[House Report 112-57]
[From the U.S. Government Publishing Office]
112th Congress Report
HOUSE OF REPRESENTATIVES
1st Session 112-57
======================================================================
TO REPEAL THE PREVENTION AND PUBLIC HEALTH FUND
_______
April 11, 2011.--Committed to the Committee of the Whole House on the
State of the Union and ordered to be printed
_______
Mr. Upton, from the Committee on Energy and Commerce,
submitted the following
R E P O R T
together with
DISSENTING VIEWS
[To accompany H.R. 1217]
[Including cost estimate of the Congressional Budget Office]
The Committee on Energy and Commerce, to whom was referred
the bill (H.R. 1217) to repeal the Prevention and Public Health
Fund, having considered the same, report favorably thereon
without amendment and recommend that the bill do pass.
CONTENTS
Page
Purpose and Summary.............................................. 2
Background and Need for Legislation.............................. 2
Hearings......................................................... 3
Committee Consideration.......................................... 3
Committee Votes.................................................. 3
Committee Oversight Findings..................................... 5
Statement of General Performance Goals and Objectives............ 5
New Budget Authority, Entitlement Authority, and Tax Expenditures 5
Earmark.......................................................... 5
Committee Cost Estimate.......................................... 5
Congressional Budget Office Estimate............................. 5
Federal Mandates Statement....................................... 7
Advisory Committee Statement..................................... 7
Applicability to Legislative Branch.............................. 7
Section-by-Section Analysis of the Legislation................... 7
Changes in Existing Law Made by the Bill, as Reported............ 7
Purpose and Summary
H.R. 1217, a bill to repeal the Prevention and Public
Health Fund in the Patient Protection and Affordable Care Act
(PPACA)(Public Law No. 111-148), was introduced on March 29,
2011, by Rep. Joseph Pitts (R-PA), and was referred to the
Committee on Energy and Commerce.
The goal of H.R. 1217 is to reduce federal spending,
deficits, and debt by repealing mandatory programs with limited
Congressional oversight.
Background and Need for Legislation
The Prevention and Public Health Fund, Section 4002 of
PPACA, is a $17.75 billion account (FY12-FY21) administered by
the Secretary of Health and Human Services (HHS) to provide for
``expanded and sustained national investment in prevention and
public health programs to improve health and help restrain the
rate of growth in private and public sector health care
costs.''
Section 4002 appropriates $1 billion for FY 2012; $1.25
billion for FY 2013; $1.5 billion for FY 2014; $2 billion for
FY 2015 and each fiscal year thereafter in perpetuity. The
proposed legislation would repeal Section 4002 and rescind any
unobligated funds.
The Secretary has full authority to spend funds in this
account on any program or activity under the Public Health
Service Act (PHSA) the Department chooses without further
Congressional action. Repealing this fund does not cut any
specific program. The Prevention and Public Health Fund
provides supplemental funding for PHSA programs above their FY
2008 level. The House-passed health care bill in the last
Congress, H.R. 3962, did create a public health trust fund at a
cost of $34 billion over 10 years. However, this fund would
have been subject to Congress providing a subsequent
appropriation.
Providing an advanced appropriation limits Congressional
oversight of spending under the PHSA. Rather than provide the
Secretary a large appropriation with broad discretion, the
Committee believes Congress should identify worthy public
health service programs and authorize them at appropriate
levels. Congress can then set fiscal priorities by subsequently
providing funding through the appropriations process after
weighing the relative value of different programs.
The large and permanent advanced appropriation made
available under Section 4002 also comes at a time when the
growth in federal spending, particularly health care spending,
has fueled mounting deficits and debt. The President's Budget
calls for $3.8 trillion in federal spending for FY 2011. These
spending levels represent 25.3 percent of GDP and are well
above the historical average of 20.3 percent.
Consequently, this record spending has lead to a FY 2011
deficit of $1.6 trillion (10.9 percent of GDP). Deficits for
2011 represent an all-time record both in nominal terms and as
a share of the economy post-World War II.
