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Public Statements

Panel III Of A Hearing Of The Health Subcommittee Of The House Energy And Commerce Committee - Comprehensive Health Reform


Location: Washington, DC

Chaired By: Rep. Frank Pallone (D-NJ)

Witnesses: Jeffrey Levi, Executive Director, Trust For America's Health; Brian Smedley, Vice President And Director, Health Policy Institute, Joint Center For Political And Economic Studies; Mark Kestner, M.D., Chief Medical Officer, Alegent Health

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REP. PALONE: Okay, could I ask those who are standing to -- or talking to leave the room -- (laughs) -- so we can get on with our third panel?

Okay, let me introduce our three witnesses here. Again, starting with my left, s Dr. Jeffrey Levi, executive director of the Trust for America's Health. Next, is Dr. Brian Smedley, vice president and director of the Health Policy Institute, Joint Center for Political and Economic Studies. And then we have Dr. Mark Kestner, who is chief medical officer for -- is it Alegent Health?

DR. KESTNER: (Off mike.)

REP. PALONE: Allegent Health.

And this panel is on prevention and public health, certainly one of the more important parts of the what we're discussing in the discussion draft. And you've heard me say before that -- we asked you to talk for about five minutes; and your written testimony -- your complete written testimony will become part of the record. And we'll have questions after, for five minutes, from the members. And we may send you written questions afterwards, which we'd like you to respond to as well.

I see we're joined by our ranking member, Mr. Deal.

And we'll start with Dr. Levi. It is Levi?

MR. LEVI: Yes, it is.

REP. PALONE: Okay, thanks.

MR. LEVI: Thank you, Mr. Chairman, and thank you for the opportunity to testify on the House discussion draft of health reform legislation.

Trust for America's Health and our colleagues throughout the public health community are delighted that this legislation recognizes that prevention, wellness and a strong public health system are central to health reform. We also support the premise that without strong prevention program, and a strengthened public health capacity surrounding and supporting the clinical care system, health reform cannot succeed.

While my testimony will focus on the public health provision for the discussion draft, I must first say that universal quality coverage and access to care are central to health reform. We believe that the bill can achieve that goal. Inclusion of evidence-based clinical preventive services, as part of the core benefits package, with no copayment, also assures cost-effective health outcomes.

Trust for America's Health has worked with over 200 organizations to articulate the importance of prevention and wellness to health reform. Our joint statement is attached to my written testimony and I will briefly review its key components.

First, we have urged that as part of a renewed focus on public health, Congress should mandate the creation of a national prevention strategy. The discussion draft meets the central criterion by requiring the secretary to develop a national prevention wellness strategy that clearly defines prevention objectives and offers a plan for addressing those priorities.

Second, the groups urged establishment of a trust fund that would be financed through a mandatory appropriations for expansion of public health functions and services that surround, support and strengthen the health care delivery system. We envision the trust fund supporting core governmental public health functions, population level non-clinical prevention and wellness programs, workforce training and development, and public health research that improves the science base of our prevention efforts.

We applaud inclusion of the Public Health Investment Fund, which will support, through mandatory appropriations, the core elements of the public health title, including the Prevention and Wellness Trust. By including mandatory funding for community health centers, the discussion draft also assures a much closer link between the prevention and wellness activities that happen in the doctor's office and in the community.

Let me now review some of the key activities associated with the Investment Fund and our rationale for supporting them:

On workforce: The focus on frontline health providers and the public health workforce places appropriate emphasis on where the need is greatest in our health care system. Assuring the development of a robust public health workforce and the creation of the Public Health Workforce Corps, which will offer loan and scholarship assistance, finally place public health improvement, training and retention on a par with the medical profession.

Community prevention and wellness programs are also critical. The expanded investment in these programs will be important to the success of health reform. There are evidence-based, proven approaches that work in the community setting to help Americans make healthier choices -- by changing norms and removing social, policy, and structural barriers to promoting healthier choices. We know that targeted use of these interventions can reduce health care costs. We are particularly pleased to see that this draft recommends establishing Health Empowerment Zones, where multiple strategies can be used at one time.

In terms of support for core public health functions, we appreciate the recognition in this draft that the strength of our nation's state and local health departments will significantly affect the success of the health reform effort. Without the capacity to monitor population health, respond to emergencies, and implement key prevention initiatives, the health care delivery system will always need to backfill for a diminished public health capacity -- at a higher price in both dollars and human suffering.

Improving the research base and reviewing the evidence is also an important component of this legislation, and it makes a crucial investment in both public health and prevention research. While we have a strong base for prevention interventions today, much more needs to be learned about non-clinical prevention and interventions, including how to best translate science into practice, and how we might best structure public health systems to achieve better health outcomes.

Dr. Smedley will address in more detail the issue of inequities. I want to note that we are pleased that this draft focuses on the disparities in access and health outcomes. From better training, to targeting of resources in communities where disparities are greatest, we can harness what we already know will work to reduce these inequities. We must recognize that the goal of health reform is not just creating equality of coverage and uniform access, we need to assure equity in health outcomes too.

Mr. Chairman, there are few times that we -- there are few times that we have the privilege of watching history being made. This may well be one of them. If the public health provisions of this discussion draft become law, in the years ahead we will witness the transformation of our health system from a sick-care system to one that emphasizes prevention and wellness. This is what our nation needs and what the American people want.

Recently, Trust for America's Health released the results of a national bipartisan opinion survey. Perhaps the most impressive finding in that survey was that, given a list of current proposals being considered as part of health reform, investing in prevention rated highest, even when compared to concepts like prohibiting denial of coverage based on preexisting conditions. In short, by placing this emphasis on prevention and wellness in the discussion draft, this committee is responding to a compelling call from the American people.

On behalf of our partners in the public health community, Trust for America's Health thanks you for your leadership and looks forward to working with you to see these provisions enacted into law.

REP. PALONE: Thank you, Dr. Levi.

Dr. Smedley.

MR. SMEDLEY: Thank you, Mr. Chairman for the opportunity to provide testimony on the potential to address racial and ethnic inequities in health and health care in the context of the Tri- committee health reform legislation.

For nearly 40 years, the Joint Center for Political and Economic Studies has served as one of the nation's premier think tanks on a broad range of public policy issues of concern to African Americans and other communities of color. We therefore welcome the opportunity to comment on this important legislation.

Many racial and ethnic minorities -- particularly African Americans, American Indians and Alaska Natives, Native Hawaiians and Pacific Islanders -- experience poorer health relative to national averages from birth to death. These inequities take the form of higher infant mortality, higher rates of disease and disability, and shortened life expectancy.

Health inequities carry a significant human and economic toll and, therefore, have important consequences for all Americans. They impair the ability of minority Americans to participate fully in the workforce, thereby hampering the nation's efforts to recover from the current economic downturn and compete internationally. They limit our ability to contain health care costs and improve overall health care quality. And, given that half of all Americans will be people of color by the year 2042, health inequities increasingly define the nation's health.

It's therefore important that Congress view the goal of achieving equity in health and health care not as a "special interest," but rather as an important central objective of any health reform legislation. To that end, the draft Tri-Committee legislation contains a number of important provisions that will strengthen the federal effort to eliminate health and health care inequities. Importantly, the legislation offers the kind of comprehensive strategy of targeted investments that are likely to help prevent illness in the first place, manage costs when illness strikes, and improve health.

Over the long haul, these provisions will result in a healthier nation with fewer health inequities, greater workforce participation and productivity, and long-term cost savings. These provisions do several things: They emphasize and support disease prevention and health promotion. For example, the legislation would require the CDC Clinical Preventative Task Force and Community Preventative Task Force to prioritize the elimination of health inequities. In addition, the legislation would authorize "health empowerment zones," as Dr. Levi has emphasized, locally-focused initiatives that stimulate and -- (inaudible) -- coordinated, comprehensive health promotion and community capacity-building.

