[Joint House and Senate Hearing, 118 Congress]
[From the U.S. Government Publishing Office]


                                                    S. Hrg. 118-143

                    THE ECONOMIC IMPACT OF DIABETES

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                                HEARING

                               BEFORE THE

                        JOINT ECONOMIC COMMITTEE

                                 OF THE

                     CONGRESS OF THE UNITED STATES

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             JULY 27, 2023

                               __________

          Printed for the use of the Joint Economic Committee
          
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        Available via the World Wide Web: http://www.govinfo.gov
        
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                    U.S. GOVERNMENT PUBLISHING OFFICE                    
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                        JOINT ECONOMIC COMMITTEE

    [Created pursuant to Sec. 5(a) of Public Law 304, 79th Congress]

SENATE                               HOUSE OF REPRESENTATIVES
Martin Heinrich, New Mexico,         David Schweikert, Arizona, Vice 
    Chairman                             Chairman
Amy Klobuchar, Minnesota             Jodey C. Arrington, Texas
Margaret Wood Hassan, New Hampshire  Ron Estes, Kansas
Mark Kelly, Arizona                  A. Drew Ferguson IV, Georgia
Peter Welch, Vermont                 Lloyd K. Smucker, Pennsylvania
John Fetterman, Pennsylvania         Nicole Malliotakis, New York
Mike Lee, Utah                       Donald S. Beyer Jr., Virginia
Tom Cotton, Arkansas                 David Trone, Maryland
Eric Schmitt, Missouri               Gwen Moore, Wisconsin
J.D. Vance, Ohio                     Katie Porter, California

                  Jessica Martinez, Executive Director
                 Ron Donado, Republican Staff Director
                           
                           
                           C O N T E N T S

                              ----------                              

                      Opening Statement of Member

                                                                   Page
Hon. Martin Heinrich, Chairman, a U.S. Senator from New Mexico...     2

                               Witnesses

Buu Nygren, Ed.D., President, Navajo Nation, Window Rock, AZ.....     5
Janet Brown-Friday, RN, MSN, MPH, President, Health Care and 
  Education, American Diabetes Association, Washington, DC.......     6
Benedic N. Ippolito, Ph.D., Senior Fellow, American Enterprise 
  Institute, Washington, DC......................................     8
Mark A. Herman, M.D., E.L. Wagner, M.D., Chair of Internal 
  Medicine II, Chief, Section of Endocrinology, Diabetes, and 
  Metabolism, Baylor College of Medicine, Houston, TX............    10

                       Submissions for the Record

Prepared statement of Hon. Martin Heinrich, a U.S. Senator from 
  New Mexico.....................................................    36
Prepared statement of Dr. Buu Nygren, President of Navajo Nation, 
  Window Rock, AZ................................................    39
Prepared statement of Mrs. Janet Brown-Friday, RN, MSN, MPH, 
  President, Health Care and Education, American Diabetes 
  Association, Washington, DC....................................    44
Prepared statement of Dr. Benedic N. Ippolito, Senior Fellow, 
  American Enterprise Institute, Washington, DC..................    51
Prepared statement of Dr. Mark A. Herman, E.L. Wagner, M.D., 
  Chair of Internal Medicine II, Chief, Section of Endocrinology, 
  Diabetes, and Metabolism, Baylor College of Medicine, Houston, 
  TX.............................................................    61

 
                    THE ECONOMIC IMPACT OF DIABETES

                              ----------                              


                        THURSDAY, JULY 27, 2023

                            United States Congress,
                                  Joint Economic Committee,
                                                    Washington, DC.
    The hearing was convened, pursuant to notice, at 10:04 
a.m., in Room 192 of the Dirksen Senate Building before the 
Joint Economic Committee Chairman, Martin Heinrich.
    Senators: Hassan, Heinrich, Kelly, Welch, and Lee.
    Representatives: Schweikert, Ferguson, Smucker, 
Malliotakis, Beyer, and Moore.
    Staff: Nicholas Aquelakakis, Christina Carr, Tess Carter, 
Hannah Ceja, Sebi Devlin-Foltz, Ron Donado, Michael Farren, 
Tomas Gallegos, Owen Haaga, Colleen Healy, Jeremy Johnson, 
Brooke LePage, Mirella Manilla, Jessica Martinez, Michael 
Pearson, Elisabeth Raczek, Alfredo Romero, Christopher Russo, 
Jeff Schlagenhauf, Alexander Schunk, Douglas Simons, Lia 
Stefanovich, and Garrett Wilbanks.

      OPENING STATEMENT OF HON. DAVID SCHWEIKERT, A U.S. 
  REPRESENTATIVE FROM ARIZONA, VICE CHAIRMAN, JOINT ECONOMIC 
                           COMMITTEE

    Vice Chairman Schweikert. All right. Shall we give this 
hearing a start? Welcome to the JEC. I actually have to give 
Senator Heinrich and the entire team, both the Democrat and 
Republican staff.
    This is one, I am not even going to do this from some sort 
of script, has been in sort of discussion for quite a while. As 
we look at the health statistics of our nation, particularly 
diabetes, its cost to society not only just in health care cost 
but in so many of our brothers and sisters that just have 
misery.
    And where this partially came from is about two-three years 
ago, we were actually doing a weird experiment. What is the 
real cause of income inequality in America? And yes, we saw 
education, we saw other things, but the one thing we were not 
prepared to see was health.
    The numbers of folks in, I hate to use the economic term, 
in some of the quartiles that had real health issues and a 
number of it was diabetes. And so we have spent almost two 
years sort of digging around in the literature, trying to 
understand what is going on in society, particularly the growth 
of our population that are suffering, but also now we are 
seeing juvenile, our young people.
    A chart came out about three weeks ago that basically said 
at the end of this decade, almost half of our kids will 
technically be obese, and then the cascade effect of potential 
diabetes with that.
    Maybe there is a moment here where this is not Republican 
or Democrat, right or left. It is actually focusing on what is 
going on in our society and our moral obligation to find a way 
to end this misery, bring back productivity and there is a 
punchline for those of us who often sound like accountants on 
steroids. It is actually really good economics.
    So I am--for our two witnesses, and then I will hand it 
over to the good Senator, Dr. Mark Herman serves of the Chief 
of the Section of--I always get the word wrong--Endocrinology. 
All right, thank you for bailing me out, diabetes and Metabolic 
at Baylor College of Medicine.
    Dr. Herman is both a practicing doctor and leading medical 
researcher. His primary focus is on diabetes treatment and 
care. As an expert in metabolic diseases, Dr. Herman's research 
has improved our understanding of diabetes itself, as well as 
made advancements in diabetes treatment.
    Doctor, and we did our best on this, Lullipo?
    Dr. Ippolito. Ippolito.
    Vice Chairman Schweikert. Not even close. He is a Senior 
Fellow of Economics and Policy Studies at the American 
Enterprise Institute. His research focuses on public finance 
and health economics. He has written on health care finance, 
competition and pharmaceutical markets, and the economics of 
value of medicine innovation.
    He has earned his Ph.D. in Economics from the University of 
Wisconsin-Madison. Senator Heinrich.

OPENING STATEMENT FROM THE HON. MARTIN HENRICH, A U.S. SENATOR 
      FROM NEW MEXICO, CHAIRMAN, JOINT ECONOMIC COMMITTEE

    Senator Henrich. Thank you, and I want to start just by 
thanking Vice Chairman Schweikert for his passion in this area, 
and it is something that touches all of us. It certainly 
touches our two states, and when you look at just the raw 
numbers, the economic impacts of diabetes on our economy and 
our nation, are really astounding.
    More than 37 million Americans, about one in ten, have 
diabetes, and another 96 million adults have pre-diabetes. 
Diabetes is growing more prevalent, with an estimated one in 
three Americans expected to develop the disease at some point 
in their lifetime, and that is just an astounding figure that 
drives so much of our health care costs.
    The rising costs of diabetes are due to the high price of 
medications and treatments in the doctor's office, and also 
lost earnings due to sickness, lower employment rates and the 
cost of early retirement. These costs are borne by the patient, 
by our health systems, by employers and really by entire 
communities as we will hear about today.
    That is where we focus in this hearing today I think, 
identifying the direct and indirect costs of diabetes on our 
economy, finding bipartisan solutions that ensure that we have 
a healthy population who really can fully contribute to their 
economies. Part of tackling this is making sure that all 
Americans have access to quality, affordable health care, no 
matter their means or where they live geographically.
    When patients lack access to health care, minor challenges 
can quickly become major challenges, with a lack of proper 
diagnosis and treatment, and that is especially true in rural 
and tribal communities, where diabetes is increasingly 
prevalent.
    Too many Americans are living with undiagnosed to untreated 
diabetes, because they cannot afford to see a doctor, to pay 
for prescribed medications, or travel the long distances 
required to get to a provider. Living with undiagnosed diabetes 
can delay more effective treatments that prevent more extreme 
complications, and impact people's ability to provide for their 
families.
    Like most diseases, we know that Type 2 diabetes 
prevention, early intervention and health education are both 
cost effective and lead to better health outcomes. Beyond that, 
we must understand and address the upstream causes of the 
disease, including factors like socioeconomic status and access 
to quality nutrition.
    Food insecurity is closely associated with Type 2 diabetes. 
When families have access to nutrition programs like SNAP and 
WIC, they are able to more consistently access healthy food, 
and we have seen associated reductions in both poverty and 
health care expenditures. Fortunately, medical science has also 
had recent breakthroughs on pharmaceutical treatment options 
for diabetes, and I am looking forward to hearing more about 
how recent breakthrough treatments have had positive outcomes 
for patients, and have helped to change their lives for the 
better.
    Unfortunately however, many of those treatment options 
remain unaffordable for many patients. The Inflation Reduction 
Act was an important step in controlling drug costs. The law 
established several cost control measures like limiting insulin 
co-pays for Medicare beneficiaries to $35 a month, and capping 
annual out of pocket prescription drug costs at $2,000 starting 
in 2025.
    The Act also gives Medicare the ability to negotiate the 
price of some high cost prescription drugs, and forces drug 
companies to pay a penalty when the prices that they charge 
Medicare rise faster than inflation. These actions will all put 
downward pressure on drug costs, while having little impact on 
innovation.
    It is clear that the most--the most effective treatment for 
diabetes requires a comprehensive and holistic approach 
addressing diet, lifestyle, mental health and other societal 
factors alongside medical treatments. We have had some 
successes on this front, such as with the Special Diabetes 
Program for Indians, which Congress established in 1997. This 
program provides funding for diabetes prevention and treatment 
services to over 300 Indian health programs across the United 
States, and provides grantees with flexibility to design and 
implement diabetes interventions that address locally 
identified community priorities.
    Through this program, we have seen youth-based outreach, 
the planting of community gardens, running and fitness events 
and partnership programs for pharmacies that help patients 
manage their prescriptions.
    The Special Diabetes Program for Indians has been extremely 
effective. Since it started, the prevalence of diabetes, end 
stage renal disease and diabetes-related eye disease among 
American Indians and Alaska Natives have all declined.
    We need to increase the funding for this program to allow 
it to keep up with costs and better serve all tribes. And 
looking beyond tribal communities, we should look to this 
program as a model for how we can design and implement 
comprehensive disease treatment and management nationwide.
    I am pleased to join my colleagues from both sides of the 
aisle to further explore these issues, and more today in this 
bipartisan hearing, and I am looking forward to hearing more 
today on the impacts of diabetes on our communities from the 
ways we can address the upstream causes, to the role of health 
and nutrition programs and prevention, treatment and the role 
of pharmaceutical interventions.
    It is my pleasure to also introduce our two other 
distinguished witnesses. We have President Buu Nygren, who was 
elected as the 10th President of the Navajo Nation, an office 
he assumed in January of this year. He also serves as the 
Navajo Area Representative to the National Indian Health Board.
    President Nygren previously served as the chief commercial 
officer for the Navajo Engineering and Construction Authority--
we need more engineers around here, by the way president--a 
quasi-independent tribal enterprise headquartered in Shiprock, 
New Mexico from 2010 to 2018.
    President Nygren was a national operation trainer and a 
project manager at a multi-billion dollar construction company 
that built schools, senior living homes and public safety 
facilities from Nevada to Florida. President Nygren also served 
as the first president of the Change Labs' board of directors, 
a non-profit that continues to support Navajo and Hopi 
entrepreneurs, with basic tribal-specific technical assistance.
    President Nygren has a B.S. in Construction Management and 
an MBA from Arizona State University. You have heard of that, 
right?
    [The opening statement of Chairman Heinrich appears in the 
Submissions for the Record on page 36.]
    Vice Chairman Schweikert. I have the same MBA.
    Chairman Heinrich. And a Doctor of Education in Organized 
Change, or sorry, Organizational Change and Leadership from the 
University of Southern California.
    Mrs. Janet Brown-Friday is the president of Health Care and 
Education at the American Diabetes Association. Mrs. Brown-
Friday has been a registered nurse for more than 40 years, and 
most recently serves as the clinical trial manager at the 
Albert Einstein College of Medicine's Diabetes Clinical Trials 
Unit.
    Mrs. Brown-Friday serves on the National Board of the 
American Diabetes Association, and she remains a current member 
of the NYC Community Leadership Board for the ADA. Mrs. Brown-
Friday also previously served as a committee member for the 
National Diabetes Education Program and as a special government 
employee and a council member for the National Institute of 
Diabetes and Digestive and Kidney Diseases Advisory Council.
    Mrs. Brown-Friday holds an MPH in Community Health 
Education, and an M.S. in Community Health Nursing from Hunter 
College in New York City, New York.
    President Nygren, we are going to begin with you and your 
testimony, and then we will go left to right or right to left. 
Okay, right to left down the dais today. So welcome President, 
and we look forward to hearing your testimony.