Record deficits have also induced record borrowing. The
federal government is now borrowing 42 cents for every dollar
it spends. By the end of the decade, the federal debt will
nearly double from $14 trillion to $26 trillion. Interest
payments alone will increase to $841 billion annually by 2021.
In light of these facts, reigning in government spending is
the only responsible course if we are to avoid a debt crisis.
H.R. 1217 helps achieve this goal by eliminating a mandatory
appropriation that would not have been subject to Congressional
oversight.
Hearings
The Subcommittee on Health held a hearing on a discussion
draft identical to H.R. 1217 on March 9, 2011. The following
witnesses testified at the hearing:
The Honorable Ernest J. Istook, The Heritage
Foundation
Dr. John Goodman, President and CEO,
National Center for Policy Analysis
The Honorable Joseph F. Vitale, New Jersey
State Senate
The Secretary of HHS also testified before the Health
Subcommittee at a March 3, 2011 hearing regarding the
President's FY 2012 Budget and implementation of PPACA.
Committee Consideration
H.R. 1217 was introduced by Mr. Joseph Pitts on March 29,
2011, and was referred to the Committee on Energy and Commerce.
On March 31, 2011, the Subcommittee on Health met in open
markup session to consider H.R. 1217. Subsequently, the
Subcommittee ordered H.R. 1217 favorably reported by a recorded
vote of 14-11.
On April 5, 2011, the Energy and Commerce Committee met in
open markup session to consider H.R. 1217. Subsequently, the
Committee ordered H.R. 1217 favorably reported by a vote of 26-
16.
Committee Votes
Clause 3(b) of rule XIII of the Rules of the House of
Representatives requires the Committee to list the record votes
on the motion to report legislation and amendments thereto.
Committee Oversight Findings
Pursuant to clause 3(c)(1) of rule XIII of the Rules of the
House of Representatives, the oversight findings and
recommendations of the Committee are reflected in the
descriptive portions of this report, including the finding that
reigning in mandatory spending is necessary to avoid a debt
crisis.
Statement of General Performance Goals and Objectives
In accordance with clause 3(c)(4) of rule XIII of the Rules
of the House of Representatives, the performance goals and
objectives of the Committee are reflected in the descriptive
portions of this report, including the goal of avoiding a debt
crisis by reigning in mandatory spending.
New Budget Authority, Entitement Authority, and Tax Expenditures
In compliance with clause 3(c)(2) of rule XIII of the Rules
of the House of Representatives, the Committee finds that H.R.
1217 would result in no new or increased budget authority,
entitlement authority, or tax expenditures or revenues.
Earmark
In compliance with clause 9(e), 9(f), and 9(g) of rule XXI,
the Committee finds that H.R. 1217 contains no earmarks,
limited tax benefits, or limited trade benefits.
Committee Cost Estimate
The Committee adopts as its own the cost estimate prepared
by the Director of the Congressional Budget Office pursuant to
section 402 of the Congressional Budget Act of 1974.
Congressional Budget Office Estimate
Pursuant to clause 3(c)(3) of rule XIII of the Rules of the
House of Representatives, the following is the cost estimate
provided by the Congressional Budget Office pursuant to section
402 of the Congressional Budget Act of 1974:
H.R. 1217--A bill to repeal the Prevention and Public Health Fund
Summary: H.R. 1217 would repeal a fund established by the
Patient Protection and Affordable Care Act (PPACA), the
Prevention and Public Health Fund, which provides grant
assistance to entities to carry out prevention, wellness, and
public health activities. The bill also would rescind any
unobligated balances appropriated to the fund.
CBO estimates that enacting the legislation would decrease
direct spending by more than $6 billion over the 2012-2016
period and by $16 billion over the 2012-2021 period. Pay-as-
you-go procedures apply because enacting the legislation would
affect direct spending.
The bill contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act (UMRA).
Estimated cost to the Federal Government: The estimated
budgetary impact of H.R. 1217 is shown in the following table.
The costs of this legislation fall within budget function 550
(health).