Provisions in this draft of the legislation would also improve the diversity and distribution of the health professional workforce. For example, by increasing funding for the successful programs, such as the National Health Service Corps, and Health Careers Opportunity Program; expanding scholarships and loans for individuals in needed health professions in shortage areas, particularly nursing; and encouraging the training of primary care physicians. It will also strengthen Medicaid by expanding eligibility and by increasing reimbursement rates for primary care providers. And it will improve access to language services, for example, by requiring a Medicare study and demonstration on language access.

While the Tri-committee draft bill addresses a number of important needs to achieve health and health care equity, there are several areas where the legislation could be strengthened with evidence-based strategies that will improve the federal investment in health equity. These include:

Encouraging the adaptation of a federal Cultural and Linguistic Appropriate Services standards, which would help improve access and quality of care for diverse populations;

Expanding successful community-based health programs, such as the Centers for Disease Control and Prevention's Racial and Ethnic Approaches to Community Health program;

Addressing health in all policies, by funding and conducting Health Impact Assessments to understand how federal policies and projects in a range of sectors influence health;

Strengthening the federal health research effort by elevating the National Center on Minority Health and Health Disparities to institute status -- the National Center has led an impressive effort to improve research on health inequities at NIH, and needs the resources and influence associated with institute status to continue this work;

Strengthening federal data collection by establishing standards for the collection of race, ethnicity and primary language data across all public and private health insurance plans in health care settings;

And ensuring that immigrants lawfully present in the United States face the same eligibility rules as citizens for public programs, including Medicaid, Medicare and CHIP.

Mr. Chairman, in conclusion, addressing health inequities requires comprehensive strategies that span community-based primary prevention to clinical services, a long-term commitment and investment of resources, and a focus on addressing equity in all federal programs and in all elements of health reform legislation.

To fail to do so ignores the reality of important demographic changes that are happening in the United States, and fails to appreciate the necessity of attending to equity as an important step in our effort to achieve the goals of expanding insurance coverage, improving the quality of health care, and containing costs.

Encouragingly, the Tri-Committee draft bill recognizes the importance of achieving equity in health and health care and proposes a number of policy strategies to reach this goal. Thank you, Mr. Chairman, and we look forward to working with you on this important legislation.

REP. PALONE: Thank you, Dr. Smedley.

Dr. Kestner.

DR. KESTNER: (Off mike.) Good afternoon, Mr. Chairman and members of the committee, and thank you for the opportunity to be with you today.

My name is Dr. Mark Kestner and I'm the chief medical officer for Allegent Health. Today I want to give you a brief overview of Allegent Health's experiences in prevention and wellness. We are both a large employer and a substantial provider of healthcare, which gives us a unique perspective on these issues.

Alegent Health is a faith-based, not-for-profit health care system that serves eastern Nebraska and western Iowa. We have 9,000 employees and 1,300 physicians, and are proud of the care we provide in our 10 hospitals and over -- in our 100 sites of service. Alegent is the largest non-governmental employer in Nebraska and each year we serve more than 310,000 patients.

As a provider, we believe we are a model of a post-reform healthcare system. We employ substantial health information technologies to improve the quality and safety of the care we provide. Through the dedication and commitment of our physicians, a combination of both employed and independent physicians, give standardized care and implement evidence- based care order sets across more than 60 major diagnoses that are continually raising the bar on the quality of care we provide. Our CMS Core Measure and HCAHPS Scores are consistently among the highest in the nation.

In June of 2008, the Network for Regional Healthcare Improvement identified Alegent as having the best combined healthcare quality scores in the nation. Through the implementation of health IT and the adoption of evidence based care, Alegent Health is increasing the quality of the care we provide, while simultaneously lowering the costs -- (inaudible) -- Last year we reduced our resource utilization and the cost of care continued to decline.

We are proud to have shared these and other initiatives with Health and Human Services Secretary Kathleen Sebelius just 10 days ago when she paid a visit to us. And yet, Mr. Chairman and members of the Committee, in our estimation, the efforts of providers to raise quality and lower costs is only a small part of what we need to do. We adamantly believe that people must be more accountable for their health, and, in doing so, we must incentivize them and give them good information.

We began our journey to greater consumer involvement in health care three years ago when we made a commitment, as an organization, to more fully engage our workforce in their health. We spent a year designing a new benefit plan that promoted health and wellness among our employees.

In pioneering the new benefit plan, we identified incentives to encourage healthier behaviors and tools to provide meaningful cost and quality information as areas where Alegent could foster more individual engagement in health care.

There are two important constructs to Alegent's employee health benefit plan.

First, preventative care is free. This ranges from services like annual physicals and mammographies, childhood immunization and colonoscopies. If it is preventative, it is free. As a result, our workforce is consuming more than two-and-a-half times the preventative care as the nation at large. That's an investment we're willing to make, even without longitudinal studies to quantify the financial benefit to our organization.

And second, through an innovation called "Healthy Rewards Program," we pay people to make positive changes in their lifestyle. If an employer -- if an employee quits smoking, loses weight, more effectively manages their chronic disease like diabetes or makes other positive changes that affect their lifestyle, Alegent provides a cash reward. To encourage wellness and prevention and help our employees get healthy, we offer a variety of assistance programs free of charge: free weight-loss counseling, free smoking cessation programs and chronic disease management programs. For those who need an extra -- a little bit of extra help, we offer free personal health coaches.

Our objective was first and foremost to improve the health of our workforce. And we believed by doing so our costs would decline. And while we are still building data on the effects of our efforts that have -- that have been on productivity and absenteeism and organizational health care costs, I can report that a majority of health -- a majority of our employees take an annual health risk appraisal and, to date, have lost 15,000 pounds as a workforce and more than 500 of our employees have quit smoking.

Our approach has allowed us to substantially slow the growth of our health care spending. Over the first three years, our cost increases were limited to an average of 5.1 percent, despite trend in the 8 to 10 percent range. And as we approach a new benefit plan year, we are carefully constructing an Advanced Medical Home pilot for our chronically ill employees and several large employers in the community.

The key to our results is the use of the HSA and HRA accounts, which give employees better control in their health-care dollars and allow us to directly reward people for changing unhealthy behavior. The data we examined developing our benefits plan suggested to us that people would be more inclined to take advantage of health and wellness programs, even free ones, if they were incentivized to do so. For us, the use of HSAs and HRAs facilitate this process and provides employees with immediate tangible benefit in the form of subsidized health care costs.

But to give our employees more control required us as providers to make other dramatic changes. First and foremost, we created tools to provide meaningful and relevant cost and quality information. We have a quality website where we publicly report our 40 quality measures, the CMS 20, the 10 SCIP and the 10 Stroke Measures. And our compliance with these measures ranges anywhere from 97 to 100 percent.

In January of 2007, we introduced a web-based cost estimating tool called "My Cost" which is the first of its kind in the country. By working with a third party payer insurance database, "My Cost" is able to verify insurance policies and deductibles in order to provide patients an extremely accurate price estimate on more than 500 medical tests and procedures. In a little over two years, 85,000 individuals, employees and members of our community have used it.

In summary, Alegent Health began our health care reform several years ago when we made an organizational commitment to dramatically improve quality, lower costs and adopt health information technology. We knew that this would help us become more effective, efficient providers, and the data shows that we're becoming successful in reducing our costs and our resource utilization.

And yet, Mr. Chairman and members of the committee, that was simply not enough. Our challenge as a country, as physicians, nurses, members of Congress and employers, individuals and families, is to find a way to help people become more individually responsible for their health care.

Thank you.

REP. PALLONE: Thank you. Thank all of you.

And we'll now take questions, and I'll start with five minutes.

I wanted to really focus, if I could, on questions to Dr. Smedley, because of the disparities issue. All of you talked about the importance of prevention and wellness, and that's certainly what we hear in regard to health reform. And specifically, experts tell us we have to address prevention and wellness at the community level if we want health reform to lead to the best health outcomes for our constituents. And that's the definitely the case for the elimination of health disparities. Disparities arise not just because of differences in medical care, but also because of factors that make it harder for some people than others to make healthy choices.

