before.
Dr. Syed. Well, sure. I mean, all of us got into medicine
to help people. None of us thought that we would be getting
into healthcare and spend hours every day focused about the
documentation required for reimbursement.
So what I would like to see is, really, more education
about Medicare Advantage, because our current system is based
on sick care rather than primary care. You see, with the
Medicare Advantage model, it puts the primary care doctors at
the very center of the entire care delivery system. You see,
then the doctor has the time to look into the causes of the
causes, and then you get to know the patients better than any
other random doctor.
I think what you mentioned about the choice, patients
should be able to go to any doctor they want whenever they
want. And it sounds great in theory, but when your health is on
the line, you really want a referral from the doctor who knows
you the best, the one that you trust the most. And with the
Medicare Advantage world, yes, I just want to say that, that it
gives me the time to establish the trust with my patients and
make the same referrals I would for my mom or my dad.
Ms. Eshoo. I hate to interrupt----
Mr. Bucshon. Thank you for that information, and I yield
back.
Ms. Eshoo. Thank you. Thank you very much, Doctor. It is a
pleasure to recognize the gentleman from Oregon, Mr. Schrader,
for your 5 minutes of questions.
Mr. Schrader. Thank you very much, Madam Chair, I
appreciate it.
I, too, am a supporter and cosponsor of Ms. Bustos' bill on
the Social Determinants Accelerator Act, and I think it is very
important to have that coordination. We have heard here today
from our witnesses and others that, without that coordination,
it is very difficult to get things done.
And in my home State of Oregon, one of the big projects
that has worked extremely well is our coordinated care
organizations to deliver Medicaid or Oregon Health Plan
benefits for a lot of folks. And they are grown up from the
ground up. It is not something that is put top-down from
Washington, DC. And it actually has those social determinants
worked on by the community organizations that know that
community best, and I think that is what Dr. Bucshon was
alluding to, and I would agree with him.
We shouldn't be managing counting different things that
should be about providing quality healthcare. Dr. Syed, I
think, hit the nail on the head in his comments and responses
there. I think it is just so important to coordinate this sort
of thing.
Dr. Blauer, with the interagency council suggested in the
Bustos bill, how do you see that getting out best practices
like we have in Oregon to folks around the country?
Ms. Blauer. Thank you, Congressman, for the question. I
think the most important thing is that, oftentimes,
particularly when we talk about data or IT infrastructure, our
gut is to put data and IT folks on these interagency
committees. And what we need are subject matter experts who are
knowledgeable about the impacts of program decision making and
the realities of program delivery on the ground.
So I think, first and foremost, you need to make sure that
they are staffed with people who have deep, programmatic
expertise and who understand what the objectives of the work
are and understand how they can leverage tools and technology
to actually do the delivery of the services and to support the
work of the committee. So subject matter expertise, absolutely.
And then prioritization. We need leadership that actually
can lead with prioritization. We will end up in a boil-the-
ocean moment if we don't have clear goals that are articulated
and measurable and that we can focus our work collectively on.
There is a lot of work to be done, and without that kind of
direction that will allow for us to have those sort of clear
priorities outlined, we are going to be in a situation where we
are going to get overwhelmed very quickly. And governance
allows you to create prioritization with the inputs of that
subject matter expertise. Thank you.
Mr. Schrader. Very good. Thank you. Thank you.
Dr. Syed, you talked about being fully capitated. Fully--
that that makes a difference. What is your definition of fully
capitated to make the Medicare Advantage system work, in your
eyes?
Dr. Syed. It is a model of--especially with primary care,
where the doctors are not concerned about generating revenue by
billing. Being fully capitated, we take on the full
responsibility of the total health of the patient. And so it
gives us the flexibility to treat seniors with multiple chronic
medical issues according to their actual individual situations.
Mr. Schrader. I agree with that, and I think that is--
points to Dr. Bucshon's concern about it shouldn't be the M.D.
that has to worry about counting all the widgets and worrying
about reimbursement. If you have a coordinated care group like
we have in Oregon, that organization deals with that and
decides, along with the physicians, with the hospitals, with
the mental health providers, with the pharmacies, about who is
getting what amount of money based on those local needs.
I don't see why we don't even just transition to that. Fee-
for-service is so outmoded. I have remote parts of my district,
very rural parts, that are part of coordinated care districts
that provide much better health service tailored to those
individuals.
Dr. Walker, I appreciate you mentioning the value-based
payments, you know, as we just discussed here. Were--what
policy should we be pursuing to foster growth in that arena?
We are actually trying to do that--Mr. Guthrie, Mr. Mullin,
and I--with regard to pharmaceuticals. But I think it,
obviously, applies here, in terms of just care delivery. What
should we be doing to foster growth in that area?
Dr. Walker. Thank you, Congressman, for the question. I
think it is essential, as some of the bills indicate, that we
need to incorporate incentives, expertise, and make sure that
States have the bandwidth to move forward with value-based
payment. That often can start with Medicaid but go beyond, once
you learn the lessons. Medicare Advantage is fully taking on
this value-based payment role.
But it does take a bit of guidance. And, you know, the
Caring for Social Determinants Act does include a
recommendation to include the updated guidance to allow for
innovations like the CCOs to flourish in other places. But it
does take leadership, it takes alignment, and it takes the
right expertise. That is where, you know, having data to look
at the alignment of incentives can be incredibly helpful too.
Mr. Schrader. Very good, thank you. Thank you all for your
work.
And I yield back, Madam Chair.
Ms. Eshoo. The gentleman yields back. It is a pleasure for
the Chair to recognize the gentleman from Oklahoma, Mr. Mullin,
for your 5 minutes of questions.
Mr. Mullin. Madam Chair, thank you so much. Thank you for
putting this hearing together.
Dr. DeSavio--I hope I am saying that right. If I am not,
please correct me. I--based on your experience in public as a
public official, can you kind of speak to the importance of
aligning Federal programs to address the social determinants of
health?
Dr. DeSalvo. Thank you, Congressman. On behalf of my
husband's family, I will say it is DeSalvo.
Mr. Mullin. DeSalvo, thank you.
Dr. DeSalvo. You know, Congressman, in Oklahoma you have an
incredible example of how a group of primary care clinicians
came together to create an information exchange--this is My
Healthy Data--and built a global population health model like
we were just describing, to really allow the docs to care about
the patients, and then the data gets collected around them, and
the patients--that data now tells the story of a community's
health, as well.
So it is informing public health action. It is a wonderful
example of how Federal action to spur the innovation and models
of primary care, of health information exchange can then also
not only improve the care of patients but begin to tell a story
and--or improve the care of populations that--that group, for
example, has done incredible work in COVID, creating dashboards
that can help the community understand--I believe you had the
opportunity to see some of those. So----
Mr. Mullin. I have.
Dr. DeSalvo. You know, I think it is a wonderful, also,
example of how the foundation of electronic health record
information that--primarily for the use of individuals, when
anonymized, can be useful to help understand the health of a
whole community. And it is the kind of innovation that we could
spur or scale across the country and shorten the timeline to
being able to do good work.
What is great about that particular effort, by the way, is
that it is transparent. The docs have a lot of say in the data
and how it is used, but also it helps to build a virtuous cycle
of improving the quality of care and, as I said, improving the
health of the population.
Mr. Mullin. Are there any examples, like, in your
experience that you can use to kind of highlight on how this
has been working?
Dr. DeSalvo. Definitely. I think, in addition to the
example in My Healthy Data, there's a couple of States that
have been leaders in this area of using existing data that was
built on a foundation, often from a Federal program, and then
gets expanded.
I will call out another primary care example, one called
Macroscope, which was built in New York City by the public
health department using data from their primary care clinics, a
similar idea. We already have data. Let's not repeat the
collection. Let's be efficient. Let's anonymize it and use it
as a way to understand what are the rates of diabetes and high
blood pressure in our community. And it is a pretty timely,
actionable, granular set of data that public health now can use
to target interventions, to address inequities, to address the
social determinants of health.
I could go on a long list, Congressman, but I think what I
would love for the committee and for others to know is
innovation in--between public-private partnerships, community
led, on the ground is happening all over America. I visited so
many in the course of my career. We have written about them in
Public Health 3.0 and the National Academy of Medicine report I
referred to earlier that we just recently put out on public
health. So we have a sense of what works and we have a sense
also of what works from the data.
Now what we need to do is make sure that we have got
strategy and prioritization and direction, but also fill gaps
in the data layers and make sure that that data layer is
interoperable and can help us address inequities.
Mr. Mullin. Well, that actually leads me right into my next
question, which was going to be: What can Congress do to kind
of help--easier for private sector and nonprofits to work
together on various funding streams to coordinate in this way?
Dr. DeSalvo. This is an interesting and complex area. One
of the calls that comes from community often is, when they
create collaborations they want to not only share governance
and data, but they want to be able to pool or share resources.
And there are actually--there is more latitude, probably, than
many communities realize. Communities like Oregon, or Rhode
Island, Vermont have found ways to blend and braid funding to
support particularly low-income populations and address social
determinants.
But I will tell you what, I have done that on the other
end, when I was health commissioner addressing needs of youth
and violence. It is very hard to blend and braid funds
sometimes. So I think some of the considerations in the bills--
for example, these interagency councils--could be to catalog or
understand what are the flexibilities that communities could
use to not only blend and braid the public-sector dollars, but
how can the private sector contribute in a way that is again,
transparent, shared governance, and shared accountability for
the outcomes.
Mr. Mullin. Doctor, thank you so much.
And Madam Chair, I will yield back the remainder of my
time. I want to thank you again for putting this together,
though. This is vitally important to a lot of our communities,
especially the rural parts of the country.
Ms. Eshoo. It is, and you asked wonderful questions. Thank
you.
The gentleman yields back. The Chair now has the pleasure
of recognizing Mr. Cardenas from California for your 5 minutes
of questions.
Mr. Cardenas. Thank you, Madam Chairwoman, and also thank
you, Ranking Member Guthrie, for having this very, very
important hearing. And I always appreciate all of our experts
coming to educate us policymakers so that we make sure that we
can do the best job we can to serve our country. And we are up
here on a 30,000-foot level, and you are there on the ground.
So thank you so much for all of your expertise and your
wonderful insight.
Also, Chair and Ranking Member, thank you so much for
putting H.R. 3969 on the agenda today, as well. I am chairing
that bill with Representative Curtis, and I appreciate it being
in the hearing today. This bill would include spending on
activities related to social determinants of health, and the
calculation of private health insurance plans and medical loss
ratio.
In introducing this legislation, we recognize that social
determinants of health like reliable transportation,
availability of nutritious food, safe housing are all primary
drivers of health outcomes. And to achieve health justice and
equality for all, we must be more intentional about how we
address their impact in all parts of our healthcare ecosystem.
Dr. Batra, in your testimony you discussed the Senior Care
Action Network, SCAN, the approach to addressing social
determinants of health. Could you please talk about the impact
of this approach on members in your network?
Dr. Batra. Absolutely. I think we started off by making
sure we collect data the way the members want the total data to
be reported, how they identify. So for us, having the data
around race and language was very important.
Similarly, we have collected years' worth of data on our
members around their social needs, their transportation, food
insecurity, loneliness, in-home caregiving and support, hearing
dysfunction. And we have really used that data to help identify
members and even connect them to the right benefits and the
right programs.
So, for example, 70 percent of our population suffers from
hearing dysfunction, which, as you know, can interfere with so
many different things, lead to isolation, lead to loneliness,
also lead to poor health outcomes. We have hearing aids as one
of our supplemental benefits. So we try and engage with members
and connect them to that.