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By fiscal year, in billions of dollars--
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2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2012-2016 2012-2021
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CHANGES IN DIRECT SPENDING
Budget Authority.................................. -1.0 -1.3 -1.5 -2.0 -2.0 -2.0 -2.0 -2.0 -2.0 -2.0 -7.8 -17.8
Estimated Outlays................................. -0.4 -0.9 -1.3 -1.6 -1.9 -2.0 -2.0 -2.0 -2.0 -2.0 -6.1 -16.0
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Note: Numbers may not sum to totals because of rounding.
Basis of estimate: For this estimate, CBO assumes that the
legislation will be enacted by the end of September 2011.\1\ As
established by PPACA, the Prevention and Public Health Fund
provides grant funds to federal agencies to award to public and
private entities to carry out prevention, wellness, and public
health activities. The Act provided annual funding of $750
million in 2011 rising to $2.0 billion per year by 2015. CBO
estimates that H.R. 1217 would prevent the Department of Health
and Human Services from obligating any unobligated funds
appropriated to the Prevention and Public Health Fund. CBO
expects that all of the appropriated funds for fiscal year 2011
will be obligated by the time H.R. 1217 would be enacted. As a
result, CBO estimates that enacting H.R. 1217 would reduce
direct spending by $6.1 billion over the 2012-2016 period and
by $16 billion over the 2012-2021 period.
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\1\If the bill were to be enacted sooner than the end of fiscal
year 2011, a larger unobligated balance may remain than is estimated
here. In that case, the amount of budget authority that could be
rescinded by this legislation would increase, resulting in a
corresponding increase in savings.
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Pay-as-you-go considerations: The Statutory Pay-As-You-Go
Act of 2010 establishes budget reporting and enforcement
procedures for legislation affecting direct spending or
revenues. The net changes in outlays that are subject to those
pay-as-you-go procedures are shown in the following table.
Enacting H.R. 1217 would have no impact on federal revenues.
CBO ESTIMATE OF PAY-AS-YOU-GO EFFECTS FOR H.R. 1217, AS ORDERED REPORTED BY THE HOUSE COMMITTEE ON ENERGY AND COMMERCE ON APRIL 5, 2011
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By fiscal year, in billions of dollars--
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2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2011-2016 2011-2021
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NET DECREASE (-) IN THE DEFICIT
Statutory Pay-As-You-Go Impact............. 0 -0.4 -0.9 -1.3 -1.6 -1.9 -2.0 -2.0 -2.0 -2.0 -2.0 -6.1 -16.0
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Note: Numbers may not sum to totals because of rounding.
Intergovernmental and private-sector impact: H.R. 1217
contains no intergovernmental or private-sector mandates as
defined in UMRA. By rescinding funding amounts made available
by the Prevention and Public Health Fund, the bill would
decrease the amount of resources that state, local, and tribal
governments receive to conduct prevention, wellness, and public
health activities.
Estimate prepared by: Federal Costs: Lisa Ramirez-Branum;
Impact on State, Local, and Tribal Governments: Lisa Ramirez-
Branum; Impact on the Private Sector: Jimmy Jin.
Estimate approved by: Holly Harvey, Deputy Assistant
Director for Budget Analysis.
Federal Mandates Statement
The Committee adopts as its own the estimate of Federal
mandates prepared by the Director of the Congressional Budget
Office pursuant to section 423 of the Unfunded Mandates Reform
Act.
Advisory Committee Statement
No advisory committees within the meaning of section 5(b)
of the Federal Advisory Committee Act were created by this
legislation.
Applicability to Legislative Branch
The Committee finds that the legislation does not relate to
the terms and conditions of employment or access to public
services or accommodations within the meaning of section
102(b)(3) of the Congressional Accountability Act.
Section-by-Section Analysis of the Legislation
Section 1 repeals Section 4002 of PPACA and rescinds
unobligated funds made available by such Section 4002.
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets and
existing law in which no change is proposed is shown in roman):
PATIENT PROTECTION AND AFFORDABLE CARE ACT
* * * * * * *
TITLE IV--PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC HEALTH
Subtitle A--Modernizing Disease Prevention and Public Health Systems
* * * * * * *
[SEC. 4002. PREVENTION AND PUBLIC HEALTH FUND.
