[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).

--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                  By fiscal year, in billions of dollars--
                                                   -----------------------------------------------------------------------------------------------------
                                                     2012    2013    2014    2015    2016    2017    2018    2019    2020    2021   2012-2016  2012-2021
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                               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
--------------------------------------------------------------------------------------------------------------------------------------------------------
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.
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                               By fiscal year, in billions of dollars--
                                            ------------------------------------------------------------------------------------------------------------
                                              2011   2012    2013    2014    2015    2016    2017    2018    2019    2020    2021   2011-2016  2011-2021
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                             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
--------------------------------------------------------------------------------------------------------------------------------------------------------
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\
---------------------------------------------------------------------------
    \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).
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \3\ACA, Section 4002.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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).
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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).
---------------------------------------------------------------------------

                    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.
---------------------------------------------------------------------------
    \9\For a description of these activities, see http://
www.healthcare.gov/news/factsheets/prevention02092011a.html
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \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).
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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).
---------------------------------------------------------------------------

                           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.

                                  
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