Dr. Smedley, I've been most familiar with this with Native Americans, because I'm a vice chair of the Native American caucus. I don't have any tribes in New Jersey, but over the years, being on the resources committee, I paid quite a bit of attention to Native American issues. And the best example probably was with the Pima, the Tohono O'odham, where you saw the, you know, traditional diet, ranching, desert, you know, products were lost and they were, you know, using -- eating processed foods and it was hard to go back to traditional diet because the ranches were gone and the desert, you know, had changed and it just wasn't possible to do that.

So in the draft proposal, we target funds to community-based interventions or services with the primary purpose of reducing health disparities. Can you tell us how the recommendations from the Community Prevention Task Force that is housed at CDC and whose work is strengthened in the draft proposal can be used to target health disparities and anything else about addressing health disparities within the context of prevention and wellness? What do you see as some of the areas that require new or additional research? All in about a minute -- (laughs) -- because I have a second question to you.

MR. SMEDLEY: Sure, Mr. Chairman. Well, I'll try to be very brief.

As you pointed out, place matters for health. Where we live, work, study and play is very important. Certainly, it's important that we all take responsibility for our individual health choices, but sometimes those health choices are constrained by the context in which live, work and play.

As you pointed out, in many communities of color, we face a number of health challenges. Often the retail food environment is poor in segregated communities of color. They have a relative abundance of fast food outlets, poor sources of nutrition, a relative lack of grocery stores where you can get fresh fruits and vegetables. Similarly, in many communities of color we lack safe places to play, recreational facilities, places to exercise. It's harder to encourage an active lifestyle under those conditions.

So the CDC preventative task force is an evidence-based process that tries to identify what are the kinds of community-based prevention strategies that will help to address these kinds of conditions. We think that's very important, so I certainly applaud the provisions in the draft bill that would strengthen that process.

REP. PALLONE: Now, on the workforce, again, I'll use American Indians because I'm most familiar. I think there are, I don't know, maybe two -- over 2 million Native Americans and at last count, less than 500 American Indian doctors, 400-something. They have an organization. I went to speak to them once. And that's the entire membership.

In the discussion draft, there are a number of provisions that will increase representation of racial and ethnic minorities. We have additional investment in the National Health Service Corps.

Basically, how would these workforce provisions help address health disparities? And why is increasing the diversity of the workforce and not just its scale important in reducing health disparities? I mean, you could argue, you know, why do you need more Native American doctors? Why can't other people take care of Native Americans? But I know that there's an issue there and I'd like you to discuss it.

MR. SMEDLEY: Sure, absolutely. The research is very clear that when we increase the diversity of the health provider workforce, all of us benefit. So, for example, we know that providers of color are more likely to want to work in medically under-served communities. Their very presence increases patient choice. We talk a lot about patient choice. For many patients of color, it's often harder to bridge those cultural and linguistic barriers without a provider of your own racial or ethnic background.

It's also true that diversity in medical education and other health professions education settings increases the cultural competence of all providers. We need to be thinking about ways to improve the cultural competence of all of our health care systems because, as I mentioned in my testimony, very soon -- in shortly over 30 years -- this is about to be a nation with no majority population. Our health systems need to be prepared to manage that diversity. And so this is one of the many reasons why diversity among health professionals is important. And the provisions in the draft bill such as strengthening the Title 7 and 8 programs of the Health Professions Act are a very important step toward increasing the diversity and distribution of providers.

REP. PALLONE: Thank you.

Mr. Deal?

REP. DEAL: Thank you, Mr. Chairman.

This whole panel is supposed to be dealing with prevention and public health. I appreciate all of you being here.

I've heard a lot of words and I've had very little examples of specifics on this thing, because, it seems to me, if we talk about the words "prevention" and "wellness," we're talking about changing of lifestyles. Now, we heard Dr. Kestner talk about his company and the way that they incentive wellness was through financial-type rewards. We heard Dr. Smedley just a minute ago talk about community-based strategies and the fact that we don't have enough grocery stores in some communities to fill -- to sell fresh fruits and vegetables; don't have safe playgrounds that cause us maybe not to get as much exercise.

In a health bill -- a health reform bill -- what are the specifics we can do to change people's lifestyles? Because you don't think of that in the normal context of a health care reform measure. Now, specifically -- I'm going to use this as a specific example of a question that I think we ought to address -- in the food stamp program, for example, we're pouring millions and hundreds of millions of dollars into it. And the recent stimulus package has poured even more money into the food stamp program. But we don't have any guidelines like we have in the WIC program, as I understand it, to make sure that the taxpayers' dollars that are helping to fund the purchasing of food doesn't go to buy things that work at counterpurposes with what we're talking about here of wellness.

Dr. Levi, let me start with you and ask if you would just comment on that.

MR. LEVI: Sure. I think your point is very well taken. I think we -- if we think of this as not a health care financing bill but a health bill, then we need to be addressing all of the elements that comprise helping people be healthier. And a lot of that is about exercising personal responsibility, but then creating the environment where people can -- not just through financial incentives, but really the -- we change the norms of our society so people make healthier choices.

To that end, there is actually an experimental program now that is getting under way within the food stamp program so that people will be -- will, in a sense, get higher credit if they buy healthier food. So that's one way of incentivizing people. There are certainly other things that can be done within the food stamp program that would incentivize the purchase of healthier food.

But we also have to make sure that those healthier foods are available, and that -- which is not the case in all communities. We need to make sure that people understand and know that the healthier foods are, indeed, what they should be eating. And so what it really takes is the kinds of community interventions that I think are envisioned in this legislation that, particularly in -- on the concept of the health empowerment zone, look at multiple aspects of the community -- is healthy food accessible? Do people know about the healthy foods? What's happening in the schools in terms of educating kids and changing norms? How active is it -- is it -- are kids able to be? How active are adults able to be? -- and taking all of those elements and developing comprehensive strategies.

We have examples of successes like that. We have them in the Steps Program funded by CDC and the REACH Program funded by CDC and the Pioneering Healthier Communities that are organized by YMCA and other national organizations to bring communities together to identify what their communities need to make healthier choices easier choices for the average person. That's what going to change -- you know, we're talking about bending the cost curve. If we do that, we can have a dramatic impact on health -- on people's health and on what they will be demanding on the health -- of the health care system.

REP. DEAL: I think we all agree we want our children and everybody to be healthier and exercise better choices in their lifestyles.

Dr. Smedley, are we talking about subsidizing grocery stores to come in to certain communities as a way of providing these kind of choices? Is that what you're talking about?

MR. SMEDLEY: Well, Congressman, there actually are some very interesting initiatives that have leveraged public investment to stimulate private investment. Pennsylvania, for example, the Commonwealth of Pennsylvania has the Fresh Food Financing Initiative, which has provided that double bottom line of benefits both to private investors as well as to government investing in creating incentives so that we can create a healthier retail food environment.

I think that many of the examples that Dr. Levi just mentioned are important examples of comprehensive strategies, because often we find that there's not just one issue that's a problem in the community. It's not just a problem of food resources and food options, but there are many multiple and systemic problems. Addressing those comprehensively as the REACH Program does and other programs is the way to go.

REP. DEAL: And I think in our educational activities, maybe we should teach people how to turn the television set off a little bit.

MR. SMEDLEY: Absolutely.

REP. DEAL: Thank you.

REP. PALLONE: Chairman Dingell. Is he there? No? I'm sorry.

Our vice chair, Ms. Capps.

REP. LOIS CAPPS (D-CA): Thank you, Mr. Chairman. I thought you were seeing something I couldn't see.

I have to say, as someone who's spent my life, the last couple of decades, in public health as a school nurse, this is a panel that I really appreciate the testimony of each of you. And I also look forward to this five minutes being just dedicated to proving the worth of prevention; in other words, my frustration with CBO for not being able or not scoring this topic.

And Dr. Levi, I'll start with you, but I hope there's a chance for each of you to comment.

Your testimony mentions a report from Trust for America's Health released last year showing the return on investment from proven community level prevention. Can you explain briefly the methodology of this report, if you think this could help me or help us all in our case toward scoring savings? We have to learn how to do this as a government as well. Otherwise we're not going to be able to counter, you know, some of the front costs that are entailed here.