[(a) Purpose.--It is the purpose of this section to establish
a Prevention and Public Health Fund (referred to in this
section as the ``Fund''), to be administered through the
Department of Health and Human Services, Office of the
Secretary, to provide for expanded and sustained national
investment in prevention and public health programs to improve
health and help restrain the rate of growth in private and
public sector health care costs.
[(b) Funding.--There are hereby authorized to be
appropriated, and appropriated, to the Fund, out of any monies
in the Treasury not otherwise appropriated--
[(1) for fiscal year 2010, $500,000,000;
[(2) for fiscal year 2011, $750,000,000;
[(3) for fiscal year 2012, $1,000,000,000;
[(4) for fiscal year 2013, $1,250,000,000;
[(5) for fiscal year 2014, $1,500,000,000; and
[(6) for fiscal year 2015, and each fiscal year
thereafter, $2,000,000,000.
[(c) Use of Fund.--The Secretary shall transfer amounts in
the Fund to accounts within the Department of Health and Human
Services to increase funding, over the fiscal year 2008 level,
for programs authorized by the Public Health Service Act, for
prevention, wellness, and public health activities including
prevention research, health screenings, and initiatives, such
as the Community Transformation grant program, the Education
and Outreach Campaign Regarding Preventive Benefits, and
immunization programs.
[(d) Transfer Authority.--The Committee on Appropriations of
the Senate and the Committee on Appropriations of the House of
Representatives may provide for the transfer of funds in the
Fund to eligible activities under this section, subject to
subsection (c).]
* * * * * * *
DISSENTING VIEWS
We, the undersigned Members of the Committee on Energy and
Commerce, oppose the passage of H.R. 1217, a bill to repeal
Prevention and Public Health Fund (established in the Patient
Protection and Affordable Care Act) and accordingly, submit the
following comments to express our concerns about this highly
regressive, extremely short-sighted, and deeply divisive
legislation.
Introduction and Background
Enacted in 2010, the Patient Protection and Affordable Care
Act (ACA)\1\ expands access to health care for some 32 million
Americans and improves health benefits for millions more who
are already insured.\2\
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\1\ACA is comprised of two public laws, P.L. 111-148 and P.L. 111-
152.
\2\Letter from Douglas W. Elmendorf, Director, CEO to Speaker Nancy
Pelosi (Mar. 20, 2010) (on line at http://www.cbo.gov/ftpdocs/113xx/
doc11379/AmendReconProp.pdf).
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But as valuable as it is, health insurance cannot do
everything necessary to make our nation healthy. Even if other
parts of the ACA make it possible for virtually everyone to be
insured, there will still be a major role for public health.
Moreover, there will be an ongoing need for funding for these
public health activities.
``Public health'' includes many different things:
It is working with groups and whole communities to
improve health, often more effectively than could be done
between a provider and a patient. Fluoridation of water for a
town is, for instance, vastly better than simply filling every
citizen's cavities. Exercise programs to prevent obesity are
better than having to treat diabetes among people who become
obese.
It is tailoring health insurance and health care
to prevent and diagnose disease early rather than simply
treating it in its later stages. Immunizations are always
better than outbreaks. Screening for hypertension is better
than simply waiting for strokes.
It is providing for safety-net services where the
insurance market alone fails to do so. Community health
centers, HIV-service providers, and family planning clinics
provide care to people who might not otherwise be able to find
a provider. Health professions education programs can add to
the primary care workforce when the market might produce only
specialists. (Such programs will be even more necessary once
the insurance expansion provisions of the ACA are implemented.)
And, least glamorous but crucial, it is the
infrastructure of daily disease control and health promotion.
Closing down unsanitary restaurants is better than treating
food poisoning. Compiling and studying epidemic trends can
prevent major waves of disease.
The case might be made clearer by analogy: No community
would be well-served if all its homeowners had fire insurance
but there were no fire departments, firefighters, fire
hydrants, smoke detectors, or indoor sprinklers. That very
well-insured town would still burn to the ground. Insurance is
necessary, but it is nowhere near sufficient.