Similarly, a good example during the pandemic was around
transportation. People wanted to get the vaccine, did not have
caregivers around them, had a son or daughter-in-law living in
a different State. We were able to arrange those rides for
them.
The other unique thing that we did during the pandemic and
vaccination was, as people were getting vaccinated in doctors'
offices and convention centers and pharmacies, we had folks who
were homebound and could not leave their homes. We were able to
get the vaccine to their home, not only for the members, but
also the caregivers, because they were the ones taking care of
their loved one, who happened to be with us.
So those are some of the high-level benefits that we have
used. We have done studies that show that, if you have
transportation insecurity or food insecurity, you are going to
have a worse outcome on your diabetes. And so we are
consistently looking at ways and engaging our population with--
whether it be a program or a benefit, and ensuring them they
have it, so as to fulfill their needs.
Mr. Cardenas. Yes, thank you. And can you give us at least
one example about what we can do, going forward, as Congress?
What kind of effort can Congress afford you out there in
the community?
Dr. Batra. Absolutely. So as we--you know, first and
foremost, I want to really thank the Congress for providing us
the flexible--benefit flexibility. We were able to design all
these newer benefits to meet the social needs of the population
that started in 2019. So the benefits that I alluded to: in-
home caregiving, meals after discharge, care coordination,
support, and occupational therapist. However, these are based
on medical needs, so you have to have a qualifying diagnosis,
like you have diabetes or you have heart disease or end-stage
renal disease.
If you truly believe there should be equality for all, if
you truly believe that social needs are the first and foremost
drivers of health, then perhaps we should be allowed to kind of
design some of the benefits based on the social needs of the
population. So that is one area that comes to my mind.
And the second area is, during the pandemic, as we were
scrambling we did about 100,000 social outreach calls to--
checking on members. We actually have a benefit that helps
people sign up so they can--somebody can be their help, so they
can have the telehealth visit to their doctors. We notice there
are ZIP Codes with a high social vulnerability index, where
people did not have access to Wi-Fi and iPads and technology.
And for those, the telephonic assistance was really, really
important in order to extend the reach of the primary care
physician. That is the other area we really want Congress'
help, in keeping telephone as one of the ways of engaging with
the member, engaging with the patients, and helping them.
Mr. Cardenas. Thank you, Dr. Batra. And it is very rare for
us Members of Congress to get a thank you. So thank you for
slipping that thank you in there.
And I just wanted to say how focused many of us are on
making sure that we modernize our public health data,
infrastructure, and outreach, because those are some of the
major lessons that we learned during this pandemic.
My time has expired, Madam Chair. Thank you so much for
having this hearing. I yield back.
Ms. Eshoo. You are most welcome. It is a pleasure to
recognize one of the doctors on our subcommittee. And we have,
I think, five. I think five doctors.
Dr. Dunn from Florida, you are recognized for your 5
minutes of questions.
Mr. Dunn. Thank you very much, Madam Chair, and also thank
you, Ranking Member Guthrie, for hosting this hearing today to
examine the ways that data can affect public health.
You know, over the course of the COVID-19 pandemic,
Congress spent hundreds of millions of dollars to support data
collection and data infrastructure modernization. And whether
those dollars were used for a centralized CDC data assimilation
or grants to States and local governments for data collection,
the money is already out the door. And we need to evaluate how
these funds are being used, I think, before we consider another
slate of new bills to advance more data collection as it
relates to improving the care of the health of the American
people.
High-quality healthcare starts with the doctor-patient
relationship. Dr. Syed said that in his testimony. And then it
should consider the individual needs of patients. You can't
just crunch data and pigeonhole people without taking a
holistic approach to the patient.
We also can't rely on bureaucrats in Washington to make
decisions about healthcare for our individual patients. People
simply cannot be reduced to a set of data points, no matter how
voluminous they are.
I also want to associate myself with the remarks of my
colleague, Dr. Burgess, when thinking about requiring more and
more data collection. The potential that that information will
be shared across other entities requires that we have reliably
strong safeguards in place to ensure patient data remains
private and that HIPAA protections are, in fact, upheld. And
with that I would like to ask Dr. Syed a question.
I appreciated reading your testimony, hearing your views on
creating more value in the healthcare system. You touched on
coordination of care and a strong doctor-patient relationship
and matching the resources to the patient's needs in order to
drive improved outcomes. It seems to be you are an advocate for
the flexibilities that the Medicare Advantage system allows, in
terms of value. And you cited many examples in your testimony,
and let me say I share those views with you.
From your perspective, is increased data collection in the
primary care setting the sine qua non to improved health
outcomes?
And so a lot of these proposals are talking about involving
significant additional reporting requirements and gathering a
great deal of data. And I know personally that doctors are
already suffering from a fair amount of burnout and stress over
administrative burdens. Dr. Bucshon made allusion to that in
his questions. What is your perspective on that question, sir?
Dr. Syed. Thank you very much. I--with regards to data and
collecting more data to improve patient health, there are some
things that I feel, as a doctor, I could speak to.
When we are talking about improving health, I am thinking
about, if we know medications are critical to improving health,
we should not let patients walk out the door without their
medications. Like, if we know that heart disease is the number-
one killer in the country, then we should have cardiologists
working hand in hand with the primary care doctors. And if we
know that a major part of improving health is overcoming the
barriers to the care, then we should have social workers
integrated into the care teams.
I think, rather than collecting more data, we should kind
of relook at how care delivery is happening right now in the
country. And to what someone else said earlier today, you know,
if we know that doctors are getting burnt out from doing all
the nondoctor work, we should have the care teams take over all
the administrative duties and just let the doctors be doctors.
Mr. Dunn. So I--and let me say I like that answer very
much. It certainly would have made my life a little easier the
last 10 or 15 years.
You shared a story about uncontrolled diabetes, I believe,
in your father.
Dr. Syed. Sure.
Mr. Dunn. And I think that you would agree that data helps
with that. But also, it is that personal time you spend with
them, saying, ``Let's work with each other, and let's do the
right things.'' In other words, it is really a relation step
with the doctor-patient relationship. Would you agree with
that?
Dr. Syed. Absolutely. I think about--yes, absolutely. I
think about a patient I had with morbid obesity. And because of
the flexibility with the Medicare Advantage program, I was able
to see him as often as I needed to see. And I was more of a
health coach than I was a doctor for him. And I was able to--in
6 months I was able to see him 7 times and get his weight down
from 250 to 220 pounds. In my previous job, I couldn't even see
him more than twice a year. So that is just the difference. It
is a different, completely different, approach towards
delivering on the care.
Mr. Dunn. Certainly--our time is about over here--I was
saying I certainly appreciate that. I agree with you.
In Florida we experimented with sort of a hybrid Medicare
Advantage/Medicare fee-for-schedule, so--the specialists and
the primary care, working together.
But I thank you for your comments, I thank the witnesses,
and I thank our chair and ranking member, and I yield back.
Ms. Eshoo. The gentleman yields back, It is a pleasure to
recognize the gentleman from Maryland, Mr. Sarbanes.
You have 5 minutes to question. Great to see you.
Mr. Sarbanes. Yes. Thank you, Madam Chair. I want to thank
the witnesses for being here for this important hearing.
I deeply share the concerns of my constituents and those at
our hearing today about the impacts that the coronavirus has
had on communities of color. I believe Congress should use
every available tool--and equitable recovery as well as address
the root causes that have created health disparities for years.
For too long, the Federal Government has failed to
adequately recognize and address structural racism as the
public health crisis that it is. Black and Brown communities
have been denied access to quality, affordable healthcare, have
faced barriers to securing safe, quality, affordable housing,
and have suffered the consequences of environmental racism for
generations.
The COVID-19 pandemic, as we know, unveiled and exacerbated
longstanding racial disparities in health outcomes. It is time
we recognize and treat structural racism and police brutality
through a public health lens when we can.
Under the Biden administration, the CDC has begun this work
by declaring racism a public health threat and committing to
addressing racism in the context of health equity. I commend
the CDC for this step, and we in Congress are committed to
assisting in the effort. One way to do that is by passing the
bills we are discussing today, including the Anti-Racism in
Public Health Act and the Social Determinants Accelerator Act.
The Anti-Racism in Public Health Act is a critical bill
introduced by my colleagues, Representatives Ayanna Pressley
and Barbara Lee. This bill would expand Federal research and
investment into the public health impacts of structural racism,
require the Federal Government to proactively develop
antiracist health policy, and take a public health approach to
combating police violence. Among other things, it would create
a national center for antiracism at the CDC, which would award
grants to study the health impacts of structural racism.
Dr. Walker, I wanted to turn to you to elaborate on this a
little bit. What is the significance of the CDC recognizing
racism as a public health issue?
Dr. Walker. There is clear evidence that racism creates a
public health threat, and it creates not only immediate
stressors but also long-term health effects that we need to
combat.
But many of those factors are ones that we have talked
about: the social indications around housing, around
transportation, around can you just get access to the care that
you need?
We know, for children and adolescents, some of those
factors are around mental health access and needs, and
resources in schools. And so having the ability to really
provide Federal resources to make sure that States and local
communities can invest in these factors and increase the
ability to address it at a community need base, on those
priorities and those areas of local context, are important for
us to be able to incentivize health and well-being at the most
local level.
Mr. Sarbanes. Thank you very much. And I am sure you would
agree that gathering up research and data in this space, and
having that inform this perspective on the health impacts of
structural racism, is also a key undertaking.
What significance would it have to establish a national
center for antiracism to serve as a resource hub to share
information at the Federal, State, and local levels, in your
view?
Dr. Walker. I think that the benefit is that we could make
sure that there is some data standardization but also expertise
that often is not accessible in State agencies. So having a
national center can lend technical support, can lend some data
standardization, but also can support--and collaboration with
academic partners in State and local data. And I think having
those resources come together in a national center can be very
beneficial and can't necessarily be done 50 times over in other
areas. And I think that is a--national center, we have worked
with them in the past and I think can be a great resource.
Mr. Sarbanes. Thank you.
Ms. Blauer, at Johns Hopkins--and let me just say how proud
I am, being from Baltimore, about the great work that Johns
Hopkins has done, particularly gathering critical data during
the pandemic, and the university's Coronavirus Resource Center,
as we all know, was a trusted source of information for so many
people over the past year.
Could you expand on the role data played in responding to
the pandemic, and what additional data and resources might have
been helpful, particularly to respond better to the challenges
faced by communities of color during the pandemic?
Ms. Blauer. Yes, thank you, Congressman. I can say that it
wasn't until several months into the pandemic response in our
work that States even started to release COVID data,
demographic data that was rich enough for us to even validate,
the kind of frontline anecdotal information we were getting
about the disproportionality that that virus was having on
residents.
And it has taken us a long time to even get any kind of
guidance around demographic sharing of data. We are still only
at the CDC reporting around 60 percent of demographic data for
the cases and the deaths of people that have been impacted
disproportionately by the virus. We are still operating,
certainly, in an environment of confusion when it comes to the
disproportionality and the effects. And so having some guidance
and some standardization around demographic data is so vital as
we continue this last mile of work around COVID, but certainly
as we think about how we look at the social determinants of
health, and the role that data plays in deepening disparities
and exacerbating bad outcomes for people. Thank you.
Mr. Sarbanes. Thank you, I yield back.
Ms. Eshoo. The gentleman's time has expired. The gentleman
from Georgia, Mr. Carter, you are recognized for your 5 minutes
of questions.
Where are you?
Mr. Carter. Thank you very much, Madam Chair, and thank----
Ms. Eshoo. Are you in the car?
Mr. Carter [continuing]. The witnesses----
Ms. Eshoo. Are you in the car? Where are you?
Mr. Carter. No.
[Laughter.]