STATEMENT OF BUU NYGREN, PRESIDENT, NAVAJO NATION, WINDOW ROCK, 
                            ARIZONA

    President Nygren. Good morning Chairman Heinrich and Vice 
Chairman Schweikert, and esteemed Members of the Joint Economic 
Committee. I am Dr. Buu Nygren, president of the Navajo Nation. 
I serve as also the Navajo Area Representative to the National 
Indian Health Board. I come before you to speak about a matter 
that not only affects the welfare of our nation, but also a 
significant issue for all indigenous people across the United 
States.
    We are here to discuss the importance of the special 
diabetes program for Indians. Today, the Navajo Nation provides 
governmental services to over 400,000 members, and our on-
reservation population is about 200,000, which accounts for 
one-third of all Natives living in Indian country.
    Like many other American Indian tribes, Navajo people 
experience higher rates of preventable nutrition-related 
diseases such as obesity, diabetes, heart disease and cancer 
than the general U.S. population. These health issues are not 
part of our heritage, but the consequences of painful history 
marked by colonization, forced assimilation, displacement from 
our tribal homelands and relocated to reservation lands.
    Historically, our communities thrived on farming, herding 
and hunting and gathering. These traditional practices provided 
us with nutritious foods that sustained us for generations. 
However, this way of life has been systematically eroded over 
time, as processed foods high in fat, sugar and salt have 
replaced all our traditional food sources.
    This compounded by poverty, unemployment and the lack of 
transportation has amplified the health disparities we face 
today. In 1997, Congress established the SDPI, a critical 
response to the escalating diabetes epidemic in Indian country.
    This program, as mentioned earlier, has a budget of 150 
million funds, over 300 community-based intervention programs 
to prevent Type 2 diabetes. Despite these efforts, diabetes 
remains a persistent public health problem among our people.
    In 2011, the Navajo Nation, in collaboration with HIS, 
changed their approach. We began to engage local community 
input and implement interventions that are culturally relevant 
and sensitive to our unique circumstances. Recognizing our 
inherent sovereignty, we have initiated our own disease 
prevention activities, data collection, policy development and 
evaluation initiatives.
    In 2014, the Navajo Nation enacted the Healthy Action Act, 
that introduced a two percent tax on unhealthy foods. This Act 
has generated 10 million, funding over--funding vital local 
community wellness projects. This approach has provided much-
needed funding and promoted healthier eating habits within our 
community.
    However, these efforts alone are not enough. The special 
diabetes program for Indians is critical in providing quality 
diabetes care and prevention practices, resulting in lower 
incidence in end stage renal disease and lower prevalence of 
Type 2 diabetes among Native Americans.
    All these things save taxpayer dollars in medical costs. 
From 1996 to 2013, incident rates of end stage renal disease 
among Native Americans of diabetes declined by 54 percent. This 
reduction along is estimated to have a value of 520 million 
over nine years.
    These programs have had a tangible impact on our 
communities. The Navajo Wellness Centers funded by SDPI have 
already shown promising results, providing health screenings 
and conducting wellness activities. These centers help detect 
and manage diabetes, and have also been successful in promoting 
overall health and well-being within our communities.
    However, the current funding levels for SDPI are barely 
enough to maintain existing initiatives. We need to ensure that 
every Navajo individual who is fighting this disease has access 
to the resources and care they need. Our ask today is for the 
reauthorization of the SDPI and for an increase in funding that 
will enable us to expand our programs, reach more people, 
ultimately turn the tide in this fight against diabetes.
    We support legislation passed by committees in each chamber 
that would renew the SDPI for two years at a funding level of 
170 million per year to serve more Native Americans 
effectively. The special diabetes program for Indians is the 
gold standard when it comes to diabetes treatment, and probably 
considered one of the most effective public health programs 
ever created.
    We urge you to consider human faces behind the statistics. 
Our elders, our children and our family, they all look to you 
and hope that their government will continue to support them in 
their fight against this devastating disease. You have the 
power to turn this hope into reality. Thank you for your time, 
your consideration and your continued support. (Speaks in 
Navajo language) Thank you.
    [The statement of President Nygren appears in the 
Submissions for the Record on page 39.]

   STATEMENT OF JANET BROWN-FRIDAY, RN, MSN, MPH, PRESIDENT, 
   HEALTH CARE AND EDUCATION, AMERICAN DIABETES ASSOCIATION, 
                         WASHINGTON, DC

    Mrs. Brown-Friday. Thank you. Thank you Chairman Heinrich 
and Vice Chairman Schweikert, and distinguished Members of the 
Joint Economic Committee, for inviting me to testify on behalf 
of the American Diabetes Association, regarding cost of living 
with diabetes. We appreciate you considering this important 
topic at this critical time.
    The ADA is the nation's leading voluntary health 
organization, fighting to bend the curve on the diabetes 
epidemic and help people living with diabetes thrive. For more 
than 80 years, the ADA has been driving discovery and research 
to treat, manage and prevent diabetes, while working 
relentlessly for a cure.
    Today, I would like to take this opportunity to describe 
and offer context for some of the most significant drivers of 
cost increases for people living with diabetes, and the work 
ADA is doing to make managing diabetes more affordable and 
prevent costly adverse outcomes.
    According to the CDC, more than 37 million Americans live 
with diabetes and nearly 100 million Americans have pre-
diabetes. Diabetes is the most expensive chronic condition in 
the United States. People with diabetes account for one of 
every four dollars spent on health care and nearly one-third of 
Medicare drug spending. People of color and other under-served 
populations, those who lack access to adequate health insurance 
coverage, health care services and the tools they need to 
manage bear a disproportionate share of the costs.
    That is because 18 percent of black Americans, 17 percent 
of Latino Americans and nearly 15 percent of Native Americans 
have diabetes, compared to seven percent of white Americans. 
Because diabetes diagnoses are less likely when people have 
access to resources, diabetes prevalence is inversely related 
to household income.
    Individuals who earn less than $30,000 per year are three 
times more likely to have diabetes than those who make more 
than $80,000. Lower income Americans in rural, in both rural 
and urban areas are also likely to develop diabetes, experience 
complications from poorly-managed diabetes and die younger than 
higher income Americans.
    These costs and disparities become even more acute during 
the recent pandemic, and consequent economic impact. Americans 
with diabetes and other related underlying health conditions 
were hospitalized with COVID-19 six times as often and died of 
COVID-19 12 times as often as those who did not have diabetes.
    One in ten coronavirus patients with diabetes died within 
one week of hospital admission. Americans with diabetes 
accounted for 40 percent of COVID-19 fatalities nationwide, 
despite making up just ten percent of the U.S. population at 
the time.
    Some of the major drivers of these high costs are care of 
people with--for care of people with diabetes, high rates of 
hospitalizations. Having health insurance is the strongest 
single predicter of whether adults with diabetes will receive 
high quality health care services.
    More than 27 million uninsured Americans have a higher 
likelihood of having undiagnosed diabetes because they are 60 
percent less likely than insured individuals to have regular 
office visits with a physician, and have 168 percent more 
emergency room visits.
    Comorbidities. People with undiagnosed diabetes are more 
likely to develop comorbidities, from kidney failure to 
coronary artery disease, increasing costs and severely limiting 
their ability to get healthy.
    Costs of prescription drugs. Americans spend more treating 
diabetes than any other chronic condition. People with diabetes 
in the U.S. spend two and a half times more on health care than 
those who do not have diabetes, and one in four insulin-
independent Americans report rationing their insulin supply.
    The lack of access to diabetes technology. 31 percent of 
individuals with diagnosed diabetes or ten million Americans 
are treated with insulin and stand to benefit from a continuous 
glucose monitoring insulin pump, and yet we know that people 
who lack adequate access to health care providers and rely on 
Medicaid for health insurance coverage are least likely to be 
prescribed an CGM and other diabetes management technology.
    Lack of access to healthier foods can lead to being 
overweight and obesity, both of which are proven risk factors 
driving as many as 53 percent of new cases of Type 2 diabetes 
each year. And we now know that rates of both Type 1 and Type 2 
diabetes have increased and may be linked to COVID-19 
infections, as has been seen in some studies.
    I thank you for the opportunity to testify before the Joint 
Economic Committee on the cost of diabetes. The ADA looks 
forward to continuing the work with Congress to address health 
inequities, reduce cost to patients, and help Americans with 
diabetes access the tools, medications and services they need 
to stay safe and healthy.
    [The statement of Mrs. Brown-Friday appears in the 
Submissions for the Record on page 44.]
    Chairman Heinrich. Thank you, Mrs. Brown-Friday.
    Vice Chairman Schweikert. And Mrs. Brown-Friday, some of 
that was wonderfully helpful, because you were--actually he and 
I are going to--Wow, did you hear what she said?
    Doctor.

