[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
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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
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Tuesday, December 13, 2022
Page
Subcommittee Hearing:
Food as Medicine: Current Efforts and Potential Opportunities.... 1
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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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December 13, 2022
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