[Congressional Record Volume 159, Number 63 (Tuesday, May 7, 2013)]
[Senate]
[Pages S3104-S3108]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]


                   Prevention and Public Health Fund

  Mr. HARKIN. Mr. President, I was deeply disturbed several weeks ago 
to learn of the White House's plan to strip $332 million in critical 
funding from the Prevention and Public Health Fund and to redirect that 
money to educating the public about the new health insurance 
marketplaces and other aspects of implementing the Affordable Care Act.
  No one is more interested in ensuring the successful implementation 
of the health insurance exchanges than I am. I chair that committee. I 
was working with both Senator Kennedy and Senator Dodd in formulating 
these aspects of the Affordable Care Act. But it is ill-advised and 
shortsighted to raid the prevention fund, which is making absolutely 
critical investments in preventing disease, saving lives, and keeping 
women and their families healthy.
  Last year they took $5 billion from the prevention fund. I will get 
to that in a moment. So, again, in their raiding of this prevention 
fund, not only is it a case of misplaced priorities, it is frankly an 
outrageous attack on an investment fund that is saving lives by 
advancing wellness and prevention initiatives in communities all across 
America.
  A major purpose of the Affordable Care Act is to begin to transform 
our current sick care system into a genuine health care system, one 
that is focused on saving lives through a greater emphasis on wellness, 
prevention, and public health. I have been saying for 20 years or more 
that we do not have a health care system in America, we have a sick 
care system.
  When you think about it, if you get sick, you can get pretty good 
care in America. We have the best surgeons and best cancer clinics. If 
you are sick, there is probably no better place in the world to be than 
in America to get cured. But what we are lousy at is keeping you 
healthy in the first place and preventing illness, preventing diseases, 
preventing chronic conditions.
  Every expert acknowledges that we will never reduce health care costs 
or have a healthier and more productive society until we have a major 
focus on prevention. However, I have no choice but to conclude that 
when it comes to prevention and wellness, some people in this 
administration just do not get it.
  The prevention fund already has been a giant step forward for public 
health in our Nation. Typically, prevention and public health 
initiatives have in the past always been an afterthought. This means 
that important community-based interventions often go unsupported. The 
prevention fund, as part of the Affordable Care Act, is making it 
possible for us to make national investments in evidence-based programs 
that promote physical activity, improve nutrition, and reduce tobacco 
use.
  This is not the time to mention all of the many ways this fund is 
already making Americans healthier. I want to mention several 
representative investments that are happening right now.
  The prevention fund is already investing $226 million to reduce 
chronic diseases, including diabetes and heart disease. Heart disease 
disproportionately affects women. In fact, it is the No. 1 cause of 
death for women in this country. Some 42 million women in America are 
currently living with some form of heart disease.
  The World Health Organization estimates that a staggering 80 percent 
of heart disease, diabetes, and stroke could be prevented as a result 
of changes in smoking, nutrition, and physical activity alone.
  Moreover, this investment by the prevention fund is not only saving 
lives, it is also saving money. Right now, heart disease costs our 
Nation about $440 billion a year--$440 billion a year in health care 
costs from heart disease alone.
  Cigarette smoking kills an estimated 173,000 women a year. If current 
smoking rates persist, more than 6 million kids living in the United 
States today will ultimately die from smoking.
  This year the fund is supporting a second round of the highly 
successful media campaign called ``Tips From a Former Smoker.'' It is 
estimated that last year's campaign will save $70 million annually 
based on just the smokers who successfully quit in reaction to this 12-
week ad campaign. These ads are extremely powerful and effective. 
Within 2 days of the first ad appearing last year, the number of calls 
to our quit lines tripled. So mark my words, these ads are going to 
save lives. In fact, the second phase of this ad campaign is expected 
to inspire half a million quit attempts and to help at least 50,000 
Americans quit smoking forever.