    STATEMENT OF BENEDIC N. IPPOLITO, PH.D., SENIOR FELLOW, 
                 AMERICAN ENTERPRISE INSTITUTE

    Dr. Ippolito. Well, Chairman Heinrich, Vice Chairman 
Schweikert and Members of the Committee, my name is Ben 
Ippolito. I am an economist at the American Enterprise 
Institute, where a lot of my work focuses on the issue of high 
health care cost, broadly speaking. So thank you very much for 
having me today.
    And you know, when you think about diabetes, as the 
incidence of diabetes has grown, so too have its costs, both to 
individuals and, as was mentioned earlier, the country more 
broadly. I think a lot of us focus on the heath cost, the 
direct health cost and that is for good reason.
    Higher health care utilization contributes nearly $300 
billion a year in health care spending, and that is just 
adjusting prior estimates for inflation over the last five 
years or so. Individuals with diabetes, of course, pay some 
portion of that through higher out of pocket spending, but they 
do not pay all of it, right?
    The rest of those costs fall on other people, including 
those paying premiums, particularly in the commercial market, 
but also on taxpayers and the federal government. And when you 
think about the incidence of the cost of diabetes it was just 
mentioned. Actually one-third, I think it was, of Medicare's 
drug spending is on diabetics. A very large share of this is 
borne through the Medicare program, which falls on taxpayers of 
course and the federal government.
    But beyond just the direct health costs, there are indirect 
costs, and we see this with other conditions, but diabetes 
certainly. The condition affects labor market outcomes by 
increasing absenteeism, lower productivity of workers and ends 
up resulting in lost work years and other outcomes.
    That adds up to another $100 billion a year in the cost of 
the disease. So that is really, really significant, even above 
and beyond the direct health costs.
    So as a result, treatments for diabetes can convey 
significant value, a point that I think is particularly notable 
given recent advancements in drugs like GLP-1 and please do not 
ask them to say their full name.
    So I am going to highlight a few issues related to those 
treatments that I think are relevant for folks considering 
policy in this space. All right. The first is that it is not 
obvious how new therapies are going to affect the overall cost 
of diabetes, and that is because you have counteracting forces.
    On one hand new treatments come with their own costs. They 
have prices. But on the other hand, they offset some costs. So 
either they replace existing therapies, they lower the use of 
other health care services, or they affect labor market 
outcomes. They might increase productivity, right.
    How those things balance out is not obvious, and I will say 
in this particular case it is particularly not obvious because 
this drug market itself is very much in flux. We are seeing new 
treatments come to market, and as that happens, there is more 
competition to get on formularies, to get on insurance plans, 
and I included some data in my written testimony that shows 
that even in the last couple of years, some of the GLP-1s that 
were at $6,650 net price for the year are now around 4,000.
    That is a really big chance over the course of a couple of 
years, and so thinking about how that is going to evolve across 
this whole market in the next, two, three, four, five years is 
hard to do.
    That said, I will say it is still best to consider more 
than just budgetary effects for new therapies. If we are buying 
health, if we are effectively making people healthier, we 
should be willing to pay something for that. Not indefinite 
amounts of course, but something for that.
    The second thing is going to echo earlier comments, is that 
new therapies raise questions about affordability and access, 
and I will make a simple point here, which is to encourage you 
to consider those questions holistically, rather than 
addressing affordability for specific drugs or conditions 
individually.
    The reason I say that is for twofold. The first is that the 
health care system is very, very complicated as it is. When we 
have one-off approaches to different diseases or different 
types of conditions, it makes it all the more complicated to 
keep track of everything.
    The second thing is that I think it raises legitimate 
equity questions. Should you preference Disease X over Disease 
Y? If so, why and how much? I think those are legitimately 
challenging questions. And so I would encourage you think about 
approaches like what we have seen with Medicare Part D.
    There were bipartisan efforts to try and impose an out of 
pocket limit for folks in that program. That tries to address 
affordability, the high end of financial exposure in a broad 
way that affects everybody, regardless of condition.
    And then finally I focus a lot on drugs in my own work, but 
while new drugs can improve the toolkit available to address 
health conditions, there are many non-pharmaceutical 
interventions that can remain highly cost effective.
    And so in the case of diabetes, we have heard people talk 
about it, things like self-monitoring of blood sugar, lifestyle 
changes are sort of chief among those. So to the extent that 
those inventions provide good value for money, we want to make 
sure not to preference pharmaceuticals to the exclusion of 
those other interventions.
    That is hard to sort of nail down in a specific policy, but 
as a conceptual approach I think that is important to keep in 
mind.
    So all told, diabetes is a very costly disease along with a 
host of dimensions, and that is true for people with the 
disease and it is true for people who do not have the disease. 
And so I thank you very much for inviting me, and I look 
forward to your questions.
    [The statement of Dr. Ippolito appears in the Submissions 
for the Record on page 51.]
    Vice Chairman Schweikert. Doctor, thank you. Dr. Herman.

     STATEMENT OF MARK A. HERMAN, M.D., CHIEF, SECTION OF 
   ENDOCRINOLOGY, DIABETES AND METABOLISM, BAYLOR COLLEGE OF 
                    MEDICINE, HOUSTON, TEXAS

