[Senate Hearing 117-614]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 117-614

                   FOOD AS MEDICINE: CURRENT EFFORTS
                      AND POTENTIAL OPPORTUNITIES

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

                                HEARING

                               BEFORE THE

                            SUBCOMMITTEE ON
                   FOOD AND NUTRITION, SPECIALTY CROPS, 
                           ORGANICS, AND RESEARCH

                                 OF THE

                       COMMITTEE ON AGRICULTURE,
                        NUTRITION, AND FORESTRY

                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             SECOND SESSION

                               __________

                           DECEMBER 13, 2022

                               __________

                       Printed for the use of the
           Committee on Agriculture, Nutrition, and Forestry
           
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]         


                  Available on http://www.govinfo.gov/
                               __________
 
                   U.S. GOVERNMENT PUBLISHING OFFICE                    
51-395 PDF                  WASHINGTON : 2024                    
          
-----------------------------------------------------------------------------------                    
                  
           COMMITTEE ON AGRICULTURE, NUTRITION, AND FORESTRY


                 DEBBIE STABENOW, Michigan, Chairwoman
PATRICK J. LEAHY, Vermont            JOHN BOOZMAN, Arkansas
SHERROD BROWN, Ohio                  MITCH McCONNELL, Kentucky
AMY KLOBUCHAR, Minnesota             JOHN HOEVEN, North Dakota
MICHAEL F. BENNET, Colorado          JONI ERNST, Iowa
KIRSTEN E. GILLIBRAND, New York      CINDY HYDE-SMITH, Mississippi
TINA SMITH, Minnesota                ROGER MARSHALL, Kansas
RICHARD J. DURBIN, Illinois          TOMMY TUBERVILLE, Alabama
CORY BOOKER, New Jersey              CHARLES GRASSLEY, Iowa
BEN RAY LUJAN, New Mexico            JOHN THUNE, South Dakota
RAPHAEL WARNOCK, Georgia             DEB FISCHER, Nebraska
                                     MIKE BRAUN, Indiana

                 Erica Chabot, Majority Staff Director
                 Chu-Yuan Hwang, Majority Chief Counsel
                    Jessica L. Williams, Chief Clerk
               Fitzhugh Elder IV, Minority Staff Director
                              ----------                              

  Subcommittee on Food and Nutrition, Specialty Crops, Organics, and 
                                Research

                   CORY BOOKER, New Jersey, Chairman
PATRICK J. LEAHY, Vermont            MIKE BRAUN, Indiana
AMY KLOBUCHAR, Minnesota             MITCH McCONNELL, Kentucky
KIRSTEN GILLIBRAND, New York         JOHN HOEVEN, North Dakota
RAPHAEL WARNOCK, Georgia             JONI ERNST, Iowa
MICHAEL F. BENNET, Colorado          ROGER MARSHALL, Kansas
                                     DEB FISCHER, Nebraska
                            
                            
                            C O N T E N T S

                              ----------                              

                       Tuesday, December 13, 2022

                                                                   Page

Subcommittee Hearing:

Food as Medicine: Current Efforts and Potential Opportunities....     1

                              ----------                              

                    STATEMENTS PRESENTED BY SENATORS

Booker, Hon. Cory, U.S. Senator from the State of New Jersey.....     1
Braun, Hon. Mike, U.S. Senator from the State of Indiana.........     3

                               WITNESSES

Richards, Martin, Executive Director, Community Farm Alliance, 
  Berea, KY......................................................     7
Penniman, Leah, Founding Co-Executive Director, Soul Fire Farm, 
  Petersburg, NY.................................................     8
Bulger, John, DO, Chief Medical Officer, Insurance Operations and 
  Strategic Partnerships, Geisinger Health Plan, Danville, PA....    10
Volpp, Kevin, MD, Ph.D., Founding Director, Center For Health 
  Incentives and Behavioral Economics (CHIBE), University of 
  Pennsylvania, Member, Advocacy Coordinating Committee, American 
  Heart Association, Philadelphia, PA............................    12
Chestnut, Bob, MD, Chief Medical Director, Cummins Inc., 
  Columbus, IN...................................................    14
                              ----------                              

                                APPENDIX

Prepared Statements:
    Richards, Martin.............................................    36
    Penniman, Leah...............................................    40
    Bulger, John, DO.............................................    44
    Volpp, Kevin, MD, Ph.D.......................................    51
    Chestnut, Bob, MD............................................    57

Document(s) Submitted for the Record:
Booker, Hon. Cory:
    NEJM Catalyst, document for the Record.......................    62
    Jennifer Maynard, letter for the Record......................    70
    Jasmine Moreano, letter for the Record.......................    79
Braun, Hon. Mike:
    Kentucky Department of Agriculture, document for the Record..    82
Marshall, Hon. Roger:
    JAMA Internal Medicine, document for the Record..............    85

 
     FOOD AS MEDICINE: CURRENT EFFORTS AND POTENTIAL OPPORTUNITIES

                              ----------                              


                       Tuesday, December 13, 2022

                                        U.S. Senate
    Subcommittee on Food and Nutrition, Specialty Crops, 
Organics, and Research
         Committee on Agriculture, Nutrition, and Forestry,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10 a.m., in room 
328A, Russell Senate Office Building, Hon. Cory Booker, 
Chairman of the Subcommittee, presiding.
    Present Senators Booker [presiding], Klobuchar, Bennet, 
Smith, Lujan, Braun, Boozman, Ernst, Marshall, and Fischer.

 STATEMENT OF HON. CORY BOOKER, U.S. SENATOR FROM THE STATE OF 
                           NEW JERSEY

    Senator Booker. I keep forgetting when I am rolling with 
Senator Braun that he is fashion forward, on time, tie-less, 
and he is what the Senate should be, although I hear he may be 
leaving me to another job soon, which, as a person who has been 
in that problem I feel already sad.
    I am really grateful to be here, and I want to begin by 
heaping more praise on Senator Braun. Early in this Congress, 
when he and I both got this post, this Chair and Ranking, we 
talked a lot about our common ground, and this idea that the 
private sector was doing a lot to reduce prices really 
intrigued us a lot, as well as increased health.
    I want to just thank the witnesses that are here. I want to 
let you all know that we have been, as a team, focused on the 
nutrition crisis that our country is facing.
    Voice. Gavel in.
    Senator Booker. Oh, I am sorry. All this official-ness. We 
have begun. How is that? Good? That satisfies it? All right.
    Senator Braun and I have been focused on the nutrition 
crisis, and I want to start today by reminding our audience of 
the scale of the crisis we are facing in America and the 
explosion of diet-related diseases.
    Currently in the United States, half our population is pre-
diabetic and has type 2 diabetes. Each month diabetes causes 
13,000 new amputations, every month, 5,000 new cases of kidney 
failure, 2,000 new cases of blindness in our country, and that 
is something that is not exclusively affecting older people. We 
are seeing growing rates of diabetes in our youth as well. One-
quarter of our teenagers today are pre-diabetic or have type 2 
diabetes.
    Much of that can be attributed to the alarming fact that 
ultraprocessed foods now compose two-thirds of the calories in 
the diets of our children and teens. It is estimated that half 
of all children today will be obese by the time they are 35 
years old--half of all children today.
    Broadly speaking, diet-related chronic diseases are now the 
leading cause of death in the United States. According to the 
FDA, on average, 2,700 people die per day from diet-related 
diseases, and the effects of diet-related diseases are not 
limited to the health care field. They are causing an economic 
crisis that is spiraling out of control. Nearly 1 out of every 
3 dollars in the Federal budget now goes toward health care 
spending. In five years, the health care costs of type 2 
diabetes alone has risen 25 percent to a staggering $237 
billion. This is simply not sustainable in the long term.
    Right now it is imperative that embark on a whole-of-
government approach to address diet-related diseases, and one 
of the most promising solutions that we can adopt is something 
that is alluded to in the 2000-year-old writings of 
Hippocrates, and it is rooted in the practices of many of the 
indigenous communities in our own country. It is the idea that 
the food we eat is intrinsically tied to our health, the 
growing recognition that food can act as medicine. Researchers, 
health care professionals, farmers, policymakers across the 
country are already putting this idea into practice and 
achieving successes.
    Let me take you back in time. When I was mayor of Newark, 
one of the challenges we faced was the fact that many 
communities in our city were suffering from food deserts, 
places where residents did not have access to healthy food. We 
did many different things to address this crisis, including 
starting to grow more fruits and vegetables and distribute them 
locally in our city.
    One of the projects was the creation of the largest urban 
farm in New Jersey, a multi-acre farm on an entire city block 
in a low-income neighborhood. I recently went back and visited 
that farm. While there I met two women who came up to me and 
told me their stories. The first one said that she had been 
having gastrointestinal issues. For the treatment, she was 
paying $100 per month co-pay for medication. The Federal 
Government took on the remaining cost of $600 a month for her 
prescription drugs. She was able to change her diet by taking 
advantage of the Gus Schumacher Nutrition Incentive Program 
(GusNIP), run through the New Jersey-based nonprofit City 
Green, which allowed her to double her Supplemental Nutrition 
Assistance Program (SNAP) benefits for the purchase of fruits 
and vegetables. When the woman used the GusNIP program at the 
community farm to incorporate substantially more fruits and 
vegetables, she saw her gut issues disappear.
    The second woman was in her 80's and was a diabetic. After 
she began to source the majority of her food from the farm she 
told me that her diabetes went away.
    Those two stories are not anomalies. We hear today from our 
witnesses about how food as medicine programs can be 
transformative for the health of individuals and families 
receiving foods, as well as lowering costs. We will hear how 
these programs can lead to that health care cost savings and 
the savings of human misery.
    Finally, our witnesses will testify how programs like 
GusNIP, Double Bucks and produce prescriptions can be 
transformative economic opportunities for families across the 
country. These investments are enabling farmers to grow healthy 
food for their neighborhoods and are helping to build resilient 
local and regional food systems.
    I am encouraged to see the Federal Government begin to 
recognize the promise of food as medicine. In September, as 
part of the White House Conference on Hunger, Nutrition, and 
Health, which Senator Braun and I led the call for, the White 
House released a bold blueprint to end hunger, improve 
nutrition, and reduce the epidemic of diet-related diseases. A 
key component of the national strategy is a call to continue 
researching and scaling up of food as medicine programs such as 
funding pilot programs to integrate medically tailored meals 
and nutrition counseling into our Medicare and Medicaid 
programs. Although these are promising steps, we also need to 
integrate food as medicine strategies directly into our FDA 
programs.
    This is a top priority for me in the Farm Bill will be to 
increase the incentives for farmers to grow fruits and 
vegetables to a level that we currently support in commodity 
crop production. Our dietary guidelines tell us that 50 percent 
of the food we eat should be fruits and vegetables, but less 
than 10 percent of our farm bill subsidies currently go there.
    One, we must substantially scale up programs like GusNIP, 
and two, we should create a new USDA specialty crop food box 
program to provide locally sourced fruits and vegetables to 
Medicaid participants. I look forward to working with Senators 
of both sides of the aisle on these commonsense, pragmatic 
steps to make for a healthier America and lower costs in our 
Federal Government.
    I am excited about the witnesses, I am excited about the 
insights that we are going to hear, and I want to recognize my 
friend and someone who has been such a strong partner on these 
issues, Senator Braun, for opening comments that he would like 
to make.