[[Page S3106]]

Now, that is the $93 million for the anti-tobacco education and support 
campaign. As I pointed out, over 6 million kids--if we do not do 
something about it, 6 million kids today in America will die from 
smoking.
  Let's talk about the immunization program. The prevention fund is 
investing in immunization programs that protect kids and save billions 
of dollars in downstream costs. For every dollar spent on childhood 
immunizations, Americans save $16 by avoiding the costs of treating 
preventable diseases. Furthermore, by ensuring that all adults get 
recommended routine vaccines, we can prevent 40,000 to 50,000 deaths 
annually. So the $82 million that was cut for immunizations in the 
prevention fund by the action by the White House could have saved our 
Nation up to $1.3 billion in unnecessary health care costs. Again, this 
is the very definition of penny wise and pound foolish budgeting.
  Investments from the prevention fund are not just at the national 
level, they are also at the community level. The fund is helping 
States, cities, and towns to implement evidence-based programs that 
meet their particular local needs.
  For example, the State of Illinois has made improvements to its 
sidewalks and has marked crossings in order to increase levels of 
student physical activity for students going to school. Because of 
these improvements, the number of students who are walking to school 
has doubled. Not only is this good for their health, it is expected to 
save the school system about $67,000 a year on bus costs.
  In Florida, the school board of Miami Dade County will soon implement 
the Play, Eat, Succeed project in order to reduce the prevalence of 
childhood obesity among students with disabilities and children in the 
Head Start Program. The project will focus on improving nutritional 
habits, increasing physical activity levels, and achieving a healthy 
weight.
  In California, the Los Angeles County Department of Health has worked 
with more than 100 clinical teams to provide accessible clinical 
preventive services to control high blood pressure and cholesterol, 
reaching approximately 200,000 adults just in Los Angeles County alone.
  In my State of Iowa, the Black Hawk County Board of Health is working 
with the local agency on aging to implement the Better Choices, Better 
Health Program. This initiative is designed to help individuals who are 
living with chronic conditions to find practical ways to self-manage 
pain, fatigue, and to make healthier nutrition and exercise choices, to 
set realistic goals, to understand treatment options and communicate 
with family and health care providers about their condition.
  I mention all of these to show that the prevention fund is not just 
top-down from Washington; we are trying to encourage communities, 
cities, towns, counties, and, yes, some States to do work on their own, 
to come up with innovative ideas on how to encourage people to live 
healthier lives, to prevent smoking, to, for instance, get more kids to 
walk to school. And this is a big problem. A lot of kids in America can 
walk to school, but they do not have sidewalks, they do not have safe 
passages to school, so they take a bus. Simple things like that are 
done at the local level with the prevention fund, and when local levels 
experiment and do things like this and they find that they work, then 
other people adopt it. To me, this is one of the key elements of the 
prevention fund. It is sort of letting a thousand flowers bloom, 
getting more ideas out there from people at the local level on what 
they can do, how they can buy into this.
  What can they do, and how can they buy into this to have a good 
prevention and wellness program on the local level?
  Let's look at the return on investment. We always wonder about the 
return on investment for the kind of money we spend in government. The 
prevention fund all across America is investing in proven locally 
developed programs, as I mentioned, that promote health and wellness, 
and they save lives. Not only is this improving our health outcomes but 
it will save us money.
  According to a study by the Centers for Disease Control and 
Prevention, the National Diabetes Prevention Program to prevent or 
delay nearly 885,000 cases of type 2 diabetes would save our health 
system about $5.7 billion over the next 25 years. The National Diabetes 
Prevention Program is a public-private partnership of health 
organizations that work together to prevent type 2 diabetes to life 
style change programs right in our home communities. Given that in 2007 
diabetes alone accounted for about $116 billion in direct medical 
costs, it is all the more critical that we continue to invest in proven 
programs such as this.
  I want to point out that for these investments, for every dollar we 
put in a childhood immunization series, it has been proven we saved 
$16.50. Yet if I am not mistaken, the White House is taking about $85 
million out of this fund--penny wise and pound foolish.
  Tobacco control programs: For every $1 we invest, we are saving $5. 
Chronic disease prevention: For every $1 we spend, we save $5.60. For 
workplace wellness programs: $3.27 for every $1 we spend. Any way you 
look at it, in all of these programs, just the return alone--not 
mentioning the productivity of people who are healthier, who don't 
smoke, who don't have chronic illnesses--their productivity is much 
higher than those who have chronic illnesses.
  The list goes on and on. The Trust for America's Health released a 
study showing that a 5-percent reduction in the obesity rate could 
yield more than $600 billion in savings on health care costs over 20 
years. Again, this is from the Trust for America's Health. A 5-percent 
reduction in the obesity rate, 5 percent only, could yield more than 
$600 billion in savings on health care costs over 20 years.
  Studies such as this confirm what common sense tells us. Your mother 
was right; prevention is the best medicine for our bodies and for our 
budgets alike. That is why nearly 800 organizations have spoken against 
misguided efforts to slash or eliminate the prevention fund.
  Despite ill-advised efforts to cut or eliminate the prevention fund, 
most Americans understand what is at stake. Prior to creation of the 
prevention fund, for every dollar spent on health care, 75 cents went 
to treating patients with chronic diseases, while only 4 cents was 
spent on efforts to prevent those diseases. Again, before the 
Affordable Care Act, 75 cents of every health care dollar was spent on 
treating you after you got sick. Only 4 cents was spent on preventing 
those diseases.
  This chronic underinvestment has had devastating consequences. Nearly 
half of American adults have at least one chronic condition. Two-thirds 
of the increase in health care spending between 1987 and 2000 was due 
to increased prevalence of chronic diseases.
  We had a briefing from three highly acclaimed medical practitioners 2 
or 3 weeks ago, and they pointed out that two-thirds of the money we 
spend in Medicare goes for treating chronic illnesses--two-thirds.
  When we talk about the money we are spending on Medicare and how do 
we control Medicare costs, some people say we have got to make it 
tougher for people to get Medicare or you have got to cut down on 
Medicare, when the answer is staring us right straight in the face: 
prevention and wellness programs. For elderly people who do have a 
chronic condition, there are interventions that will save us money and 
make their lives better through prevention and wellness programs. We 
know that. There are evidence-based programs which are proven to work.
  The prevention fund gives us an unprecedented opportunity to bend the 
cost curve by jumpstarting the transformation of America into a true 
wellness society, a society that focuses on preventing disease, saving 
lives and saving money.
  As I said, the fund is doing both; it is saving lives and saving 
money. To slash this fund as the White House intends to do is bad 
public policy and bad priorities. To take money from the prevention 
fund is to cannibalize the Affordable Care Act in ways that will both 
cost us money and lives. I think it is a violation of both the letter 
and the spirit of this landmark law. Again, one more time, we know 
prevention saves lives.
  Cancer deaths: About 567,000 people die from cancer annually in the 
United