MR. LEVI: I agree. And, you know, I think making the case to the Congressional Budget Office is going to be critical at some point. I would preface my explanation of our report and our work by saying whether or not CBO is convinced should not stop us from investing in prevention, because whether we meet the narrow criteria that CBO is forced, in some respects, by law to address shouldn't mean that we don't see this as a worthwhile investment in improving the nation's health.

We worked with the New York Academy of Medicine Prevention Institute and, above all, the Urban Institute economists -- the Urban Institute economists developed a model that looked at the successful community-level prevention efforts -- in other words, efforts that took place outside of the doctor's office -- to see whether, through education, through changing the environment, changing policies, we could see improved health outcomes.

We focused ultimately on smoking cessation, physical activity and nutrition, which are the drivers of some of the most expensive health care costs that we see today. And what we found was that there are indeed successful examples of those interventions.

What we found also is that we probably can implement those at probably less than $10 per person. And even if we saw only a 5 percent impact of those interventions, which is very much on the conservative side in terms of what the evidence shows, we could see a $5.60 return for every dollar we invest.

The challenge here is that the winners in this, if you want to call them winners -- the people who save -- are Medicare, the private insurers, and, to some degree also, Medicaid. In the CBO scoring system, a discretionary investment that has a payoff on the entitlement side can't be scored in anyone's favor, and that's actually a congressional rule. But, just as importantly, I think what we need to think about is that those who benefit are not necessarily contributing. And so we need to think of this as a public investment that will ultimately reduce overall health care costs.

REP. CAPPS: My question to you now is very pragmatic, and I'm going to expand it to all three of you. And time is of the essence. I mean, we really -- this is really an obstacle, in my opinion, to the push-back against the huge cost, as it's portrayed, of this health care legislation.

Can you give us some advice? What can Congress do to facilitate the process of enabling CBO, or whatever term you want to use, to be able or to have that capability of scoring prevention? And, you know, you're not even talking about quality of life for consumers of health. I mean, we'll take that off the table because that's probably hard to measure, or longevity, which actually has been held up by some to be a deterrent, because if people live longer, they're going to get more chronic diseases over the course of their lifetime. You know, what should we do on this committee to begin that process?

I'll start with you briefly, but if there's time, I'd like to --

MR. LEVI: Very brief -- two very quick comments. One is, Congress can remove this fire wall between discretionary investments and entitlement savings.


MR. LEVI: I think the second is to start a dialogue with the economics community and the Congressional Budget Office, because not everyone agrees with this notion that you just mentioned that if we reduce illness -- if we reduce these chronic diseases, then people are going to live longer and they're ultimately going to cost more.

There's this whole concept called compression of morbidity, which suggests that if we actually reduce obesity -- and there are a number of models from a number of different economists now that tend to show that, for example, if you reduce obesity, you are not necessarily prolonging life, but you are improving the quality of life and reducing health care costs. The chronic diseases are additive. They don't necessarily shorten life. And so I think those are two examples -- start that dialogue and remove some barriers.

REP. CAPPS: Okay, thank you. And I know I've used my time. I don't know if there's a way for a quick response from the other two if they want to.

REP. PALLONE: Go ahead, sure.

MR. SMEDLEY: Sure. I would just add, I think that Dr. Levi answered that quite well. We also need to consider the next generation is likely to be less healthy than the current adult population.

REP. CAPPS: Why is that?

MR. SMEDLEY: Because they are more obese. They are at risk for more chronic diseases. So we need to be considering the fact that this is the generation that will support my colleagues and I in our old age. So hopefully we will be forward-thinking --

REP. CAPPS: Is that documented that they're less healthy?


REP. CAPPS: Any further point from you, Dr. Kestner?

MR. SMEDLEY: I'd be happy to provide (references ?).

REP. CAPPS: And please do.

DR. KESTNER: I would just comment that we have -- (inaudible) -- experience showing that preventative care decreases -- (inaudible).

REP. CAPPS: So there is data out there. Any of you want to supply any information on that -- I appreciate this very much -- any written information.

REP. PALLONE: Sure. Any follow-up in writing is appreciated. Thank you.

The gentleman from Texas, Mr. Burgess.

REP. MICHAEL BURGESS (R-TX): Thank you, Mr. Chairman.

Dr. Smedley, I'm very interested in some of the things on which you testified, and that may be beyond the scope of what we're doing and dealing with for these hearings. But I have similar neighborhoods in my district, and there is not a grocery store from one end of the community to the other; plenty of places to buy alcohol, typically in 40-ounce containers, and plenty of places to buy fast food. And, of course, cigarettes are available on every street corner.

This just points to one of the difficulties that we have. And we'd worked with a group, Social Contact. We're so far away from the last Census in 2000, it's very difficult to get private grocery stores interested in moving back to the area because they say, "Well, the demographics just won't support a grocery store." But, in fact, the demographics have changed and the purchasing patterns have changed.

And again, we're so far away from the Census, (but ?) Social Contact was able to put up some data that showed perhaps this is worthwhile of a Wal-Mart Supercenter, for example, locating in the area. We're actively trying to push that, but it is just extremely difficult to get those things accomplished; no problem at all getting another liquor store to move in. They're there and ready; hard to keep them out, in fact.

I just wonder if we shouldn't allow a little more flexibility in some of our federal food stamp programs. You can't buy alcohol; that's correct. You can't buy cigarettes; that's correct. You can't buy hot food. But there are some hot foods, like a rotisserie chicken, for example, that may serve a family's nutritional needs very well. And the fact that that activity is restricted may be putting an undue burden on people who are willing to move into the community.

And I don't purport to have any of the answers. I've worked with some of the people with Robert Wood Johnson in trying to craft language that we might put in a bill, but it is extremely difficult. But I appreciate what you're doing, what you're trying to do, because I think that gets to the root of a lot of the problems, and I know I see it at home. And you're correct; the next generation is only going to be successively less healthy because of some of the learned behaviors that are going on today.

I want to talk about Alegent for just a moment, because you are a success story. And we heard from a previous panel that maybe we should be pursuing evidence-based policies. And your policies at Alegent are clearly something that are worthy of not just our attention (and study ?), but perhaps our emulation.

And you have shown rather dramatically, I think -- you and -- (inaudible) -- have shown that not just you can't just make things free; you've got to make them important. And the way we make things important is we attach money to them.

And so I hope that this committee will look seriously at what you have done with your health reimbursement accounts and your health savings accounts and your ability to bring people in, not just to affect things on a small scale, but to affect things on a large scale. And the impressive thing is you did it with your 9,000-member workforce first before you went forward and began to sell it to the rest of the community.

So, again, I hope we will look seriously at what you've done and what you've been able to accomplish.

My understanding -- and tell me if I'm correct, Dr. Kestner, on the consumer directed health plans, well, if you look at high-option PPO plans they're growing at about at a 7.5 percent rate a year, rate of growth as far as cost; Medicare and Medicaid, 7.3 (percent) to 7.8 percent, depending upon who you want to read.

But, consumer-directed health plans are growing at about 0.2 (percent), 2.25 percent a year. Has that been your experience as well?

DR. KESTNER: Our accumulative two-year experience is 1.5 (percent).

REP. HALL: 1.5 (percent)?

DR. KESTNER: Excuse me, I'm sorry, 5.1 (percent) -- 5.1 (percent). And I think we recognized that the impact, going forward, will be on our preventive measures. We still have patients that have problems with obesity, smoking, and those are things that we are going to have to -- that are going to be expensive to us in the long-run.

So, on the short-term we've already seen the benefit in implementing the strategy, and in the long term -- (inaudible) -- we've seen increasingly a decrease in our health care expenses.

REP. HALL: Now, I don't know if you've had a chance to read the draft that's before us today for discussion, but, as far as you're aware, does the draft that has been proposed by the majority, does it increase or decrease your ability to do what you want to do?

DR. KESTNER: Well, I think, you know --

REP. HALL: Particularly with health savings accounts.