    Dr. Herman. Thank you for the opportunity to discuss the 
impact of diabetes and some of the emerging technologies and 
therapeutics to address the ongoing epidemics of diabetes and 
obesity. Currently I serve as the chief of the Section of 
Endocrinology, Diabetes and Metabolism at Baylor College of 
Medicine.
    My work as a physician and researcher is focused on caring 
for individuals with obesity, diabetes and other endocrine 
diseases. My scientific laboratory is committed to deciphering 
the molecular mechanisms responsible for these conditions, so 
that we can identify effective ways to treat these diseases.
    Over the past decade, we have made significant strides in 
understanding how obesity, diabetes and associated 
cardiometabolic diseases develop in people. We have also made 
remarkable progress in developing medications and technologies 
for people with these diseases.
    Today, I would like to highlight three areas of progress 
for you. One, the vital and revolutionary role of GLP-1 
receptor agonists and related medications in treating diabetes 
and obesity. Two, the rapid advances in medical devices and 
technologies for diabetes, and three, our growing knowledge of 
the complex nature of diabetes and its complications, and what 
it means for the future of diabetes care.
    I am sure you are aware of the news around GLP-1 receptor 
agonists. This class of medication, which mimics a natural 
hormone, has proven vital in improving glycemic control and 
promoting weight loss. GLP-1 receptor agonists were initially 
developed to reduce blood glucose levels.
    This is of course a major goal in the treatment of 
diabetes.
    However, these medications are remarkably effective in 
helping patients feel full, reduce their caloric intake and 
subsequently lose weight. Moreover, clinical trials are showing 
the GLP-1 receptor agonists reduce the risks of cardiovascular 
events and death in high risk patients with Type 2 diabetes.
    With obesity being a primary risk factor for diabetes and 
cardiovascular diseases, the potential of GLP-1 receptor 
agonists to induce meaningful and sustained weight loss may 
represent a significant advancement in preventative care.
    In sum, GLP-1 receptor agonists have ushered in a new era 
in the management of diabetes and obesity. They are the latest 
evidence that a growing understanding of endocrine physiology 
can lead to therapies for pressing public health challenges.
    Next, I would like to address how new medical devices and 
technologies are transforming diabetes management. You are no 
doubt aware of continuous glucose monitors, which are replacing 
the painful and inconvenient method of multiple daily finger 
sticks.
    Real-time continuous glucose tracking offered by CGMs helps 
to prevent severe hypoglycemic episodes, a source of morbidity 
and fear, particularly in children with Type 1 diabetes. 
Similarly, insulin pumps have revolutionized the delivery of 
insulin, providing a more flexible approach compared to daily, 
multiple daily injections.
    The pump delivers a continuous infusion of rapid-acting 
insulin, that can be adjusted with a click of a button to mimic 
the insulin production of a health pancreas.
    The next steps in diabetes technology are artificial 
pancreas devices. These devices combine continuous glucose 
monitors and insulin pumps with an advance control algorithm to 
automate insulin delivery and reduce the burden of diabetes 
management. The ongoing integration of these technologies into 
patient care emphasizes the transformative power of digital 
health in managing chronic diseases like diabetes.
    Finally, I would like to discuss the considerable progress 
we are making into coding varieties of diabetes. Research is 
showing us that diabetes is not a single disease rather a group 
of disorders with common traits. By analyzing common genetic 
variation, we have realized that different subtypes of diabetes 
may be driven by different genetic factors, and can lead to 
different adverse outcomes.
    In parallel, examination of a rare genetic variation has 
allowed us to identify unusual forms of diabetes that point to 
underlying mechanisms that participate in development of more 
common forms of diabetes. By understanding the different 
genetic contributions to diabetes, we can move towards a more 
promising frontier of personalized and precise approaches to 
treatment.
    Without a doubt, we stand on the cusp of revolution in 
diabetes and obesity management, powered by scientific 
breakthroughs and technological advancements. So thank you for 
allowing me to share my perspective with you, and I look 
forward to your questions.
    [The statement of Dr. Herman appears in the Submissions for 
the Record on page 61.]
    Vice Chairman Schweikert. Thank you, Doctor. Your 
questions.
    Chairman Heinrich. I want to thank Vice Chairman Schweikert 
for allowing me to go first this morning. I am going to have to 
hop over to Appropriations here in just a few minutes. But I 
want to start with President Nygren. You know, Congress 
established the Special Diabetes Program for Indians in 1997, 
in response to the growing prevalence of the disease among 
American Indian and Alaska Native populations.
    It provides funding for diabetes prevention and treatment 
services to over 300 Indian Heath programs across the nation. I 
think the strength of SDPI is that it provides grantees with a 
great deal of flexibility, and we have heard a little bit about 
that on the Navajo Nation today, to design and implement 
interventions that are culturally competent and directly meet 
the needs of those individual communities.
    President Nygren, how have you been able to tailor health 
programs on the Nation, and do you think that--this kind of 
approach can be successful at a wider scale in non-Native 
communities as well?
    President Nygren. Good morning, good morning Senator 
Heinrich. Thank you so much for that question. One of the 
things that I want to mention too is I recently went to an 
event out in Crystal, New Mexico, which is south of--north of 
Window Rock, Arizona, and there was a couple of hundred 
walkers.
    So people came out to walk either half a mile, one mile, 
two miles or three miles, and they were provided with bananas, 
good foods to eat and education. So we had the whole Navajo 
Department of Health was out there. So it was a very community 
approach. This is an opportunity for people to come out.
    Not only one of the things that people take a lot of pride 
in too is the tee shirts that are being provided at those 
events, and a lot of those tee shirts encompass culture, 
encompass health, and this is something that they like to wear 
out in the community, and just--and it also brings them a lot 
of sense of pride.
    This might be their first tee shirt that is brand new for 
the year, and they look forward to these events. So I think 
that the custom approach to the community is a very critical 
approach, because not every tribal community is the same across 
the country.
    I know there is 574 communities across the country. Navajo 
is one of them, but I know that land-wise, population-wise, we 
are very unique. But I know that if by allowing every 
individual tribe to have their own unique approach, it is 
setting them up for success, because there is things in Navajo 
culture that are not the same with Hopi or not the same with 
Laguna, or different tribes across the country.
    So I think having that tailored approach is a good way to 
utilize resources, and I think that just seemed to decrease not 
only in diabetes on Navajo, because of SDPI it is something 
that is related to having a tailored approach, just again just 
kind of like everybody's tailored suit today.
    So we want to be walking. It is a little easier to walk 
around with something that is a little tailored. So again, just 
thank you so much to the Committee, to the programs for 
allowing us to be successful since 1997. But obviously the 
funding has also been the same since 1997.
    So I know there is people that need to be hired and staff 
and to actually expand, and then Indian country is very rural 
and remote as Navajo. So again, thank you so much Senator.
    Chairman Heinrich. Thank you President, and that is a great 
point. We have had flat funding for so many years in this 
program. As a result of inflation over those years, we have 
really lost a lot of buy-in power, and that is something that 
all of us need to look at.
    Dr. Ippolito, President Nygren touched a little bit on 
nutrition, but I want to ask you, given that this Congress is 
one where in theory at least we are going to pass a new Farm 
bill, and if we look back in time to when diabetes really took 
off, in the 1970's we kind of re--we changed our agricultural 
policies and we focused more on commodities over horticulture, 
over nutrition.
    And we saw these incredible increases from the 1970's to 
today in the prevalence of diabetes. So do you have thoughts on 
how we should be approaching the Farm bill in light of our 
challenges with diabetes?
    Dr. Ippolito. Well, I guess I will answer that by focusing 
on the sort of underlying point, which is that, you know, we 
are accustomed to thinking about new pharmaceuticals, for 
example, as being cost effective or not. Do they deliver value 
for the money?
    But when you look at things like diabetes and other 
conditions, there is ample evidence that suggests there is all 
sorts of other things that are cost effective if you look at 
them through the similar framing.
    Chairman Heinrich. Right.
    Dr. Ippolito. And so I think nutrition, eating habits, sort 
of lifestyle changes, it seems like there is fairly strong 
evidence for that. And so to the extent that that is something 
that fits within the purview of the Farm bill, it seems like it 
is something worth considering.
    Chairman Heinrich. Great. Mrs. Brown-Friday, diabetes 
should be managed through a whole combination of prevention and 
treatment, and we have heard that here today. For most 
patients, this involves first being able to be diagnosed and 
treated with a combination of lifestyle changes related to 
nutrition, physical exercise, alongside the advances in medical 
interventions that we have heard about.
    Many Americans simply do not have access to adequate health 
care that can prevent or delay the onset of diabetes, and 
prevent some of the more extreme complications of the disease. 
How do issues with accessing health care, such as being 
uninsured or under-insured, having trouble affording 
medication, create disparities in diabetes outcomes for 
different populations in the United States?
    Mrs. Brown-Friday. I think that--sorry. I think that being 
under-insured or uninsured creates a problem for the population 
across the United States, across the board, across ethnicities, 
across cultures. I think that when you are under or, or not 
insured, you do not have access to the health care providers, 
or you have less access to the health care providers that can 
actually provide the information that you need, so that you can 
take better care of yourself.
    You go and see a physician or a nurse practitioner or a 
diabetes educator for maybe 15-20 minutes, and the rest of the 
time you have to do it yourself. So it is--those visits are 
extremely important and valuable, because during--if you have 
access to health care because you are well-insured, you have 
those visits in order to get those diamonds, those jewels that 
will be able to take you when you leave here to take better 
care of yourself, to know how to take your medications.
    Not just to take them, but how to take them and also to 
choose, have better choices. Under-insured does not--does kind 
of correlate also with food insecurity. Frequently people who 
are under and are uninsured are in areas or food deserts where 
healthier foods are just not available, where their 
supermarkets are just not available or not close to them, even 
in both urban and rural areas.
    Chairman Heinrich. Thank you. I want to thank you all for 
your testimony today. This is a topic of incredible interest to 
both the Vice Chairman and myself. I am going to have to go 
over to Approps, and I am going to leave it in his capable 
hands.
    But I really want to thank all of you for your input. This 
is, this has huge budget ramifications, but it also has huge 
ramifications for every individual constituent of ours.
    Vice Chairman Schweikert. Thank you, Senator Heinrich. I am 
going to try to be respectful for everyone's schedule, because 
you are here during sort of the screwy time of year. Senator 
Lee, you're up.
    Senator Lee. Thank you so much, Mr. Chairman. It is great 
to have all of you here, and it is good to see my friend 
President Nygren again. He and I hold the alliance between Utah 
and Arizona in check. I was born in Arizona and moved to Utah 
as an infant. He was born in Utah, moved to Arizona young in 
life, and so it is good to see you sir.
    I am grateful, Mr. Chairman and Mr. Vice Chairman, for the 
fact that you have scheduled this hearing. This is a really 
important topic. As of 2018, there were about 185,000 people 
living with diabetes in the state of Utah alone, and this is a 
significant disease.
    It is a significant disease that presents all kinds of 
challenges. It manifests itself 24 hours a day. It never 
sleeps, and in the case of Type 1 diabetics, there is no 
reasonable prospect of living without it. There is no 
reasonable prospect, with the technology in existence today, of 
becoming no longer insulin-dependent. It is essentially with 
you for the rest of your life.
    And so as a result of that, this causes all kinds of 
headaches, financially, emotionally in every aspect of your 
life. At every moment of your day it can step in and cause 
problems.
    While the subject of today's hearing focuses on one 
disease, I believe my comments in some instances may be 
relevant to multiple conditions. I believe the federal 
government has itself been one of the main driving obstacles to 
increased innovation and we know, of course, that increased 
innovation brings about higher quality, better prospects for 
treatment of the disease, and ultimately brings down the cost. 
It produces cost savings with additional competition.
    Sometimes when confronted with issues such as drug 
shortages and high costs, the government seeks impulsively to 
intervene through increased spending, and even more regulation. 
But this strategy ignores the fact that such shortages and 
those high prices are often the results of excessive and unwise 
government action in the first place.
    It shows up all the time in the case of over-regulation. It 
is so difficult to get approve, sometimes needlessly so that 
there are fewer and fewer competitors. It is a natural barrier 
to entry. Sometimes it comes about in the form of price 
controls.
    Take the Inflation Reduction Act, for example, which seeks 
to impose price controls on certain pharmaceuticals. Now the 
Congressional Budget Office, the nonpartisan entity that we 
hire to perform analyses like this, predicted that this would 
result in 15 fewer new drugs being launched over the next 30 
years. Experts are increasingly warning that this policy will 
exacerbate shortages.
    Instead of increasing spending and imposing mandates and 