[[Page S3107]]

States. Fifty percent of those are preventable and much cheaper than 
all the long-term care costs, not to mention the devastation that 
happens in families' lives when a parent is lost to cancer.
  Preventable diseases, heart disease, diabetes, and stroke: About 
796,000 people die from heart disease, diabetes, and stroke annually in 
the United States. Eighty percent of those are preventable. Yet we are 
going to cut money from the prevention fund? It doesn't make sense.
  Prior to the Senate adjourning for this last recess, I put a hold on 
Ms. Marilyn Tavenner's nomination to serve as the Administrator for the 
Centers for Medicare and Medicaid Services. Ms. Tavenner, in her role 
as Acting Administrator, signed a directive in March that channeled 
critical funds away from prevention. I must say, as the chairman of the 
committee, and as the author of the prevention fund in the Affordable 
Care Act, I was never notified until the decision had been made. I was 
not consulted. No one was. It was just sort of signed away.
  Again, I want to make it very clear the hold I put on Ms. Tavenner 
was not a secret hold. In fact, I don't believe in secret holds. Too 
often people put on secret holds and you don't know who is doing it. I 
would never do that. I issued my hold publicly. Why? In order to 
heighten public awareness of this administration's ill-advised policy 
decision to cut prevention money and hopefully to get the White House 
to start to reconsider. I wanted to give people in the White House the 
chance to understand that their assault on the prevention fund is 
shortsighted, destructive, and perhaps suggests other sources of 
funding for implementing and overseeing the marketplace.
  Last year the administration, as I said, approved a $5 billion--and I 
am correct here--a $5 billion cut to the fund as part of the middle-
class tax bill. That was last year. I thought after that we had an 
agreement that was not going to happen again, the clearer cut 
agreement.
  Now the administration has made it clear they intend to move forward 
with even more cuts--$332 million this year--to the prevention fund. 
What we are seeing from the administration is, at best, mixed signals 
and, at worst, a betrayal of the letter and spirit of the Affordable 
Care Act.
  I repeat, these are bad policy choices. This choice to take money out 
of the prevention fund will have negative serious consequences for the 
future health of the American people.
  Again, I don't know and I am unsure as to who is giving advice to the 
President, but I want to say to President Obama, I think you are 
getting bad advice, bad advice on where the money is coming from and 
how it is affecting the prevention fund, and there are other sources of 
funding for the marketplace other than the prevention fund.
  I want to make it clear I don't want to interfere with the important 
work of the Centers for Medicare and Medicaid Services. I also happen 
to believe Ms. Tavenner is very well qualified and strongly qualified 
to be the next Administrator. I believe it is urgent to have an 
effective leader at the helm of CMS as we enter a critical stage in 
implementing the Affordable Care Act.
  Accordingly, I am removing my hold on her nomination. However, as I 
do so, I repeat, it is deeply disappointing and disturbing that the 
White House once again is raiding the Prevention and Public Health 
Fund.
  I would hope Ms. Tavenner, in her future role as the head of the CMS, 
will understand that while she works for the President, advice and 
consent of the U.S. Senate might be something worth considering in her 
future actions. I hope and expect again that the White House will 
respect the intent of Congress in creating the prevention fund, not as 
an afterthought but as a critical feature of the Affordable Care Act--
every bit as critical as the exchanges, the marketplace, and everything 
else.
  I hope the administration will join us in fighting for the prevention 
fund and in making smart, evidence-based investments in prevention and 
wellness. This is what real health reform is about. It is not about how 
you pay the bills. If all we are going to do in the Affordable Care Act 
is jiggle around on how we pay the bills, we are sunk. Real health 
reform is about changing our society away from a sick-care system to a 