 STATEMENT OF HON. MIKE BRAUN, U.S. SENATOR FROM THE STATE OF 
                            INDIANA

    Senator Braun. Thank you, Mr. Chairman. It is interesting 
when you come together on a topic like this that should be so 
obvious to everyone, that an ounce of prevention is worth a 
pound of cure.
    We have been at it with the White House forum that was put 
together, but I go back to when I was a CEO. I did that for 37 
years prior to becoming a Senator. You know, it was 15 years 
ago when I said enough is enough, with how lucky I am that my 
health care costs are only going up five to ten percent this 
year. I had to do something, just like you did as mayor, that 
was going to take a dynamic that was built in and try to change 
it.
    Very simple. When they told me that so much of the health 
insurance cost is not a catastrophic accident or a very 
catastrophic disease. It is the minor health care that you 
overuse and use too much of due to type 2 diabetes, heart 
conditions that brew over a long period of time.
    In a nutshell, I took all that, because I was frustrated, 
and we built a system based upon wellness and avoiding the 
health care system in making my employees engage in their own 
well-being, created the incentive, gave them a free biometric 
screening. If you did not get it, you were going to get 
penalized because you were not doing the right thing.
    We did all of that, and all I can tell you is I checked 
just to make sure how we were doing, since I have not been 
there for a while, thinking we were eating a lot of cost 
increases. Employees have not had a premium increase in 15 
years, and they go into their deductible less now than they did 
then because they have become health care consumers.
    In a nutshell, that is what we need to do more broadly 
across the country and try to incentivize that through this 
Committee and how we can just get that word out again that an 
ounce of prevention is worth a pound of cure.
    According to the CDC, nine percent of Americans do contend 
with type 2 diabetes, 33 percent have pre-diabetes. American 
Heart Association, half of American adults have cardiovascular 
disease or hypertension, two of the easiest things to treat, 
No. 1, but even before you get into a treatment you can avoid 
it by lifestyle changes. If left untreated they become a 
significant health care consequence.
    Nutrition and wellness are the ideas that each of us should 
incorporate into our lives. Companies need to be promoting it 
across the country, and at every level of government we need to 
be getting the word out.
    Market mechanisms need to come into play as well. Basically 
what I did is create an incentive for my employees to be health 
care consumers, not just telling them to do it, offering those 
tools of wellness that created kind of a mini-market that got 
everybody thinking in that same direction. It got people to 
acknowledge what their own health care issues were. They 
embraced that free biometric screening, and you heard the 
results.
    Through employers, through government we need to all be 
working in that direction. If not, we are never going to 
address the fact that health care is 20 percent of our GDP. 
That is nearly 50 percent more that almost all other developed 
countries, and they generate results that are as good as ours. 
A lot of what ails our health care system is overutilization 
because we have never changed the lifestyles that take us into 
the health care system in the first place, and that starts with 
your diet. What you eat is what you are.
    You know, how we are going to get to the point where we 
convince all of America, we do it through our agriculture 
programs currently. You know, we push nutrition. Something just 
seems like it is not quite working. I think we need to find, 
with all the money that we have spent over like 200 programs, 
20 agencies, there may need to be a focus on this in and of 
itself. Because like back in Indiana, when we were working on 
work force development, we had 20 agencies spending tons of 
money, not coordinated, never to get to the right results 
there. We started focusing on it, started getting to some of 
the solutions on something unrelated, but it was disaggregated.
    I think here what we ought to strive for is maybe to focus 
on how we narrow this into something that focuses purely on 
what has got to be one of the most important things in our 
society--how do you eat well to avoid the health care system in 
the first place? How do you take care of yourself so that you 
prevent it before you get there and have to spend a fortune on 
getting remediated?
    I yield back.
    Senator Booker. Thank you for that opening statement. Let 
the record show that I said ``Hallelujah, amen'' to his 
comments.
    I want to recognize that the Ranking Member of this entire 
Agricultural Committee is here, the powerfully pragmatic 
pugilist, Senator Boozman. I do not know if you want to say 
anything at all, sir?
    Senator Boozman. No. Thank you.
    Senator Booker. All right. Then I am going to go ahead and 
introduce the witnesses, and I am going to start with Martin 
Richards. Mr. Richards is the Executive Director of the 
Community Farm Alliance in Kentucky. Formed from the farm 
crisis of the 1980's, Community Farm Alliance is a Statewide, 
grassroots organization whose mission is to organize and 
encourage cooperation among rural and urban citizens and to 
ensure an essential, prosperous place for family scale 
agriculture in economies and communities.
    Mr. Richards has been an active member of the Community 
Farm Alliance for over 20 years. He has served on the board as 
board chair and as Executive director since 2010. From growing 
up in steel towns to Kentucky's tobacco fields and coal towns, 
Mr. Richards has a long history of working with communities to 
revitalize their economics. Prior to the Farm Alliance, Mr. 
Richards was a tobacco and cattle farmer.
    I want to thank you for being here, Mr. Richards. I am 
grateful for you.
    Ms. Leah Penniman is a Black Kreyol farmer and mother, 
author, and food justice activist from Soul Fire Farm in 
Grafton, New York. It is finally good to see you in person. She 
co-founded Soul Fire Farm is 2010, with the mission to end 
racism in the food system and reclaim our ancestral connection 
to the land. As Executive Director and Farm Director, she is 
part of a team that facilitates powerful food sovereignty 
programs, including farmer training for Black and brown people, 
a subsidized farm food distribution program for communities 
living in food deserts, and domestic and international 
organizing toward equity in the food system.
    She is a member of clergy in the West African Indigenous 
Orisa tradition, and through her work at Soul Fire Farm she has 
been recognized by the Soros Racial Justice Fellowship, 
Fulbright Program, the Pritzker Environmental Genius Award, 
Grist 50, and James Beard Leadership Award, amongst other. 
Extraordinary.
    Thank you so much for being here today.
    Dr. John Bulger is the Chief Medical Officer for Grisinger
    Am I pronouncing that right?
    Dr. Bulger. Geisinger.
    Senator Booker. Geisinger. Forgive me. My staff told me 
that seven times--Geisinger Health Plan, which is Statewide a 
health care provider and insurance company in Pennsylvania that 
serves more than one million people. I am just mad that the 
Giants lost to the Eagles recently. That is why I am doing 
this.
    Dr. Bulger is responsible for working with community 
partners to improve the quality of medical care for the 
patients and members of Geisinger Services.
    Dr. Bulger is a general internist and has practiced in 
inpatient and outpatient settings. Dr. Bulger earned his 
bachelor of science degree from Juniata College in Huntington--
help me out here, sir. Come on. I am failing. I am sinking 
here.
    Dr. Bulger. Juniata.
    Senator Booker. Juniata--Pennsylvania, and his Doctor of 
Osteopathic Medicine degree from Philadelphia College of 
Osteopathic Medicine. He also holds a master's degree of 
business administration from Penn State University.
    I want to thank you for being here, even though I have 
butchered multiple times the things you are working on so well.
    I want to turn to my Ranking Member Braun who will 
introduce our next two witnesses.
    Senator Braun. Thank you, Mr. Chairman. Our next witness is 
Dr. Kevin Volpp, who is Founding Director of the Center for 
Health Incentives and Behavioral Economics, and the Mark V. 
Pauly President's Distinguished Professor at the Perelman 
School of Medicine and Health Care Management at Wharton at the 
University of Pennsylvania.
    As you will hear today, Dr. Volpp's work focuses on 
developing and testing innovative ways to apply behavioral 
economics in improving patient health behavior and affecting 
provider performance. He has also worked with groups at nearly 
every point in the health care delivery chain to test the 
effectiveness of different behavioral economic strategies in 
addressing tobacco dependence, obesity, and medication non-
adherence.
    Dr. Volpp earned his MD from the University of 
Pennsylvania's Perelman School of Medicine, and a Ph.D. in 
health economics, public policy, and management from Wharton at 
the University of Pennsylvania.
    The final witness this morning is Dr. Bob Chestnut. Dr. 
Chestnut serves as the Chief Medical Officer at Cummins. 
Cummins is a great company, not too far away from where I live, 
in southern Indiana, Columbus, Indiana. In this role he works 
with other key leaders within the company to support the 
physical, mental, social, and financial well-being of Cummins 
employees and their families. Sounds like kind of what did back 
in my company. Love it.
    Previously, Dr. Chestnut leveraged his expertise in 
occupational and environmental health to shape Cummins' 
strategy during the pandemic. He also served as a medical 
director at the Cummins LiveWell Center in Columbus, Indiana, 
for several years prior to his current role.
    Dr. Chestnut earned his MD and master's degree in 
occupational health at the University of Utah. He is residency-
trained and board-certified in both occupational and 
environmental medicine and family medicine.
    Thank you to everyone for being here today.
    Senator Booker. All right. To the witnesses again we thank 
you. We take it not for granted that you give up your time and 
resources to be here to testify before your Federal Government 
in this Subcommittee. I want to remind you that your written 
testimonies are going to be included in the record, but we are 
very eager to hear from you in your cogent, five-minute opening 
testimonies.
    Mr. Richards, you may proceed first with your testimony.

  STATEMENT OF MARTIN RICHARDS, EXECUTIVE DIRECTOR, COMMUNITY 
                    FARM ALLIANCE, BEREA, KY

    Mr. Richards. Thank you and good morning Chairman Booker 
and Ranking Member Braun, for this opportunity to talk about 
the challenges and opportunities that food as medicine presents 
for Kentuckians.
    An apple a day may keep the doctor away. Unfortunately, 
Kentucky consistently ranks in the bottom five nationally for 
diet-related disease and leads the Nation in rates of food 
insecurity, with over 15 percent of Kentuckians living in food-
insecure households. Kentucky also ranks 50th in the 
consumption of fruits and vegetables, with only 4.7 percent of 
the State's population reporting eating two or more vegetables 
or three or more fruits each day.
    As a former farmer this is unacceptable. Kentucky is a 
proud farm State with over 74,000 family farms, the sixth-most 
of any State in the country, and we should be able to feed our 
neighbors.
    To address these hunger and nutrition challenges, 
Kentuckians have undertaken innovative approaches from the 
grassroots to the hunger initiative launched by Agriculture 
Commissioner Ryan Quarles. My organization, Community Farm 
Alliance (CFA), was proud to launch Kentucky Double Dollars 
(KDD) in 2014, and Fresh Rx for Moms on Medicaid in 2019, as 
strategies for increasing the consumption of Kentucky-grown 
healthy foods for Kentucky families. These programs have been 
incredibly beneficial to recipients utilizing SNAP, WIC, and 
Seniors Farmers Market Nutrition Program benefits to increase 
their buying power at farmers markets, community markets, and 
retail locations.
    From 2017 to 2022, this past year, over $900,000 in 
Kentucky Double Dollars leveraged the same amount in Federal 
funds, putting almost $1.9 million into Kentucky farmers' 
pockets and creating over $3.1 million in economic impact for 
Kentucky communities, and we have just begun to scratch the 
surface.
    Equally important, 99 percent of Kentucky Double Dollar 
customer survey noticed positive changes in at least one of the 
seven food-related behaviors that we measured, and 49 percent 
reported positive changes in all seven behaviors.
    Food security has also been severely impacted by COVID and 
extreme weather events. Approximately 54 percent of KDD 
customers said that COVID made it more difficult to access 
fresh and healthy foods, but 82 percent said they began 
visiting farmers markets more often. The KDD program seems to 
have provided both consumers and producers in Kentucky with an 
important safety net during this time of uncertainty.
    The physical and human infrastructure that has developed 
around Kentucky Double Dollars has also played an enormous role 
in mitigating crises. During COVID, CFA, the Department of 
Agriculture, and other organizations were able to quickly 
provide farmers markets with additional resources and technical 
assistance that enabled many farmers markets to not only remain 
open but made them safe places to shop. Following historic 
floods of 2022, this infrastructure proved to be an important 
mechanism for getting food to those most impacted while also 
supporting farmers.
    It turns out building strong local food infrastructure is 
critical for communities to create food system resiliency in 
the face of adversity.
    Although Community Farm Alliance administers Kentucky 
Double Dollars, the program is a collaboration of many 
organizations. Besides the 70 KDD outlets, 26 stakeholder 
organizations make up the KDD Advisory Council to continue to 
improve this program. KDD funding is also diversified with 
almost a dozen Federal, State, and private philanthropic 
organizations having contributed over the past eight years. The 
program's two largest funders, the Kentucky Agricultural 
Development Fund and USDA GusNIP programs, have been critical 
catalysts in helping many Kentuckians access healthy food.
    Sustainability for food as medicine programs like KDD and 
Fresh Rx for Moms is an ongoing challenge. The USDA GusNIP 
grant program has been critical for CFA. However, with only 
$38.7 million available this year, just eight GusNIP projects 
were funded. Unfortunately, Kentucky Double Dollars, along with 
many other applications, did not receive awards that could have 
had an extraordinary impact on communities' food and nutrition 
security.
    Without those much-needed GusNIP resources we find 
ourselves asking how to sustain this work. Food as medicine 
represents a vast opportunity to help Kentucky farmers, 
communities, and those who are dealing with diet-related 
diseases, but Federal funding for this work is critical. I 
would strongly urge that the Senate Agriculture Committee to 
scale up the GusNIP program while reducing the match 
requirement in the next farm bill so that more food as medicine 
projects in Kentucky and around the country can reach their 
full potential in both rural and urban communities.
    Thank you again for this opportunity, and I look forward to 
any questions.