The ACA addresses both approaches, with insurance and with
public health. This required going beyond the investments in
the law to provide health insurance to also include provisions
to make significant public health investments.
It would be insufficient simply to authorize future
appropriations for these activities while providing mandatory
spending for coverage initiatives. While the Committee on
Appropriations of both the House and the Senate has shown
ongoing and great leadership in these public health programs,
the budget allocations for them have been too tight to allow
significant new initiatives of these sorts. Consequently, the
ACA provides as firm a funding and organizational base for
these services as possible--mandatory spending--because they
are essential in making insurance efficient and productive and
in making the nation healthier.
Among those programs designated for mandatory spending in
the ACA is the Prevention and Public Health Fund (Fund). Its
purpose is ``to provide for expanded and sustained national
investment in prevention and public health programs.''\3\ It is
the first and only federal program with dedicated, ongoing
resources specifically designed to improve the public's health,
and in turn, to make the United States a healthier nation.
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\3\ACA, Section 4002.
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The Fund is administered by the Secretary of the Department
of Health and Human Services (HHS) and may be used to support
``programs authorized under the Public Health Service Act.''\4\
It provides $5 billion in mandatory spending for these
activities over the period FY 2010 through FY 2014 and $2
billion in mandatory spending each fiscal year thereafter. This
significant and ongoing level of support is necessary to
address the chronic underfunding of prevention activities which
by some estimates, account for only 2% to 4% of national health
expenditures.\5\
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\4\Id.
\5\J. M. Lambrew, A Wellness Trust to Prioritize Disease
Prevention, Brookings Institution (Apr. 2007) (on line at http://
www.brookings.edu/papers/2007//media/Files/rc/papers/2007/
04useconomics_lambrew/04us).
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Support for prevention has long been a bipartisan
perspective. Members of this Committee from both sides of the
aisle and across the political spectrum have spoken strongly in
favor of this public health function.\6\ Beyond the halls of
Congress, this support is also widespread. A public opinion
survey by Trust for America's Health and the Robert Wood
Johnson Foundation found that 71% of Americans favored an
increased investment in disease prevention.\7\ And nearly 600
national, state, and local organizations support the Fund as a
primary vehicle for making public health investments that would
not only help to improve the public's health, but also to
create jobs and lower long-term health care costs.\8\
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\6\See, e.g., comments made by Reps. Pitts, Murphy, Matsui, and
Cassidy in support of prevention efforts during the full Committee mark
up of H.R. 1217, House Committee on Energy and Commerce, Business
Metting to Mark Up H.R. 1217, To Repeal the Prevention and Public
Health Fund, 112th Cong., p. 242 (Apr. 5, 2011) (transcript of the
proceeding):
Rep. Pitts: ``I am not against prevention and wellness'';
Rep. Murphy: ``I believe all of us are pretty strongly in
favor of anything that has to do with prevention'';
Rep. Matsui: ``We are talking about having healthier
Americans. . . . ``[M]ost people here truly believe that prevention is
probably the best way to do this'';
Rep. Cassidy: ``I strongly believe in many aspects of
preventative medicine. . . .'';
\7\See http://healthyamericans.org/newsroom/releases/?releaseid=198
for a description of the poll's complete findings.
\8\Letter from Jeffrey Levi, PhD, Executive Director, Trust for
America's Health (on behalf of 600 health-related organizations) to
Chairman Fred Upton, Ranking Member Henry Waxman, Chairman Joe Pitts,
and Ranking Member Frank Pallone, Jr. (Mar. 30, 2011) (on line at
http://healthyamericans.org/assets/files/Groups%20Supporting
%20PreventionFund%20-state%20by%20state-04-05-11.pdf).
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Prevention Fund Dollars at Work
The Prevention and Public Health Fund is one of a number of
ACA initiatives that is already in place. Currently, all 50
states and the District of Columbia are receiving Fund
support.\9\ Among other activities, Fund dollars are being used
for community-based projects to reduce tobacco use and obesity,
prevent HIV infection, build epidemiology and laboratory
capacity to track and respond to disease outbreaks, and train
the public health workforce.