true health care system, keeping people healthy, promoting wellness, 
having prevention programs at every level of society, in our schools, 
in our workplaces, and in our communities from the earliest moments of 
life, immunization programs. This is for those who are elderly, who may 
have a chronic condition but who can control that, at less cost and 
with healthier lives through good prevention and wellness programs. 
That is what true health reform is about, and it is our best bet for 
creating a healthier and more prosperous Nation. To that important end, 
the Congress and the White House should not be working at cross 
purposes. We should be working together. I say we must rededicate 
ourselves to the great goal of creating a reformed health care system 
that has a major focus on prevention and wellness, not just for a few 
but for all Americans. That is what the intention was of the Prevention 
and Public Health Fund.
  As I say again, and I say very clearly, I don't know who is advising 
the President, but I think the President is getting bad advice. I 
understand the President has a lot on his plate, everything from Syria 
to Afghanistan--a lot. I understand that.
  I hope that those in the White House who are advising the President 
would take a closer look and find some way of replenishing that $332 
million and hopefully making some ironclad agreements that they are not 
going to raid the fund again next year.
  I thought we had an agreement that last year was it, that $5 billion 
was it. I thought we had that agreement. I was operating under that 
assumption. Will we take more money out of the prevention fund again 
next year too to meet some exigency that may come up? That is what has 
been wrong with our sick-care system in the past. We are so focused on 
paying today's bills we don't focus on the future and how to keep 
people healthy. We just pay today's bills, keep paying the bills and 
paying the bills. Like clueless dodos, we wonder why health care costs 
are skyrocketing. It is because we don't focus on keeping people 
healthy in the first place.

  So I will remove my hold on Ms. Tavenner, but I hope the 
administration will find a way to replenish that $332 million this year 
and make a firm commitment to not raiding this fund in the future.
  Mr. LEAHY. Mr. President, I am glad the Senate is finally confirming 
David Medine as Chairman of the bipartisan Privacy and Civil Liberties 
Oversight Board, PCLOB. The confirmation of this nominee is a 
significant victory for all Americans who care about safeguarding our 
privacy rights and civil liberties. The American people now have a 
Privacy and Civil Liberties Oversight Board that is at full strength. 
This Board should help ensure that we honor our fundamental values as 
we implement a strategy to keep our Nation safe. Today's victory is 
also a reminder of the challenges we face, and the commitment we must 
keep, to protect personal privacy as new technologies emerge. Last 
month, the Judiciary Committee unanimously reported bipartisan 
legislation that Senator Lee and I authored to update the Electronic 
Communications Privacy Act. I hope that the Senate will promptly 
consider and pass this good privacy bill, as well.
  The Judiciary Committee favorably reported this nomination last May 
along with a bipartisan group of nominees to serve as members of the 
Board. This nomination should not have taken a year to be considered 
and confirmed by the Senate. The Senate finally confirmed all of the 
other individuals, those nominated to serve as members of the Board, 
last August. Republican Senators refused to vote on the chairman's 
nomination. This was a needless delay and prevented the Board from 
functioning at full strength. This is reminiscent of how they have 
obstructed this President's nominees to the National Labor Relations 
Board and the Consumer Financial Protection Bureau, as well as so many 
of his judicial nominees. Now, after a year of obstruction, the Senate 
will finally vote on the nomination, and the Privacy and Civil 
Liberties Oversight Board we in Congress worked so hard to establish 
will finally be able to begin to carry out its important work on behalf 
of the American people.
  The Privacy and Civil Liberties Oversight Board is a guardian of 
Americans'