engaging in even more aggressive regulatory action, in many 
instances Congress just needs to buckle down and focus on 
addressing the excessive government intervention problem, 
dealing with the regulatory stranglehold that exists.
    If I could talk about two pieces of legislation that I have 
introduced to address those regulations, that prevent some of 
these innovative new treatments from coming forward and lower 
cost drugs from coming to market.
    Recently, I introduced S.2305, the Biosimilar Red Tape 
Elimination Act. This is a bipartisan bill that I filed 
alongside my colleagues Senators Lujan, Braun and Vance. The 
bill would align the U.S.'s biosimilar program along with the 
rest of the developed world, by getting rid of the arbitrary, 
unwise and unnecessary distinction between approved biosimilars 
and interchangeable biosimilars.
    Biosimilars, you see, that is a word we use that is 
essentially the functional equivalent of generics for complex 
biological drugs. The U.S. is the only country that has these 
two tiers of approval, approval and interchangeability.
    Congress created the interchangeability designation, and I 
have concern that there might be a risk of switching from one 
biologic to its biosimilar, and that they might not function 
the same way and that might cause problems. However, those 
concerns simply have not been borne out empirically. The 
science does not back them up.
    What we gain from the distinction is next to nothing, and 
what we lose is significant. A lot of voices in the scientific 
community that the FDA's initial approval of a biosimilar is 
sufficient to establish that the biosimilar is in fact 
interchangeable to its--to and with its reference product.
    Moreover, the interchangeability designation has confused 
states, patients, doctors and those who work with them by 
signaling that biosimilars are significantly different from 
their reference products. This in turn makes it less likely 
that they will be available for use, that they will be used as 
substitutes and the availability and use of substitutes brings 
down costs.
    And so interchangeability thus raises cost, because 
biosimilars would otherwise provide much-needed competition for 
biologics. Biologic drugs make up approximately 46 percent of 
U.S. prescription drug spending despite making up less than 
one-half of one percent of all prescriptions, just 0.4 percent.
    So when we talk about the high cost of drugs, we are often 
really talking about biologics, even though they are a tiny, 
tiny share of the overall picture. My bill would help increase 
biosimilar competition by declaring that all biosimilars, upon 
initial approval, shall be deemed interchangeable.
    Now the FDA's subject matter experts have communicated to 
my office that the bill would align our biosimilar program with 
current scientific understanding and improve biosimilar 
approval and uptake. This bipartisan legislation would help 
usher in greater biosimilar competition, thus reducing prices 
and benefiting all patients, including and especially those 
with Type 1 diabetes, who are for the rest of their lives 
dependent on insulin.
    Another way that I have sought to support Type 1 diabetes 
is by exploring ways in which the current regulations simply do 
not make sense for innovative treatments, treatments of the 
sort that could actually bring about a functional cure for the 
disease, or something approaching that.
    When we just throw money at government programs, sometimes 
we incentivize the status quo. We lock in on existing 
technology. To use an analogy, if we had done that in our music 
listening devices, we might still be stuck in the eight track 
tape world, something most people in this room do not even 
remember.
    We do not want to do that with health care, especially in 
an area like the treatment of Type 1 diabetes, where 
technological advances are so important. For example, this year 
I was joined by Senators Braun and Blackburn in introducing S. 
2205, the Increased Support for Life-Saving Endocrine Treatment 
Act or the Islet Act. Islets are these micro-organs inside the 
pancreas that produce insulin.
    Now patients who have Type 1 diabetes do not have normally 
functioning pancreatic islet cells. We are not sure why but 
they stop working. The theory is that there is an autoimmune 
condition that attacks the healthy pancreatic islet cells and 
kills them or causes them to be non-functional. So they 
routinely require these insulin injections.
    These treatment options are important, but they can become 
burdensome and expensive and cause the patient constantly to 
have to chase between highs and lows, which is its own form of 
hell. Thankfully we do have other options and possibilities.
    Scientists have found ways to take pancreatic islet cells 
from deceased donors and transplant them into the bodies of 
patients with Type 1 diabetes. Some patients who have received 
these procedures have been able to go years without either any 
insulin injections or any type of continuous glucose 
monitoring.
    But regulations have squashed the procedure. They have made 
it almost impossible. Rather than regulating islets as organs, 
HHS and FDA have regulated islets as drugs since 1993, despite 
the fact that other countries appropriately regulate islets as 
organs and not as drugs.
    We have to take care of this. We have to fix this problem, 
and I have serious concerns about the FDA's recent action on 
this. The FDA recently approved a drug for this treatment, 
rather than going the route proposed by the Islet Act.
    I am out of time. I wish I could have had more time to do 
this, but I do want to know eventually from the FDA how they 
decided to approve this product's biological licensing 
application as a drug, especially since one of their previous 
reports had said that the agency could not assure the product's 
attributes correlate with clinical outcomes.
    And how will the FDA's decision impact access to allogenic 
islet transplantation? Would such procedures be more affordable 
and accessible if islets were regulated as organs? The answer 
is almost certainly yes. The FDA has a lot to answer for. In 
this and in countless other areas, they are needlessly making 
this disease more expensive, more deadly, more long-lasting 
simply because of their own regulatory malfeasance. Thank you.
    Representative Beyer. First of all Vice Chairman 
Schweikert, thank you for convening this. I greatly appreciate 
it. I thank all of you for being here. I thought I knew a lot 
about diabetes. I have learned so much this morning.
    I want to add one factoid that came from our last Joint 
Economic Committee meeting, when Mick Mulvaney, who used to 
chair the Office of Management and Budget at OMB, was talking 
about how much of the Medicare budget is spent on end stage 
renal disease and dialysis, and the number he came up with was 
31 percent. There is roughly $250 billion a year of taxpayer 
money just spent on dialysis.
    You know, Senator Lee just talked about not incentivizing 
the status quo. A perfect comment, because we are marking up 
the Agriculture, the five-year Farm bill right now. And this is 
very relevant, because the Farm bill entrenches food policy in 
a way that supports our current food behaviors.
    By subsidizing commodity crops, our current food--and 
rather than working on ensuring that specialty crops can be 
produced, we are sort of denying the nutritious greens that we 
need to do. We are really good at making corn cheap and sugar 
cheap, and that then of course gives us a food industry that 
specializes in making highly processed foods, without the 
education and intervention that will keep us from just 
continuing to promote Type 2 diabetes.
    So we need to be concerned about unintentionally 
structuring a farm system at the federal level that supports 
the trend of obesity. But if you look at the rest of the Farm 
bill, you have SNAP and WIC. We know that Supplemental 
Nutrition Assistance Program reduces severe food insecurity 
between 12 and 19 percent. It is food insecurity and inadequate 
nutrition that Mrs. Brown-Friday pointed out.
    You know, the lower the income, the more likely you are to 
get diabetes, and the higher the income, the better the food, 
the less likely. We are struggling with a budget right now 
where they are talking about fiscal year funding for 2024 for 
the SNAP program at a level of 2007. We are rolling it back 
decades.
    Same with the WIC program, Women, Infants and Children's 
Program. They are going to cut it by $800 million, which is 
five million women and children losing fruit and vegetable 
vouchers. So we have really got to look hard at the Farm bill, 
and in the light of the diabetes challenge that we are facing 
right now.
    Mrs. Brown-Friday talked about food deserts. President 
Nygren, can you specifically talk about food deserts in the 
Navajo Nation?
    President Nygren. Congressman, thank you. When it comes to 
food deserts could you----
    Representative Beyer. How big a challenge is it for you, 
with the Navajos who live both on the reservation and off, in 
terms of the ability to get the healthy food that will give 
them the lifestyle they need?
    President Nygren. Okay, okay. Thank you,
    Congressman. When it comes to food and having grown up 
myself, the nearest grocery was 75 miles, which is Farmington, 
New Mexico. So in order to get to a Walmart, you have to go 75 
miles where I grew up from, and most of the time the nearest 
grocery store is the local trading post or the local gas 
station.
    So all of us have been in a gas station. If you go to a 
Speedway or Sinclair, whatever the gas station is, most of the 
time it is candy, food, chips, things that are normally for 
people that are just on the road and headed to a certain 
direction. So I know that one of the things that--that is why 
we imposed that tax on junk food, to try to hopefully encourage 
our grocery stores and gas stations to at least carry some 
fresh fruits, some fresh vegetables and things like that.
    But it is just when you are in really remote locations like 
Navajo, it is difficult to get access to quality foods. That is 
kind of the landscape of the Navajo Nation is you can go one 
hour or two hours and the only thing you will find is gas 
stations.
    So I think the location of more stores that offer farm 
goods would be great, because I know on Navajo, we are really 
trying to encourage a lot more of our people to be farmers, to 
utilize some of the water, to go back to traditional practices, 
because overall I think that when it comes to being able to be 
able to farm and sell foods and groceries, I think that is a 
way.
    As President, I am trying to encourage our people to do 
that. But regular grocery stores, they are hard to find.
    Representative Beyer. Thank you very much. Mrs. Brown-
Friday, as you know so much of the debate on the Hill the last 
20 years has been about health insurance and access to health 
insurance for the American people.
    Can you talk from your perspective at ADA and others about 
why health insurance is critical for people with diabetes, 
especially we talked about CGMs, the continuous glucose 
monitors? How do you get a CGM if you do not have health 
insurance?
    Mrs. Brown-Friday. I would say it is basically impossible. 
Thank you so much for reminding me. I would say it is basically 
impossible to get a CGM without health insurance, because most 
people who are under or uninsured do not, cannot afford the 
cost of a CGM and all the supplies that go with it.
    And so therefore the American Diabetes Association is 
really supporting people having better access to health 
insurance, easier access to health insurance, so that they can 
have--they can afford the medications and the instruments, and 
the technology that could actually help them have a better life 
with relation to their diabetes.
    Representative Beyer. Thank you very much. And Dr. Herman, 
I am very excited about the agonists and the impact that they 
are having. But I agree with you that we cannot just think 
about taking a pill to solve all these problems.
    Are you at all concerned about the down sides, the latest 
reports about stomach paralysis or gastroparesis? How are we, 
how are we balancing the negative side effects on these 
agonists?
    Dr. Herman. So that is a really important question, and it 
is quite clear the GLP-1 receptor agonist, many patients that 
take them experience some sort of gastrointestinal side effect 
including gastroparesis, so slowing of the transit of food 
through the GI tract and some combination of constipation, 
diarrhea or abdominal distension.
    And we have, we have put together kind of algorithms for 
titrating these medications, to try to avoid some of those side 
effects. Most people, if they continue those medications, they 
tolerate them. Even with some of the side effects, the side 
effects tend to go away with time.
    So those gastrointestinal side effects do not seem to be 
permanent or persistent. Some people cannot tolerate the 
medications because of these side effects, and they choose not 
to continue them and then we move to other options. But the 
majority of patients can tolerate those medications and those 
side effects tend to wane.
    Now the other aspect of your question is what are the long-
term potential adverse effects, and to date we have not 
identified any significant long-term adverse events or effects 
related to GLP-1 receptor agonists. They are clearly in large 
clinical studies reducing the use of insulin while also 
reducing glycemia. So they are, they are saving lives, and we 
have not identified any long-term adverse consequences at this 
point.
    Vice Chairman Schweikert. Thank you Mr. Beyer. Ms. 
Malliotakis.
    Representative Malliotakis. Thank you Mr. Chairman, and 
appreciate you all participating in this important hearing. 
Obviously, we want to be proactive to help Americans stay 
healthy, to improve their quality of life, to lower their 
medical costs, and to also save taxpayers money.
    It is no secret that Medicare has a solvency problem and 
diabetes and obesity are some of the main drivers. Nearly one-
third of Medicare spend is attributable to diabetes population 
and as the obesity rate in the U.S. continues to rise, so will 
the rate of diabetes.
    Of nearly $300 billion, diabetes currently accounts for 
one-fourth of all U.S. health care spending. The Congressional 
Budget Office has identified several options to rein in costs. 
However, many of these could be harmful to our seniors already 
suffering from inflation.
    Promising new drugs and medical devices such as GLP-1, 
Ozempic and continuous glucose monitoring certainly should play 
a role in reducing the risks diabetics face and lowering costs 
to both individual finances and the federal government.
    However, other innovations are happening in the health are 
space to treat diabetes, obesity and other diet-related 
diseases, so again people can live longer, healthier and happy 
lives. One of these innovations is medical nutrition therapy. 
MNT is provided by a nutritionist with the goal of assisting a 
patient choose and buy foods that are healthier, manage complex 
medical issues like diabetes by creating sustainable, 
behavioral changes.