    [The prepared statement of Mr. Richards can be found on 
page 36 in the appendix.]

    Senator Booker. Thank you for your testimony.
    Ms. Penniman, rightfully a finalist for an Environmental 
Genius Award, no pressure, but we are looking forward to your 
five minutes.

  STATEMENT OF LEAH PENNIMAN, FOUNDING CO-EXECUTIVE DIRECTOR, 
                 SOUL FIRE FARM, PETERSBURG, NY

    Ms. Penniman. Good morning and thank you, Chairman Booker, 
Ranking Member Braun, and members of the Subcommittee. I am 
honored to be allowed to speak before you today from my 25 
years of direct experience as a farmer providing food as 
medicine to those in greatest need in our community. I am the 
co-founder, executive director, and farm manager of Soul Fire 
Farm in Grafton, New York, and a member of the Northeast 
Farmers of Color Land Trust and the National Black Food and 
Justice Alliance. I am also a mother of two.
    As a mother I know of no greater yearning than the sacred 
imperative to feed our children. When Emet was a newborn and 
Neshima was just two, we moved to the South End of Albany, New 
York, a neighborhood termed a ``food desert'' by the Federal 
Government due to the paucity of grocery stores, high poverty 
rates, and disproportionate burden of hunger, diabetes, heart 
disease, and other diet-related illness.
    Our family struggled to feed our children fresh fruits and 
vegetables, not for lack of effort but because there was no 
accessible public transportation, grocery stores, farmers 
markets, or community garden plots. In getting to know our 
South End neighbors, we found we were not alone in the struggle 
to nourish our children. In fact, around 40 million Americans 
live in food deserts where we cannot access or afford the life-
giving foods that make us whole.
    When our neighbors learned that we were seasoned growers 
they started teasing us--``Why not start a farm for us, a farm 
for the people?'' We took that challenge seriously and started 
exploring nearby land to see which parcel would claim us as 
friends and stewards.
    In 2006, we wed ourselves to 80 acres of eroded, Degraded, 
affordable mountainside land in Mohican territory which would 
become Soul Fire Farm. We spent years healing the soil with 
cover crops and mulch, regenerating the forest, building a 
straw bale, solar-powered home and education center by hand, 
and assembling a team.
    Soul Fire Farm opened in 2010 from the collective yearning 
of Black, multiracial, and low-income families to feed 
ourselves. We established a sliding-scale doorstep delivery 
program for vegetables and eggs that allowed members to choose 
how much to pay, based on what they could afford. Starting with 
the South End of Albany, this ``Solidarity Shares'' grew and 
now covers four neighborhoods in Albany and three neighborhoods 
in Troy, reaching over 200 people every week. The weekly box 
reflects the bounty of the land's 100-plus heirloom and 
heritage crops, like callaloo, plait de Haiti tomato, and fish 
pepper.
    Our members grew inspired to learn to cultivate their own 
food, so we created a home gardens program that provides 
lumber, soil, plants, seeds, and mentorship to aspiring urban 
gardeners. We surveyed our members, and 100 percent reported 
every year that they were eating more fruits and vegetables and 
that health indicators like blood pressure and cholesterol were 
improving. They also reported increased feelings of overall 
well-being, energy levels, and a sense of empowerment. Local 
health clinics started to take notice and make referrals, as 
did the refugee resettlement program. We could not meet the 
demand for no-cost and affordable doorstep deliveries of 
vegetables, so we started talking to other farmers and 
collaborating with farmers across the region. Folks like Corbin 
Hill Food Project, Rock Steady Farm, Poughkeepsie Farm Project, 
Schenectady Food Box, Sweet Freedom Farm, and Rocky Acres Farm 
become some of the many New York, farmer-led food as medicine 
projects in our networks.
    Our farmers soon realized that our members struggled to 
afford even the lowest tier of the sliding scale pricing 
system, and when the pandemic hit, folks' capacity to pay 
evaporated completely. As farmers, we need paid for our crops 
in order to sustain ourselves and remain economically viable, 
but we could not charge our struggling customers, and we were 
not willing to drop them from the program because of their dire 
economic situation.
    That is why Federal nutrition programs are so important. 
The farmers in our network started collaborating and created 
partnerships and working with initiatives like SNAP, the USDA 
Farmers to Families Food Box Program, GusNIP, and the Farm to 
Food Bank Projects. These programs provide a way for farmers to 
access a steady and reliable revenue stream for their crops 
while providing food to at-risk families. It is a win-win. The 
farmer is able to stay afloat and communities can access 
nutritious food.
    In preparation for this hearing, I reached out to hundreds 
of Black, indigenous, and people of color farmers in our 
national network to hear about their experience with Federal 
nutrition incentive programs. Every respondent who participated 
said these programs are essential.
    By fully funding and expanding farm to community nutrition 
incentive programs we benefit both the farmer and the consumer, 
and by increasing outreach to young farmers and farmers of 
color we invest in the future of American agriculture.
    Those young children I mentioned at the beginning of my 
statement are now nearly grown up, with my eldest in college 
studying sustainable agriculture. She wanted me to tell you 
that ``the food system is everything it takes to get sunshine 
onto our plates,'' and as civic leaders it is our 
responsibility to make sure that process is unimpeded. From the 
farmer to the food business owner, to those with hungry 
bellies, it is our duty to move that sunshine along so that 
everyone can thrive. Thank you.

    [The prepared statement of Ms. Penniman can be found on 
page 40 in the appendix.]

    Senator Booker. Thank you.
    Dr. Bulger, please.

STATEMENT OF JOHN BULGER, DO, CHIEF MEDICAL OFFICER, INSURANCE 
 OPERATIONS AND STRATEGIC PARTNERSHIPS, GEISINGER HEALTH PLAN, 
                          DANVILLE, PA

    Dr. Bulger. Thank you. Good morning. I would like to thank 
Chairman Booker, Ranking Member Braun, and members of the 
Subcommittee for the opportunity and the invitation to 
participate in today's discussions on the challenges of food 
insecurity and food as medicine as a viable solution to treat 
chronic health conditions.
    My name is Dr. John Bulger. I am the Chief Medical Officer 
of Insurance Operations and Strategic Partnerships at 
Geisinger. As was noted, Geisinger is an integrated delivery 
system so we have clinicians, hospitals, and we also have a 
health plan, and in my role I sit between the two as Chief 
Medical Officer of the health plan but also working on the 
clinical side.
    Geisinger has a long history of innovation, impacting the 
health of populations. One of those interventions that we have 
championed is the Fresh Food Farmacy, which was developed with 
the following goals in mind: One, to improve healthy food 
access for residents in our communities with chronic 
conditions. We started with diabetes. Two, to educate members 
on the connection between nutrition and health through clinical 
interactions and evidence-based programs. Three, to reduce the 
burden of type 2 diabetes and related medical complications and 
optimize the use of prescription drugs and ultimately to lower 
the cost of medical care. Four, to narrow the meal gap for 
those who are food insecure by ensuring participants have 
access to at least 10 fresh, healthy meals per week for them 
but also for the other members of their household. Last, to 
collaborate with community partners to align and enhance the 
operations and the offerings of the Fresh Food Farmacy.
    How does a Fresh Food Farmacy work? First, patients are 
screened in the primary care setting, one, to see if they have 
diabetes. We took people who had a hemoglobin A1C greater than 
8, which means they are at least 1 1/2 times higher than normal 
for their average blood sugar. We then asked people, as well, 
if they were food insecure using the USDA food insecurity 
questions, and matched those people that had diabetes and were 
food insecure, to be qualified for the Fresh Food Farmacy.
    Those people were enrolled in clinical interventions like 
care management, dieticians, diabetic education, and had 
consultants on a team. They were also given access to a 
facility, the Fresh Food Farmacy facility, which offers healthy 
products that meet the American Diabetes Association 
recommendation, which includes lean meats, whole grains, fruits 
and vegetables, and limited sodium and cholesterol and fat 
content. Then the program provides enough food to cover 10 
meals per week, as I said, for the patients, but it also 
important that we provide those meals for the household 
members.
    What are our results? How does it work? We have had about 
1,600 patients enrolled in the Fresh Food Farmacy so far. Those 
are in three communities, both urban and rural--Scranton, 
Pennsylvania; Shamokin, Pennsylvania, which is in the coal 
region of Pennsylvania; and Lewistown, which is in a rural area 
in southcentral Pennsylvania. We screened more than 800,000 
patients to get into the program. We provided almost two 
million pounds of food and 1.7 million meals.
    What we found is we could lower the patient's average blood 
glucose as measured by something called the hemoglobin A1C by 
about half. Those beginning were about twice as high as they 
should be, getting them close to the normal range.
    We also decreased hospital utilization, so they end up in 
the hospital less, and about 30 percent emergency room visits.
    The one great example of this is the first person in the 
program, Rita. She is a 55-year-old widowed grandmother, caring 
for her grandchildren. When she enrolled in the program her 
sugar was about three times what it should be. She weighed 181 
pounds, and her cholesterol was twice what it should be. After 
going through the program she actually had normal blood sugars, 
so she dropped her blood sugars by two-thirds, she lost 50 
pounds, to 135 pounds, and dropped her bad cholesterol from 
being twice what it should be to being about half the high end 
of normal.
    Given our initial results, we have expanded the Fresh Food 
Farmacy now to additional diseases like kidney disease and 
heart failure.
    Again, I would like to thank you for the opportunity to 
present today on this critical health issue. We stand ready to 
be a resource at Geisinger for the Committee on this issue, and 
we are really excited about the further discussion. For the 
benefit of the Committee, my written testimony provides further 
information on the Fresh Food Farmacy, and I am happy to answer 
any questions you have. Thank you.

