[Congressional Record (Bound Edition), Volume 155 (2009), Part 18]
[Senate]
[Pages 24831-24834]
[From the U.S. Government Publishing Office, www.gpo.gov]




                           HEALTH CARE REFORM

  Mr. HARKIN. Mr. President, all five congressional committees involved 
in the health care reform debate have completed their work now and the 
core

[[Page 24832]]

elements of this landmark legislation are now clear.
  The media has done a good job of reporting that the emerging bill 
will crack down on abuses by health insurance companies and extend 
quality health coverage to the vast majority of Americans. In addition, 
much attention has been paid to the public option which I am confident 
will be in the bill we send to the President later this year. So there 
has been a lot in the press about the public option; about coverage; 
how much this costs; will there be an excise tax; what will the 
penalties be. Almost all of the debate we see--I should say 
discussion--surrounding the health care reform is about how we pay the 
bills, when we think about it. It is about how are we going to pay all 
of these bills.
  There is one huge part of the health reform bill that is not being 
discussed very much that I believe will have a transformative effect on 
the system we have in America today, which I have often referred to as 
not a health care system but a sick care system. When we think about 
it, that is what we have in America: a sick care system. If you get 
sick, you get care one way or the other, but we do precious little to 
keep you healthy in the first place. As one of the comedians on one of 
these late night talk shows I happened to tune in to one night said, 
you know, they are talking about everything except health care.
  What do we need to do to keep people healthy in the first place? 
Well, quite frankly, that is in our bill. That is what I wanted to 
discuss this morning, which is some of the aspects of the bill that I 
believe will bend the cost curve in the future and make us a genuine 
wellness society. The bill we reported out of our HELP Committee 
creates a sharp new emphasis on fitness, physical activity, good 
nutrition, disease prevention; in short, keeping people out of the 
hospital in the first place. This will give Americans access to a 21st 
century true health care system focused on preventing disease and 
helping us live healthy, active, productive lives, and it will reduce 
wasteful, avoidable costs that are built into our current system. 
Again, this sort of disease management approach we have in our country 
now is about patching things up after people develop a serious illness 
or a chronic condition. It is a system that overspends, which we know, 
and underperforms. It has been a colossally expensive failure.
  We can and must do better. As President Obama said in his speech to 
Congress back in February:

       [It is time] to make the largest investment ever in 
     preventive care, because that's one of the best ways to keep 
     our people healthy and keep our costs under control.

  To most of us, it is self-evident that cost-effective preventive 
services will save money in the long term. This first chart is of a 
poll taken which shows that 76 percent of the American people said we 
should invest more in preventive care--76 percent. They get it. The 
American people get it. This support comes from across the political 
spectrum. Eighty-six percent of Democrats, 71 percent of Republicans, 
and 70 percent of Independents say we should be spending more on 
prevention.
  This next chart shows that 77 percent of Americans support a new 
emphasis on prevention in a health care reform bill because they know 
it is the right thing to do. It is common sense. If we can use cost-
effective screenings and other upfront intervention programs to prevent 
tens of millions of occurrences of chronic diseases such as cancer, 
diabetes, and cardiovascular disease, it is self-evident that we are 
going to slash health care costs very significantly.
  Some critics have claimed that a new emphasis on wellness and 
prevention will cost more money and it will drive up health care costs. 
To support this claim, they have created a straw man, assuming that we 
are going to do all of these preventive services for everybody all the 
time, but that is not what is in our bill. I wish to emphasize that our 
committee's bill takes a very rigorous approach to prevention. We 
target appropriate preventive services and screenings only to those 
segments of the population that are at risk of a disease or a 
condition.
  For example, under our bill, mammogram screenings would be free--no 
copays, no deductibles--but to those most at risk of breast cancer--
women over the age of 40.
  At every step, what we have relied on are the latest recommendations 
of the U.S. Preventive Services Task Force. This task force has been in 
existence since the early 1980s. It evaluates clinical preventive 
services on the basis of scientific evidence related to effectiveness, 
appropriateness, and cost-effectiveness. So what we have said is that 
if the U.S. Preventive Services Task Force gives a certain preventive 
measure or screening an A or a B score, then the insurance companies 
and providers must provide that without any copays or deductibles. So 
it is targeted. It is not everything, but we are targeting the most 
cost-effective.
  We also say that this task force has to meet at least once every 5 
years and take in the latest scientific evidence and make 
recommendations for revising the mix of clinical preventive services.
  Let me review some of the ways the Senate HELP Committee bill, in a 
very careful way, will put prevention and wellness at the very heart of 
health reform.
  First, we create a Federal level prevention and public health council 
to improve coordination among Federal agencies in incorporating 
wellness into a national policy, and will develop a national prevention 
and a public health strategy. All of the departments should be doing 
this, not just the Department of Health and Human Services but the 
Department of Agriculture, the Department of Defense, the Department of 
Veterans Affairs, the Department of Transportation, and on and on. All 
of them ought to have as an integral part of their deliberations and 
proposals for future legislation that they might propose in the 
Congress an element of prevention and wellness. Take the Department of 
Transportation, for example. When they are thinking about highways, 
bridges, roads, and things such as that, are they thinking about bike 
paths and walking paths and sidewalks in cities that could be 
incorporated into the planning if they want Federal money? Well, they 
have not so far. This is what I mean. We need this kind of an overall 
coordinating council at the White House level, at the department level.
  We also start a prevention and public health investment fund to 
provide for expanded and sustained national investments in prevention 
and public health programs in communities all across America.
  A 2007 study by the Trust for America's Health found major savings 
from community-based prevention programs. There is clinic-based 
prevention where you get a screening, but then there are community-
based programs to improve physical activities, nutrition, reduce 
smoking rates, and things such as that. They found that a national 
investment of just $10 per person per year--think about that, $10 per 
person per year--in certain community-based wellness programs would 
yield these kinds of savings: in 1 to 2 years, $2.8 billion; 5 years, 
$16 billion; and 10 to 20 years, $18.5 billion.
  Again, on both the community level and the clinical level, we provide 
for funding and a structure to make wellness and prevention an integral 
part of our health care system. For example, our bill would target 
nutrition counseling to prediabetic patients. Right now, under 
Medicare, for example, and most insurance companies, they will 
reimburse thousands of dollars to take care of your diabetic conditions 
once you get diabetes. They will pay for amputating a foot or a leg. 
They will pay for all these expensive things after you get diabetes. 
They will pay for a lifetime of treatment. But now they will not 
reimburse for the cost of nutrition counseling--a few hundred dollars 
for someone who is prediabetic and who could prevent the disease 
through changes in diet. That doesn't make sense. Our bill would change 
this by requiring insurance plans to reimburse for nutrition counseling 
for prediabetic individuals--another example of a cost-effective 
approach.
  For essential screenings and annual physicals, our bill would get rid 
of