    In a nationwide representative study, a large health care 
provider showed that $130 per member per month savings or 
nearly $1,600 per year from giving members over 65 access to 
this type of nutrition guidance. But today in Medicare, only 
diabetes and renal disease are covered, while obesity, pre-
diabetes and other chronic illnesses which lead to diabetes 
related to poor nutrition is not.
    Yet if we look at the private payor space and then 
Medicaid, we are seeing with MNT coupled with tools to stretch 
people's food dollars in ways that allow them to meet their 
diet, cultural and religious needs, saving costs to patients, 
saving costs to the system and improving health outcomes.
    My staff recently met with a company that works with 
private payors, Medicare Advantage plans and Medicaid MCOs to 
deliver telenutrition services to patients, and they have data 
right now that shows MNT patients lose an average between four 
to 6.5 percent of their weight, and continue losing weight 
after Year 2, due to behavioral changes.
    Mr. Ippolito, should Congress press entities like the 
Congressional Budget Office to review this data, to help us 
understand how we can leverage nutritional programs as a 
strategy to provide relief to those at risk of diabetes, as 
well as to taxpayers continually paying for it?
    Dr. Ippolito. Well, I guess my short answer is that I think 
Medicare could use any budget help they can get. So if you have 
got a proposal that could save money, then it certainly seems 
like something CBO should look at.
    Representative Malliotakis. Anyone else want to chime in 
before I move to my next point? All right. Well during my time 
in Congress, I have been advocating and pushing to require at 
least in part or incentivize SNAP recipients to purchase 
healthy foods. I am joining Congressman Garbarino, also of New 
York, on an effort to end a ban on purchasing prepared and hot 
foods with SNAP, which would be I think a big step.
    Dr. Herman, how would these reforms in the SNAP program 
affect the rates of obesity and diabetes among recipients, and 
do you believe that this would play a role in reducing 
government spending on obesity-related chronic conditions?
    Dr. Herman. So it is an excellent question. I have to say I 
am not an economist or an epidemiologist, so the impact of 
changing policy on spending is really outside of my expertise. 
What I would say is that lifestyle management is always a part 
of diabetes and obesity care, and its demonstrated benefits.
    Representative Malliotakis. Yes, I guess that really is at 
the end of the day the real question, is will it help people 
improve their health? Will it lead to healthier options for 
Americans who are SNAP recipients, so they can make, make these 
choices, I mean to not allow for prepared for hot food I think 
is a mistake that probably pushes people into a different 
direction or some of these, you know, preserved foods and stuff 
like that. Anybody else would like to respond?
    Mrs. Brown-Friday. Yes, Representative Malliotakis. I would 
say that any time anyone has an opportunity to have an 
healthier diet, I think that they would be able to take 
advantage of it, and I think it----
    With the programs that you are proposing, that even 
starting at younger ages, the younger you start in these 
programs, the younger you are exposed to healthier foods, the 
more likely you are to continue that into adulthood and 
prevention, I think, is really the key. I think that prevention 
of obesity is definitely something that can be beneficial from 
these programs.
    Representative Malliotakis. Great. Thank you both.
    Vice Chairman Schweikert. Thank you. Ms. Moore.
    Representative Moore. Thank you so much, and I want to 
thank the panel for being here today. I was caught up on other 
duties, so I was late. But I was listening to a lot of your 
testimony before I arrived, and I was intrigued, Dr. Brown-
Friday, by some of your testimony that talked about diabetes, 
the onset of diabetes starting at younger. Not juvenile 
diabetes, but Type 2 diabetes.
    And do you attribute that to the junk foods and stuff that 
President Nygren, for example, has talked about? To what do we 
attribute that?
    Mrs. Brown-Friday. Well first I want to make a correction. 
I am not a doctor.
    Representative Moore. Okay.
    Mrs. Brown-Friday. I am a registered nurse by profession.
    Representative Moore. That is good.
    Mrs. Brown-Friday. I am very proud to be one. So in terms 
of Type 2 diabetes, starting at younger ages, this is something 
that has been a concern for the medical community and the 
American Diabetes Association for quite a while.
    And I definitely agree with Dr. Nygren, that the 
availability of healthy foods and having it closer to your 
availability fast foods, not just for Dr. Nygren it is the gas 
stations, and for me, who works in the Bronx, it is access to 
McDonald's and I am sorry, and other fast food companies, where 
it is just high fat in the foods and younger people are not----
    Like I said, once you are introduced at a younger age to 
healthier foods, then the more likely you are to have those 
foods when you are older.
    Representative Moore. So Mrs. Brown, it is sort of 
counterintuitive for us to be cutting fruits and vegetables 
from the WIC formulary, as an example, and upping things like 
cheese as part of the formulary for WIC. It just does not make 
any sense if we are trying to curb the cost of diabetes, to be 
cutting fruits and vegetables out of WIC.
    That is my statement. I will not make you say it. I am 
intrigued by the disproportionate presence of diabetes in black 
and Native Americans and Latino communities. And so I guess Dr. 
Herman, there is no sort of genetic proof that these folks are 
disproportionately susceptible to enduring diabetes. So what 
would you say would--or why do you, how do you explain the 
disproportionate onset of diabetes in these populations?
    Dr. Herman. I think that is really an excellent question, 
and I do not know the answer to that question. I will say there 
are, there are many investigators out there looking at that 
question specifically.
    What we do know is that, is that obesity and diabetes in 
all populations is an interaction between genetic background 
and environmental exposure, and that includes diet and exercise 
and all sorts of things. And so if there is an increase in 
prevalence of obesity and diabetes in one population, it is 
some combination of a change in their environment, interacting 
with a change--with their genetics, which is not changed over 
decades that is producing that outcome.
    It takes intensive research to identify within specific 
populations what those specific factors are, but there are many 
scientists and physicians out there searching for those answers 
within specific populations at this point.
    Representative Moore. Well thank you so much. Your 
testimony, I think Mrs. Brown-Friday, made the testimony that 
85 percent of people who have diabetes are obese, are 
overweight. This is one of the reasons that I am so happy that 
I have reintroduced a bill called the Treatment to Reduce 
Obesity Act. I think that it will give us some great results 
with regard to stemming one of the causes or one of the present 
features of diabetes.
    I want to ask President Nygren, the Menomonee and Oneida 
Nations in my state of Wisconsin have taken on a culturally 
relevant project to use sort of Native foods to stem the tide 
of diabetes. Can you describe what you all are doing in the 
Navajo Nation to include culturally relevant foods?
    President Nygren. Congresswoman, thank you for that 
question. I am very happy to hear that our other tribal 
communities are doing that, and on behalf of the Navajo Nation 
one of the things we are doing is walking and running. That has 
been very a part of our culture, and at the same time 
introducing them to foods such as fruits and vegetables at all 
of our events, along with like almonds and nuts and things like 
that that really help and promote a healthy lifestyle.
    Because one of the things we have always done is we take 
the IHS, the best practices, and we try to focus on one of them 
for the year so that we can implement and educate our people on 
that. So we really have taken an approach where we invite the 
people out to the events, and then they do a walk, a run or we 
educate them on foods. But as far as farming, we are really 
trying to reintroduce farming, because Navajo people have been 
farmers for a very long time.
    It is just that it is a lot easier to drive a couple of 
hundred miles and get a bag of groceries than to actually do 
the work and to produce healthy foods. But that is something 
that we are really working on, Congresswoman. Thank you.
    Representative Moore. My time is waning, so I just want to 
get another question in with Dr. Brown-Friday. I did not 
understand why the continuous glucose monitor is not available 
to more low income people. Is that something that is not 
authorized by Medicare, or what are the dynamics in terms of 
getting these continuous glucose monitors available to low 
income people?
    Mrs. Brown-Friday. Unfortunately, I am not an expert in 
Medicare, and so what I would have to say that in general, what 
I have heard from patients is that their insurance will not 
cover the cost of utilizing the continuous glucose monitor if 
their blood sugars are not at a certain range, or if they are 
not taking a certain number of injectable medications.
    And so therefore those are the things that are regulating 
the availability----
    Representative Moore. Bureaucracy is stopping us from 
saving money. Okay. I will yield back to you, Mr. Chairman.
    Vice Chairman Schweikert. Thank you Ms. Moore, and we are 
going to talk about that, because there has been a crash in the 
price of those units and some new products that just came in 
the market within the last six weeks. Mr. Ferguson or Dr. 
Ferguson.
    Representative Ferguson. Thank you, Vice Chairman. I want 
to thank y'all for hosting this and to the witnesses, thank you 
for your time and your presence here. It matters and we have 
learned a lot. So thank you for taking time out of your 
schedules to help educate us.
    I want to start my comments by saying that I truly believe 
that diabetes is probably the cruelest and most underrated 
disease in America. There are a lot of other things that get a 
lot of attention, and I am glad to see that this body is 
stepping up and focusing on this, because it is such a long, 
debilitating process.
    Many times, you know, we tend to ignore because we do not 
see the rapid decline of someone. So this is important, so 
thank you for being here. I was a practicing dentist for 25 
years. I saw the oral effects of this week-in and week-out in 
my practice.
    But I also saw the systemic effects, and my ability to 
treat patients was, if they had diabetes, was greatly 
restricted. How they responded to care, how they responded to 
infections, how their body responded to antibiotics all played 
a role in their overall health.
    I want to focus on something that this Committee, that some 
of the questions have already started to go to, because 
President Nygren, your comments about what you are doing in 
terms of food is really important. But I want to start with Dr. 
Herman.
    If you go back and look at the last, I do not know, 40, 50, 
60, 80 years, when did we really see the explosion or the 
exponential growth in diabetes within various populations? What 
is sort of the time line and how has that accelerated?
    Dr. Herman. I think the dramatic increase in prevalence 
began largely in the 70's, of both obesity and paralleled by 
diabetes. Those both dramatically increased at that point, and 
I think the increase has been pretty consistent since the 70's.
    Representative Ferguson. Okay. When we look at--when we 
look at things that have changed from a policy standpoint, and 
this may be a question for anybody on this panel as well that 
may have a better history on this than I do, what--what in the 
early 70's changed our food supply? What did we begin to 
prioritize and what was the--and what was the biggest part of 
that? It was calories, right?
    So when we started to value calories over quality 
nutrition, then we set this thing in motion. When I first 
started my dental practice in 1992, I could tell the difference 
in kids that grew up in the country on well water and kids that 
grew up in the city limits, that grew up on fluoridated water, 
because the quality--their oral health was dramatically 
affected because the kids that grew up on well water had, you 
know, just--they were ravished by cavities. Income did not 
matter, okay.
    Kids that grew up in the city on fluoridated water, again 
because without regard to income, they had much better oral 
health outcomes. As I went through 20 years of practice, I 
could no longer distinguish between the two of them, and the 
common link that I saw in this was the food supply and the 
increase in sugar in our food supply in every form of refined 
carbohydrates.
    I think we have got to take a--I think we have got to be 
very focused on our food supply. We can talk about spending 
more money on SNAP, listen. Again, I think cutting fruits and 
vegetables out of nutrition programs is absolutely, is absolute 
lunacy.
    But I also think that funding, you know, allowing folks to 
buy high sugar content foods is like us saying we are going to 
pay somebody to keep smoking while they have got lung cancer. I 
do not mean to equate the two, but again, let us be smart about 
what we are doing here.
    President Nygren, when y'all have done the work and you 
have talked about the success that you have had, what--other 
than money, what is the most important thing you think of or do 
you think we should be doing as a government in terms of the 
nutritional aspect of what your program is--your programs are 
focusing on?
    President Nygren. Thank you Congressman. I think one of the 
most important things, as you mentioned, being able to tailor 
the nutrition and the programs to Navajo people and in the 
different tribes across the country, which is important because 
every tribal nation is different.
    There are different foods and exercises and ceremonies that 
they use throughout their history. But if we can continue to 
tailor that, because I know over the past 20 years or the past 
decade when we have actually been able to tailor it more geared 
towards more Navajo, more Navajo foods, more Navajo types of 
exercises, the actual statistics have gone down because it 
was--we were able to tailor it to work with the existing 
dollars that we have been getting.
    It has been very helpful. So I think that when we continue 
to think about the group specifically to their needs, then it 
is a lot easier, because I know up on Navajo, as I mentioned 
earlier, it is very remote and rural. But there is just so much 
access to processed foods that there is not enough options that 
people can have more access to. So I think education is very 
critical in that part too, so thank you.
    Representative Ferguson. Yes, thank you. And look, I do 
not--there is--I think we do not, we should not try to make 
this a one, make a false choice here of either addressing the 