Mr. Carter. I am in the hearing room.
Ms. Eshoo. Oh, good, OK. I am glad you got out of your car.
Mr. Carter. I am, too. Thank you, Madam Chair, and thank
the witnesses for being here. Very important subject matter.
Dr. Batra--I apologize--and Dr. Syed, Medicare Advantage
plans have more than doubled enrollment over the past decade,
and these plans clearly offer beneficiaries greater benefits
and care versus traditional fee-for-service plans. And this is
good. This is a good product that, obviously, is being
utilized, and I am glad to hear that.
My question, Dr. Batra, is this: How would beneficiaries
benefit by Medicare Advantage plans offering new and existing
breakthrough technologies and devices that are FDA-approved but
do not fit into an existing benefit category for certain
targeted populations, like those with chronic conditions?
Dr. Batra. Yes, we--I think what we have done consistently
is look at, as these new things become available, what has
shown proven evidence, what has shown to prove--help with the
needs of the membership that we serve. Wherever we have, you
know, guidance from Medicare, either through their NCDs or
LCDs, we follow those guidances. Where we don't have guidance
available right away, we look at other data sources, other
peer-reviewed studies, other evidence-based sources, and see if
we can fit the need of the population and go from there on.
The other thing that we have done and encouraged in our
members is, as things become available, some of them are in the
experimental trial phases, which is available through them--to
them through Medicare trials.
Mr. Carter. I don't mean to interrupt you, but I indicated
if they were FDA-approved.
Dr. Batra. Oh, they are FDA-approved, and we do have the
flexibility in evaluating what is available, in terms of
evidence, and then considering them for the right populations.
Mr. Carter. OK, and you have a review process for that,
whereas you review it among your yourselves----
Dr. Batra. Yes.
Mr. Carter [continuing]. And decide whether it is going to
be covered or not?
Dr. Batra. Yes, we do have medical policy departments that
work together alongside our provider partners, working very
closely with our provider partners, alongside experts--some of
them are academic experts--to review them on a case-by-case
basis, to look at the needs in a population, to look at what
else is available, to look at the comparative effectiveness. So
multiple factors play a role in that.
Mr. Carter. OK. Dr. Syed, what about you? What about your
company?
Dr. Syed. Our--we understand that more than 70 percent of
modifiable health outcomes are actually based on a preventive
lifestyle, lifestyle interventions. So when you have a system
that is focused on prevention and the doctors are allowed to
focus on prevention, then the patients are more safe at home
rather than going to the hospitals. It eliminates all the
medical costs, actually, before they even occur. You know, we
focus on improving health and reducing suffering through
preventive and early interventive measures.
If there is an FDA-approved treatment or a product that can
help benefit the patients, then, as long as it is FDA-approved,
then we would evaluate that on a case-by-case basis.
Mr. Carter. Do the individual patients have some type of
appeal process, some kind of prior approval process, or
anything through your company?
Dr. Syed. I--that I am not--in the full risk model, I am
not aware of having to go through that type of process.
Mr. Carter. OK, all right. Let me move on.
Dr. Batra, again, I serve a very rural community, and many
of my constituents have trouble getting to physicians for care.
Even during the past 6 months, many of these same constituents
could not access vaccines for extended periods of time. It
appears that SCAN Health Plans have been recognized as a leader
in getting COVID vaccines to homebound and rural patients. Can
you share with us what you all are doing to--that maybe other
plans could duplicate to improve access to care for
beneficiaries in rural communities?
Dr. Batra. Absolutely. We absolutely follow the principle
of leave no older adult behind. So, right from the very
beginning, as the vaccine was being developed, we put all hands
on deck on figuring out how do we get the right people to the
right places. Those who could drive, how do we get them there,
give them information, and those who could not get there, how
do we get them rides to get there?
But we also serve a large swath of people who are homebound
members, who have caregivers taking care of them. So we worked
very closely with an organization that then deploys paramedics
in people's homes that could carry the vaccine in a safe way,
had oversight provided by nurses and physicians. We were able
to schedule those visits for them. And within the comfort of
their own home, under watch of a paramedic, as well as the
oversight of a nurse, we were able to deliver those vaccines in
people's arms. To date we have done several hundred of those,
and we will continue doing that with the goal of leaving no
older adults behind.
Mr. Carter. Well, I just want to compliment you and thank
you, for your service to the rural communities, in particular,
is extremely important. So thank you.
And I will yield back.
Ms. Eshoo. The gentleman yields back, and now another one
of the doctors on our subcommittee, Dr. Ruiz from California.
You are recognized for your 5 minutes of questions.
Mr. Ruiz. Thank you, Chair. This is so important. Finally,
it is a premed dream come true. You see, back in the 1990s,
when I was premed and in medical school, those of us who
understood social determinants of health would shout it out in
lectures. We would talk about it in the halls of the different
academic hospitals. And everybody was so singularly focused on
the specifics of medicine, that they didn't really understand.
And now we are actually having a hearing on how to improve
data collection for social determinants of health and our
public health system. This is groundbreaking. This is
incredible. This is the spear of much more to come, the tip of
an iceberg.
And I am so proud of Congressional Hispanic Caucus member
Nanette Barragan and all the other members of our committee who
have pushed forward great legislation to finally get our social
determinants of health in the limelight, so that we can really
take a comprehensive look at health.
It is not just the absence of disease. It is the ability to
enjoy one's life and have wellness and fulfill our human
potential in our communities. And from breathing in the toxic
air around the Salton Sea in my district, to working in the
fields, the grape fields, the bell pepper fields under the
blazing sun, to food insecurity, I have seen firsthand in my
district how social determinants negatively affect my
constituents and my patients'--I am an emergency physician, by
the way--my patients' health.
So many of my constituents do not have access to healthy
foods, whether that is because they live in a food desert or
because healthy food is more expensive. Ironically, the same
farm workers who pick the healthy foods can't afford those
healthy foods at this--sometimes, or they do not have adequate
health insurance.
So no matter what the reason is, all these factors
contribute to higher rates of underlying chronic diseases like
obesity. In fact, nearly half of Black and Hispanic Americans
are living with obesity, and this puts them at greater risk of
200 serious diseases, including serious conditions like
diabetes and heart disease and serious complications of COVID-
19.
This is why I joined several of my colleagues in
introducing H.R. 1577, the Treat and Reduce Obesity Act, which
would increase access to effective treatments for obesity.
Bills like the Treat and Reduce Obesity Act, as well as several
that are under consideration today, will help us address some
of these social determinants of health straight on.
And while it is critical to address the social determinants
of health in order to improve the health of all Americans, we
cannot do that without really understanding the problem. And to
really understand the problem, we need adequate, accurate, and
timely data that describes the social factors that impact
health outcomes like economic status, access to transportation,
access to healthy foods, educational attainment, housing, and
environmental influences on health.
This data has been challenging to procure in public health,
in part due to a number of barriers that range from inadequate
design of systems like electronic health records to the use of
phone survey systems and a lack of trust for those being asked
about their social risk factors.
Dr. DeSalvo, can you speak more on the importance of
collecting health quality data on the social determinants of
health, and then how to translate that into actual policy and
public health programs?
Dr. DeSalvo. Congressman, let me just first say I woke up
with that same enthusiastic pep in my step today. This is,
like, 20 or 30 years of work, and all the data, equity, and
public health together and the social determinants are just the
things that I care so passionately about. So I appreciate your
enthusiasm and really look forward to working with you and
others as we bring this to fruition.
Maybe I will just hearken back to my experiences in New
Orleans, since you mentioned obesity, and say that when I was
the health commissioner, one of the first--when I went two
blocks down the street from my medical school, where I was
faculty, and took the helm of the health department, I had in
my head all the information from the quantitative survey data I
had seen saying that cardiovascular disease and cancer were
killing the people in my community. And I needed to focus on
that.
Within the first 5 minutes of the first coffee I had in a
church hall, they said, ``Our priorities are violence, mental
health, and economic opportunity.'' And it was a real mind
shift for me, of really respecting and appreciating that the
data I might see that is quantitative and collected in some
ways doesn't always reflect the now and what is on the mind of
my community.
And so mixing qualitative and quantitative is important. We
can scale that by leveraging novel data sources. I mentioned
earlier search symptoms trends that public health could use. It
is anonymous and can give them a snapshot of their community.
But I took those lessons from them, and I looked at a
through line and realized that fitness, obesity, lack of
nutritional fitness were contributing to cancer and
cardiovascular disease. And as I talked to them more, I
realized they needed sidewalks, playgrounds, access to healthy
foods. We had to work with our economic department to get
grocery stores to go in communities. We had to work on school
lunches. Kids designed it, told us they wanted--you know, how
they wanted the salad, what would drive them to go away from
french fries and pizza, and have some other healthy food. We
did it with kids, not for them.
So I think what--once you have the data in front of you,
quantitative and qualitative, local leaders can bring people
together, and that community can make decisions about how to
make interventions and measure success, so we can know what
works and continue on that generational trajectory of improving
health.
Mr. Ruiz. I love it. Thank you all for the work you do.
Ms. Eshoo. The gentleman's time has expired. The gentleman
from Florida, Mr. Bilirakis.
Mr. Bilirakis. Thank you, Madam Chair.
Ms. Eshoo. You have--minutes for your questions.
Mr. Bilirakis. I appreciate it. Thank you. Thanks for
holding this very important hearing. Madam Chair, data drives
decision making, as you know. And the integrity of these
decisions lies in the integrity of the data.
As you know, I am from the great State of Florida, and
Florida's COVID-19 story is one of success driven by reliable
data and following the science. I have included a press release
exposing myth versus fact regarding Florida's COVID-19 data.
And I ask unanimous consent that this be entered into the
record, Madam Chair.
[Pause.]
Mr. Bilirakis. Madam Chair?
Ms. Eshoo. Did you hear? So ordered.
[The information appears at the conclusion of the hearing.]
Mr. Bilirakis. Yes, I--OK, thank you. Yes, I didn't hear
that. Thank you.
Dr. Walker, Representative Blunt Rochester and I introduced
the bipartisan Collecting and Analyzing Resources Integral and
Necessary for Guidance for Social Determinants Act, and it is
H.R. 3891--excuse me, 3894. And what it does is it provides
regularly updated guidance to States to address social
determinants of health under Medicaid and CHIP, building upon
the success that some State Medicaid programs have already had
since testing innovative delivery and payment models.
Additionally, several members of this committee are
championing the Social Determinants Accelerator Act, which is
H.R. 2503, which would help States and communities devise
strategy to better leverage existing programs and authorities
to improve the health and well-being of those participating in
Medicaid.
So my question is a couple of questions. How might HHS do
more to coordinate social determinant efforts, even without
additional congressional authority?
And then also, could you explain how HHS could use its
leadership in Medicaid to more broadly catalyze efforts to
better coordinate and measure the impact of resources and
initiatives that address social determinants of health?
And this is for Dr. Walker.
Dr. Walker. Thanks, Congressman, for the opportunity to
address this question.
It is absolutely critical to think about how to refine
ongoing guidance to States around how to address social
determinants of health. We know these impacts continue to
evolve, and so, even when I was State secretary of health and
social services, it was extremely helpful to have this updated
guidance provided. It informs waivers, it informs how you can
think about State plan amendments. And as you mentioned, it
doesn't require, necessarily, additional authority but gives
clarity around where existing resources can be deployed and
used most efficiently.
And there are several models out there. So another strategy
could be that models like that at the State level are
incentivized through CMMI or other waiver authority like North
Carolina's.
I expect we will continue to learn from these models, so
having evaluations and the data available can be incredibly
useful but also providing resources for technical assistance,
updated guidance, and examples are tremendously beneficial.