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\9\For a description of these activities, see http://
www.healthcare.gov/news/factsheets/prevention02092011a.html
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In general, the Fund is intended to provide support for
programs generated at the local or community-based level. This
is as it should be--communities know best what public health
challenges they face and what interventions are most likely to
work. Specific examples of this type of initiative include the
following from the Centers for Disease Control and Prevention
website:\10\
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\10\Id.
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MOBILE COUNTY, ALABAMA, HTTP://WWW.MOBILECOUNTYHEALTH.ORG $3 MILLION
FOR TOBACCO PREVENTION
The Alabama Communities Putting Prevention to Work project
will address tobacco prevention efforts in Mobile County.
Working with the Mobile Children's Policy Council, the
Coalition for a Tobacco Free Mobile, and the Mobile Leadership
Team, the program will implement a media campaign to educate
Mobile citizens about the health benefits of clean, smoke-free
indoor air and promote existing cessation services. The project
will also educate decision makers about the public health
impact of comprehensive smoke free policies. Mobile County will
work with tobacco retailers to restrict point of purchase
tobacco advertising and will support systems change in
worksites and schools by increasing the availability of
cessation services and tobacco-free environments. The intent of
these systems and policy approaches is to reduce exposure to
secondhand smoke, reduce social acceptability of tobacco use,
and increase cessation attempts by tobacco users.
SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL HTTP://
WWW.SCDHEC.GOV/ $1.6 MILLION FOR OBESITY PREVENTION
The South Carolina Department Health and Environmental
Control received $1.6 million for a statewide obesity, physical
activity, and nutrition program. South Carolina will pilot a
statewide Farm to School program. Key objectives include
developing and maintaining an infrastructure to support local
implementation of farm to school programs. With approximately
1100 public schools in South Carolina, school meals are a
lifeline for many children, especially low-income children.
Each day the state's schools serve approximately 733,000 meals
and provide opportunities for those students to learn about
healthy nutrition and the importance of agriculture to South
Carolina. Systems leveling approaches, like Farm to School
programs, have the potential to impact not only the student
population and school staff, but also the surrounding
communities. Increased consumption of fruits and vegetables can
build healthy children, schools, farms and communities and in
the long term will reduce obesity and obesity-related chronic
diseases.
DEKALB COUNTY BOARD OF HEALTH, GEORGIA HTTP://WWW.DEKALBHEALTH.NET/
$2.35 MILLION FOR OBESITY PREVENTION
The DeKalb County Putting Prevention to Work initiative
will work with community partners and local government
officials to create a Master Active Living Plan (Plan). The
Plan will include a policy that will allow neighborhood
residents access to school recreational facilities affording
them easy access to places for physical activity, and
establishing community vegetable gardens in local parks. These
changes will make it easier for children and adults to eat
healthier and be more physically active. The goals of these
CPPW initiatives include achieving (1) increased physical
activity, (2) improving nutrition; and (3) decreasing
overweight/obesity prevalence. The interventions will strive to
reduce the burden of chronic disease, reduce health disparities
and improve public health across the lifespan of DeKalb
residents and will be adapted as necessary to meet the diverse
cultural and linguistic needs of our community.
PITT COUNTY, NORTH CAROLINA HTTP://WWW.PITTCOUNTYNC.GOV/DEPTS/HEALTH/
The Pitt County Health Department (PCHD) will strive to
improve access to nutritious food through The Corner Store
Initiative, which is centered on increasing access and
availability of healthy food/drink/, improving product
placement and attractiveness, and changing the relative prices
of healthy versus unhealthy items in convenience stores. PCHD
also plans to collaborate with three cities to develop point of
decision making signage to encourage physical activity. PCHD
also proposes to partner with state and local entities to
develop the necessary infrastructure to support Safe Routes to
Schools. In addition, the community will build upon established
partnerships with local planning agencies and transportation
officials to develop and place signage within communities to
point out public parks, other recreational opportunities, and
the availability of bike lanes and alternate forms of travel.