DR. KESTNER: Right. I think any strategy needs to engage the patient in the dialogue, empower them in economic decisions with regarding access, but allowing open access. And I think the most important thing, from my perspective, is the ability to engage the dialogue when they're well.

All too often we access health care at the point of sickness. And, really, preventative care is engaging people and starting the dialogue when they're well. So, any strategy that focuses on prevention and begins that dialogue early, I think, are of benefit -- (inaudible) --

REP. HALL: Just one more brief question.

Do you allow for partnering with your physicians and your facility at all? Are there, like, ambulatory surgery centers where there's physician ownership involved in any of Alegent's facilities?

DR. KESTNER: Yes. We have joint ventures, ambulatory surgery centers.

REP. HALL: Are you aware the draft under discussion today would prohibit such activities in the future?

DR. KESTNER: I am superficially aware of discussions that are going on.

REP. HALL: Do you believe in the pride of ownership? I mean, when a physician has an ownership position in an entity, my feeling is that it makes it run better.

DR. KESTNER: I believe, with the dialogue that we've had in our health system, all physicians feel the pride of ownership, whether they have an invested interest or not. I think that's been part of our culture of giving physicians decisionmaking, and the ability to drive health care through evidence-based care, and empowering them to make decisions for our health care delivery model.

So, whether they have an investment interest or not, I think we have tried to make sure that they have a pride of ownership in our system.

REP. HALL: Do you think this bill before us today fosters that empowerment?

DR. KESTNER: The one that's up for discussion at this point in time?


DR. KESTNER: -- (inaudible) --

REP. HALL: Thank you.

REP. PALONE: Thank you.

The gentlewoman from the Virgin Islands, Ms. Christensen.

DEL. CHRISTENSEN: Thank you, Mr. Chairman.

And thank you also for being here -- to all of the panelists.

Dr. Levi, we have really appreciated the work for the -- from the Trust for America's Health, and we appreciate also your support of the Health Empowerment Zones.

One of the basic services that is not covered for adults is dental care. How important do you think that is that it be included, in terms of prevention, or its impact on chronic diseases and other health care problems?

MR. LEVI: Clearly, access to dental care is a vital component to keeping people healthy and keeping people functioning and economically productive.

There is growing evidence, especially around preventive care, of links of good dental health with even heart disease. And so there is, indeed, a correlation with some chronic diseases.

But, just as importantly, I think it's, you know, good oral health keeps people healthier, keeps people functioning, keeps people out of pain, and, therefore, probably more employable. So, it is both a health benefit and an economic benefit.


Dr. Smedley, welcome back. The IOM report on unequal treatment, of which you were the lead author and editor for the landmark document, and the recommendations from that report have been held up as a standard for eliminating health disparities.

You mentioned a few areas, but if there are any others, to what extent does this draft legislation meet and address those recommendations, and where are we falling short?

MR. SMEDLEY: Yes, thank you.

There are a number of provisions within this draft bill that have addressed some of the provisions of -- that are recommendations of the IOM medical treatment report. As I mentioned in my oral testimony, there are some areas where we can go further, in terms of adopting the federal cultural and linguistic appropriate services standards, ensuring that we strengthen our federal health research.

Data collection is also one of those areas where I think it's clear that we're going to have to have a much more robust, systematized system of collecting data on race, ethnicity, primary language and probably other demographic variables, in order to understand when, and under what circumstances, we see inequality in both access to, and the quality of care, as well as outcomes.

I would even go a step further and suggest that we ought to publicly report these data because that will give us a level of accountability, both for consumers, for providers and health systems, as well as government. One of the responsibilities of government is, of course, to ensure that there is not unlawful discrimination in the provision of care. And until we publicly report, and more carefully collect this data, we will not know when that occurs.


Dr. Kestner, I really applaud the fact that in the absence of the longitudinal data showing what that investment might pay back from providing that free preventiveness (sic) care, you did provide it for all employees. And you've talked about some of the short-term benefits that you've already seen.

And looking at the public plan that we're proposing, and it's the possibility that it would allow for innovation, you're a not-for- profit, is there something in your experience that can inform, and maybe support, what we're trying to do in a public plan, and its ability to do the kind of innovation that we see that you're doing at Alegent?

DR. KESTNER: Well, I would hate to see any plan be nothing more than a reproduction of what we already have, which is people seeking care when they hurt; people being given a pill and not understanding the cost of that pill; and then not returning unless they've been noncompliant or haven't gotten better.

And so I think that any plan that engages the consumer in the dialogue about not only the consequences of their health care decisions, but the cost of their health care -- (inaudible) --


And, Dr. Smedley -- in my last couple of minutes, we talked about diversity in the health care workforce. You weren't just talking about doctors and nurses, were you?

MR. SMEDLEY: Yes. We need diversity in all of our health professions -- allied health professions, the mental health field, dentistry, all of these --

DEL. CHRISTENSEN: What about some of those commissions and councils and task forces?

MR. SMEDLEY: The CDC task forces, or?

DEL. CHRISTENSEN: -- (inaudible) --

MR. SMEDLEY: Yeah -- oh yes, absolutely. We need diversity on all of the policymaking bodies that are outlined either in this draft legislation, as well as existing bodies, because, again, with the changing demographic of this nation, with the importance of addressing diversity and equity issues -- (audio break) -- it's (re-represented ?) on these task forces and panels


Thank you, Mr. Chair.

REP. PALONE: Thank you.

The gentleman from Georgia, Mr. Gingrey.

REP. GINGREY: Thank you, Mr. Chairman.

Dr. Smedley, in your testimony you talk about racial and ethnic minorities, and disparity in care. You state a potentially significant source of racial and ethnic health care disparities among insured populations lies in the fact that minorities are likely to be disproportionately enrolled in, I think, were, quote, "lower-tier health insurance plans."

There are large access problems in the Medicaid program, where many beneficiaries are unable to find a doctor that accepts Medicaid because of inadequate reimbursement and high administrative burdens. Do you believe the government-run Medicaid program, and how it is administered, exacerbates health disparities?

MR. SMEDLEY: Well, Congressman, I think that in the case of Medicaid, you're absolutely right, that low reimbursement rates simply make it prohibitive for providers to accept, in some cases, Medicare -- Medicaid patients. But, this draft bill would increase reimbursement rates in ways that I think will hopefully encourage take up of Medicaid patients.

Unfortunately, we have associated a stigma with Medicaid despite the fact that it's a very comprehensive benefit plan. As Mrs. Wright Edelman pointed out earlier, it offers a number of very, very important benefits, particular for children who are at risk for poor health outcomes.

So, I think we can build on the Medicaid program, improve it, and ensure that patients who have Medicaid coverage are actually able to get the care that they need.

REP. GINGREY: Well, thank you for that response.

And, of course, you mentioned that it would be improved reimbursement. That is true for primary care physicians and medical home managers, but certainly the reimbursement is likely to be less for specialists, general surgeons, OB/GYN doctors, et cetera.

So, do think if Medicaid beneficiaries had an opportunity -- and we have suggested that from this side, our ranking member has suggested it a number of times, if Medicaid beneficiaries had the opportunity to opt into a private policy, with government assistance, so-called "premium support," do you believe they would find it easier to find a doctor that would take them?

MR. SMEDLEY: Congressman, you know, I'm not aware of any data that would suggest -- that would inform an answer. I know that some of the proposals that were offered, in terms of tax credits, and so forth, were insufficient to cover the cost of private health insurance. I believe the cost estimates now for a family is about $12,000.

So, clearly, we'd need a sizable tax credit for a low-income family to afford a private plan like that. But, unfortunately, I have no data.

REP. GINGREY: Yeah, well, reclaiming my time, certainly it would remove the stigma.

And when you're talking about -- let's say, the CHIP program, rather than having the child or children running all across town trying to find a doctor who would accept CHIP, it'd be wonderful if they could, with premium support, be enrolled in a family policy so everybody can, kind of, go to the same medical clinic.

Let me switch over to Dr. Kestner for just a second, because you were talking about HSAs. Dr. Kestner, I think you, in your testimony you credited HSAs and HRAs as keys to these managed lifestyle changes.