Thank you.
Mr. Bilirakis. Thank you. And the next question is for Dr.
Batra.
Recently I introduced H.R. 4074, the Addressing Social
Determinants in Medicare Advantage Act, which increases
flexibility for Medicare Advantage to offer supplemental
benefits that would help address social determinants of health.
Can you discuss how supplemental benefits have improved the
lives of your members and how adding benefits that address
social determinants of health in Medicare Advantage and
broadening beyond just those with specific chronic conditions
would mitigate social inequities and allow plans to assist even
more members in need?
Dr. Batra. Absolutely. I have shared with the committee
before, we really appreciated getting that flexibility. Post
that flexibility, we have designed multiple, newer benefits. I
mentioned our benefit called Return to Home around medications,
care coordination, and in-home caregiving. We also introduced
benefits like respite care for our populations who have
caregivers who could use that kind of help, so we use benefits
for that.
Beyond that, we extended our meal benefits to provide meals
for our folks suffering from chronic conditions, who perhaps
need that meal for their diabetes or need a meal for their end-
stage renal disease that is appropriate for the condition, so
they can have a better food lifestyle in order to improve on
the chronic conditions.
So those are a few high-level benefits that we introduced.
We have seen, based on our--either both the utilization
adoption data as well as our outcomes data when we look at our
utilization from ER visits, or admissions or improvement in
diabetes control and improvement because of those kind of
benefits.
We continue looking at more benefits. And as I had shared
with the committee, I would love to have benefits based on your
social needs or just based on your medical conditions. Right
now we do have the flexibility, but they are still tied to
chronic conditions like diabetes or heart disease or
cardiovascular disease or chronic kidney disease. But we know,
as I shared, we have about 20 percent of our membership that
has, at one time or the other, shared with us they have food
insecurity. We would be able to do more if we were able to
address the needs of a larger population, not limiting
ourselves just to chronic conditions. Thank you.
Mr. Bilirakis. Thank you.
And I just want--Madam Chair, this particular bill, H.R.
4074, I filed it, due to timing, alone. But I welcome
bipartisan support, both in this committee, Ways and Means, and
any Members that want to--I think this is a very important
issue for the constituents.
Thank you, and I yield back. Thank you for the extra time,
Madam Chair.
Ms. Eshoo. Yes. The gentleman yields back. It is a pleasure
to recognize the gentlewoman from Michigan, Mrs. Dingell, for 5
minutes of questions.
Mrs. Dingell. Thank you----
Ms. Eshoo. Right there from the very beginning, and taking
everything in. And I think we hear more bounce in your voice,
so you are feeling better.
Mrs. Dingell. We are getting there, slow but sure.
Ms. Eshoo. Good, good.
Mrs. Dingell. Thank you, Madam Chair--wonderful--and
Ranking Member Guthrie for convening this hearing to discuss
legislation to address deficiencies in public health data and
technologies, which I really care about.
As our witnesses have mentioned, the HITECH Act and funding
have led to improvement in data collection that have helped
drive better outcomes for patients in the clinical settings.
However, while we have seen additional resources directed at
gathering and disseminating actionable public health data
during the COVID-19 pandemic, longer-term reforms are needed to
address these gaps in our public health data infrastructure.
Additionally, doing so will allow us to better direct
healthcare resources towards areas of greatest need to better
address deep-seated inequities in disadvantaged communities or
populations. And I love seeing Dr. Ruiz excited, so I want to
get him the data he needs to be able to do that.
But my questions are for you, Dr. Batra, because it was
good to see you highlight the Independence at Home program in
your testimony. IAH ensures Medicare patients can maintain
their independence while meeting their unique medical needs and
lowering costs. And I was glad to part with my colleagues on
this committee as part of a bipartisan effort to successfully
reauthorize and expand the IAH program at the end of last year.
Dr. Batra, you also mentioned that voluntary health risk
assessments used to identify members' health needs have a 35
percent response rate--not very good--with a completion rate of
80 percent for special need plan members. What barriers do you
see in raising response rates for these assessments?
Dr. Batra. Absolutely. Right now, the way we do these
assessments are either over the phone or through mailing. But
you are absolutely correct. We could do more.
We have a significant membership that is aging in and
joining MA plans, including ours. For them we have to be ready
to provide an online assessment, if that is the way they want
to engage with care. So that is one area that we are exploring.
The other area that we are also exploring is for folks who
perhaps are homebound, have caregivers who are really busy
doing other things and not have the time to fill out the
assessments, or they are not available themselves--of
assessments. So could we go into their homes and help do those
kind of assessments to get a better idea on them? That is a
second way of doing it.
The other things that we are also exploring is building out
these assessments in different languages. We are based out of
California. We serve a diverse population that speaks many
different languages. We right now have assessments that are
available in three to four languages. We need to address the
needs of our population. We really have to expand those
languages, as well, so we can really get feedback from all of
our members, not just some of our members.
So those are a few areas that we are thinking about.
And then finally, you know, our providers also do a lot of
assessments, and we are looking at interoperability to say,
hey, where we do not have those assessments, perhaps our
providers have it. How do we get that data and build it in our
system, so that we have a more holistic understanding of our
population?
Mrs. Dingell. So let me follow up on that--and I am going
to run out of time, so I am not going to be able to ask all my
questions--but how do nonresponses and other gaps in data
affect your organization's ability to provide targeted
intervention to seniors based on social determinants of health?
Dr. Batra. It does make a big difference because we--
generally, when we get this data, that is where we act on. We
have an algorithm to say who is going to reach out, who should
be offered certain programs, who should be enrolled in certain
services. So we are always looking, how can we make our data
more comprehensive and robust?
And our approach has been to work with our providers to see
how we can further make that data more comprehensive.
Our approach also has been, how do we engage with
caregivers? Perhaps they are also the people who can help us in
getting those assessments completed.
How do you work with community-based organizations? Looks
like Meals on Wheels that perhaps are going in people's homes,
and get data from that perspective.
So we are trying to look from everybody who is available at
the community level, at the individual level, at the provider
level, at the delivery system level to make that data complete.
Mrs. Dingell. OK, so I am going to rush a question. So
missing, incomplete, or nonstandard public health data is more
common than anybody would like, particularly when it comes to
long-term services and supports as well as other services
utilized by our Nation's seniors, which I care deeply about.
And I was a caregiver. Yes, I could have filled it out better
than anybody.
But how would uniform public health standards, like those
in the Health STATISTICS Act before us today as well as
improved quality measures for LTSS, improve your organization's
ability to meet the need of older adults your organization
serves?
And you have 1 second.
Dr. Batra. Absolutely. We do have a fully integrated dual
eligible specialties plan, so we do offer those long-term
services and supports. We absolutely believe in the importance
of it. And so we are working with in-home community partners,
caregivers, formal and informal, in completing the data.
Mrs. Dingell. OK, thank you.
I yield back, Madam Chair.
Ms. Eshoo. The gentlewoman yields back. It is a pleasure to
recognize the gentleman from Utah, Mr. Curtis, for your 5
minutes of questions.
Mr. Curtis. Thank you, Madam Chair. I am pleased to be here
today.
Dr. Batra, my bipartisan legislation coled by my friend Mr.
Cardenas that we are discussing today aims to give private
individual market health insurance plans more flexibility and
incentive to spend money focused on improving patient outcomes.
It does this, specifically, allowing plans to count social
determinants of health expenditures toward the Affordable Care
Act's medical loss ratio requirement. Services could include
partnering with ride sharing companies to help beneficiaries to
get to and from appointments, or even paying for groceries.
While SCAN is a Medicare Advantage plan not in the
individual market, could you explain how insurance plans are
engaged in providing social determinants of health services to
beneficiaries?
Dr. Batra. For us, as a MA plan, we design our benefits
based on the supplemental benefits that are made available. One
more time, they are made available based on the chronic
conditions that they have. If you look at our ongoing data and
look at opportunities to close gaps in care, whether they be
social gaps in care or, in some context, it may be even medical
gaps in care, like affordable medications or access to
telehealth vendors, so our approach of planning and designing
benefits is based on that approach, and also offered through
the Congress giving us the flexibility to design these kind of
benefits with social needs as one of the drivers.
Mr. Curtis. So that plays right into my next question,
which is what can Congress be doing to help offer incentives to
help you do your job better?
Dr. Batra. In my mind, offering these benefits in a more
holistic manner will really help us a lot.
So right now, the benefits, one more time, are based on
your medical condition, which we know is the driver for 10 or
15 percent of your overall outcome. If we were able to design
those benefits based on your social conditions--perhaps you are
housing insecure and do not have other chronic conditions that
may have qualified you for a benefit--that would be one idea
for us to do it.
And also thinking of populations that perhaps are not
completely fitting into the MA mold, so people experiencing
homelessness--could we offer them some differentiated benefits,
based on their social needs versus just their medical needs?--
is another one that comes to my mind.
Mr. Curtis. That is good. Thank you. Could you comment on
this--along those same lines, would it be helpful to remove
some of the barriers such as reforming Stark Law, and could
that enhance care coordination between providers, increasing
savings for the patients?
Dr. Batra. It is always great, and being a primary care
physician, the more we can collaborate and coordinate with the
primary care physician--not only just the primary care
physician, but their teams, and their extensions of their
teams, whether it be in the hospital setting, or be it in the
ER setting--we are always looking at opportunities to do more
of it, whether it be through the data exchange or it be through
our teams or working closely together.
Mr. Curtis. Thank you.
Dr. DeSalvo, could you talk for a minute about how Google
is partnering with healthcare systems or insurance plans to
gain a stronger understanding for healthcare trends in certain
communities or within patient populations?
Dr. DeSalvo. Thank you for the question, Congressman. I
think one of the opportunities that we all have has come up in
the hearing, and that is how can the data that is already
available be more intuitive, more accessible, easier for the
doc or nurse to find right at the bedside or in the clinic.
Also, for the patient, how do we minimize or reduce the
need for them to repeat over and over again what their medical
conditions are or, in the case of social determinants, to have
to prove they are hungry or unhoused over and over again? What
are the ways that we can be more efficient and effective with
the data that we are already collecting?
And so, in that context, Ascencion Health System asked if
Google could be helpful to apply that notion of making the
electronic health record data easier to find and make it more
intuitive for doctors when we are trying to make sure we can
not only get through the day with our patients but be able to
spend time looking them in the eye and not looking at the
computer.
Mr. Curtis. Yes.
Dr. DeSalvo. So that is an example----
Mr. Curtis. If----
Dr. DeSalvo [continuing]. Of how we are working on data.
Mr. Curtis. I am going to jump in on you, simply because we
are----
Dr. DeSalvo. OK.
Mr. Curtis [continuing]. So short on time. Talk to me for
just a little bit about privacy of this data, and how do we put
patients totally in charge of their own data and still reach
our interoperability goals?
Is blockchain technology--what technology is out there that
we can be thinking about to give patients total control over
their data?
Dr. DeSalvo. Oh, thank you. Thank you for raising that,
because, first and foremost, people do need to understand how
their data is being used. That is the transparency piece. They
need to have choice about who is going to get it and then
control across the journey, something that I spent a lot of my
career working on.
And in fact, as we have talked about earlier today, 21st
Century Cures pushed this idea of APIs, doorways to the data
that consumers control. So it is a great example of how
consumers have the control of saying, ``I want this data, and I
want to share it in--with these trusted healthcare partners,''
for example. All of that would fall under HIPAA and with
consent, so that the notions are already there and the systems
are building.
And the last administration, in the interoperability rule,
further pushed this idea technologically, raising an important
additional concept, which is, are there ways that data isn't
all stored in one place and that it can be visited or borrowed
in the moment, when the person is either critically ill, having
a heart attack, or when you need to use it for more long-term
diabetes care?