food supply or continuing to innovate, because it is going to 
take both of these things in my humble opinion.
    Ms. Brown-Friday, just a comment, and again I practiced in 
a rural area. My hometown was about 64 percent African-
American. It was, and again I saw this on a very regular basis. 
You talk about access to health care and access to health 
insurance.
    I want us to move, because I truly believe that Americans 
have access to some type of health care, whether it is 
Medicaid, whether it is private insurance, whether it is care 
on the Exchange. I want us to really focus on utilization, and 
because I can tell you in my practice, patients had access to 
care.
    It was the utilization of the system, and all too often and 
to be candid with you what we saw is that too many of our 
fellow Americans live in poverty, and they live in the crisis 
of the moment. And the preventive aspect of health care and the 
early access many times takes a back seat to a plethora of 
other emergencies that are going on in somebody's week and a 
given time.
    And Ms. Brown-Friday, I am not--I do not mean to lecture 
you on this; please do not take it like that. But help us talk 
more about the utilization of the system, in addition to making 
sure that the people have access to care? With that Mr. Vice 
Chairman, I yield back. Thank you again for hosting this.
    Vice Chairman Schweikert. And Senator Kelly.
    Senator Kelly. Thank you Mr. Chairman, and thank you all 
for being here today to discuss this critical issue that faces 
too many Americans, that carry not only physical but also, you 
know, medical effects for families, but also you know, the high 
cost for folks that live with diabetes.
    President Nygren, great to see you here. Good to see you 
again, and thanks for being such an important voice on this 
issue. I, you know, spent a good amount of time on the Navajo 
Nation, and I know well the impact that diabetes has on our 
tribal communities.
    We have got 22 tribes in this state, and this disease has 
dire consequences. There are a lot of individuals that are 
suffering from this and many are members of your tribe and the 
other tribes. I know you have worked very hard to impress upon 
the federal government the importance of the special diabetes 
program for Indians. Could you talk a little bit more indepth 
about that, the impact it has had on the Navajo Nation and tell 
us why it is so important that Congress reauthorize this 
program before it expires at the end of September, and what are 
the consequences if we do not reauthorize it?
    President Nygren. Thank you, thank you Senator Kelly. I 
appreciate. I am always happy when you spend some time out in 
our communities and all the communities across the state of 
Arizona. Well one of the effects that it has had is just kind 
of--just to kind of read some statistics here, is for the first 
time diabetes prevalence in American Indian and Alaska Native 
adults has decreased and has done so consistently for four 
years, dropping 15.4 percent from 2013 to--from 2013 to 2017.
    So I think just the decrease in diabetes prevalence was 
great through the SDPI program. Also diabetes-related mortality 
has decreased from about 37 percent during those times. Again, 
these are just some of the stats. The key thing there is it is 
decreasing. One of the percentages is that this program is 
working, and we are really trying to----
    It is very unique. There is over 300 communities that it is 
serving across the country. I know there is I think about a 
dozen that is tailored to the Navajo Nation. But overall, I 
think it is critical because we are trying to make sure that we 
can continue to have healthy people in our communities, so that 
they can thrive and for it to be renewed, which is coming up 
very soon, and I think that the--both houses, both the Senate 
and the House has approved it for about 170 million through 
their committees.
    Really, that is 20 million more than the 150 that we were 
initially getting, and that 150 has been consistent for 20 
years. So this 20 million is a good amount of increase to 
really help us get some of those programs out there implemented 
right away.
    Because it is critical in terms of not every Indian country 
is the same, but the tailored approach and the partnership that 
we have been able to develop through this program has really 
helped us. Because I always see pictures of our elders. They 
were slim, they were fast, they looked very healthy a lot of 
the time.
    So when you look through histories of--because as the 
president I have access to historical photos and things like 
that that I look at that is within our communities. There were 
farmers, there were ranchers, there were gardeners and you just 
look at how healthy some of these people look through history.
    And then you look at the people now. It is very sad to see 
that we have come from very self-determined, self-resilient 
people to people that are just really trying to fight for their 
lives on a daily basis. So again, I think that this program is 
critical, and I definitely would continue to urge both the 
House and the Senate to approve this. So thank you Senator.
    Senator Kelly. What would happen if we did not reauthorize 
it?
    President Nygren. We would--for the Navajo, all of Indian 
country would lose about--they would lose staff, they would 
lose the program, they would lose the people.
    Senator Kelly. But tell me what the consequences of that 
would be. I mean I think we know what the consequences are.
    President Nygren. Yeah. I think you would lose a lot more 
people to diabetes.
    Senator Kelly. Yeah, people would die.
    President Nygren. Yes.
    Senator Kelly. And probably in significant numbers.
    President Nygren. Significant numbers, and you would also--
a lot of people would lose hope and faith, and they would just 
be very, I think it would just break a lot of hearts, because 
not only are you looking at communities that are already in 
dire poverty levels, but you would put them in even tougher 
situations.
    Senator Kelly. And folks even, you know, some cannot even--
you know for seniors, you know, insulin is now capped at $35 a 
month and you know for some other individuals, the 
pharmaceutical companies have provided insulin at $35 a month. 
But that could still be very hard to afford for members of the 
Navajo Nation, which is one of the poorest areas of the 
country.
    And that is true for the other tribal communities in the 
state of Arizona and across the nation. So it is critical that 
we reauthorize this program in September. Thank you.
    Representative Smucker. Thank you, Mr. Chairman. This has 
been a fascinating discussion, and I think very important that 
we hold this hearing. Obviously yes, the Chairman has said 
previously this is a driver of our health care costs, that will 
impact our future expenditures, our future debt.
    But it is also, and as he is fully aware, it affects so 
many other areas. It affects the ability for individuals to 
lift themselves out of poverty by taking a great job. It 
affects that workforce participation rate that is critical for 
us to grow an economy, and it affects the everyday ability of 
individuals to live their lives to the fullest.
    And I think if there is--there is a lot of things we could 
do for our constituents, but if somehow diabetes could be 
solved, it would have a dramatic impact, perhaps more impact on 
our constituents than anything else that we could possibly do.
    And by the way, the same thing could be said for heart 
disease, for cancer and for Alzheimer's. All of these are 
drivers of all of these conditions, including our expenditures 
and including the impact on people's lives. It has been a great 
discussion. I agree with so much of what has been said here.
    I agree with Senator Lee, that we should--we should create 
a system that promotes additional private investment, private 
innovation to help come--to help to develop new solutions for 
treatment. But I also agree with others who have talked about 
the government role in this.
    You know, I have always supported investment in NIH 
funding, which is very, very important to drive, to drive the 
underlying research and development that leads to some of those 
innovations. And then like it or not, I think the government 
has for a long time been engaged, through the choices that or 
the incentives maybe is a better way to put it, the incentives 
that we have had in the system regarding nutrition, regarding 
the food that people eat.
    You know, we have done food pyramids, we have done 
recommendations, we have done school lunches, recommendations 
there, and then we have done the SNAP program, the Farm bill. 
All of these help to lead to decisions that folks are making 
about their own lifestyle, about their own nutrition exercise 
and so on.
    And so we are in this like it or not, and so we ought to be 
looking not only at the opportunities for additional new 
treatments that we could help to ensure that the right 
conditions are there for those to develop, but we ought to be 
incentivizing the right human behaviors to prevent the disease 
to the extent that we can, that individuals can prevent it in 
the first place.
    So I guess the first question I have, Dr. Herman, I would 
like to--I would like to get your thoughts. We have talked 
about the link between obesity and diabetes. We have talked 
about the link from the early 70's of the commodization of 
food, so what we have promoted.
    How much of diabetes is related to these lifestyle choices 
that individuals make? If you had--just imagine for a minute 
that people are eating healthily, they are exercising, they are 
doing the things that we know are good lifestyle choices. How 
much of diabetes would we do away with if that were the case?
    Dr. Herman. So thank you for the question. It is really an 
excellent question. It is quite clear that, you know, a 
significant, a significant proportion of Type 2 diabetes is the 
direct result of obesity, and it is also clear that some 
lifestyle choices play into the development of obesity and 
diabetes in that path.
    It is hard to quantify how much is, you know, how much of 
the lifestyle, which components of lifestyle or other 
environmental factors are the specific factors that have led to 
this epidemic. And so there is a tremendous amount of 
controversy around what are the specific nutritional components 
or combination of nutrients, or how--or in what fashion are 
they presented that leads to obesity per se and diabetes.
    And yet it is clear that that is a major component. It is 
hard to nail down an amount.
    Representative Smucker. Sure. Anybody else want to take a 
stab at that? I know President Nygren, you have talked about 
the importance of programs that encourage good nutritional 
choices and exercise and so on. Does anybody else, you know, 
want to take a stab at how much we could resolve if people were 
making the right choices and had access to the right nutrition?
    President Nygren. Again as president, one of the things of 
the Navajo Nation I have noticed is that--thank you 
Congressman--is that when people get out there, I think they 
are really enjoying these walks and their runs and opportunity 
to educate themselves on healthy foods, healthy diets, healthy 
lifestyles. I have seen a lot of people change, come turn 
around, and they tell me President, this is what I looked like 
a couple of years ago and now I have been attending these 
events that are being hosted and sponsored by this program that 
we are trying to get reauthorized.
    Really to me it is--it helps. It helps dramatically. I do 
not know the percentage or the numbers, but I think that it is 
better, it would definitely decrease and it is just--I think 
overall mental health, depression, diabetes. I think it really 
just helps the person overall if they can eat healthier and 
participate in exercise.
    So I think that in my community, it has really been working 
so----
    Representative Smucker. Yeah, and I do not know. Go ahead.
    Mrs. Brown-Friday. I think that you said a very key thing. 
I think the availability of healthy foods is really a very big 
key access. You said that let us imagine that everybody is 
eating healthily, but that is not the case.
    Representative Smucker. Right.
    Mrs. Brown-Friday. Everyone does not have the healthful 
foods available to them, and/or they cannot afford the 
healthful foods that are out there. I think that that is one 
of--that is the key that we have to think about. I think that 
definitely, as President Nygren was saying, when people are 
introduced to things and they are introduced to healthier 
lifestyles and healthier ways, they really do want to take 
advantage of it.
    I am not saying it is 100 percent obviously, but I think 
that for the most part, and those who I have worked with, who I 
have introduced healthier lifestyles through a lifestyle change 
programs, have embraced it and have made significant changes. 
But again it is access.
    Representative Smucker. If I could just follow up on that, 
I could not agree more with that, by the way, and we do not 
maybe know the exact amount. But you know, a dramatic impact. 
We, I think all would agree with that, and so I think this is a 
wonderful discussion to have in regards to how we can ensure 
that new treatments are being developed.
    But I think we need to spend a lot of time figuring out how 
government programs today are incentivizing bad nutritional 
choices, and I am talking about the SNAP program. I am talking 
about the Farm bill. You know, we subsidize a lot of 
agricultural development as well, a lot of farming.
    We ought to be thinking about how we can ensure that we are 
educating, we are encouraging people to make the right choices, 
and then access is so critical. I completely agree. These are 
discussions that we really should be having to, you know, help 
to ensure that people have access to being able to make the 
right choices, and know what those choices should be.
    So thank you so much for holding this hearing. It has been 
a great discussion.
    Vice Chairman Schweikert. Thank you Mr. Smucker. To my good 
friend Peter.
    Senator Welch. Thank you. It is very good to be with my 
colleagues from the House. You know, the two issues that we 
have been talking about, everyone seems to be focusing on are 
nutrition and exercise, right, because it is after the fact. If 
you get diabetes, then you get into the incredible medical 
challenges that folks face.
    So I am interested in what are the policies, but it is 
tough to get good food. Dr. Ferguson left, and he was talking 
about how being poor is a hard job. It is a full-time 
occupation, just to try to figure out how to get from here to 
there, you know. You might have to take three buses as opposed 
to just get in your car and go.
    You have to really try to figure out where you can get 
something that is affordable for you, which is not necessarily 
the most nutritious. So I am just interested in maybe hearing 
from each of you, what are like the two things that could be 
done to try to help folks who are really low income and 
struggling with a lot of the everyday challenges, of trying to 
make things work. What could be two policies that would help 
both with nutrition and making exercise available? Dr. Herman, 
