[Joint House and Senate Hearing, 118 Congress]
[From the U.S. Government Publishing Office]
S. Hrg. 118-143
THE ECONOMIC IMPACT OF DIABETES
=======================================================================
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
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
53-246 WASHINGTON : 2023
-----------------------------------------------------------------------------------
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.]
SUBMISSIONS FOR THE RECORD
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
[all]