For pretty early in the journey of knowing how tools like
blockchain will work, though, there are many in the healthcare
system, in the healthcare environment, in the technology
environment trying to understand it.
I just want to emphasize the point again that consumers
do----
Ms. Eshoo. The gentleman's time is----
Mr. Curtis. Yes, I am so sorry.
Ms. Eshoo. It has expired, I am sorry.
Mr. Curtis. Yes, Madam Chair, I yield my time. Thank you.
Ms. Eshoo. OK, thank you.
Mr. Curtis. And I hope we can explore that in more detail
later.
Dr. DeSalvo. I would be delighted to.
Ms. Eshoo. Good. It is a pleasure to recognize the
gentlewoman from New Hampshire, Ms. Kuster.
Ms. Kuster. Thank you very much, Madam Chair, and thank you
for bringing us together today to discuss the opportunities and
legislation to bolster equity within public health. Today's
hearing is timely, as we continue to safely reopen our economy
from the grips of the COVID-19 pandemic and examine many of the
underlying health inequities that existed before COVID.
I have often said that this pandemic pulled back the
curtain on so many health inequities and injustices, and it is
critical for this committee to identify and advance legislation
that will support the healthcare delivery and public health
approaches for these impacted communities.
One of my main focuses in Congress has been addressing
health access issues in rural communities, which are oftentimes
underserved and underresourced, to address their unique health
challenges. We need to take a comprehensive approach to
tackling this problem, which includes everything from expanding
primary care options to increasing access to fresh foods and
produce.
The existence of food deserts represents a real challenge
for our rural communities that is directly linked to worse
health outcomes for rural Americans. Without access to fresh
food, Granite Staters who live in food deserts may be at higher
risk of diet-related health conditions such as diabetes,
cardiovascular disease, and obesity.
So that is why I am so pleased that today's hearing
includes legislation sponsored by my colleague and good friend,
Congresswoman Cheri Bustos, the Social Determinants Accelerator
Act, which I am also proud to support. Economic and social
conditions such as stable housing, access to transportation,
and healthy food have a significant impact on public health and
wellness, and this legislation will help States and localities
devise strategies to leverage existing programs and boost
health outcomes.
So my question is for Ms. Odom Walker.
Ms. Walker, your testimony touches on this bipartisan
legislation and the positive impact it will have on health
infrastructure investments. Can you expand on this and discuss
how this legislation will help rural communities address health
disparities and negative social determinants of health?
Dr. Walker. Thank you, Congresswoman, for the commitment
and need to elevate issues around inequities. And there is an
interconnection between how we look at health and all of the
social factors that influence our health outcomes.
Being able to accelerate what works and do more of it,
along the lines of creating partnerships between Federal,
State, and local agencies is important. And we know that, in
the light of the pandemic, that those interconnections were
even more important. The inequities were highlighted.
And so having the ability to provide technical assistance
and resources to make sure that we are doing more of what works
and focusing on the communities of greatest need, it is
critically important. We know that those technical resources
aren't always available, and having the data, having the know-
how to really move beyond what is kind of being done would
promote health more broadly. Thank you.
Ms. Kuster. Great. Well, thank you. Now, your expertise is
children's health. And I appreciated you highlighting the
intersectionality of children and maternal health. Can you
discuss some of the specific challenges that parenting women
face in rural communities?
And how can this committee advance meaningful legislation
to tackle the underlying negative social determinants for new
mothers and their children?
Dr. Walker. Absolutely. I think, again, it shows in the
midst of the lifelong journey of health that health starts
preconception. It starts during a healthy pregnancy. And the
health of mothers is linked to the health of their children.
And rural communities often don't have those same wraparound
services but could be supplemented by home visiting programs
and other factors, other supports.
We know that factors like trauma and stress of the mother,
even before conception, can impact the life course of the child
well into adulthood. We need to make sure that there are
resources for addressing maternal depression, and some of that
could be supported through telehealth supports even if local
resources are not available.
But I think some of these other factors around nutrition
and how we really think about creating that support impact both
cognitive well-being and others. So trying to figure out how to
deploy some of it through telehealth resources as well as local
community resources can be a benefit, particularly in rural
communities.
Ms. Kuster. Well, and thank you for your reference to
telehealth, because often transportation is a real barrier to
access to healthcare.
And with that, on the stroke of zero, I will yield back to
the chair. And thank you so much.
Ms. Eshoo. Excellent, thank you.
It is a pleasure to recognize the gentleman from Texas, Mr.
Crenshaw, for your 5 minutes of questions.
Mr. Crenshaw. Thank you, Chairwoman. Thank you for holding
this hearing today. It is an important one. And I want to talk
about the variable that we are trying to understand, the social
determinants of health. It goes--and going all the way upstream
to understand what might be impeding access to care, what is
preventing people from living a healthy lifestyle.
So I am glad to hear that our private plans are working on
this already. And as I know, many of them are solving problems
of nutrition, which is a really critical piece of preventing
health issues through food--you know, and one example is
through food subscriptions, like Hello Fresh. Many offer rides
through Uber or Lyft so they can get access to their doctor.
So first, I think we have to make sure that the government
isn't putting barriers in place that would impede private plans
from addressing social determinants. And I am glad that my
colleagues Mr. Curtis and Mr. Cardenas have a bill to do just
that.
Second, as we think through how to properly integrate these
social determinants into our public health plans, I want to
make sure we are thinking through social determinants as a
piece of the puzzle and not the sole solution to healthcare
problems.
Finally, it is important to acknowledge, as we use social
determinants to improve health outcomes, some of our most
fundamental healthcare programs are still in desperate need of
real programmatic updates. And simply integrating social
determinants won't get at some of the most critical issues with
Medicaid and Medicare, which is the fee-for-service system. So
even the most straightforward solutions are really complicated
by rules regarding payments and what regulations on what
services to cover.
Dr. Batra, my first question is for you. What lessons can
the Federal Government take from the private plans on how to
properly balance social determinants as they are integrated
into our more complicated public healthcare system?
Dr. Batra. I think the few things to learn from MA plans--
and I can speak for my plan--is having a very person-centered
view and starting from what matters to the patient. And what
matters to the member or patient or beneficiary is access,
affordability, experience, and living the life to the fullest.
So you have to balance all of them out.
Medications is a big deal for them, so having affordable
medications available to them. Access is huge and access
getting to the doctor, so that is where social benefits become
important to it.
But also, when you cannot get to the doctor, how do you get
to access, whether it be through telehealth, or it be in-home
health, if required, is another piece of it.
Mr. Crenshaw. But can we get to that point without actually
innovating the process of what we choose to cover?
I mean, you know, without reforming the fee-for-service
system?
You know, will traditional Medicare have to create and
approved new benefit categories for, you know, those Ubers or
that nutritional support? Is that really the most effective
way?
Dr. Batra. That is true, you will have to overhaul it. Like
hearing aids, for example, is not a Medicare-covered benefit.
So being a primary care physician, dental is so integral to
your medical health as well as your overall health--is not
currently covered by Medicare. There are other areas. Like,
vision is not currently covered by Medicare.
So there have to be certain areas of priority. And given
today, where we are--technology can play a lot of roles in some
of these areas. As we think about rural areas, for example,
telehealth access could be one of them. Similarly, addressing
social needs could be another one of them. And yes, you know,
we can deliver food much better now, perhaps, than we could
have done a few years back. So those all become core to it.
And you are right, there has to be a balance between social
and medical on both sides, I would say. Not only social and
medical----
Mr. Crenshaw. Yes.
Dr. Batra [continuing]. But functional and behavioral, as
well.
Mr. Crenshaw. Thank you. My next question is for Dr. Syed.
You know, based on your primary care experience, the
practice you represent is dedicated to improving primary care
for seniors. And I would like to know, would integrating a
program modeled on direct primary care, which currently does
not exist within our Federal payers like Medicare and Medicaid
but would allow for beneficiaries a personal primary care
coordinator--would you find that beneficial to improving health
outcomes?
Dr. Syed. You know, I find full-risk, full-capitated
doctors and direct primary care doctors having much in common.
I oftentimes compare our--both styles of practicing medicine.
We are both two arrows that have been shot out of the same fee-
for-service bow.
Definitely, there is a population of patients that
benefit--that would benefit from direct primary care. I believe
now there are over 20,000 direct primary care doctors out of
200,000 primary care doctors in the country. So for a set
population, I see there being benefit there. But in the world
where I live in, my patients are struggling with the basics. We
have centers, for example, in St. Louis where more than 90
percent of the patients rely on us to provide them
transportation services.
Mr. Crenshaw. In my remaining time, could you also comment
on the question I asked about moving from a fee-for-service to
a value-based system and how that is necessary to really
innovate and to be able to cover these social determinants?
Dr. Syed. Absolutely. I would like for you all to think
about value-based care, or especially the fully capitated
value-based care model, as full responsibility, where the
doctors, the primary care doctors and the primary care delivery
team, assume all the responsibility. If the quality of the care
is expensive, it is on the doctor. If----
Ms. Eshoo. Yes, the gentleman's time has expired.
Dr. Syed. Oh----
Ms. Eshoo. I am sorry to interrupt.
Dr. Syed. Sure.
Ms. Eshoo. OK?
Mr. Crenshaw. OK.
Ms. Eshoo. Thank you.
Mr. Crenshaw. I yield back my negative time.
Ms. Eshoo. Thank----
Mr. Crenshaw. Thank you, Chairwoman.
Ms. Eshoo. I now would like to recognize the gentlewoman
from Illinois, Ms. Kelly.
And for those that are with us today as witnesses, she
really is the mother of the issue of maternal health on our
subcommittee.
So, Congresswoman Kelly, take it away.
[Pause.]
Ms. Eshoo. Are you there?
Voice. It seems like she is having technical----
Ms. Eshoo. She may be having technical difficulties.
Then let's give her a few minutes.
Are you there, Robin?
[Audio malfunction.]
Ms. Eshoo. No, I think there is something wrong with your
audio. Maybe they can get it straightened out, and we will come
back to you.
I will recognize the gentlewoman from California, Ms.
Barragan, for 5 minutes of questions.
Ms. Barragan. Thank you, Chair Eshoo, for holding this
important hearing on advancing equity in public health, and for
including my bill, the Improving Social Determinants of Health,
as part of the conversation.
I also want to thank my committee colleagues who have
cosponsored----
Ms. Kelly. Can you hear me?
Ms. Barragan. Maybe we can ask her to mute.
Ms. Kelly. Can you hear me?
Ms. Eshoo. If Robin is on--and I don't see you--please
mute, and we are going to circle back with you. But there is
some background noise, so make sure you are muted, and we will
be back to you in a few minutes for your 5 minutes of
questions.
You could proceed.
Ms. Barragan. Thank you, Chair Eshoo.
I also want to thank my committee colleagues----
Ms. Kelly. I don't know what is going on.
Ms. Barragan. I want to thank my committee colleagues,
Representatives Butterfield, Cardenas, Clarke----
Ms. Kelly. Can you hear me?
Ms. Eshoo [continuing]. Recognizing you now, because we had
some audio problems, but--so please mute, so that we don't have
your background noise. Congresswoman Barragan is--has her 5
minutes now, and we will circle back to you. OK?
Mr. Ruiz. I will text----
Ms. Eshoo. I hope you can hear me.
Mr. Ruiz. I will text Representative Kelly, and if our--if
committee staff can text her and her staff, as well, I think
that----
Ms. Eshoo. Well, my staffer is contacting her staffer. It
is like, you know, my office calls yours, but it is--so far, it
is not working. So I am trying to intervene by just--by saying
so.