[[Page S3108]]

privacy rights and civil liberties as well as an essential part of our 
national security strategy. When we worked to create this Board in the 
wake of the Nation's response to the terrorist attacks on September 11, 
2001, we did so to ensure that our fundamental rights and liberties 
would be preserved as government takes steps to better secure our 
Nation. In the digital age, we must do more to protect our Nation from 
cyber attacks. But we must do so in a way that protects privacy and 
respects our fundamental freedoms.
  Protecting national security and protecting Americans' fundamental 
rights are not in conflict. We can--and must--do both. The Privacy and 
Civil Liberties Oversight Board should help ensure that we do now that 
the Senate has finally been allowed to act on the nomination of 
Chairman Medine.
  With that, I yield the floor and suggest the absence of a quorum.
  The ACTING PRESIDENT pro tempore. The clerk will call the roll.
  The assistant legislative clerk proceeded to call the roll.
  Mr. UDALL of New Mexico. Madam President, I ask unanimous consent the 
order for the quorum call be rescinded.
  The PRESIDING OFFICER (Ms. Heitkamp). Without objection, it is so 
ordered.
  The question is, Will the Senate advise and consent to the nomination 
of David Medine, of Maryland, to be Chairman and Member of the Privacy 
and Civil Liberties Oversight Board?
  Mr. GRASSLEY. I ask for the yeas and nays.
  The PRESIDING OFFICER. Is there a sufficient second?
  There appears to be a sufficient second.
  The clerk will call the roll.
  The bill clerk called the roll.
  Mr. DURBIN. I announce that the Senator from New Jersey (Mr. 
Lautenberg) and the Senator from West Virginia (Mr. Manchin ) are 
necessarily absent.
  The PRESIDING OFFICER. Are there any other Senators in the Chamber 
desiring to vote?
  The result was announced--yeas 53, nays 45, as follows:

                      [Rollcall Vote No. 114 Ex.]

                                YEAS--53

     Baldwin
     Baucus
     Begich
     Bennet
     Blumenthal
     Boxer
     Brown
     Cantwell
     Cardin
     Carper
     Casey
     Coons
     Cowan
     Donnelly
     Durbin
     Feinstein
     Franken
     Gillibrand
     Hagan
     Harkin
     Heinrich
     Heitkamp
     Hirono
     Johnson (SD)
     Kaine
     King
     Klobuchar
     Landrieu
     Leahy
     Levin
     McCaskill
     Menendez
     Merkley
     Mikulski
     Murphy
     Murray
     Nelson
     Pryor
     Reed
     Reid
     Rockefeller
     Sanders
     Schatz
     Schumer
     Shaheen
     Stabenow
     Tester
     Udall (CO)
     Udall (NM)
     Warner
     Warren
     Whitehouse
     Wyden

                                NAYS--45

     Alexander
     Ayotte
     Barrasso
     Blunt
     Boozman
     Burr
     Chambliss
     Coats
     Coburn
     Cochran
     Collins
     Corker
     Cornyn
     Crapo
     Cruz
     Enzi
     Fischer
     Flake
     Graham
     Grassley
     Hatch
     Heller
     Hoeven
     Inhofe
     Isakson
     Johanns
     Johnson (WI)
     Kirk
     Lee
     McCain
     McConnell
     Moran
     Murkowski
     Paul
     Portman
     Risch
     Roberts
     Rubio
     Scott
     Sessions
     Shelby
     Thune
     Toomey
     Vitter
     Wicker

                             NOT VOTING--2

     Lautenberg
     Manchin
       
  The nomination was confirmed.
  The PRESIDING OFFICER. Under the previous order, the motion to 
reconsider is considered made and laid upon the table. The President 
will be immediately notified of the Senate's action.

                          ____________________