Earlier, I don't know if you heard on the first panel, Dr. Parente, of the Medical Leadership Institute (sic), he suggested that -- rather than what is recommended in this 800-page draft or document from the Tri-committees that would require everybody to have first- dollar health insurance, and also for employers to provide it -- his suggestion was if there's going to be a requirement on the part of the so-called patient, maybe it should be a requirement for catastrophic coverage and not first-dollar. The catastrophic coverage, of course, would prevent all these bankruptcies -- these three out of five bankruptcies that people talk about, that are brought about by serious medical illnesses that folks can't pay for.

What do you think about that suggestion?

DR. KESTNER: Well, our strategy has been to be transparent with costs so that consumers can make educated decisions. So, if I have a condition that requires immediate care, I have an option of going to an urgent care center to see my primary care doctor, or an emergency department. And each of those cost something different.

Part of my decisionmaking will be what's coming out of my pocket, as far as the first dollars. And certainly it's a more cost-effective strategy to go to a primary care physician if I know I'm paying $10 for that visit, as compared to an emergency department where I would essentially be paying far more.

So, I think it is important for us to have a strategy that engages the consumer in the day-to-day decisionmaking that they have (with comparison ?) -- (inaudible) --

REP. GINGREY: Well, let me -- let me reclaim my time for the one second that I've got left -- Mr. Chairman, if you'll bear with me.

You know, there are -- it's estimated that of the 47 or 50 million people that don't have insurance in this country -- health insurance, that maybe 18 million of them are folks that make at least $50,000 a year. And I would suggest to you that a lot of them are going (bare ?), opting out of getting health insurance because they feel like they don't really need it. They're 10 feet tall, and bullet-proof, and they're kind of wasting their money.

And they know, at the end of the day, if they pay over a period of 15 to 20 years with an employer-based system, and then all of a sudden they get sick and they lose their job, that the insurance company is going to either say, "you're not insurable, we're not going to cover you;" "or, if we do, we're going to charge you 300 percent of standard rates."

Maybe, you know, there's a place here for insurance reform in regard to people like that, who have done the right thing, and have credible service and, therefore, they shouldn't have to pay these exorbitant rates, or even get in a high-risk pool because they have done the right thing.

Mr. Chairman, I know I've exhausted my time. And it's not -- probably not time for a response unless you want to allow --

REP. PALLONE: If you'd like to respond, go ahead.

DR. KESTNER: You know -- Mr. Chairman, if I could make one very short point --


DR. KESTNER: -- which is, you know, the question was about first dollar coverage, but as I understand Alegent's program there is first dollar coverage for preventive services. And since this is the panel about prevention and public health, I think it's really important to keep in mind that the things that are going to save people's lives and, ultimately, save health care costs, are the things that really need to have first-dollar coverage without copayments, because that's what's going to incentivize better.

REP. PALLONE: Thank you.

REP. GINGREY: Well, certainly for preventive care, I would agree with that.

REP. PALLONE: Thank you.

The gentlewoman from Illinois, Ms. Schakowsky.

REP. SCHAKOWSKY: Thank you, Mr. Chairman.

I wanted to ask Mr. Kestner a question. Your website says, quote, "We are proud to offer a generous financial assistance program," unquote. But, then it goes on to say, quote, "Medical bills are limited to 20 percent of a total household family income," unquote.

So, a family of four, making $55,000 a year, with a $200,000 medical bill -- my staff, they're always right, calculated that the family would have to pay $11,000. So, as we're sitting here talking about affordability, do you think a family of four, making $55,000, should be paying $11,000 in medical bills?

DR. KESTNER: I believe we do have a very generous commitment to our community with regards to indigent care. We've contributed $60 million on indigent --

REP. SCHAKOWSKY: Yeah, but indigent, you're not -- $55,000 is probably not indigent. So, I mean, the statement that you have -- I guess, really, what I'm getting at, even with your program, which may be more generous than most, we're still talking about really significant out-of-pocket costs that could be overly burdensome for a family, right?

DR. KESTNER: That could be. Yes, yeah.

REP. SCHAKOWSKY: Here's one of the things I want to -- I want to get at. This issue of the necessity of patients to really understand the cost of health care presumes that medical decisions are mostly patient- driven. And I just -- I unfortunately didn't hear your testimony. I was at the doctor. I just fractured by foot, and, you know. I didn't go in there and say, give me some x-rays, and I think I need a boot -- which I now have. And, you know, I mean, these are things that the doctors tell us.

And when we looked at the article about McAllen, Texas versus El Paso -- probably everybody's read it in The New Yorker, about the amount of -- the difference in Medicare payments per patient. Wouldn't you all agree that this is, by and large, overwhelmingly provider-driven, as opposed to consumer-driven?

DR. KESTNER: I'll just comment on our experience.

Since engaging our physician workforce in the discussion of evidence-based care, standardizing our processes, and having a transparent, quality website, we have been able to demonstrate a decrease in our cost of care. I think that's where the discussion begins, is when we have to engage people in the discussion about what the evidence shows, what is necessary, and have that healthy dialogue that we all loved in medical school.

As compared to being driven by the decisions that are being made today, which may be a fear of malpractice, may be a fear of --

REP. SCHAKOWSKY: May be self-referral, and profit?

DR. KESTNER: I think, by and large, most physicians want to do the right thing. But, I think we've put them in a system where doing the right thing may not be evidence-based, and at times may not be the best -- (inaudible) --

REP. SCHAKOWSKY: Okay, so then, Dr. Smedley, would you agree that mostly patients don't decide about their health care?

MR. SMEDLEY: I think that's absolutely right. Patient decisions are often shaped by the options presented by doctors.

And in the cases of patients of color, which is my concern, there's some evidence that patients of color are not provided with the same range of options as a majority group patient. So, if that's the case, then I think we need to be very concerned that these are not truly consumer-informed decisions.

REP. SCHAKOWSKY: You know, also one of the things that this article -- if you haven't read it, you really ought to read it, in McAllen, Texas is that the doctors actually were not directing people to preventive care; that a decision had been made, in certain places -- and I guess other places around the country too, not to engage in preventive care.

And, again, I'm assuming your testimony was, even cost-wise, aside from health-wise, this is a bad decision?

MR. SMEDLEY: That's correct.

REP. SCHAKOWSKY: Okay, thank you.

REP. PALLONE: Thank you.

Mr. Green.

REP. GREEN: Thank you, Mr. Chairman.

And I'd like to thank our panel for being here. The last panel for -- (because of ?) prevention.

We know that diabetes and obesity sometimes are economic related. But, we know in the minority community -- whether it's African- American, Hispanic, Asian-Americans, it's almost an epidemic. And one of the best ways you deal with that is through prevention -- don't wait for that diabetic to know they're diabetic, maybe it's pre- diabetes; and even wait until a diabetic episode that they, before they go into an emergency room. That's what's -- that's what's so important about the prevention.

I have to admit, on our committee I get frustrated, because literally two years ago, with our current OMB director -- we were on a health care panel for (U.S. News and World Report ?), and, like most members of Congress get frustrated because we try and get a score on prevention, and he told me, in front of all the other folks, "This is not your" -- and he was the former CBO, Congressional Budget Office director, he said, "This is not your father's CBO. Send us those and we will score them better." "We are not seeing any changes."

Now, granted, he's at OMB now, and I don't know if OMB has changed, but I would sure like it. And that's our frustration, and Dr. Levi, you talked about it. There are so many things we need to do for health care in our country that needs to push the envelope further back instead of waiting until someone finds out that they're -- they have these chronic illnesses.

Dr. Levi, as you know, school-aged children are the population group that is most responsible for transmission of contagious respiratory viruses like influenza, and just recently I introduced a bill, 2596, the No Child Left Unimmunized Act, which would authorized HHS to conduct a school-based influenza vaccination program -- project to test the feasibility of using our nation's schools as vaccination centers. And what are your thoughts on making school-based vaccinations, especially for some of the influenza virus vaccines? We already use in our district, and I know a lot of school districts use their schools for vaccinations for the mandate -- mandatory vaccinations for children at that school, but what do you think about making them for other vaccines, including influenza?