OK. Ms. Barragan, you can----
Mr. Ruiz. Can we give Representative Barragan a full 5
minutes, due to those----
Ms. Eshoo. I am not taking time out of her time for the
interruption.
You can proceed.
Ms. Barragan. OK, thank you, Chair Eshoo.
I also want to take a moment to thank committee colleagues,
Representatives Butterfield, Cardenas, Clarke, Blunt Rochester,
Rush, Kelly, Welch, and Castor for cosponsoring this critical
legislation.
The COVID-19 pandemic has had a devastating impact on
communities of color. My district is nearly 90 percent African-
American and Latino, and I have seen what the crisis has done
to low-income and underserved communities that don't have
access to the services they need. Lack of access to
transportation, unsafe or unstable housing, and food insecurity
put individuals at a higher risk for worse health outcomes.
Addressing these social determinants of health is crucial to
reducing health disparities, not only during the current crisis
but as we work to strengthen our public health infrastructure
into the future.
That is why I introduced the Improving Social Determinants
of Health Act, which would provide funds to the CDC to
establish a program focused specifically on social
determinants. It would also establish a grant program for local
public health departments to tackle these underlying issues
that contribute to inequity.
Dr. Walker, how have social determinants of health
contributed to minority health disparities, including worsening
health outcomes for those in underserved communities?
And why have these factors made it harder to care for
communities of color during the recent pandemic?
Dr. Walker. I think one of the first things that I
recognized when the pandemic arrived in Delaware was that the
communities of color would be most dramatically impacted,
because they were unable to follow my basic advice of stay home
and stay safe. They had to go to work. They had to put food on
the table, and they were worried about their livelihood, and
staying housed. And I think those are the challenges that we
are trying to navigate as you think about social factors: How
do we bring them together when issues around poverty and food
insecurity all coalesce?
So having resources, technical assistance, data to inform
better and more efficient program delivery or community health
worker support or linkages would be a tremendous asset, not
only to emerge from the COVID pandemic but also to promote
better health at local communities to really address the
inequities that we have long known existed, so we could start
to think about structural racism and the multilevel
interventions that need to be developed and addressed.
And we will have to do it collaboratively, with community
voices, with stakeholders engaged from the start. Thank you for
that question.
Ms. Barragan. Thank you.
Ms. Blauer, data from the CDC found that African Americans
and Latinos were nearly three times more likely than White
Americans to be hospitalized with COVID-19 and twice as likely
to die from the virus. Factors such as a lack of insurance,
limited access to healthcare services, working in occupations
in which telework is not an option, and being more likely to
face eviction and homelessness in times of economic instability
are only some of the reasons these disparities exist.
Unfortunately, there is a lack of complete, accurate, and
standardized race and ethnicity data to help paint the full
picture. The question is, what existing State and Federal data
infrastructure should be used to ensure clinicians and health
systems and health plans that are implementing programs to
address social determinants of health have accurate and
comprehensive data on patient populations who would most
benefit from these programs?
And where does the Federal Government need to make
additional investments?
Ms. Blauer. Thank you, Congresswoman. It is a very good
question, and it is one that I have been thinking a lot about
over the course of the last 17 months.
We still are completely in the dark in really
understanding, fundamentally, where populations had major
obstructions to even accessing the very basic tools that they
needed to navigate this pandemic, like testing and vaccine
access. And that is because of the limitations on demographic
data that has been paired with the release of COVID-19
information.
So first and foremost, there must be standardization and
requirements on how data is collected and how data is shared
from local authorities, health departments, State health
departments to the Federal Government, and there needs to be an
optimization of not only how that data is collected but how
that data is broadly shared, so that local policymaking can
align to where those needs are, so we can deploy the resources,
so that people that are living in communities, particularly
those that are disproportionately affected by health
disparities, have equal access to the very tools that they are
going to need to navigate not only this pandemic but the very
real health challenges that are associated with navigating all
of the social determinants of health that you have remarked on
in your comments today. So thank you for the question.
Ms. Barragan. Thank you so much.
And thank you, Madam Chairwoman, for your patience, given
the interruption. With that, I yield back.
Ms. Eshoo. You are most welcome. Now, let's see if our
friend Ms. Kelly is--I see her room on the screen, but I don't
see her.
Ms. Blunt Rochester. Madam Chairwoman, Ms. Kelly is in a
dual committee, and so asked if I would----
Ms. Eshoo. OK, all right. Then the Chair will go to
recognizing the gentlewoman from Delaware, Ms. Blunt Rochester,
for your 5 minutes of questions.
Ms. Blunt Rochester. Thank you so much, Madam Chairwoman,
for the recognition. And thank you to all the witnesses for
being here today to discuss the important slate of bills at the
intersection of data, health equity, public health
infrastructure, and healthy outcomes.
I also want to give a special thank you and recognition to
Dr. Kara Odom Walker from Delaware. A phenomenal job, and thank
you for being here today.
I am also pleased to see two bills from the Black Maternal
Health Momnibus Act being discussed today, and I look forward
to having my colleagues support our bill, my bill. It is a
bipartisan bill, the Moms Matter Act, H.R. 909, which is part
of the Momnibus. The Moms Matter Act would make community
investments to support moms struggling with maternal mental
health and substance use conditions, and also grow the
healthcare workforce in those sectors.
We know that maternal mental health is deeply tied to and
predicted by the social determinants of health. Given that next
month is Black Maternal Mental Health Awareness Month, I hope
that the committee will consider this bill and the entire
Momnibus.
And Dr. Walker, could you share how--how would improving
maternal mental health and the health of mothers impact the
lifelong health trajectory of their children?
Dr. Walker. Thank you, Congresswoman, and thank you for
your leadership to our great State.
I have to say that investing in maternal health,
particularly around mental health, does have long-term impacts.
We know that they are linked. We know that factors that happen
early in preconception around trauma and stress during
pregnancy and early postnatal care that--risk their own lives,
but also that of their child. And it is a huge factor in how
children develop.
So maternal depression is linked to so many other outcomes
for children: their economic success long term, their ability
to succeed in school, the likelihood that they will access
child care and early education. And I think what we know is
that even things around preconception diet all have longlasting
impacts.
So if we can really think about the cognitive and
behavioral development and the support of moms, making sure
that we are looking at maternal depression can ultimately
impact a generation, ultimately impact the well-being of the
child. And I think what we have seen in COVID is that this
issue is more important now, more than ever.
Ms. Blunt Rochester. Yes. Well, shifting gears, Americans
with lower incomes are frequent targets of tobacco industry
marketing and often face financial and other stressors that can
lead to continued tobacco use.
As we know, tobacco use is a key driver of poor health
outcomes and a major health equity concern. Medicaid enrollees
use tobacco at more than twice the rate of those with private
health insurance. Yet Medicaid tobacco cessation treatment is
often less comprehensive than what private health insurance
plans are required to provide.
In addition, there are barriers such as copays and
sometimes prior authorization or step therapy that can also
impact the insurance types.
Tobacco use also negatively impacts our Nation's children.
More than half of all children with asthma get their coverage
through Medicaid and CHIP, and exposure to secondhand smoke can
cause asthma attacks. That is why I was proud to introduce the
Quit Because of COVID-19 Act, H.R. 2125, which would expand
comprehensive tobacco cessation coverage to all Medicaid and
CHIP enrollees. Fundamentally, this bill is really about
equity, giving Medicaid enrollees equal access to effective
tobacco cessation treatment so that they can live healthy
lives.
And as we talk about recognizing and addressing social
needs and improving health data systems, I can't help but think
of Delaware's leadership as the first State to launch a
statewide health information exchange back in 2007, the
Delaware Health Information Network, otherwise known as the
DHIN.
And so, Dr. Kara Odom Walker, if you could, just speak a
little bit about the opportunities to leverage clinical health
information networks like the DHIN to strengthen our public
health data and public health response to both pandemics and
the social determinants of health.
Dr. Walker. Thank you, Congresswoman. We know that health
information exchanges make it easier to exchange clinical
information for treatment, care coordination. All of the
witnesses have talked about that interconnection. And we are
very fortunate to have a statewide health information exchange.
This would allow us to really think about an opportunity to
expand HIEs' ability and strength to not just look at clinical
data, but also how we leverage social determinants of health
data, because they are interconnected and they are causal and
they really do indicate the need.
We really do need, as physicians, to think about the
wraparound indicators around health, not just what is happening
in that one-on-one patient encounter but what happens when they
are home, when they are at church, when they are in their
communities. And I must say that the pandemic has shown us that
even more data integration across State lines is challenging.
And so having the ability to share information in that way
could be incredibly helpful for COVID. We needed that. We
needed----
Ms. Blunt Rochester. Thank you----
Dr. Walker [continuing]. To create a response across the
board.
Ms. Eshoo. The gentlewoman's time----
Ms. Blunt Rochester. Thank you, Dr. Walker.
Ms. Eshoo [continuing]. Has expired.
Ms. Blunt Rochester. Thank you, Dr. Walker.
And I yield back, Madam Chairwoman.
Ms. Eshoo. OK, let's see. We need a band to welcome her
back.
Are you there, Robin? There you are.
Ms. Kelly. I am here. Can you hear me?
Ms. Eshoo. Wonderful, all right.
Ms. Kelly. OK.
Ms. Eshoo. We are thrilled to recognize you for your 5
minutes of questions.
Ms. Kelly. Thank you----
Ms. Eshoo. And all the----
Ms. Kelly. Thank you, Chairman Eshoo and Ranking Member
Guthrie, for holding this hearing to discuss how we can improve
our public health data infrastructure to advance equity and
address social determinants of health.
The COVID-19 pandemic has highlighted the gaps in our
public health data infrastructure but also provides an
opportunity to better integrate and standardize data
collection. Unfortunately, data on race and ethnicity continue
to be incomplete across the public health system. This data--
these data are critical to identifying and addressing
disparities in disease, prevalent healthcare access, and health
outcomes. Addressing the social determinants of health is an
important way to tackle health disparities.
I applaud Congresswoman Bustos' work on the Social
Determinants Accelerator Act, and Representative Pressley's
Anti-Racism in Public Health Act. Too often, social
determinants of health is used as a stand-in for addressing
issues of interpersonal and systemic racism. So it is important
to continue addressing racism in public health.
Dr. Walker, how does racism and other structural inequities
drive social determinants of health?
And specifically in your experience, how does it affect the
health of pregnant individuals and their infants?
Dr. Walker. Thank you, Congresswoman. We know that social
determinants of health matter. And in fact, you know, what we
do in a medical setting is--about 10 percent of long-term life
expectancy. And for that reason, many have written about it--
the National Academy of Medicine.
Even at Nemours we were trying to figure out how to launch
a social determinants of health screener to better understand
all of the needs of the child. And we do that in pediatrics
from day one of life, beyond. But what we know is that some of
those predictors actually happen during the maternal period,
during preconception, during the pregnancy. And so, if we can
incorporate those same principles and strategies earlier on, we
will have a chance to promote better health, long term.
Ms. Kelly. Thank you. I would like to submit to the record
``Addressing Racism and Socioeconomic Influencers,'' coauthored
by the National Partnership for Women and Families and the
National Birth Equity Collaborative, as part of their Saving
the Lives of Moms and Babies series.
Also, Dr.----
Ms. Eshoo. So ordered.
[The information appears at the conclusion of the hearing.]
Ms. Kelly. What are the current gaps in maternal health
data collection?