Prevention Dollars Produce High Value Outcomes
Preventable diseases cost the United States significant
resources--in terms of unnecessary deaths, lost productivity,
and enormous amounts of money. Indeed, over half of the deaths
in this country are due to preventable causes such as tobacco
use, diet and activity patterns, and alcohol use.''\11\ Chronic
diseases consume an estimated 75% of the nation's $2 trillion
health care spending each year\12\ and cost employers $1,685
for each employee each year, or $225.8 billion annually in lost
productivity.\13\ Obesity alone costs $147 billion each
year.\14\ A stable, ongoing investment in prevention can help
alleviate each of these burdens.
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\11\McGinnis JM and Foege WH, Actual Causes of Death in the United
States, JAMA, 270(18): 2207-2212 (Nov. 10, 1993).
\12\Centers for Disease Control and Prevention, Chronic Disease:
The Power to Prevent, the Call to Control, At-A-Glance (2009).
\13\Centers for Disease Control and Prevention, Workplace Health
Promotion (on line at http://
www.cdc.gov/workplacehealthpromotion/businesscase/reasons/
productivity.html).
\14\Finkelstein EA, Trogdon JG, Cohen JW, et al., Annual Medical
Spending Attributable to Obesity: Payer-and Service-Specific Estimates,
Health Affairs, 28(5): w822-w831 (2009).
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It is true that some life-saving prevention interventions
actually involve expenditures. But so do most life-saving drugs
and devices. We provide mandatory funding for drugs and devices
through programs such as Medicare and Medicaid because steady
and secure funding for these programs ensures that more
Americans can live longer and healthier lives. Prevention
efforts can also reduce the number of deaths and promote the
health of Americans and should, therefore, also be supported
through the mandatory spending mechanism.
Some forms of prevention do, of course, save money--
immunizations, for example, are among our most cost-effective
public health investments. Community-based interventions can be
cost-effective as well. According to the researchers at the New
York Academy of Medicine, an investment of $10 per person per
year in proven community-based interventions to increase
physical activity, improve nutrition, and prevent smoking can
save the country more than $16 billion each year--a return of
$5.60 for every $1 invested.\15\ The Urban Institute estimates
that certain proven community-based diabetes prevention
programs can save as much as $191 billion over 10 years.\16\
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\15\Levi, J. et al., Prevention for a Healthier America:
Investments in Disease Prevention Yield Significant Savings, Stronger
Communities, Trust for America's Health (Feb. 2009) (on line at: http:/
/healthyamericans.org/reports/prevention08/Prevention08.pdf).
\16\Berenson, R. et al., How We Can Pay for Health Reform, Urban
Institute and Robert Wood Johnson Fundation (July 2009) (on line at:
http://urban.org/uploadedpdf/411932_howwecanpay.pdf).
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Mandatory Spending
Despite the good and important work being done through the
Fund, the health care savings it may help to produce, and the
chronic underfunding of prevention activities in the past,
Republicans are determined to bring the Fund to an end. They
assert two principal arguments for their opposition to it: (1)
the Fund's funding mechanism--mandatory spending; and (2) the
Secretary's authority to determine how the Fund's monies will
be allocated. The two arguments are interrelated; taken
together, they present a misleading analysis of how the Fund is
intended to operate.
ACA Section 4002(b) provides for mandatory funding for the
Fund. It authorizes to be appropriated and appropriates
specified funding levels for FY 2010 and beyond. ACA Section
4002(d) addresses the role of the congressional appropriations
committees in specifying how the appropriated funds are to be
used. That section clearly states that these committees have
explicit authority to allocate monies from the Fund (in
accordance with the Fund's purpose to support prevention and
other public health activities). Senator Harkin (author of ACA
Section 4002) addressed this very issue in a letter to the
Committee, making it clear that it is the job of congressional
appropriators to make the resource allocation decisions.\17\
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\17\Testimony of Senator Tom Harkin (submitted for the record),
Subcommittee on Health, Committee on Energy and Commerce, Hearing on
Setting Fiscal Priorities in Health Care Funding, 112th Cong. (Mar. 9,
2011) (stating, ``Contrary to misperceptions that it evades the
appropriations process, the Fund was established . . . in such a way
that appropriators direct how monies from the Funds are spent''().