MR. LEVI: I think that's a very good idea, and I think we need to be as creative as possible to make sure that as many people as possible are immunized. I think in reality, as we are facing this pandemic of H1N1 influenza and seeing that young people may be among the most vulnerable, they may be highly prioritized for a pandemic vaccine come the fall, and using our schools may be one of the most effective ways of doing that. And that could be a wonderful proof of concept for your legislation.

REP. GREEN: Any other -- or, anyone else on the panel? If not, thank you.

Mr. Chairman.

REP. PALLONE: Gentleman?

REP. PALLONE: I'll be glad to yield to my colleague from Chicago.

REP. SCHAKOWSKY: This business of how we score is a really troublesome thing. And I'm just wondering, is there the kind of research conducted, not just on health outcomes where we can see that prevention pays and it really works, but how it actually saves dollars? You know, I really think when we're talking about ten years, we're looking out into the future when we talk even about the costs, and we ought to have something. Is there research that can help us quantify that?

MR. LEVI: Well, ironically, the wider the net you cast, the more research there is, certainly in terms of productivity, in terms of contributing to the tax base, in terms of not requiring disability payments -- all those kinds of things. You know, you can't mix and match those things in the scoring process.

And I think I want to come back to something that --

REP. SCHAKOWSKY: Wait -- did you say we cannot mix and match? Why not?

MR. LEVI: Well, those things --

REP. SCHAKOWSKY: I mean, I think we need some advocacy help here to -- from those who are -- who believe that prevention is the key -- but to help us do that.

MR. LEVI: Well, we certainly agree with that, but some of these rules have been set and can be changed by Congress. And that's what -- that may indeed be what it takes.

But I also think it's important to think about sort of the evidence standard and -- you know, we look for -- there are different levels of evidence that you may need to make it move forward with a decision. But I think when you have so many businesses voting with their feet around prevention programs, whether it's clinical preventive services or even nonclinical preventive services --

REP. SCHAKOWSKY: By that you mean buying them -- (inaudible) -- yeah.

MR. LEVI: By buying it, investing in it --

REP. SCHAKOWSKY: Investing in it.

MR. LEVI: -- and saying they have the evidence for their stockholders that this saves them money, it seems odd that the private sector can be ahead of the public sector in recognizing the value of that.

REP. SCHAKOWSKY: That's a really good point. Maybe we ought to enlist some of those findings. Because I know my nephew does back -- preventing back injury at a lot of factories, and it works.

Anyway, thanks.

REP. GREEN: Mr. Chairman, I know I'm out of time, but I would hope we would push back just what this panel's about and look at prevention and, as best we can, to fund that and use our own examples, maybe over the next two years that show we can reduce obesity, we can reduce diabetes and some of the things that we're going to pay a lot of money for that if we don't in some type of national plan.

MR. LEVI: And that is certainly part of the goal through the recovery act, in terms of the community-based prevention programs that are receiving funding there, and that I know that HHS is working very hard to make sure that the evaluation system that is developed for that investment will be able to help us answer these questions.

REP. PALLONE: Thank you.

Gentlewoman from Tennessee, Ms. Blackburn.

REP. BLACKBURN: Thank you, Mr. Chairman.

You all must feel like you're batting cleanup. You've been here all day, I bet, listening to all of these, and I appreciate the focus that you have on prevention and wellness programs. I think many times we look at medical care but we don't look at health care and don't look at health, and it is frustrating for us. I know so many times I have said I feel like one of the greatest disservices that we have done to children is they no longer have physical education and they don't take life -- when they're -- all through school they don't have physical education classes that they're attending, and then secondly, when they get into high school, they don't have the life skills classes, so they don't understand the impact of what they eat, of the different food groups or the food pyramid and how that affects their life, the importance of the interface between exercise and also what they eat and how that weighs in on some of the health issues, as we have read in testimony that's been given to us today and heard from some of our witnesses. Obesity, diabetes, chronic heart disease are the -- if you address those, you move a long way toward addressing some of our nation's health care woes. And many times people say, "Well, change how you're looking at this. Look at it as health as opposed to looking at it with medical care delivery." And of course, having been someone who served in the state legislative body and looking at these issues and bringing that to bear here at the federal level, sometimes you do stop and think a little bit about that.

What I'd like to hear from each of you in the three minutes that I have -- I want each of you to tell me if this 852-page bill -- if you think at the end of the day it is going to provide a structure for Americans to be healthier and thereby need to consume less medical care, because the quality of life and the way this affects individuals should be a focus of the policy that we decide what we're -- what is going to happen if we look at health reform. We all know this system needs some reforms. I'm one of those that favors handling it through the private sector so that it stays patient-centered and consumer- driven, but I'd like to hear from each of you -- at the end of the day, the draft before you -- would it allow for greater emphasis on wellness for prevention, for healthier lifestyles and individuals to consume less medical care?

Dr. Levi, we'll start with you.

MR. LEVI: Absolutely, on both the clinical side and the community side. And I'll make three very quick points: First -- (inaudible) -- coverage with no copayments of evidence-based clinical prevention services I think is critical. Whether it's a public program or a private program -- (inaudible) -- insurance plan, it has to be there.

Second, the investment in community prevention will get us the very things that you are talking about. Some of the best community- based prevention programs are the ones that target kids, get them to change their lifestyles, and through the kids they educate their parents. Because, you know, some of us are just over the hill and uneducable unless we're reached through kids. And we can make those permanent lifestyle changes. And that's why the investment in community preventive programs is going to be so important.

And third, and I think just as importantly, is this investment in the core public health capacity, because if we strengthen our state and local health departments, then they will be able to provide the services that surround the normal health care delivery system to be sure --

REP. BLACKBURN: I need to move on. I'm running out of time.

Dr. Smedley?

MR. SMEDLEY: I'll be very brief. As you know, we spend less than five cents out of every health care dollar on prevention. This draft bill takes a step toward righting that equation. It's also true that we have not paid enough attention to the issues of achieving equity, ensuring that everybody has access to primary care. These are all important elements that are reflected in this draft bill, which I think are going to save costs.

REP. BLACKBURN: But should it be mandated or be personal choice?

MR. SMEDLEY: Well, I don't believe this bill creates a -- that kind of mandate, but what it does through the investment and prevention is it creates healthier communities.


Dr. Kestner?

DR. KESTNER: I think the bill addresses the access issue as well as the investment in primary care. I think that's -- (inaudible) -- first relationship should be established -- (inaudible) -- is in the public health sector and in primary care -- (inaudible).

REP. BLACKBURN: Thank you very much. I yield back.

REP. PALLONE: Thank you.

Gentlewoman from Wisconsin, Ms. Baldwin.

REP. BALDWIN: Thank you, Mr. Chairman. I appreciate the fact that you've had this panel today devoted to public health and prevention and health care disparities.

I'm introducing a bill today actually that is very relevant to this topic. What the bill does is it takes the first steps in identifying and addressing the health care disparities faced by lesbian, gay, bisexual, and transgender Americans. The bill is based in large part on the extraordinary work of the tri-caucuses on racial and ethnic health care disparities. The Congressional Black Caucus, the Congressional Hispanic Caucus, and the Asian-Pacific Islander Caucus have done extraordinary work teaming together to put together a bill that is called the Health Equity and Accountability Act, which I believe may also be introduced this week.

We know that there are disparities in health care faced by the LGBT community, but we know this largely based on anecdotal information or some data derived from locally administered or privately administered health surveys. And I can tell you that it was in some cases quite challenging putting together this legislation because of the lack of data and the lack of evidence. So I want to just ask some very basic questions, starting with you, Dr. Smedley.

Having studied racial and ethnic health care disparities, how important is data collection to understanding and addressing health care disparities?

MR. SMEDLEY: It's absolutely vital. In the case of LGBT populations, as you pointed out, lacking data, it's difficult to understand when and under what circumstances these populations face both health status and health care inequities. So it's very important to have that data.