    [The prepared statement of Dr. Bulger can be found on page 
44 in the appendix.]

    Senator Booker. Thank you, Doctor. I am excited about the 
results you are seeing as well.
    I would like to now recognize Dr. Volpp for his five 
minutes.

STATEMENT OF KEVIN VOLPP, MD, Ph.D., FOUNDING DIRECTOR, CENTER 
    FOR HEALTH INCENTIVES AND BEHAVIORAL ECONOMICS (CHIBE), 
   UNIVERSITY OF PENNSYLVANIA, MEMBER, ADVOCACY COORDINATING 
    COMMITTEE, AMERICAN HEART ASSOCIATION, PHILADELPHIA, PA

    Dr. Volpp. Good morning, Chairman Booker, Ranking Member 
Braun, and members of the Subcommittee. Thank you for the 
opportunity to testify on behalf of the American Heart 
Association about why food as medicine programs are promising 
and why more evidence is needed.
    My name is Dr. Kevin Volpp, and I am the leader for the 
planning committee for the Rockefeller Foundation, American 
Heart Association Food is Medicine Research Initiative as a 
volunteer member of the Association's Advocacy Committee. I am 
founding director of the Penn Center for Health Incentives and 
Behavioral Economics and the Mark V. Pauly President's 
Distinguished Professor at the University of Pennsylvania's 
Perelman School of Medicine and the Wharton School.
    For 20 years I served as a part-time primary care doctor 
and hospitalists at the Philadelphia Veterans Affairs Medical 
Center. Many of my patients struggled with chronic diseases 
such as congestive heart failure and diabetes, which were 
exacerbated by their challenges finding affordable, healthy 
food. As a behavioral economist I focused on testing strategies 
for improving patient health behavior and clinician 
performance. Through work with health plans, health systems, 
consumer companies, and individual patients, I developed deep 
understanding about what physicians, individuals, and families 
need to promote health, prevent disease, and manage chronic 
conditions.
    As you know, chronic diseases represent seven of the ten 
leading causes of death in the United States, with heart 
disease as the No. 1 killer. These chronic diseases account for 
most of the Nation's nearly $4 trillion in annual health care 
costs.
    The connection between nutrition and chronic disease is 
undeniable. For example, WIC has been shown to be associated 
with improved birth outcomes, lower consumption of added sugars 
and saturated fats, and improved academic achievement. 
Unfortunately, many individuals in the United States are 
nutrition and food insecure and do not have access to 
affordable, nutritious food.
    Food is medicine refers to diet-related intervention for 
patients with a diet-related health risk or condition and food 
insecurity to which they are referred by a health care provider 
or health plan. Evidence indicates that incorporating food is 
medicine programs into health care can be associated with 
improvements in outcomes. For example, medically tailored meals 
are associated with fewer hospital and skilled nursing facility 
admissions, fewer emergency room visits, and health care cost 
reductions. Produce prescription programs increased fruit and 
vegetable consumption and reduce household food insecurity.
    That said, there are important limitations in food is 
medicine research conducted to date. These programs have 
typically been evaluated in small-scale pilot studies. Many 
have been conducted using pre-post assessments of interventions 
without comparison groups, and the measured impact of such 
interventions may be overstated. Only a small number of 
randomized controlled trials have been done, and they have 
typically been small and thus unable to provide definitive 
answers.
    Food is medicine interventions have not generally 
incorporated freedom of choice and input from patients, 
reducing potential rates of engagement. Finally, these 
interventions have not generally been tested using intervention 
infrastructure or data platforms that are scalable beyond the 
context in which they were tested.
    To unlock the full potential of food is medicine we must 
systematically answer important questions regarding intensity, 
duration, and delivery of food is medicine interventions, the 
role of patient preferences and choice, the incorporation of 
educational behavioral strategies or coaching, the comparative 
effectiveness of ways to change behaviors and habits, and cost 
effectiveness.
    In conjunction with the White House Conference on Hunger, 
Nutrition, and Health, which came to fruition this fall, thanks 
to your leadership, Chairman Booker and Ranking Member Braun, 
the Rockefeller Foundation and the American Heart Association 
have committed to mobilize $250 million to build a national 
Food is Medicine Research Initiative, planned to launch in 
spring of 2023. We are designing a research initiative that 
will accelerate the speed of generating evidence on what works 
and for whom that can be used by public and private sector 
payers to inform coverage decisions. Working with patients and 
partnering with health plans, health system, food companies, 
and delivery services, we aim to create a platform for testing 
of ideas that significantly increases the availability of 
healthy foods to Americans, no matter where they live, our 
collective ability to learn from studies by integrating 
heretofore separate streams of data, and that facilities 
assessment of the cost-effectiveness of different interventions 
for higher-and lower-risk populations.
    Chronic disease and unhealthy diets are inextricably 
linked. Continued Federal support for nutrition research, 
including food is medicine, is needed to inform our efforts to 
prevent and treat chronic diseases, lower health care costs, 
and improve quality of life.
    Thank you for the opportunity to offer my perspective today 
and for your continued leadership. I look forward to your 
questions.

    [The prepared statement of Dr. Volpp can be found on page 
51 in the appendix.]

    Senator Booker. Thank you, Dr. Volpp.
    Our final witness and the third in our tremendous trio of 
doctors, is Dr. Chestnut. You are recognized for your five 
minutes.

STATEMENT OF BOB CHESTNUT, MD, CHIEF MEDICAL DIRECTOR, CUMMINS 
                       INC., COLUMBUS, IN

    Dr. Chestnut. Chairman Booker, Ranking Member Braun, and 
members of the Subcommittee, thank you for inviting me here 
today and for your interest in using food and nutrition to 
reduce death, disease, and disability.
    My name is Dr. Bob Chestnut. I am the Chief Medical 
Director at Cummins. Cummins is a 100-year-old company with 
headquarters in Columbus, Indiana. While Cummins was originally 
known for diesel engines, we now have solutions in natural gas, 
hybrid, electric, fuel cell, and other technologies. We employ 
more than 70,000 employees globally, in over 190 countries. We 
have manufacturing facilities in 10 States throughout the U.S., 
and a distributor network in almost every State. For me, 
growing up in a rural farming town in central Utah, Cummins was 
a household name, known for quality and dependability.
    My hometown was a food desert. We had a single gas station 
with a few rows of nonperishable items, and few were healthy. 
The nearest grocery store was more than 30 minutes away. It was 
a town of farmers and craftspeople who worked hard, had poor 
access to healthful food, and could not easily prioritize their 
health.
    As I began my journey into the practice of medicine I set 
about searching for how I could best help people like those in 
my hometown. As I looked around I realized that employers have 
unique potential in supporting population and individual 
health. This is at least for several reasons. People spend a 
lot of time at work. Over 145 million Americans are workers, 
and most spend half their waking hours at work. This opens an 
opportunity for companies to be places of influence, for 
encouraging and supporting healthier lifestyles.
    The next is alignment. The combined health care spending 
and lost productivity from suboptimal eating costs the economy 
$1.1 trillion yearly. Address diet-related health conditions 
may reduce absenteeism and presenteeism and increase 
productivity. Companies benefit directly from the improved 
health of their employees.
    The last is a consistent, health-promoting environment that 
may or may not exist at home or otherwise be available to 
employees. At Cummins we are mindful that our success as a 
business is only achievable through the work of a healthy work 
force. I will share several programs at Cummins specific to 
nutrition to improve health outcomes.
    In Columbus, Indiana, we have a patient-centered medical 
home. More than 10,000 employees, plus their dependents, live 
nearby and have access. When a person comes in with a diet-
related disease like diabetes or heart disease, they meet with 
a doctor who is trained in lifestyle medicine in addition to 
primary care. This means that nutrition and lifestyle 
modifications are an integrated part of the person's treatment 
plan. The person will also be introduced to a team who provide 
multiple layers of support. They will meet with an ambulatory 
pharmacist who can optimize their medications and balance them 
with lifestyle changes.
    Our wellness coaches check in with them often and offer 
individualized plans for adopting new lifestyle behaviors. They 
can also be referred to our teaching kitchen, to meet with our 
chef who provides hands-on experience with healthful food 
selection, food preparation, and health literacy.
    At many of our locations we offer our Lifestyle 365 
program. This is a 10-session, hands-on experience focused on 
healthful foods, physical activity, and building health-
promoting behaviors. Participants receive a prepared lunch of 
healthy food to try in each session. We also offer healthful 
cafeteria and vending items.
    Congress can take meaningful in helping the business 
community support nutrition and health initiatives. First, 
continue to include the business community in health 
discussions exploring how employers may crate health-promoting 
work environments. Federal support like tax incentives on 
corporate food as medicine investments would increase the 
ability of businesses to offer health products and services. 
Increased flexibility to offer telehealth and medical services 
across State lines would be particularly helpful to increase 
access to all of our employees.
    Congress can also support programs such as Total Worker 
Health by the National Institute for Occupational Safety and 
Health. Increased resources for the Total Worker Health program 
could help businesses developed tailored, comprehensive health 
solutions, including increasing daily access to healthier food 
and lifestyles.
    Thank you again for the great honor and privilege of 
speaking to you all today. For more comprehensive background 
please refer to my written testimony. If I can provide any more 
information on behalf of Cummins I would be honored to do so.

    [The prepared statement of Dr. Chestnut can be found on 
page 57 in the appendix.]