start with you.
    Dr. Herman. So in terms of, in terms of exercise, I mean 
the things we do with every patient we see is start with simple 
things, which is suggest try to get 10,000 steps a day. These 
are things that cut across socioeconomic status, that are shown 
to be beneficial and----
    Senator Welch. So 10,000 steps.
    Dr. Herman. Yes.
    Senator Welch. All right. How are you doing today on that?
    Dr. Herman. I am probably about a quarter of the way there 
today.
    Senator Welch. Dr. Ippolito.
    Dr. Ippolito. Yeah. The rest of the folks on the panel are 
better experts on the specific policies.
    I will just raise one thing that is important for all of 
these policies, which is if they function through insurance, we 
always have to be very careful that we do not allow insurance 
companies to use policies that really are sort of nominally 
designed to be, you know, helping people be healthier, but 
instead really just risk-select.
    They try and attract healthy people onto their insurance, 
right? So whatever the specific policies, I will just flag that 
as one consideration to keep in mind.
    Senator Welch. Thank you. Ms. Brown-Friday, you deal on the 
ground with lots of folks.
    Mrs. Brown-Friday. I do deal with a lot of folks and I 
think access, as I have been mentioning multiple times, to more 
nutrition, more nutritious foods, more vegetables in both rural 
and urban areas, as well as safe areas for people to exercise, 
because that is also--building infrastructure. Having either a 
park or even assisting people who might want to go to a gym, to 
pay for that, so that they can exercise in a safe environment.
    Senator Welch. You know, the thing that I find about 
exercise is the more easy it is to do, that is integrated in 
whatever your day is, your day is different than my day. So how 
do you find a way within your day, in anybody's day for them to 
get the exercise. If they have to go to a gym, that is a 
project.
    Mrs. Brown-Friday. Well again, it does not have to be going 
to a gym. Having a safe place in your neighborhood to walk, and 
do I have these conversations with some of my patients. Do you 
have a safe place to walk, you know, or can you just walk up 
and down your stairs?
    If you are talking about me personally, I get up at 5:30 in 
the morning. But I cannot talk for everyone else.
    Senator Welch. Thank you.
    Representative Moore. Will the gentleman yield?
    Senator Welch. Yes, sure.
    Representative Moore. Will the gentleman yield? What about 
these medications and behavior modification to medications like 
Ozempic I think is the name of one of them. What about that as 
an intervention? Dr. Herman, anybody?
    Dr. Herman. Sure. So it is clear that medications like 
Ozempic and in that class of medication, they are very 
effective in helping people suppress their appetite and reduce 
their caloric intake and lose weight. They have not been 
approached as kind of a, you know, what would their impact be 
if used widely as a preventative measure.
    But I think it is probably a matter of time before--just a 
matter of time before folks like yourselves begin to think 
about utilizing interventions like that in that way from a 
public policy perspective.
    Representative Moore. I yield back to the gentleman.
    Senator Welch. President Nygren.
    President Nygren. Thank you, Congressman. One of the things 
that I think about is trying to start early for our young kids, 
because on Navajo and a lot of reservations, there is not a lot 
of parks, not a lot of playgrounds, and not a lot of places to 
play basketball or any sports activities.
    So I think that one way for us to do it is probably to 
create those parks and facilities, so that kids while they are 
younger they can learn how to exercise, and then as adults to 
have these facilities open to them, because they are--on a lot 
of reservations, a lot of these things are funded by the 
government, but they are closed off from 8:00 to--after, they 
are only open from 8:00 to 5:00 and then they are closed, and 
then after school and people that have left high school do not 
have access to go and exercise.
    Senator Welch. Thank you very much. I yield back.
    Vice Chairman Schweikert. Thank you, Senator Welch. I do 
not think I actually got around to saying congratulations. We 
are going to actually try to do--we are trying to do the 
Canyon.
    Senator Welch. I know a House-coded insult when I hear it.
    Vice Chairman Schweikert. Oh yeah, I was heading in that 
direction, yeah. All right. I have saved myself for last 
because as for some of my colleagues here, this is a fixation 
for me. And for me it started on the economics.
    I have had--a number of you say 25 percent. I can actually 
show you really well peer-reviewed numbers that it is 33 
percent of all health care spending, 31 percent of Medicare 
spending is functionally related to diabetes.
    I hope everyone will get a chance to read the Republican 
Joint Economic Report, Chapter 3. We went to places, very 
uncomfortable for some, but we actually looked at diabetes and 
obesity in society, and it is both its cost, its moral cost, 
its potential effects on income inequality. Care a lot about 
this.
    So let me, instead of proving what an idiot I am by just 
talking, we over and over and over and over have this 
discussion, changes in the Farm bill. Access to the technology, 
the new over the skin blood glucose. A new one actually got 
released a couple of days ago. It is just a wristband that 
works.
    Number three, the adoption of some the GLP-1s for those who 
are particularly in the morbid categories, or those who have 
Type 2 diabetes, particularly now that we may have the oral, 
the single shot which is fascinating, which may be making it 
through FDA.
    And number four, maybe by the end of the decade for our 
brothers and sisters who have succeeded in getting their weight 
down, but I have seen some data sets that say about 30 percent 
of that population which had Type 2 diabetes, their body will 
not start to produce islet cells that produce insulin again.
    There is actually new, some of the new stem cells. Not just 
the cadaver bleaching model, but actually some of the ones that 
are in Type 1 that look like they already have high efficacy. 
There may be this path over the ten years of a radical change 
in diabetes in our society, and our math is that is five or six 
trillion dollars of spend in the ten years.
    It is real money, and it may be the one path we have where 
our brothers and sisters on the left and those of us on the 
right actually might agree on something. Dr. Herman, start 
there and let us go down. Tell me where I am right, tell me 
where I am wrong.
    Senator Welch. Uh-oh.
    Vice Chairman Schweikert. Yeah. I am willing to take the 
beatings.
    Dr. Herman. I think you are right.
    (Simultaneous speaking.)
    Dr. Herman. So I mean I will just say this from, you know, 
the perspective of a physician who has been treating these 
conditions for a couple of decades, the last decade has been a 
revelation with the new technology and these new medications.
    We have things to offer patients for the first time that 
are incredibly effective for conditions that were previously 
very difficult to treat, and the options seem to be improving. 
And so I am very optimistic about the possibilities over the 
next ten years in applying these medications and technologies 
more widely.
    Dr. Ippolito. I will highlight perhaps a piece of optimism 
on the cost side too. We often see sort of transformational 
developments in the pharmaceutical market or devices that are 
sort of one shot. But we do not have that here. We have classes 
with lots of different products coming to market that have 
different benefits and costs, of course.
    But that is beneficial in the short term because it means 
you have competition to get the formularies, you have price 
competition in the short term that you do not always get, and 
beyond that you as a patient now has four--it is like with 
statins. You have four options to choose from. You can choose 
what is best for you.
    But I will also highlight, you know, ten year budget 
windows, I understand the focus for you guys. But when you 
think about the cost of drugs and technologies, I think you 
have got to think longer term. You had huge savings when things 
come off patents which happens, you know, in the case----
    Vice Chairman Schweikert. And there are some GLP-1s that 
are almost at the end of their patent cycle.
    Dr. Ippolito. Right, right. And so as that starts 
happening, it is not just that those prices go down; is that it 
puts more pressure on the remaining on brand products to 
compete with those off brand products. And so I will sort of 
signal a hopeful point on the cost side, that I think it may 
not be quite as devastating as some other projections are.
    Vice Chairman Schweikert. Ms. Brown-Friday.
    Mrs. Brown-Friday. Well, from my perspective I would say 
that I am very thankful and hopeful that all the innovations do 
come to pass, and that it is available to everyday. I would say 
also that in terms of cost, insulin was not always extremely 
expensive. It became expensive due to whatever it, the 
situation came to. Yes.
    Vice Chairman Schweikert. No, no, no, you are absolutely--
and look, we have had a fixation on the co-op that is about 70 
miles from here. Medeford's is not too far from where you are, 
that actually is also producing even lower than the subsidized 
price. But the revolution is here. I do have an intense concern 
though that it be available for all populations.
    Mrs. Brown-Friday. I agree with you, if indeed it is.
    Vice Chairman Schweikert. And Navajo Nation. Look, you 
know, I have been blessed. As a young man, I spent lots of time 
in the community and most folks who have never been there do 
not understand. There is rural and then there is the Navajo 
Nation.
    President Nygren. Uh-huh.
    Vice Chairman Schweikert. And you actually have a really 
tricky job, because you know, let us be honest. Living in 
Window Rock is a lot different than some of the chapter houses, 
you know, up near the border. But I am incredibly hopeful with 
your leadership.
    What can we do if my fantasy is change the Farm bill, 
access to the blood glucose type of management so you can 
actually see your macros--to understand your diet. That maybe 
living on fried bread, even though it is delicious, is 
difficult. Forgive me for the cultural reference.
    What else can I do other than just funding another program? 
Is that revolution something we can actually deliver to the 
Navajo people?
    President Nygren. I think one of the things, I am glad that 
you have brought that up, because even like with broadband, I 
am trying to bring it up at that level.
    Vice Chairman Schweikert. Starlink.
    President Nygren. Starlink.
    Vice Chairman Schweikert. Satellites. No more waiting 
another 25 years for wire to go out to that chapter house. Put 
up the damn satellite, sorry.
    President Nygren. Yeah. So if we go down that route, some 
form of some of the latest technology that is coming out, it 
would be great to implement it within the IHS program so that 
it is being staged instead of later down the road.
    So I think that just having that better coordination with 
IHS so we can get it out to those main facilities out there, 
that would--I think that would be a key thing, is just 
communicating with the federal partners and then the Nation, 
and then being able to have our people have access to the 
latest and greatest.
    Vice Chairman Schweikert. Thank you, and in some ways this 
is a derivative of even where Mr. Beyer had asked a question. I 
am blessed to represent Salt River--Pima and Maricopa. I have 
lived my whole life next to that community and Fort McDowell. 
And you know, it is a--it is an economically stable community, 
you know, being that close. It is an urban tribe.
    And yet I have seen some data that says that maybe the 
second highest per capita diabetic population in the world, and 
their sister tribe Gila may be number one. So and sometimes it 
is more complex than just saying it is poverty. It turns out 
time, as some said, sometimes it is our need for convenience 
and those things.
    And that is why for those of you who actually also have the 
microphone and the credibility for what you all do, help those 
of us who care passionately tell the story. Maybe it is time 
for revolution in what we do in the Farm bill. Maybe just 
growing the same five commodity crops when North America used 
to grow 3,300 types of grain. Optionality, so you do not have 
to process a process to make a profit.
    Number two, the new technology. I am dying for the Apple 
watch that actually will have blood glucose in it, though I am 
told it might be two generations away so I am going to just buy 
the Samsung. Glad someone got that joke. But the GLP-1s. Every 
day I am reading an article about someone that is coming out 
with new products. So your point that prices are crashing. The 
availability here, and there may be some that are almost out of 
patent expiration.
    Maybe the crazy thing is we buy the damn patent. We buy its 
last 18 months and use that for Medicare and Medicaid, Indian 
Health Services, VA populations, because the savings is 
remarkable.
    I mean sometimes those of us who are on the right sound 
cruel because we are talking about the dollars and cents and do 
not talk enough about the morality of people's lives and their 
ability to participate in society, and the income inequality 
that health differential causes.
    But the four of you are actually on the cusp of the thing, 
that maybe the one point we can--if we can build a unified 
theory here that could have amazing impact on the U.S. solving 
debt and economic growth. But it cannot be what a lot of us 
here do, which is we talk about the one thing we know of eating 
onion rings or, you know, sorry about that.
    Have you ever had a Navajo taco? I will explain it later. 
It is--so in the last part here, I need to give myself, and 
this is the danger of being unscripted. I owe a thank you to 
the Democrat staff and the Republican staff. Thank you for 
actually communicating with each other on this. This is one 
where the solutions great economics and wonderful morality help 
us tell the story.
    The last bit I will give you is if any of you have things 
you want us to read, we are not walking away from this. This is 
almost the only path I have to dramatically change the 
direction of this society right now. Send it to us and we will 
continue to evangelize it.
    And then for all of you, you have--I think it is another 
how many days to be able to submit additional for the record?
    Speaker. Three.
    Vice Chairman Schweikert. How many?
    Speaker. Three.
    Vice Chairman Schweikert. Three days. In the House we do a 
lot more. If you have other documents that you would like us to 
put into the public record, please send it our way. Please do 
it within three days, but if you send it on the fourth day, I 
will still put it in. And with that, we call this hearing 
adjourned. Thank you for participating.
    [Whereupon, at 11:53 a.m., the hearing was adjourned.]
      

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