Dr. Walker. We know that we have data gaps, and some of
those data challenges are around just having accurate,
reliable, standardized race/ethnicity data incorporated and
geocoded at the local level. So having data dashboards is
critically important. We are, at Nemours, trying to geocode
information that we have. But we see differences by race,
ethnicity in who reports their own information. And I think
that is an opportunity to provide guidance, to provide
technical assistance and really think about data standards to
make it more informative and more useful, to allow the
collaborations between public health agencies and health
systems to better represent what is going on, and address those
inequities in case.
Ms. Kelly. Is it currently being collected by community
organizations or the private sector that will be helpful to
integrate with the clinical data, to better understand maternal
health risk factors?
Dr. Walker. Yes, it is being collected, but I think the
challenge is that there often are gaps in what we have. For
example, we have some information in our health record that
isn't necessarily the same as what is in our health information
exchange. And so there just is a process of making sure we are
using the best data available, that we are using self-reported
race/ethnicity, and that we are sharing that same information
at the highest quality available with others who are trying to
collaborate, and really address inequities.
But it does take everyone. Otherwise, we are without that
data and high-quality data. We are--our challenge in trying to
overcome the barriers and leaving people out, particularly in
communities of color.
Ms. Kelly. Thank you, and I yield back.
Ms. Eshoo. The gentlewoman yields back. I am glad it all
got straightened out, and thank you, Robin, you are wonderful.
The Chair is pleased to recognize the gentlewoman from
Minnesota, Ms. Craig, for your 5 minutes. Thanks for your
patience. We are thrilled you are on the committee.
Ms. Craig. Well, thank you so much, Chairwoman Eshoo, and
especially for holding this incredibly important hearing today.
And thank you to all of our witnesses for being so patient with
us and our very many questions, as well.
I appreciate, especially, the focus on the drivers of
health disparities: race, ethnicity, sexual orientation, gender
identity, and social determinants of health like access to
transportation and housing.
I represent a district that is equal parts urban, suburban,
and rural. And many folks living outside of the major cities
don't have reliable access to in-person appointments with
medical professionals. I was recently appointed to serve on the
Select Committee on Economic Disparity and Fairness and Growth,
where I will have an opportunity to address the economic
inequalities faced by rural communities, disparities that have
a direct impact on healthcare access and outcomes.
I am also a proud cosponsor of many of the bills up for
discussion today, including H.R. 2503, the Social Determinants
Accelerator Act. Introduced by Congresswoman Bustos, this bill
would create a program at CMS to provide grants to State and
local governments to develop plans to combat social
determinants of health that are negatively impacting health
outcomes.
With that, my first question is to Dr. Odom Walker.
Rural residents in my district face long drive times to the
doctor, and lack of high-speed internet. For instance, rural
Minnesotans seeking inpatient mental health and chemical
dependency treatment must travel three times longer than urban
patients, on average. And many in my district have limited to
no broadband access, making it very difficult to reach them via
virtual healthcare. This lack of access undoubtably leads to
worse health outcomes, and it is not an uncommon story in my
part of Minnesota.
How could the Social Determinants Accelerator Act, Dr.
Walker, which invests in State and local capacity, help rural
communities fight these factors that are leading to negative
health outcomes?
Dr. Walker. Thank you for the question, Congresswoman. I
think it is unique, and one of the opportunities with the
Accelerator Act is that--you invest at the local level to hear
from stakeholders, hear from communities about their particular
situation and needs.
For example, maybe a strategy that could be invested is a
telehealth kiosk that is at a local entity, a community center,
something that is, you know, commonly available, to provide
that telehealth and broadband access in a stable way. These are
the kind of ideas that some have deployed, but it needs scale.
It needs, you know, to do more of it where it works, because
just putting telehealth into place doesn't necessarily overcome
those challenges. And if you have to drive 3 hours to the
doctor, that also is not necessarily addressing the challenges
of rural communities.
So really trying to figure out how to make it unique for
the community that we are talking about and making sure that we
are looking at the right lens, the right problem, and with the
right data is really important in this bill.
Ms. Craig. Thank you so much, Dr. Walker. My next question
is for Dr. DeSalvo.
I am a proud original cosponsor of the Black Maternal
Health Momnibus Act, which includes H.R. 925, the Data to Save
Moms Act. One provision of the Data to Save Moms Act would
provide funding to promote representative community engagement
within maternal mortality review committees, which are
multidisciplinary committees in States and cities that perform
comprehensive reviews of deaths during or up to 1 year after
pregnancy.
Dr. DeSalvo, why is it important to gather a diverse range
of perspectives in maternal health data collection and
reporting processes, including to the elevation of voices and
experiences of people from communities most severely impacted
by our Nation's maternal mortality crisis, particularly
communities of color?
Dr. DeSalvo. Thank you for the question, Congresswoman.
We have an expression in public health that the work needs
to be done with community, not to community. And that
particular part of the Momnibus package describes that so well,
that it is not just about experts looking at the data, people
in medicine, or even public health professionals. It has to be
done with community to understand what is being seen and how to
identify appropriate interventions that are culturally
appropriate, linguistically appropriate, and are going to meet
the needs of the community.
So that kind of engagement is essential, really, when we
are tackling major public health challenges like maternal
mortality, which is higher than any other high-income country
and rising in the U.S., and particularly acute for communities
of color.
So the suite of bills not--really helps us understand. It
is quantitative. It is the voice of community. And, as you have
raised in the prior question, it is a multipronged approach. It
is not just about great medical care. We have to make sure
people have access to the social needs being addressed, as
well.
Ms. Craig. Thank you so much, Dr. DeSalvo.
And with my time expired, Madam Chairwoman, I will yield
back.
Ms. Eshoo. The gentlewoman yields back. It is now a
pleasure to recognize another one of the new members to our
subcommittee in this Congress, one of the five women on the
Democratic side of the aisle, the woman from Texas, Mrs.
Fletcher.
You have 5 minutes for your questions. Thanks for your
patience.
Mrs. Fletcher. Well, thank you so much, Chairwoman Eshoo,
for holding this hearing. And thank you to all of our witnesses
for sharing your testimony with us today. It is really
thoughtful, really insightful.
Social determinants of health has been an issue that people
in my district in Houston have been concerned about,
researching, talking about in ways that are constructive and
useful. In fact, we had a town hall on this topic shortly
before the pandemic, and several roundtable discussions. And so
I just really appreciate the perspective that you brought
today, because, of course, we have seen during the COVID-19
pandemic that these issues affected outcomes across the
country, as many of my colleagues have already discussed today.
So I think what has been really useful today is making
clear to all of us on the committee the need for data to
address the deficiencies in our public healthcare system. We
have a great slate of bills to really get at that. And I think
it is, you know, not just data itself, but more inclusive data
that takes into account the social determinants of health, as
we move forward.
And so, Dr. DeSalvo, I was really interested in your
comments on creating a system with the community to collect
data and address social determinants of health. And as we have
seen from the COVID-19 vaccine rollout, for example, you know,
as of earlier this month, I think June 7th, less than a quarter
of Black Americans had received their first shot. And there is
a considerable amount of mistrust in the healthcare system
among minority populations. And this can be a huge barrier for
people getting the care that they need.
So from your experience, how can we collect health data in
a way that engages impacted communities to better address their
needs?
Dr. DeSalvo. Thank you for the question, Congresswoman, and
just to acknowledge Houston as a place that has done some great
work in multisectoral collaboration. And so you all do know how
to address social determinants in a public-private-sector
fashion.
With respect to seeing the data and being able to act on
it, I will give you some examples that relate to public-private
sector coordination and ways, certainly, that we at Google have
been thinking about partnering, particularly with academics.
Early in the pandemic it was clear that there needed to be
more understanding of how COVID-19 was disproportionately
impacting communities of color. We worked with Morehouse, with
the David Satcher Institute, to develop a COVID equity tracker
that will also be able to now report out on other inequities or
disparities in related diseases, like diabetes. So it is an
opportunity for us to not only help them with data, but to help
build technical capacity that can support public health
decision making.
Another more recent example, since you raised vaccines, is
work that we have done with the Harvard Medical School and
Ariadne Labs, again, to not only provide data insights but
provide technical assistance and partner with them so public
health departments, healthcare systems can see where there are
vaccine deserts. Who needs extra help getting to a vaccine?
Should we put up a popup clinic on this corner to reach more
people? Those are ways where everybody together can really
begin to meet people where they are to get them the services
that they need.
Mrs. Fletcher. Terrific. Well, thank you for that, and I
want to move on with the time I have to talk about another
issue, which is that many public and nonprofit safety-net
hospitals serve large populations of low-income and diverse
patients, and they are challenged by numerous social risk
factors. And some have come together to share and innovate on
best practices. And, you know, I have seen that in Houston,
especially--you know, we have a really good collaboration, and
I think that is a part of how we do things in Houston. But they
often lack data platforms that track both medical and social
conditions and facilitate access to services that respond to
those needs.
So, Dr. Walker, in the time I have left I want to talk
about your testimony. You talked about the fact that public and
community-based organizations haven't been given the same level
of investment as other healthcare organizations. Would you
agree that investments for data platforms and safety net
providers who often struggle under difficult financial
circumstances could drive progress in addressing health
inequity?
Dr. Walker. Absolutely. I think data informs strategy. And
without that data, we are often leaving people out, leaving
individuals and populations out, and have an incomplete picture
of where we need to deploy public health resources or make
policy decisions, which, underlyingly, has been the challenge
with exacerbating disparities.
I think that there is another benefit--in the seconds I
have--just to have data available as a common good, instead of
having disparate organizations, health systems and others
trying to piece it together.
Mrs. Fletcher. Wonderful. Well, thank you so much.
And I am almost out of time, so I want to thank you again,
Chairwoman Eshoo, for holding this hearing. I am so supportive
of the legislation that we have covered today, and I am
grateful for the chance to learn more from this wonderful panel
of witnesses. Thank you so much, and I yield back.
Ms. Eshoo. Thank you. Now I--let's see. Oh, another one of
our wonderful doctors, the gentlewoman from Washington State,
Dr. Schrier.
You have 5 minutes for your questions.
Ms. Schrier. Well, thank you, Madam Chair, and thank you to
all the witnesses who spoke today.
Dr. Walker, I am so intrigued by the endless possibilities
that data sharing and interoperability offer to improve
childhood outcomes. So, from the perspective of a pediatrician,
I think, wow, it would be really helpful to know which of my
patients qualify for free and reduced lunch at school, because
that could help guide me in conversations about nutrition and
financial stressors, housing, whether the parents have the
bandwidth or the resources to help their kids in school. It
would even help me focus on community resources like story time
at the library.
It would also be really helpful to know which of my
patients rely on WIC and SNAP, since poor nutrition is
associated with adverse behavioral and academic outcomes but
also with tooth decay. And so I could use that knowledge in the
clinic to, say, apply fluoride to all my patients' teeth, as
opposed to just hoping that they will follow through and see a
dentist.
I would imagine that this kind of information would be
really helpful for teachers, as well, to know which of their
students are homeless or relying on social services.
So my question for you, Dr. Walker, is how do parents feel
about data sharing between public health, social services,
schools, and doctors?
Dr. Walker. Thank you so much for that question, and I
often think of the context of families and how, as physicians,
we are often limited by not having the entire picture. And if I
knew that a student wasn't doing well in school, in that
clinical interaction I could ask whether they have been tested
or need to be retested for vision screening or have a hearing
test, and whether that is a promoter.
But I do think that the issue of trust in data sharing is a
real one, and one that we are always careful in navigating. But
with the right support, the right technical assistance, we
could make sure that we have the right data analytics in a
protected environment and allow us to think about how to do
this in the right way, learn from those early adopter States
that have already figured some of this out, like Oregon and
some that we have mentioned earlier, North Carolina----
Ms. Schrier. Right.