    Senator Booker. We are grateful for your testimony, 
everyone.
    We are going to jump right in with member questions. I am 
going to begin with you, Dr. Bulger, not just because you have 
a great haircut but because I am extraordinarily excited about 
Geisinger, which just brings such practical wisdom that should 
inform, really, government policy. You all have three brick-
and-mortar locations and provided healthy food to nearly 1,600 
diabetes patients. What is extraordinary is a paper that was 
written about your work shows that diabetes patients who take 
two or three medications, having access to your program can 
expect their A1C to drop between 0.5 and 1.2 points, but that 
the patients at your Fresh Food Farmacy, in comparison to the 
people taking the drugs, were seeing drops of over 2 points.
    That is an amazing comparison. People who do the drugs are 
seeing one drop, but you all are seeing, just from the access 
to fresh and healthy food, 2 points. Can you explain to me, who 
has an honorary doctorate from Yeshiva University--that is 
true--but not a medical doctorate, what is A1C and what is a 2-
point drop? What does that mean for the quality of health for 
patients?
    Dr. Bulger. Sure. Great. Thank you. That is a great 
question.
    The hemoglobin A1C is a measurement of your average blood 
glucose over about three to four months. Medical professionals 
use that to tell, instead of just doing a finger stick and 
seeing what you are right now, it actually gives us an estimate 
of what your sugars look like over a longer period of time. Of 
course, it is that longer period of time with your sugars being 
high that affects you and is a chronic disease and changes 
things in your body. These changes create things like heart 
attacks and strokes, and you said earlier, vascular disease in 
the extremities, so you end up with amputations and other type 
of things.
    A normal hemoglobin A1C is generally in the 5's, less than 
6, and that equates to an average blood sugar of about 125. For 
every one that you go up it is somewhere between 25 and 30 for 
average blood sugar. When you go to 7, it is a little over 150, 
8, and so forth. If you want to get someone to normal it is 
trying to get them to less than 6.
    Now a lot of people with diabetes, the example I talked 
about in the testimony, that woman had a hemoglobin A1C of over 
13, which meant her blood sugars were running in the 300's, on 
average, and if your blood sugar is running at a 300, on 
average, chronically, that is where you have significant damage 
being done throughout the body from that sugar. By dropping it, 
in the case of our situation, dropping it by 2 1/2, is dropping 
the hemoglobin A1C about 100, 150 points toward normal. It is 
big difference for people.
    Senator Booker. I think it is a massive difference. Let us 
think about this for a second. Drugs, expense to the American 
public, that is one thing, but the health benefits. What seems 
to drive Senator Braun and myself is obviously the human 
misery, reducing that in our country, having type 2 diabetes 
rates in our country where half of our country has got type 2 
diabetes or is pre-diabetic. As I said before in my opening 
statement, every month 13,000 new amputations in American 
because of diabetes, 5,000 new cases of kidney failure because 
of diabetes, 2,000 new cases of blindness because of diabetes. 
This is a stunning set of numbers that I think drives Senator 
Braun--if I could speak for him for a moment--and I.
    We also are concerned about the cost savings, and that is 
what is my last question to you. There was a 2018 paper that 
detailed how Geisinger was seeing health care cost savings from 
its Fresh Food Farmacy program. Just really quickly, are you 
still seeing that cost-savings from this program? As two guys 
who had to run stuff before we were Senators, and that was one 
of our biggest concerns was these growing costs, are you seeing 
cost savings?
    Dr. Bulger. Yes. That is a great call out. If you look in 
the medical literature, as the hemoglobin A1C drops, cost 
drops. We have seen that same thing with our program. The other 
thing we have seen, as I noted, is the patients end up in the 
hospital much less, which is one of the big reasons for health 
care costs, they end up in emergency room much less. We have 
seen participants have a decrease in those complications you 
noted, like amputations, kidney disease, those type of things, 
and that all relates to the decrease in hemoglobin A1C.
    Yes, we continue to see the cost savings around the use of 
food as medicine.
    Senator Booker. You are fiscally conservative and liberal 
in healthiness.
    All right. Senator Braun.
    Senator Braun. Thank you. I will start with Dr. Chestnut. 
How long has LiveWell been in place at Cummins?
    Dr. Chestnut. Six and a half years.
    Senator Braun. That is a pretty good stretch of time to see 
if you are getting some results. Have you ever published that 
data so others can learn from it, and would you share what you 
have accomplished with it from when you started to where you 
are now?
    Dr. Chestnut. Yes, so we definitely share our activities 
and our programs as best practices with others. As far as our 
results, we do track them internally but do not publish them 
broadly. I can say we have had some tremendous results. We have 
had many individuals with diabetes who have experienced 
complete reversal, and many others who have had dramatic 
experiences with reducing the medications that they are on.
    Senator Braun. Have you incorporated free biometric 
screenings into what you offer your employees?
    Dr. Chestnut. We have, at various times, biometric 
screening. For example, our Lifestyle 365 program we do pre and 
post biometric screening. Individuals will get their 
cholesterol checked, their hemoglobin A1C, and their blood 
pressure prior to those 10 sessions. What is impressive is that 
even that intervention, 10 healthy meals, ten 30-minute 
sessions of talking through lifestyle behaviors, we have seen 
individuals have a measurable difference between that pre and 
post and see an improvement in those biometric data.
    Senator Braun. Have you found when you give your employees 
those tools, do they readily accept it or sometimes do they 
need to kind of have time to sink in that they need to use that 
information? That is one thing that we found early is that even 
when you provided it, they did not necessarily pay attention to 
it. What have you found?
    Dr. Chestnut. Much of the same. We found that we need to 
create initiatives that meet people where they are, and we need 
to be consistent over time and keep our messaging on going. An 
intervention for one group of employees needs to be very 
different than another. We have several unique groups within 
Cummins, where we do have our manufacturing employees, our 
distribution employees, and our exempt employees. For each of 
these we offer different programs and different ways to engage 
to help them become mobilized in their own health care.
    Senator Braun. Even you have not published the arithmetic--
which that was very important to me. I wanted to make sure what 
I was doing was actually going to be working in terms of the 
cost of it--has it moved in the right direction in terms of 
your cost per employee, per year, which should be the universal 
measurement when it comes to health care, and that it is making 
your employee healthier over time as well? Have you been moving 
in the right direction even though you may not want to share 
the particulars of it?
    Dr. Chestnut. Yes. We have seen improved health outcomes, 
and for the past few years our employee premiums have stayed 
the same.
    Senator Braun. For the past few years? Would you say for 
the last 6 1/2 years?
    Dr. Chestnut. I will have to followup with you on that to 
confirm where it has been over the last 6 1/2 years.
    Senator Braun. Well, the reason I emphasize that is we have 
done it for 15 years, and not had the increased premiums, and 
actually cut family premiums by a decent amount. This works, 
but you have got to get your employees to buy into it. The 
demand for remediation is very inelastic. If you have a bad 
accident or you get sick, employees, it is human nature, want 
to be fixed immediately. That is part of our system, what is 
wrong with it, because then you are in the highest-cost per 
remediation that you can get when you do not get them to buy 
into the fact that you could prevent a lot of it.
    I think a lot of what we need to do is not only from here 
but to try to share there are not many, like Cummins or Meyer 
Distributing, that ever wanted to fiddle with it because it is 
part of benefits. It is hard enough to hire people when you are 
tinkering around with the health benefit plan. We had to make a 
bold move 15 years ago and it paid off. It sounds like you have 
done the same thing. If we have a second round of questions I 
want to get into what were the macro issues.
    Senator Booker. We will have a second round. I just want 
you to clarify for the record, you keep saying ``we did it,'' 
``we have been doing it for 15 years.'' You are not talking 
about the U.S. Senate or Federal employees.
    Senator Braun. No, no, no.
    Senator Booker. Who are you talking about?
    Senator Braun. Our own company that I ran.
    Senator Booker. Yes.
    Senator Braun. Because it is not happening in enough places 
because folks like Cummins, folks like the company I ran do not 
want to take the risk because the easiest way is just to 
provide the remediation, regardless of the cost. That is why we 
suffer from the highest health care costs in the country.
    Senator Booker. All right. Thank you very much.
    We are going to turn to Senate superstar, Smith.
    Senator Smith. Thank you so much, Chair Booker and Ranking 
Member Braun. It is great to be here with my colleagues. A 
terrific panel. I really appreciate this.
    I want to start with questions to Ms. Penniman and Mr. 
Richard. We acknowledge that it is hard to be healthy if you do 
not have access to healthy food, and the link between good 
nutrition and health is undeniable, and it is also what our 
grandma taught us.
    The problem we have, it seems, is that our nutrition system 
in this country does not always support healthy eating, 
especially for people who rely on nutrition assistance. These 
are also, not coincidentally, the folks with the biggest health 
challenges, caused by poor nutrition.
    Let us talk about EBT cards, which are like debit cards for 
people who are eligible for SNAP benefits. They can be used not 
just in traditional grocery stores but also farmers markets and 
other places where people can buy healthy food, like fresh 
fruits and vegetables. Of course, then when they are buying 
from farmers markets or CSAs they are also supporting the local 
food system, which has other benefits.
    Here is the thing that I want to ask you about. I am 
hearing that EBT cards do not always work for farmers markets 
or at small vendors because of technology problems. It is like 
a good idea that is not executing because the technology does 
not work. My question is are you familiar with? What should we 
do? What can we do, in Congress, to fix this problem so that 
that EBT card is a ticket to healthy food and support for local 
food systems?
    Ms. Penniman, would you like to start?
    Ms. Penniman. Absolutely. Thank you so much for that 
question. Our farm has been accepting of EBT over the years, 
and we have made progress. You know, in the past CSAs were not 
eligible. Farmers markets, it was very difficult to use them. I 
do commend legislators for paying attention to that.
    When you come to food box programs, delivery programs, on-
demand programs, there is still a technology mismatch. In order 
for me to go drop off my food, ring the doorbell, leave it at 
the doorstep of someone, I am going to have to do a voucher 
system and then redeem it remotely later, from my portal. Then 
if I do not use it for months in the wintertime I have to go 
through a whole process of a store shutdown. Many of our 
farmers in our network have just said, ``It is too cumbersome. 
It is not worth taking EBT.''Moreover, many of the people who 
would want to use EBT, their benefits have run out by the 
middle of the month anyway, so without Double Bucks or some 
other supplementary program we are running into the problem 
where we are footing the bill anyway for our recurring 
customers.
    If we could modernize, get that system online, you know, 