Once we have that data, we not only raise public awareness, but we can focus and target our interventions so that we are addressing the problem successfully.

REP. BALDWIN: See, on the National Health Interview Study -- or, Survey, which I understand to be the federal government's most comprehensive and influential survey, does not include any questions on sexual orientation or gender identity. Do you think it should?


REP. BALDWIN: And to my knowledge, actually no federal survey at all includes any questions on sexual orientation or gender identity. Do you think this would be important as a routine inclusion in health surveys where we're trying to collect information?

MR. SMEDLEY: Yes. I believe that -- I may be mistaken about this, but I believe that BRFS, the Behavioral Risk Factor Study, may allow that as an option. But we should certainly ensure that we're understanding all of our populations where we see inequalities in health status.

REP. BALDWIN: I'd ask you also, Dr. Smedley, how important and relevant are sort of goal-setting and aspirational documents like Healthy People 2010? And I know there's an effort underway to revise and update for Healthy People 2020 document. How important are these goal-setting documents to reducing health care disparities?

MR. SMEDLEY: Again, vitally important. Some have criticized Healthy People 2010 for having goals that are difficult to attain, but unless we articulate what our vision is of a healthy society, it's going to be very difficult to put in place the policies and indeed to create the political will to achieve those goals. I believe it's very important that we have strong aspirations for equity for many population bases.


MR. LEVI: If I could just add one point here -- I don't know --

REP. BALDWIN: Yes, Doctor.

MR. LEVI: I think one of the criticisms in the past of the Healthy People process has been we set goals and we don't have any -- we don't have the data sets to tell us whether we're even achieving those goals. And part of what's in this discussion draft is creating this secretary for Health Information, which would increase I think the transparency of the data and create a process by which we would do a better job of answering some of the questions that you want to have answered.

REP. BALDWIN: And I would note from the Healthy People 2010 document, this is sort of a vicious cycle because it is silent to LGBT health issues because the drafters of that document said, "Well, we don't have any data to point to any disparities and so we can't talk about how we need to address those disparities."

MR. LEVI: (Inaudible.)

REP. BALDWIN: Dr. Levi, I know your organization has done terrific work on demonstrating that community-based prevention programs can have a significant return on investment. And it is also my understanding that different communities targeted often respond differently to different interventions. So tell me a little bit about targeting those interventions, and how much do these programs need to be targeted or tailored to different cultural subgroups?

MR. LEVI: I guess I'd answer it in two ways. One is, we have a lot of evidence that from some national programs like the REACH program, (ASSESS ?) program, or the Pioneering Healthier Communities program, where there's an overall goal of trying to reduce certain -- the prevalence of certain conditions and a recognition that on a community basis -- what's happening in that community -- some communities need more exercise promotion; some people need more nutrition promotion; some people have higher rates of smoking -- those kinds of particular issues need to be addressed in the context of the community.

And then there's a second part, which is what subcommunities -- that's thinking more geographically. And then when you're thinking about racial and ethnic communities or the LGBT community, what particular issues do you also need to think about?

And I think the LGBT community is a perfect example. If we had thought about community prevention at the very beginning of the HIV epidemic, we would have been addressing what Ron Stall from -- formerly CDC and now at -- (inaudible) -- talks about (endemics ?), which is the risk or the disease you're wanting to prevent -- in this case, HIV -- is related to other factors, such as experience of domestic violence, mental health issues, alcohol issues; it can be smoking -- I mean, depending on what aspect you were looking at -- that all need to be addressed together. And when you're thinking about community prevention, that's what you want to do. You want to bring all of these pieces together and -- we keep coming back to the beginning -- you can't do it without data.

REP. BALDWIN: Thank you.

REP. PALLONE: Thank you.

The gentlewoman from Florida, Ms. Castor.

REP. CASTOR: Thank you, Mr. Chairman.

Thank you all for your testimony. I'm fortunate that back in my hometown I have a great college of public health. The Dean there is Dr. Donna Petersen, and I've been keeping her informed all the way along during the health care reform discussion, dialogue, from the outline now and into the discussion draft. And her initial comments were, "Boy, you all are on the right track when it comes to community health centers," and there's certainly a consensus in the Congress -- many have been leaders on the issue -- Chairman Waxman; Chairman Pallone; Mr. Clyburn, the whip. She says we're on track with workforce issues. Everyone -- there's great consensus around improving the primary care workforce, and the SGR -- how we're going to compensate those folks. She expressed some concern on whether or not we're really doing enough for community public health initiatives. We see the initial draft here, the discussion draft, and I thought that Ranking Member Deal raised a good point, too, about personal responsibility and how we get parents to turn off the TV and encourage their kids to exercise. And they it just be we hope that people see President Obama and the first lady work out in the morning and that's going to be a great inspiration. We need a new surgeon general, I think, that's going to be very proactive, though we don't have that filled yet. We need the CDC to take an even more proactive role.

Meanwhile, back home our local governments and school districts and states are under severe -- they're -- many are in severe budget crises, and oftentimes the first things to go are the sidewalks, the other -- the parks initiatives, summer programming for kids. Tell me, what is out there right now? What do local communities depend on right now from the federal government on those community public health and investing in infrastructure? What grants are there now? And then we can talk about what's in the discussion draft and where we need to go.

MR. SMEDLEY: There's a -- there certainly are federal programs that will support this kind of community prevention, but we're talking a fraction of the level of investment that's in the discussion draft.

REP. CASTOR: And is that -- of which? Is it out of HHS, Transportation --

MR. SMEDLEY: Mostly out of HHS, and mostly out of CDC. But the budgets for those programs have either been relatively flat or declining over the last five years. Our entire effort around chronic disease prevention has been declining over the last five or six years.

We have not -- obesity is a perfect example where we recognize that this is a huge public health problem and we haven't even found the resources to fund every state to have an obesity program. So -- and particularly now in a time of economic crisis, it's not like state and local governments have the resources to backfill. And in an economic recession, it becomes even more important for us to be thinking about those issues because it's harder to keep healthier, it's harder to --

REP. CASTOR: (Inaudible) -- limited time.

MR. SMEDLEY: Sure. I'm sorry.

REP. CASTOR: Is there another federal pot of money or initiative you want to identify besides the CDC? Any --

MR. SMEDLEY: The other pot of money is the big pot of money, the $650 million of community prevention that's in the Recovery Act, and that will be released shortly.


MR. LEVI: If I could add --


MR. SMEDLEY: Not only are those funds from the prevention and wellness also available, I think the entire stimulus package can be looked at as a public health intervention because of the many provisions around housing, transportation, early education. We know that Early Start, Healthy Start programs work. They save money, as Dr. Levi has indicated.

So if we can think about the stimulus dollars as a public health intervention and ensure that those dollars are going to communities to create safe public transportation, to stimulate healthy lifestyles, then this can meet multiple purposes.

REP. CASTOR: Then in the health reform bill, we need to build upon those historic investments that come out of the Recovery Act. I mean, Donna Petersen, my colleague, has a great health -- (inaudible) -- but it seems like our local communities need a new Healthy Communities Block grant initiative that is consistent over time that maybe doesn't compete with the other -- if there's anyone from the Association of Counties or League of Cities, if you all would work with us, I'd like to -- (inaudible).

Thank you, Mr. Chairman.

REP. PALLONE: Thank you.

I think we're done for today. I want to thank all of you. And again, as I mentioned, you'll probably get some written questions that we'd like you to get back to us as soon as you can. But again, this was a very important part of what we're doing -- the prevention and the public health -- (inaudible) -- so thank you, as we proceed.

And let me remind members, we are going to recess because we'll be reconvening tomorrow, as well as Thursday. Tomorrow at 9:30, the full committee will meet as we hear from the Secretary Sebelius. But after that's done, we'll reconvene as a subcommittee and have a number of panels to continue with the subcommittee's activities. So without objection, the subcommittee will recess and reconvene tomorrow following the conclusion of the full committee hearing that begins at 9:30 a.m.

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