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copays and deductibles for things such as your annual physical 
checkups, vaccinations, mammogram screenings, and colonoscopies for the 
right population group, things like that--no copays, no deductibles.
  We are going to make major new investments in the public health and 
primary care workforce. Senator Murray, of Washington, did a great job 
of incorporating workforce development in our committee bill. A lot of 
that workforce development is in the area of primary care and 
preventive care and wellness.
  Finally, we give a powerful boost to employer-sponsored wellness 
programs. Our bill would allow employers to reward employees for 
participating in wellness programs by giving them a health insurance 
premium discount of up to 30 percent. In other words, if you 
participate in a wellness program that is provided by your employer, 
you can get a discount of up to 30 percent on your health insurance 
premium. I believe this is something that has been done by Safeway and 
others, and they have shown that they have had great results. People 
can see the benefit of wellness and prevention by getting a reduction 
in their health care premiums.
  Workplace wellness programs--everything from nutrition counseling to 
smoking cessation--typically cost about $20 to $200 per employee per 
year. Again, they have a proven rate of return, ranging from $2 to $10 
within 18 months, for every dollar spent. If you don't believe me, ask 
Pitney-Bowes what they did or Safeway. I single those two out, but many 
companies have gone way ahead of us in providing wellness programs for 
their employees. Are they doing it just out of sheer generosity? No. 
They know the bottom line. They know that when they provide wellness 
and prevention programs for their employees, their rate of return per 
dollar spent on an employee is 2 to 10 times as much within just a year 
or two. They have healthier employees. They don't go to the hospital as 
often. They don't have chronic diseases and they are more productive. 
They show up for work and they are more productive. What we have done 
in our bill is expanded this nationwide to give more companies the 
incentive to do that.
  Our bill also directs the CDC to study and evaluate the best 
employer-based wellness programs and to create an educational campaign 
to promote these workplace wellness programs throughout America.
  We think about the United States and our sick care system this way: 
We spend twice as much per capita on health care as European 
countries--twice as much--but we are twice as sick with chronic 
diseases. How is this possible? The reason is clear: We have neglected 
wellness prevention and disease prevention. In the United States, 95 
cents of every health care dollar is spent on treating illnesses and 
conditions after they occur. Two-thirds of the increase in health care 
spending is due to increased prevalence of treated chronic disease. 
This chart illustrates that. In the late 1980s, we were spending about 
$313 billion a year on chronic disease. We have now doubled that. It is 
up to $627 billion, and it is going up at an ever-increasing rate. 
These are diseases that are mostly preventable. Yet we just continue to 
spend the money dealing with these chronic diseases.
  The good news is that by reforming our system and keeping people 
healthy and preventing chronic illnesses, we have a great opportunity 
to not only save hundreds of billions of dollars but to improve the 
health of the American people.
  Right now, 75 percent of health care costs are accounted for by heart 
disease, diabetes, prostate cancer, breast cancer, and obesity--five of 
them. These five diseases account for 75 percent of our health care 
costs. What do they have in common? They all have this in common: They 
are largely preventable, and even reversible, by changes in nutrition, 
physical activity, and lifestyle.
  Again, for every dollar spent, 75 cents went toward treating patients 
with chronic disease. The CDC said this:

       The United States cannot effectively address escalating 
     health care costs without addressing the problem of chronic 
     diseases.