allow for people to make orders of their produce online and pay 
online through EBT, I think it would do a lot to make it more 
accessible to the up-and-coming generation of farmers.
    Senator Smith. That is great. Mr. Richards, would you like 
to add to that?
    Mr. Richards. Yes. I mean, I think you have got to--well, 
you know, because we operate these programs in both urban and 
rural areas, and in particular Appalachia, you know, sometimes 
you are very lucky just to get a cell signal. A lot of farmers 
are very interested in doing this, and one of the things that 
we have found is we provide technical assistance to those 
markets, right. I think the Double Dollars program, they are 
attracted to it, they want to do it, but they are a little 
intimidated by the technology.
    We do it, and it is that warm body that gets up every day 
and helps make this stuff work, right, that is so important. 
That is like the third leg of this stool besides the Federal 
benefits and the incentives is the warm bodies who get up every 
day and make it work, whether it is the farmers market manager 
or those kinds of folks. People want to do it, and they are 
pretty resourceful to do it with a little helping hand.
    Senator Smith. Thank you. That is very helpful. Mr. Chair, 
I think this is an area where we could figure out work that we 
could do together in the farm bill to improve how this works so 
that it is actually delivering on the promise of connecting 
people with healthy food. I would love to work with everybody 
on this panel on this.
    I just have a minute more and I have another question for 
Ms. Penniman. This has to do with something that is near and 
dear to my heart, which is for Tribal Nations and for 
indigenous people food is nutrition, it is also culture, and it 
is also sovereignty. We know that if you have nutrition 
programs that are connected to people's food that is part of 
their culture then they are going to be healthier. In fact, 
there is often a mismatch between the food that is delivered to 
distribution programs and the food that people want to eat, 
should be eating in order to be healthy. I hear about this on 
Minnesota's Tribal Nations and indigenous communities where 
distribution programs, for example, have the inclusion of milk 
when so many people are lactose intolerant.
    My question is, from your work with food distribution 
systems, can you talk about what we can do better? I have a 
bill that is the SNAP Tribal Food Sovereignty Act which would 
give Tribes more control over their food distribution program. 
Senator Booker is one of my partners on this. Could you just 
address that briefly?
    Ms. Penniman. You have warmed my heart with that question, 
knowing that you are working on that. I would never purport to 
speak on behalf of any indigenous or Tribal nation. We do work 
in deep solidarity with indigenous nations and we see the very 
same issues in the Black community, where school lunches, 
institutional food distribution programs are a mismatch for 
cultural foods, and the lactose intolerance statement that you 
made is very pertinent also to Black community.
    I will say that small is beautiful in a lot of ways, so the 
farmers that we work with in our network, many hundreds of 
Black, indigenous, and people of color farmers across the 
country, are growing the foods that their members ask them to 
grow. That type of responsiveness is something that you cannot 
necessary get in an anonymized kind of distribution program. 
Every year we survey our members. If they want fish pepper, you 
know, for their soups, if they want callaloo, if they want 
scotch bonnet, we grow that for them and we make sure that that 
is delivered. We have a wonderful Japanese monk in our program 
down the street, and if I do not grow her specific Japanese 
sweet potatoes she will come for me.
    I think that whether it is because there is a direct 
relationship to the farm or the consumer or because we have 
made focus groups and we make sure that what is in the box 
generally matches what people are asking for, there is no way 
to have success in these programs without some level of choice 
and cultural responsiveness. That absolutely has to be part of 
it.
    Senator Smith. Thank you very much. Thank you.
    I will just say I took some of Senator Klobuchar's time.
    Senator Booker. Okay. Understood.
    All right. There has been Booker. There has been Braun, but 
the best of the B's is Boozman.
    Senator Boozman. I think Senator Ernst was here first.
    Senator Booker. I will always defer to the great Senator, 
the star from the Midwest, Senator Ernst.
    Senator Ernst. Thank you, Chairman Booker and Ranking 
Member Braun, and our Chair, John Boozman, as well. Thank you.
    This has been a great panel. Thank you all so much for 
being here. I really appreciate the time to talk and hear about 
some of the initiatives that we see across the United States, 
and I am going to divert a little bit and talk about a pressing 
issue that we have out there as well, because this week we are 
going to be voting on the National Defense Authorization Act. 
Most recent statistics that are out there, only 23 percent of 
Americans aged 17 to 24 actually meet the necessary 
qualifications to enlist in our United States Armed Services. 
There are many things that will cause folks not to qualify for 
military service. There is a lack of education, there is 
obesity, and other disqualifying health issues. When you look 
at just obesity, out of those that do not meet the necessary 
qualifications, 27 percent are obese, and most of that is, of 
course, related to their nutrition and exercise, or lack 
thereof.
    I just wanted to bring up that issue. I know it is a topic 
for another day, but making sure that our children and young 
adults have access to healthy foods is extremely important not 
just across the board, just because we want to be healthy 
Americans, but because of our readiness issues with national 
security as well. I wanted to take that twist.
    If we can come back to some of the programs that we are 
offering, many Iowans, both our children and adults, will 
suffer from digestive or inherited metabolic disorders. I have 
worked with a number of families in Iowa that are dependent on 
medically necessary foods, vitamins, amino acids for their 
treatments. Unfortunately the products come at a very high cost 
to those who depend on it, and that is why I am an original co-
sponsor of the Medical Nutrition Equity Act. All Americans 
deserve to know that they are covered for their medically 
necessary nutrition under Federal health programs and private 
health insurance, to support their proper growth and 
development and to prevent other types of medical 
complications.
    I have also heard, as many have, from Iowans, about 
incentives-based approaches as a preferred method to empower 
SNAP customers to purchase healthy foods. An example of this is 
the Healthy Fluid Milk Incentives projects program, which I led 
and was established in the 2018 Farm Bill, with the goal to 
help improve nutrition security for SNAP families through 
healthy and nutritious dairy products. I also want to note that 
there is a project in Newark that I think maybe Chairman Booker 
has maybe visited, and that is important as well.
    The dietary guidelines for Americans have repeatedly 
recommended milk and other dairy products as critical for a 
healthy meal pattern, and under this Healthy Fluid Milk 
Incentives project, shoppers that use SNAP benefits to purchase 
a qualifying fluid milk product also then receive a matching 
dollar-for-dollar coupon to use for additional free milk or 
other types of healthy dairy products.
    Mr. Richards, I see you nodding your head there, and I know 
that you are supportive of these incentive approaches for those 
nutritious dairy products. Can you talk a little bit mor about 
those types of incentives or those types of projects?
    Mr. Richards. Sure. Yes, because I mentioned Kentucky 
Double Dollars but there are actually four incentive programs, 
right. There is the SNAP fruits and vegetables, which the 
GusNIP grant has typically done, but we also double up WIC and 
Senior Farmers Market Nutrition Programs. Then Kentucky is a 
livestock State too, right, so we double up meat. We have meat, 
eggs, and dairy double up, because we recognize all those 
benefits and the fact that access to high-quality, healthy 
protein is just part of a good diet.
    It is all Kentucky-grown meat, eggs, and dairy. I am a 
former livestock farmer and my grandfather was a dairy farmer, 
so I am right there with you, Senator.
    Senator Ernst. Outstanding. Well, I appreciate it, and I am 
running out of time so I just want to once again thank our 
panelists. Extraordinary. Thanks for what you are doing for 
your communities and, of course, for the greater health of our 
Nation. We truly do appreciate it.
    Thank you, Mr. Chair. I yield back.
    Senator Booker. Thank you, Senator, for mentioning the 
Medical Nutrition Equity Act. It is also something I support 
and hope Congress will pass quickly.
    Senator Ernst. Yes.
    Senator Booker. We turn now to Senator Klobuchar.
    Senator Klobuchar. Thank you, Chairman Booker and Ranking 
Member Braun, for holding this important Subcommittee hearing, 
and I am looking forward to working with this Committee in the 
new year on the farm bill and so many other things. As we know, 
the Committee has authorized and passed bipartisan bills on 
child nutrition many, many times, through many different 
administrations. Clearly this is going to be a priority of 
ours.
    I have a bill with Senator Lummis, from Wyoming, to better 
integrate mental health promotion and education in schools. We 
know that the spike in food insecurity may impact not only the 
nutritional needs of our students but also their mental health. 
Can you talk about that connection, Dr. Volpp?
    Dr. Volpp. Well, I think for a lot of kids they are living 
with horrible food insecurity, they are living with nutrition 
insecurity, and they are living in poverty, and that 
combination of factors clearly affects kids' mental health and 
it affects their physical health. When you look at the data 
from WIC you can see that not only do we see better nutrition 
intake by kids on WIC, you also see better academic 
performance. I think that link of really trying to help the 
next generation get a better start so they are not susceptible 
to the same inequities of current adults is really important 
for us all to be thinking about.
    Senator Klobuchar. Very good. A 2021 Minnesota Department 
of Health work force report showed 80 percent of Minnesota's 
qualified shortage areas for mental health professionals. We 
actually have the lowest unemployment rate in the country. Two 
months ago we had the lowest unemployment rate of any State in 
the country in the history of America. We are down across the 
health care sector and manufacturing and the like. It is, in 
some ways, a good problem to have. There are good jobs out 
there. It is also, especially in the health care area, becoming 
a real issue. It is one of the reasons I am such a big 
proponent for immigration reform and for the Conrad 30 bill 
that I carry, which would allow people who are doing their 
residencies in the U.S., from other countries, to stay.
    The Improving Mental Health and Wellness in Schools Act 
would help address these shortages. From your perspective, what 
else could we do to provide training and to get help in rural 
settings? Obviously, doing this is something we did in the 
pandemic, and doing it via Zoom and other platforms was 
helpful, but ideas on that front.
    Dr. Volpp. Well, I think more broadly, coming back to 
something Senator Braun said a few minutes ago, we spare no 
expense to treat disease once it happens, but we do not do 
nearly the same in terms of trying to prevent disease. Thinking 
more holistically about we invest in people's well-being and 
both create incentives for them to have healthier choices but 
also availability of services should they need them is really 
critical.
    The shortage in health care of mental health providers is 
really a crisis, but the larger question we have to ask 
ourselves is why do our kids need so much mental health 
services? There seem to be real crises with anxiety, 
depression. What is causing that is really the question that we 
should be trying to answer.
    Senator Klobuchar. Very good. Last question, just someone 
else on the panel can take it. According to the Centers for 
Disease Control, more than 42 percent of American adults, about 