Dr. Walker. And then some of----
Ms. Schrier. And I think that brings me----
Dr. Walker [continuing]. That innovation.
Ms. Schrier. Thank you. I think that brings me to my next
question for Dr. DeSalvo.
First, I just want to thank you for your work on the app
that we use in Washington State that was developed by Google in
combination or in partnership with our department of public
health so that, if you have got your phone with you and you are
near somebody with a positive COVID test, it notifies you.
And so, given that experience with public-private
partnerships and with privacy, I was just wondering, when we
talk about kind of a relationship between schools and social
services and public health and doctors' offices, how do you
address privacy issues related to that kind of data sharing
that would help patients and would--yes, how would you address
the privacy issues?
Dr. DeSalvo. Yes, Congresswoman, thank you so much for
raising the question. And I will echo what Dr. Walker shared,
which is--I am an internist. And always, we want to know more
about the home context or the social context to understand if
that is what is, you know, driving some of the--uncontrolled
diabetes, as an example.
I think what I have learned from not only patients, but
what people tell you in focus groups and surveys, and you
being--when the National Partnership for Women and Families
does surveys, or the--or when we did the--met the office of
national coordinator--is people want to know that they can have
some sense of knowledge about who has access to their data.
That is the transparency part. And they very often--people they
trust. They just need to know that they have some control over
how that happens.
And the--in this space that you are describing, which--I
mean, technically, some of those entities fall outside of
HIPAA--there has been a lot of work in thinking about how, as
we are going to--as a healthcare system, and a public health
system, be more inclusive of data, give consumers that choice
and control----
Ms. Schrier. That makes sense.
Dr. DeSalvo [continuing]. Sharing.
I will just call out the particular place that provides
the--that has been doing the thinking on it. It is a group
called the CARIN Alliance, not as in my Karen, but C-A-R-I-N,
working with consumers and others to understand content.
Ms. Schrier. Thank you. One more question for you. There's
a lot of what-ifs about COVID and how we handled it, what could
have gone better. And I think about whether, you know, if we
had a really modernized, interoperable, digital, wonderful
health infrastructure, if we could have used, say, wastewater
testing for COVID in order to really direct our public health
response, and now we are talking about tracking COVID-19
variants in a--in one of the bills being discussed today. How
could an optimally situated public health department use data
about new variants to curb spread of disease?
Dr. DeSalvo. In a few seconds, just to say what was
desperately missing for public health was not only the now,
casting the data that Dr. Blauer was able to provide the
country, but the opportunity to forecast and be able to predict
what--where the virus was going to spread and where variants
would spread into the future.
We have partnered to create a system called Global.Health
with Global Public Health to begin to advance that work in
forecasting. But the bills that you have before you, the kind
of work that Congress is doing, is thinking about not just the
data but the infrastructure and the people who work on that
data around it. So it has got to be a system in order to
prevent the kind of outcomes that we had in this last pandemic.
Ms. Schrier. Thank you very much.
I yield back.
Ms. Eshoo. The gentlewoman yields back. I am getting a kick
out of myself saying ``yields back,'' because I have let so
many Members to go way over. So they really don't have any time
to yield back, but we have accommodated everyone. I hate to cut
people off, because everything, every question and answer, is
just so important to us.
And now, last but certainly not least, a real value-added
new member to the committee, the gentlewoman from
Massachusetts, Congresswoman Trahan.
You have 5 minutes for your questions.
Mrs. Trahan. Well, thank you----
Ms. Eshoo. How about 5\1/2\?
Mrs. Trahan. The joys of going last, I get a little extra
time. No, thank you, Chairwoman Eshoo. And thank you to all the
witnesses here today. It has been so informative.
There is no question public health data is multifaceted,
and it resides in different agencies and institutions that span
across, you know, social services, education, behavioral
science, and so much more. And improving data collection and
closing those gaps is critical to our not only addressing the
ongoing COVID-19 pandemic but all of our other public health
challenges.
You know, in 2015 my home State of Massachusetts recognized
the value that data innovation has in inadequately--excuse me,
in adequately addressing public health crises and passed
Chapter 55, a law which authorized the Massachusetts department
of health to link multiple, traditionally siloed data sets with
insight into the opioid crisis, an approach that had never been
before sort of cross-studied. And the reports and underlying
analysis drew insight from a database that linked mental health
data, jail and prison data, vital records, you know, substance
addiction treatment data, ambulance and counter information,
the States' all-payer claims database, and others. And based on
all those insights from Chapter 55, the reporting and the data
visualizations, measures like limiting first-time opioid
prescription to 7 days, a first-in-the-Nation measure, was
signed into law.
So in 2017, when opioid-related overdose deaths fell for
the State population as a whole, data showed it rose by 44
percent for Black males. And this data led the health
department to develop a community-based public awareness
campaign to focus on and reach Black men.
So you know, Dr. DeSalvo, I will start with you. Can you
just speak once again to how cross-departmental sharing of
information can be used to drive policy to combat public health
crises in the country, such as the opioid epidemic?
Dr. DeSalvo. Yes. Thank you so much, Congresswoman, for
reminding all of us that bubbling under the surface is another
epidemic that was here prior to the pandemic and is beginning
to reemerge. So we have to, when we are thinking about building
public health data systems, we have to remember they need to be
useful not only for communicable disease but for other
conditions that affect communities, opioids being a great
example in Massachusetts, in this case, as in others.
It has been smart about leveraging multiple data sources
that tell the story of a person's health or a community's
health beyond just the healthcare episode. You are describing
data sources that describe there are social and human services
interactions, as well as their healthcare needs. And all of
that will be necessary, if you are going to take a multipronged
approach to developing community interventions to drive equity
and address social determinants as well as medical needs and
then measure the outcomes, as you describe.
So a takeaway for me from that lesson you all have been
teaching the country is multiple sources of data needed to tell
the story of somebody's health or needs, and take action in a
multipronged way at the community level and know if we are
making a difference in outcome. And we need to build those
systems to be agile, so they can address the multitude of
community needs that are there on the front lines.
Mrs. Trahan. Thank you. You know, one other thing that was
made clear to me is that, in order to collect robust data to
tackle these public health crises, we must heavily invest in
both public health infrastructure and workforce in the field of
data and informatics.
And over the years, researchers have discovered a large
variety of human biases that shows the things that people
understand or believe do not always reflect what is actually
happening in the real world.
And so, question for you, Dr. Walker: Could you just speak
to how investing in a diverse pipeline of individuals and
health data analytics can work to mitigate, you know,
unconscious bias in the analysis of data that drives our
policies?
Dr. Walker. Thank you for that question. I think having a
diverse workforce is--allows you to interpret the data in the
right way. But I would also say it is not just about the
professional workforce. It is also trying to figure out how to
have community and stakeholders involved in that data
interpretation stage.
So thinking about piecing together information, whether it
is for the opioid pandemic or other inequities, we know that
bringing them together is critically important and requires an
investment of expertise, but also of what you do with it and
how you put it out to the world, whether it is a data dashboard
that we found incredibly valuable in the past year and a half,
or whether it is putting it in the hands of local community
advisory boards who can say whether, for their community, it is
more important to have broadband investments or to think about
transportation.
So I think it is essential, and we just have to figure out
where to----
Mrs. Trahan. Yes. Well, thank you. And making that data
consumable is job number one, so we know how to act on it.
So I am out of time, even though the chairwoman was
gracious enough to give me a little bit more. So thank you so
much for all of your input today. It is very helpful in our
policymaking.
I yield back.
Ms. Eshoo. The gentlewoman yields back.
Well, we have come to a conclusion of all of this time with
Members asking their questions. I want to thank each one of the
witnesses.
You have been with us for a long time today, almost 4
hours--20 minutes shy of 4 hours. So I hope you had breakfast,
because you certainly have missed lunch.
Dr. DeSalvo, Dr. Batra, Ms. Blauer, Dr. Syed, and Dr.
Walker, you have all been terrific.
Now, Members have 10 business days to submit additional
questions for the record. So witnesses, we are asking you to
please respond as promptly as possible to the written questions
that are going to be submitted to you.
And now I want to go to my friend, the ranking member of
the subcommittee, Mr. Guthrie, because we have 23 documents to
be submitted into the record, and I would like to request
unanimous consent, but I need your consent.
Is Mr. Guthrie with us?
Mr. Guthrie. Our side consents.
Ms. Eshoo. There you are. Thank you very much.
All right. So there is unanimous consent to enter the these
documents into the record, and I think that is it.
[The information appears at the conclusion of the hearing.]
Ms. Eshoo. So thank you, everyone. Bravo to each one of the
witnesses. It was a terrific hearing.
And we are going to move these bills. We have 13 today, in
this legislative hearing. I think 6--I think there are 6 or 7
that are bipartisan. So we are always pleased and proud about
that.
But all of them are a reflection of the very important work
of many Members of Congress in writing the legislation and
having our subcommittee have the honor of having a legislative
hearing.
So God bless all of you. God bless our country. Thank you
for being witnesses.
And the Subcommittee on Health will now adjourn.
[Whereupon, at 2:12 p.m., the subcommittee was adjourned.]
[Material submitted for inclusion in the record follows:]
Prepared Statement of Hon. Richard Hudson
I want to thank Chairwoman Eshoo and Ranking Member Guthrie
for holding this important hearing today, and thank our expert
witnesses for their time and testimony.
As you may recall, last summer, I requested a hearing on
the disparate impact COVID-19 was having on our minority
communities, to which this Committee responded and held one. I
am pleased we are reexamining this issue, particularly in the
context of how we can work toward solutions by examining social
determinants of health and the data associated to correctly
address the issues raised.
I think we all can agree that minority communities are and
have been experiencing gaps in access and health outcomes. This
problem has been further emphasized during the COVID-19
pandemic. There is no question that across the Nation, there
remains alarming data of the disproportionate impact the
Coronavirus pandemic has had on our minority communities.
Fayetteville, North Carolina, in my District, has a large
and diverse community. At one point during the pandemic, I
heard from leadership at a local hospital, Cape Fear Valley
Medical Center that, while African Americans made up 57% of
their COVID-19 patients, Cumberland County, where Fayetteville
is located, is only 34.9% African American.
These inequitable outcomes are not just isolated to COVID-
19. I continue to hear from my District about how the
differences and lack of access to medical, economic,
educational, and community resources leads to disproportionate
outcomes.
Unfortunately, this is not localized to my District--this
is a national and global issue, and we must not continue to
settle for the status quo.
We must be looking at avenues to address the impact of
social determinants of health, including some of the bipartisan
bills discussed today.
I would particularly like to emphasize the importance of
further enabling and promoting private sector innovation. I
believe this can effectively be accomplished by continuing to
incentivize public-private partnerships. This is an area I have
focused on this Congress, and I look forward to working with my
colleagues on this Committee to engage and bring forward
bipartisan solutions.
I also agree with many of the witnesses and my colleagues
today who have noted the need for more data. Data will help us
dive deeper into the issues--allow us to effectively,
efficiently, and appropriately conduct analyses, comparisons,
and juxtapositions--to better inform not only us as
policymakers, but the folks on the ground who are taking steps
every day to work towards more equitable outcomes.
With that being said--I also think this data must be
collected and examined in modern and responsible ways. We
cannot solve this problem by creating additional bureaucracies
and duplicative programs. Our health systems already have
enough on their plate.
We should ensure the initiatives we are proposing are
streamlined and straightforward to implement, particularly in
this constantly evolving technological area.
Again, I greatly appreciate the discussion today, and am
committed to working with my colleagues on the Health
Subcommittee to address healthcare inequality and the racial
disparities in our healthcare system.
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