  Ninety-six cents of every Medicare dollar--we always hear that we are 
not going to have enough money for Medicare in the next 10 or 12 years, 
however long it is. Well, 96 cents goes for chronic disease. If you 
want to cut down on how much money we spend on Medicare, let's focus on 
prevention and wellness, especially for that group of individuals who 
are between 55 and 65, about ready to go on Medicare. Eighty-three 
cents of every dollar spent on Medicaid is spent on chronic diseases. 
Why don't we understand this and get it right? Yet, just like blind 
dodos, we say we will just keep spending the money and we won't address 
wellness and prevention. And we wonder why we can't get health care 
costs under control. Well, that is why. We are not addressing the 
underlying issues of wellness and prevention.
  Again, it makes no sense to me that we spend all this time and all 
this effort to figure out a better way to pay the bills in a system 
that is dysfunctional, ineffective, and broken. We have to change the 
health care system itself. We have to change from a sick care system to 
a health care system, beginning with a sharp new emphasis on prevention 
and public health and wellness. That is in this bill, and that is not 
being talked about by the media. It is one of the fundamental parts of 
the health care reform we are going to be putting through here on the 
Senate floor and, hopefully, in Congress and to the President by the 
end of the year.
  It also has to be comprehensive. Not everything that deals with 
wellness and prevention can be done in this bill. For example, very 
soon we have to reauthorize the child nutrition bill, which deals with 
the School Lunch Program and the Breakfast Program. We have to get 
better food, more nutritional food for our kids in school and get the 
junk food out. Why do we have vending machines in schools? Do we have 
vending machines in schools to provide more healthy food for kids in 
school? You know the answer to that. Of course not. Why do you have the 
vending machines in schools? Is it so that the school can make money so 
it can buy band uniforms or maybe football uniforms and things like 
that? Is it so we can get our kids on junk food and high-sugar sodas, 
which leads to obesity and leads to diabetes and other kinds of chronic 
illnesses? Do we really want that for our kids in school? We have to 
have more nutritional foods. That is the child nutrition 
reauthorization.
  Next year, under our committee, I say to the occupant of the chair, 
who is now a distinguished member of our committee, we are going to 
reauthorize the Elementary and Secondary Education Act, which is also 
called No Child Left Behind. What about making sure we leave no child 
behind also in terms of their health? Right now, we are cutting down on 
physical activity with kids in school. We are cutting down on recess 
and time for them to exercise. That is just nonsense. We have to do 
more to provide for exercise and healthy foods for our kids in school. 
That is where it all begins.
  To close, Winston Churchill once said something I always thought was 
pretty much right on point:

       Americans always do the right thing--after they have tried 
     everything else.

  We have tried everything else in health care, and it has failed. It 
has led us to bad health and to the brink of bankruptcy. Let's try 
something new--wellness and prevention. Times change the paradigm of 
health care. Let's recreate America as a genuine wellness society. 
Let's change the focus and make it easier to be healthy and harder to 
be unhealthy. Right now, it is easier to be unhealthy and hard to be 
healthy. Let's change that around, and in doing so we will build a 
health care system and bend that cost curve. That is the only way to 
get the job done.
  The PRESIDING OFFICER. The Senator from Oklahoma.
  Mr. COBURN. Mr. President, I wonder if the Senator from Iowa will 
yield for a question.
  The PRESIDING OFFICER. The Senator has no time remaining.
  Mr. COBURN. On our time.
  The PRESIDING OFFICER. Without objection, it is so ordered.

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  Mr. COBURN. Mr. President, the Senator from Iowa listed five 
diseases. I think he mentioned prostate cancer and breast cancer. Can 
he give us a reference of where he gets that data? Having practiced 
medicine for 25 years, most of my prostate cancer patients and breast 
cancer patients would want to know what the prevention is to prevent 
those diseases. Since we don't have anything in scientific literature 
right now that says that, I was wondering if he could refer us to the 
data.
  Mr. HARKIN. Mr. President, I will be glad to get that for the 
Senator. I will get that to the Senator.
  Mr. COBURN. I thank the Senator.

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