100 million people, had obesity issues before the pandemic. As 
we know, having just visited Mayo and talked to them about 
that, it has only upticked, I believe, since the pandemic. 
Nearly three-fourths of American adults have issues with 
weight. Roughly one in five kids have obesity. Furthermore, 
studies have estimated that nearly two-thirds of COVID 
hospitalizations are related to obesity and diabetes.
    What strategies can the Committee consider as we move 
forward with nutrition programs to not only make up for lost 
ground during the pandemic but to promote healthier lifestyles, 
healthier eating?
    Anyone want to take that? Except not Dr. Volpp. He answered 
everything.
    Dr. Chestnut. Something that was frustrating for me in 
practice was that oftentimes the only weight loss programs you 
could enroll a patient in was the weight loss program that was 
associated with bariatric surgery. It was essentially a high-
cost procedure that was subsidizing weight loss. It would be to 
uncouple that and better fund deliberate weight loss programs 
that people could engage with.
    Senator Klobuchar. Thank you. Anyone else?
    All right. Thank you. Oh, Dr. Volpp?
    Dr. Volpp. It was mentioned a couple of times. One of the 
reasons why in the work we have done we provided food to the 
whole family is it really starts in the younger ages. Once you 
get to the point where you do not have access to fresh fruits 
and vegetables, you do not know how to cook fresh fruits and 
vegetables, it ends up being a lifestyle change over time.
    I think really targeting at the younger ages and trying to 
change it from the beginning up I think is one place to focus.
    Senator Klobuchar. Very good. Thank you. Thank you, Mr. 
Chairman.
    Senator Booker. Thank you, Senator Klobuchar. Senator 
Boozman.
    Senator Boozman. Thank you, Mr. Chairman. Thank you for 
having this hearing, you and Senator Braun. This is really 
important.
    Dr. Volpp, I was listening to you in the sense of being an 
old VA doctor, and you saw lots of patients, and you also, Dr. 
Chestnut, really kind of were saying the same thing that I am 
trying to express. You saw lots of patients, lots of folks that 
drank too much, ate too much, smoked too much, and you did your 
best to help them get through that, but you really were not 
changing their behavior. I mean, that is really, in the sense, 
you know, you are a busy practitioner, you are seeing patients, 
and it is just not part of it.
    My brother was an ophthalmologist, and before he became an 
ophthalmologist he was a pediatrician. It has been a while ago, 
but at that time they really had not seen hardly any cases of 
type 2 diabetes in kids. That is rampant right now, as you all 
know.
    This is just not an easy thing, and I am struck by the 
panelists here that are doing such a good job. You all have a 
systems approach. Senator Braun had a systems approach. You 
know, you just cannot do this by being a practitioner, 
prescribing this or that, handing somebody a prescription for 
vegetables or whatever. It just does not work.
    We really are going to have to rethink this and provide 
incentives, but the incentives do not work, to me, unless it 
really is an approach where you start changing--it is behavior 
modification. We are doing a good job. In fact, I think we are 
ratcheting down too much on our school lunch programs, where it 
is going to be equivalent to, you know, if you are on 
essentially a severe heart disease diet. It is not only what 
you eat, in that regard, the good stuff. It is staying away 
from eating too much of the bad stuff.
    All of this goes together, and I am really interested, 
again, in your being here, your great testimony, great work 
that you are doing. What we have got to do is figure out, it is 
just not that easy, you know, again, to think that we can--I do 
not know that the BMI average of health care workers is any 
better than the general population, and certainly they know 
what is going on. The same, I am sure, the farm community. You 
know, they are out there in the fields and have access to all 
this stuff. Like I say, their BMIs, it is not any better than 
anybody else's.
    Will you comment on that real quick, Dr. Volpp, because you 
are going to get into this. You know, I am excited about the 
fact that--and I want to learn more about the Rockefeller 
Foundation's effort to get into this. I would just encourage 
you, like I say, whatever we come up with has to be more than 
the simplicity.
    Dr. Volpp. Yes. As you summarized----
    Senator Boozman. Especially with the children. We are going 
to see the devastating effects of that because they are getting 
sick at a much earlier age. That is going to cost society a 
great deal, besides their health.
    Dr. Volpp. As you summarized, health care practitioners 
around the country are in a reactive mode of taking what comes 
and trying to do the best they can with the patients in front 
of them, but we do not have a system that is very good at being 
proactive and trying to prevent disease, change behavior.
    A lot of what we are trying to do with the American Heart 
Association Rockefeller Fund Initiative is figure out how can 
we really increase access to healthy foods, how can we create 
incentives, how can we make it easier for people to access 
those foods, and how do we determine what is sufficiently cost-
effective that private or public payers would be willing to pay 
for that.
    Senator Boozman. To keep them away from eating too much of 
the bad stuff.
    Dr. Volpp. That is one of the central problems.
    Senator Boozman. Or drinking too much, or whatever.
    Dr. Volpp. Because we all pay for the consequences, health 
care cost consequences when people get sick, but we do not 
invest very much in trying to keep people healthy, and we need 
to figure out what evidence would help make that logical for 
either private or public payers to do more widely.
    Senator Boozman. Very good. With that I yield back, Mr. 
Chairman, and again, thank you for a really good hearing.
    Senator Booker. Thank you for that, and I will turn to the 
very patient, marvelous Mr. Marshall.
    Senator Marshall. Well, Senator Chairman Booker, thank you 
so much, but before I start I just want to take a quick drink 
of the most wholesome, healthiest, nutritional drink every 
known to mankind. Here is to the farmers and the dairy folks.
    I am excited to be here to talk about food as medicine. 
This has been a priority for my entire professional life. I 
think it would be good to take a moment of pause, what is 
working out there when it comes to food as medicine. I think 
the WIC programs are outstanding. Food banks are doing a great 
job, and more and more there are opportunities for healthy 
choices at food banks. Meals on Wheels is doing an incredible 
job. Our senior citizen centers, where they get lunches, not 
only are they getting nutrition but they are getting some 
psychosocial help there as well. Something else I have seen out 
there that has worked in the real world are the Double Bucks 
for rewarding healthy choices.
    As we write a farm bill, it is part of my job as a Senator 
to figure out what is working and how can we accentuate them.
    As we think about nutrition, I cannot help but think about 
Medicare and Medicaid, that Medicare is facing a cliff, really 
insolvency, in 2028. Medicaid funding is always a challenge up 
here. What would be the impact of good nutrition on Medicare 
and Medicaid?
    I want to submit for the record an article from JAMA. It is 
April 22, 2019. It is entitled ``The association between 
receipt of a medically tailored meal program and health care 
use,'' an article that I read several years ago, and it 
demonstrates that the readmission rate for Medicare patients 
sent home with 10 tailored meals per week, that readmission 
rate was 20 percent of the control group. If you think about 
it, the average cost for a Medicare admission is $13,000. If 
there were 80 percent less of those, how could that be used to 
fund good nutrition? You know, maybe you make it an investment 
of $400 or $500 to save taxpayers $13,000, and not to mention 
it is the right thing to do.
    I think that is a great concept. Chairman of the all-power 
Ag Congress, as Senator Roberts taught me, and I are 
introducing legislation that would be a Medicare pilot project 
to do just that, to take a bigger group of patients, sending 
them home from the hospital with medically tailored meals. I 
think that is a great bipartisan opportunity.
    Next, Senator Booker and I, I think, are working on a 
project maybe that would attack more of the Medicaid 
population, and specifically I think there is the lowest-
hanging fruit are pre-diabetic folks. What could we send them 
home with? What should they be getting as far as a nutrition 
diet as well? We look forward to continuing that discussion, 
maybe based on BMI. Let us not even do a blood test. Just let 
them enter the program very easily. Use BMI perhaps, and maybe 
followup hemoglobin A1Cs as well. We are looking forward to 
that.
    Then Senator Gillibrand and I are working on getting milk 
back into the lunch program, specifically whole milk. We are 
going to have a generation of women that have osteoporosis and 
osteopenia in their 40's rather than in their 50's because they 
are not drinking milk at school. We want to bring that back 
into the program as well.
    This whole concept here reminds me about dynamic scoring, 
and when you have the CBO does not use dynamic scoring and how 
do we overcome that as well.
    I am preaching to the choir here, of course. One of my 
concerns is that the FNS recently provided recommendations for 
WIC that included additional non-dairy substitutes for moms and 
children in the WIC program. Again, the WIC program near and 
dear to me, something that my patients used every day. I think 
this is contrary to the recommendations of increased 
consumption of dairy products in the dietary guidelines for 
Americans.
    Then I am concerned about meatless Mondays and the impact 
of less protein in people's diets as well.
    I think my question is for Dr. Volpp. Do you believe meat 
and dairy are important sources of nutrients, like protein and 
calcium, for children and pregnant women?
    Dr. Volpp. It is a complicated question to answer. A lot of 
what you said I really agree with. The study you cite I believe 
was a Berkowitz et al. study that really showed very impressive 
results in terms of medically tailored meals for chronically 
ill post-hospitalization patients. I think those kinds of 
initiatives for the patients' post-acute care who are frail are 
really important.
    We also really need to think about programs for patients 
for primary prevention, so the patient with diabetes, the 
patient with diabetes who is not frail but who would benefit 
from easier access to healthy food, subsidized access to 
healthy food.
    I think the questions about meat are complicated because 
there are some meats that are healthier than others. Saturated 
fat is obviously a problem for people with heart disease, and 
the same thing with dairy. There are healthier alternatives in 
some cases, but it is very important for people to have enough 
protein in their diet. We need to figure out, holistically, how 
do you accomplish that, given the full range of food options.
    Senator Marshall. I appreciate that. I just hope we do not 
forget, though, that we need to be able to absorb the fat-
soluble vitamins somehow as well. I think for pregnant women 
especially it is very important. Those vitamins A, D, E, and K 
are very important as well. There are some good fats as well.
    I think I have passed my time. The last comment I would 
make is we almost need coaches as much as we need nutritionists 
and experts. I think most of us know what a healthy diet looks 
like, and we can make that more accessible. Somehow we have to 
get this coaching part of it as well and changing lifestyles, 
changing healthy lifestyles, and that is where it tends to 
break down.
    Dealing with pregnant women is probably the only time I saw 
huge lifestyle changes, and that is because they had a 
secondary motivation. The WIC program, all those folks so 
involved. How do we take that concept and expand it? It has 
been a question I have tried to answer for over 30 years, and 
maybe we will make some progress.
    Thank you. I yield back.
    Senator Booker. You had a paper you wanted to be put into 
the record. Without objection, that is put in the record.