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It is only when Congress fails to pass an HHS
appropriations bill that the HHS Secretary would have the
authority to designate which public health programs or
activities would receive Fund support. While it is true that
the Secretary has already exercised this authority, it is also
true that she has deferred spending these monies when requested
to do so by Congress.\18\ Contrary to what Republicans have
suggested, monies from the Fund have been allocated and are
being used in accordance with both the Fund's purpose and the
public health needs of the country.
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\18\See the letter from Senator Tom Harkin, Chairman, Senate
Committee on Health, Education, Labor, and Pensions and Chairman,
Senate Subcommittee on Labor, Health and Human Services, Education, and
Related Agencies, Committee on Appropriations to HHS Secretary Kathleen
Sebelius (Jan. 4, 2011) in which he requested that the Secretary
allocate monies in accordance with the prevention and public health
priorities set forth in the proposed FY 2011 omnibus, year-long
continuing resolution, including the Community Transformation Grants
Program and tobacco prevention and control. The Secretary subsequently
announced a spending plan for FY 2011 which closely tracked Chairman
Harkin's request. (see HHS press release on line at http://www.hhs.gov/
news/press/2011pres/02/20110209b.html). However, at the request of
Reps. Denny Rehberg and Harold Rogers, the Secretary has not yet
allocated any resources from the Fund for FY 2011. (Letter from
Chairman Denny Rehberg, Chair, House Committee on Appropriations and
Chairman Harold Rogers, Chair, Subcommittee on Labor, Health and Human
Services, Education, and Related Agencies, House Committee on
Appropriations to HHS Secretary Kathleen Sebelius (Mar. 2, 2011)).
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An Anti-Health Reform Ideological Agenda
In light of both the Fund's purpose and track record to
date, it comes as a great disappointment that Republicans have
targeted this program for elimination. Surely, this is not
because of Republican assertions--made in this report and
elsewhere--about the merits of discretionary spending versus
mandatory spending or the need to protect Congress's
prerogative to fund or not to fund health programs. Congress,
Republicans and Democrats alike, makes those kinds of choices--
often difficult choices--all of the time.\19\ And given
traditional bi-partisan support for prevention activities,
Republican opposition cannot be based on the substance of the
program.
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\19\For examples of various federal programs that are supported
through mandatory spending, see Committee on Energy and Commerce,
Democratic Staff, The Pitts Proposal to Block Mandatory Funding in the
Affordable Care Act (Mar. 9, 2011) (on line at: http://democrats.
energycommerce.house.gov/sites/default/files/image_uploads/
Fact%20Sheet_03.09.11.pdf).
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Pure and simple, H.R. 1217 represents the Republicans' new
line of attack to disrupt, dismantle, and ultimately destroy
the ACA--even those programs that have been funded and are up
and running, and even those that make good health policy sense,
in or out of the health reform law. What they have not been
able to achieve whole cloth,\20\ Republicans are now attempting
to do piece by piece. H.R. 1217 puts the Prevention and Public
Health Fund in the frontline of this ongoing assault.
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\20\Although the House of Representatives has passed legislation to
repeal the ACA, that legislation will not become law since the Senate
has defeated the proposal. (H.R. 2 passed the House of Representatives
in January 2011 (Congressional Record, H322-323 (Jan. 11, 2011)). The
Senate defeated a similar proposal a month later. (Congressional Record
S475 (Feb. 2, 2011)).
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In our view, this is not where the Prevention and Public
Health Fund should be. Rather, it should remain exactly where
it is--at the forefront of helping to realign the nation's
approach to health and health care, making us a healthier and
more productive people.
Henry A. Waxman.
John D. Dingell.
Diana DeGette.
Bobby L. Rush.
Edolphus Towns.
Lois Capps.
Jay Inslee.
G.K. Butterfield.
Jan Schakowsky.
Tammy Baldwin.
Frank Pallone, Jr.
Gene Green.
Anthony Weiner.
Edward J. Markey.
Eliot L. Engel.
Doris O. Matsui.
Mike Doyle.
Anna Eshoo.
Charles A. Gonzalez.
Donna M. Christensen.