    [The documents can be found on pages 62-92 in the 
appendix.]

    Senator Booker. No. 2 is you all know it is Senator Dr. 
Marshall, and he carries a lot of weight, I think, not only on 
this Committee but also in the entire
    U.S. Senate, and your passion for medically tailored meals 
and your partnerships on both sides of the aisle. I just wanted 
to recognize how grateful I am to work with you on some of 
these key issues.
    We are going to go into a second round because Senator 
Braun and I are in charge.
    [Laughter.]
    Senator Booker. We are going to jump right in to Ms. 
Penniman.
    The more I have learned about food as medicine programs 
such as yours in New York, which really should be in New 
Jersey, the more excited I am for the potential of these 
programs not just for the recipients of the healthy food but 
also for the positive benefits that these programs can have for 
small family farms.
    Can you please talk about that, about the benefits that 
your program has had on the farmers themselves, who are a group 
in America that are really struggling, especially independent 
family farmers.
    Ms. Penniman. Absolutely. Thank you very much, Senator 
Booker.
    As mentioned, when you all called me up and asked me to 
come to the Senate for the first time in my life I was nervous, 
so I asked for help. I called hundreds of farmers in our 
national network, and our network is small, beginning farmers, 
Black, indigenous, and people of color farmers, to say, you 
know, what are your experiences with this program?
    I got hundreds of responses. Everyone said these are 
essential, and I will highlight a couple.
    I spoke with Corbin Hill Food Project, which is a New York-
based, Black-led food distribution program, and they are able 
to keep 200 regional farmers afloat with purchases through the 
GusNIP program. That is incredible.
    I also talked to Bil Thorn, at Sky Island Farm, which is 
the largest Black producer in Washington State and a 
participant in the Farm to Pantry and Prescription program, and 
he said these programs keep small and midsized farms afloat. 
Otherwise they primarily sell wholesale, and those outlets 
often do not take quantity, and they do not take quantity 
reliably. Having that steady market is really important.
    As you mentioned, Senator, farmers in this Nation are 
absolutely at risk. The average age of the U.S. farmer is now 
58. For Black farmers it is almost 62. 96 percent of farmers 
are relying on off-farm income just to survive.
    We are part of the National Young Farmers Coalition, which 
did a survey nationally of the up-and-coming farmers, who we 
really need to pay attention to or farming will die out in this 
country. They said that, again, the super-majority of farmers 
are struggling to make ends meet, but importantly, 83 percent 
of young farmers are motivated by social concerns, like ending 
hunger, as one of the primary reasons they want to farm.
    There is a huge opportunity to connect these Federal 
programs with these up-and-coming young farmers who are 
socially motivated, who want to make a difference in their 
communities, who care deeply, and are connected.
    As we noted, these anonymized programs just do not work. 
People need to be in communities that have a culture of health, 
and these farmers are in community with folks who need this 
food and are ready to engage in that way.
    Senator Booker. Thank you very much. That was incredible, 
firsthand testimony.
    Really quickly, Mr. Richards, you testified that your most 
recent application for GusNIP was not funded. Could you talk 
about what impact that loss of Federal funding will have on 
your work?
    Mr. Richards. Well, we are working very hard to minimize 
that impact, and we are reaching out to many of our funders.
    The fastest-growing sector of the work is the retail, 
right, and most folks utilizing SNAP use their benefits at 
retail outlets. We have worked at five retail outlets. Four of 
those are members of the Independent Grocers Association 
Eastern Kentucky, in which 40 percent of their customers are 
utilizing SNAP. Without the dollars to double up the SNAP 
fruits and vegetables, just at those four locations, we are 
talking about eastern Kentuckians, Appalachians not getting 
almost $200,000 worth of fresh fruits and vegetables. We are 
talking about those same Appalachian farmers not getting almost 
$200,000 worth of sales. It is going to be pretty tough, right.
    I think, you know, we have built this momentum over the 
last six years, and even a pause in it is going to destroy that 
kind of momentum. For anybody in Kentucky, there is a story 
about the time that the Bell Pepper Co-Op came in to help 
tobacco farmers, instead of growing tobacco growing bell 
peppers, and they formed a co-op, and all the farmers signed up 
for it. Then the co-op kind of went away.
    Any time you talk about something in Kentucky and you 
mention the Pepper Co-Op, farmers are like, ``Yes, I know what 
you are talking about.'' I do not want Kentucky Double Dollars 
to be used in the same sentence as the Bell Pepper Co-Op.
    Senator Booker. Amen to that. Senator Braun.
    Senator Braun. Thank you. What we were able to do, in the 
business I ran, is put in a solution that worked. It was in a 
broken system. There is nothing like health care, as it has 
currently evolved into, where there is more lack of 
transparency, where there are barriers to entry to get into the 
business of health care at so many levels, competition so 
growing less rather than more, and then I mentioned earlier you 
do not have an engaged consumer.
    The classic market, if it is going to work, has to have 
full transparency to where the suppliers and the consumers have 
an equal amount of information. You have got to have a lot of 
competitors, and you cannot have barriers to entry that 
normally come from lobbyists.
    We were able to tease out some of the transparency that is 
in the system on the fringes. Like if you pick up the phone, 
you get on the Web, you can generally find savings of 30 to 70 
percent on a lot of prescriptions, and some of the procedures 
like MRIs, colonoscopies, CT scans.
    If we could take the cost out of it, you could all of a 
sudden start investing more in the wellness portion of it. I 
would like the opinions of a couple of doctors that I have not 
spoken to--Dr. Volpp, Dr. Bulger--how much of our problem is 
the system itself lacking the engaged consumer, having a 
delivery system that gives you none of the features of a 
competitive market, 20 percent of our GDP, 12 percent 
everywhere else, and if we brought that cost down then you 
could start pouring resources into where it ought to be--
prevention, wellness, and so forth. What do you think?
    Dr. Bulger. I think that is a great question. I do think 
that inherent in the payment system is you are paid for doing 
things.
    Senator Braun. Yep.
    Dr. Bulger. Not necessarily paid in most cases, for keeping 
people healthy. I think one of the things that we have been 
able to do in our neck of the woods at Geisinger, in the fact 
that we are both a payer and a provider, and one of the places 
in that nexus of those two where we created the Fresh Food 
Farmacy, where we do both, I think one of the reasons we were 
incented to do that is because we were the payer, and we know 
that by focusing on prevention you will decrease the total cost 
of care, and on our provider side that created something like 
the Fresh Food Farmacy.
    I think that disconnect where the payment system is paying 
for doing things as opposed to worrying about the total cost of 
care and keeping people healthy, and I think that was probably 
one of the differences why, in your business, you did something 
different because you were at risk for the total cost of care 
for your employees, so you said, ``What can I do differently 
here?'' and thought about prevention and how that would 
decrease the total cost of care, instead of worrying about what 
you were paying out.
    Senator Braun. Do you think the system, as it currently 
exists, especially where hospitals have now grown to like 43 
percent of that health care bill that used to be closer to 30, 
try getting some transparency to find out what that is going to 
cost? It is nearly impossible. The fact that they do not make 
it easy--where else do you spend that much money and do not 
really have any idea what it is going to cost until you get 
your bill, two to three months later, and then you hold your 
breath?
    Dr. Bulger. Yes.
    Senator Braun. On the other hand, the consumer has no 
incentive because they do not have skin in the games. That is 
one of the features we created, so they do not shop around.
    When you see someone at a grocery store trying to save a 
buck on a $5 item, that is transparency. That is competition 
because it works there.
    I think we are kind of spinning our wheels because we know 
what needs to be done, but we have got a broken system we are 
working within.
    Dr. Volpp, what do you think?
    Dr. Volpp. A few additional observations. When you look 
across countries and you look at the combination of health and 
social service spending, the U.S. actually is right in the 
middle of the OECD countries. When you look at just health 
spending, we are an outlier. As you know, we rank something 
like 36th in life expectancy. We are trying to address a lot of 
issues by paying for expensive health care, and that is 
obviously not a very cost-effective solution.
    Thinking critically about what do we pay for, how much do 
we pay, and can we encourage innovation of cost-effective ways 
to keep people healthy outside of health care is very important 
for us to do, and food as medicine can be part of that.
    Second, I agree with you that we need more price 
transparency. People have no idea how much it is going to cost 
them to go to the emergency room and get hospitalized. If you 
are trying to encourage people to use urgent care instead of 
the emergency room, it would be very helpful if people knew 
what the relative prices were ahead of time.
    We could do a lot more with transparency and incentives to 
encourage people to use both lower-cost providers and higher-
quality providers if that information were more widely 
available.
    Senator Braun. Most of those other systems are closer to a 
one-payer system because the clout of the payer has got a 
little more parity with the system itself that provides health 
care. I do not think we need to go there, but if we do not fix 
it, I think it is up to the health care industry to embrace 
transparency, competition, bring the cost down, and then have 
them, as the remediators, start promoting wellness as well. 
That is when we get to the best of both words. We are just so 
far away from it.
    Dr. Volpp. Yep.
    Senator Booker. All right. Even though I have been warned 
by the higher-ups in the U.S. Senate that there is too much 
common sense being discussed at this hearing--it is very un-
Senate-like--I just want to jump really quick to some speed 
rounds so we can all get out of here.
    Real quick, Dr. Bulger, I think that both Senator Braun and 
myself focused on the data and follow the data, but I imagine 
there are things you are seeing that right now are not really 
being measured. Your program, for example, the Fresh Food 
Farmacy, is it having an impact on the entire family beyond 
just your patient?
    Dr. Bulger. It is, and I think one of the things we have 
seen is that--and we are beginning to measure this--is that our 
patients and their families engage much more in health care 
when they get the food. The food is almost the carrot to bring 
them in and get them to engage with clinical nutritionists and 
nurses and other things which they would not engage with 
necessarily if the food was not there.
    Senator Booker. Even though you are measuring, you are 
confident this has a multiplier effect on the health and well-
being of the entire family.
    Dr. Bulger. Right.
    Senator Booker. You guys, it is common sense. You are 
looking at this in diabetes but you are probably going to 
expand this program to patients with other diet-related 
diseases. Yes?
    Dr. Bulger. Absolutely.
    Senator Booker. Yes, because it would be malpractice, of 
sorts, not to try to continue to do that and expand it. 
Correct?
    Dr. Bulger. Yes.
    Senator Booker. Thank you very much.
    Ms. Penniman, you talked about the impact that this kind of 
scale of funding is having on a lot of different farmers you 
surveyed in your world. Just thing we really have not talked 
about is this growing reality in America that we have these 
massive health care disparities along racial lines in this 
country, where African Americans, in particular, have some of 
the highest morbidity rates on diseases. It is stunning that 
besides Native populations, Black men have the lowest life 
expectancy.
    Can you just really quickly give me a concise thought on 
how this kind of funding for these key programs, like GusNIP, 
really have, from an equity perspective?
    Ms. Penniman. Absolutely, and that is both for the consumer 
and the farmer. We work with low-income people of color 
populations that we distribute food to, who have fibromyalgia, 
diabetes, heart diseases, struggle with weight, kidney failure, 
and again, 100 percent of respondents over the 15 years of this 
program have said ``improved outcomes.''
    On the farmer side, we also have to reckon with the fact 
that the USDA has a huge racial equity issue--97.8 percent of 
all government payments are given to white farmers. In that 
National Young Farmers Coalition survey I mentioned, they were 
asking young farmers, ``How many of you, of all races, how many 
of you applied for any USDA program?'' Half of them have never 
applied, and 75 percent do not even know which ones they would 
qualify for.
    Something that is fascinating, though, and there are 
historical reasons why, you know, they are a little problematic 
for this, but farmers of color tend to disproportionately grow 
fruits and vegetables and livestock. White farmers 
disproportionately grow grain and oil seed crops. It has to do 
with access to good land and the history of that and the failed 
promise of 40 acres and a mule, right?
    Asian farmers, Black farmers, Latina farmers are growing 
these specialty crops disproportionately and are also 
underfunded by the USDA. There is an opportunity here, by 
scaling up GusNIP and other programs that target these 
specialty crops, in also starting to address the equity issues 
because farmers of color are the ones disproportionately 
growing these crops.
    We do have to make sure we are talking to these communities 
because there is a mismatch often in the growing season with 
the application process, with produce delivery scheduled in the 
winter months when there is no produce, with culturally 
inappropriate food. It is not just as simple as increasing 
funding. We need to make sure we are talking to these people. I 
think there is a huge opportunity to address inequity in 
funding farmers through these programs.
    Senator Booker. I wish we had more time to talk about that, 
but what you just said is so powerful in closing racial wealth 
gaps, closing racial health gaps. Not necessarily a program 
that is targeted toward Black people but programs that are 
targeted to these larger societal problems, not only heal 
health but also heal a lot of these historic divides.
    Last, back to Kentucky. It all comes back to Kentucky. 
Last, Mr. Richards, you are a farmer yourself. I love that you 
were a tobacco farmer. I am never going to forget the bell 
pepper example. If I am ever in Kentucky I will never bring up 
the Bell Pepper Co-Op. ``Hi, I am from the Federal Government. 
Let's talk about bell peppers'' will never come out of my 
mouth.
    Finally, can you close us out with a high point of talking 
about really scaling up the GusNIP program? As a former farmer 
yourself, besides all the benefits the other doctors were 
talking about, could you just last--because it is a big rural 
divide. We talked about an ethnic divide, there is a real rural 
divide in this country. Could you please just allow us to 
understand how really scaling up will help rural America in a 
significant way?
    Mr. Richards. Yes. I mean, I can only talk about my 
experience. As a tobacco farmer, every February I got the 
letter, I got my quota. This is how much tobacco I could grow 
that year and market, and that set my whole year out. The 
infrastructure was there. All the technical, the TA was all 
there for me.
    When I started growing food I did not have any of that 
support system. I did not know what I was going to make that 
year. It was all completely unknown.
    So we, at CFA, looked at the Federal food nutrition 
programs, the 14 of them that are in Kentucky, specifically how 
many SNAP dollars were coming into our State. We thought, how 
can we leverage these Federal food nutrition programs to create 
the equivalent of the tobacco program for farmers who are 
growing food? That is how this work started.
    Why it is so important for these GusNIP fund is because it 
creates a baseline of support that farmers know, from year to 
year, how much they can expect to sell. Right now--well, this 
December, but starting next month folks are going to start 
ordering seeds. They are going to start planning the year. For 
almost 1,200 Kentucky farmers that is dependent upon Kentucky 
Double Dollars and the Fresh Rx Program for Moms.
    The other important think, and I think as Leah said, for 
beginning farmers, for BIPOC farmers, growing fruits and 
vegetables, that is it. Our State FSA office recently testified 
that the fastest-growing sector in Kentucky agriculture is from 
one to nine acres, and that is because those are the folks that 
are growing fruits and vegetables as an entry point, and then 
they start scaling up.
    I could go on and on, obviously, but I will stop there.
    Senator Booker. No, we appreciate that.
    Before I do the official closing I just want everybody know 
this is the last Subcommittee hearing of the 117th Congress of 
this Subcommittee. I want to say, for the record, how much of 
an honor and a privilege it has been to work with Senator 
Braun. He has been a really powerfully, prodigiously, pragmatic 
partner--how is that for alliteration?--but really courageous 
in his willingness to step out there, in a bipartisan way, 
whether it is with the White House, with me. You have just been 
truly a gift to me, as my first time chairing a subcommittee in 
the Agriculture Committee, and you have made this work not only 
more pleasant, but you have helped to push, I think important 
conversations that we need to be having about how to make 
American greater, more healthy, more economically wise.
    It has just been an honor to work with you, my friend.
    Senator Braun. My pleasure to do it.
    Senator Booker. Right. I wish you the best on wherever your 
journey takes you.
    Then on closing, to everybody, we would ask that any 
additional questions that anybody has, to the staffs of the 
other Senators that are here, be submitted to the clerk five 
business days from today, or 5 p.m. next Monday, December 19th.
    I want to thank the incredible panel that is here. You all 
have been extraordinary. This hearing is adjourned.

    [Whereupon, at 11:50 a.m., the hearing was adjourned.]

      
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