Executive Session

Floor Speech

By:  Tom Harkin
Date: May 7, 2013
Location: Washington, DC


Mr. HARKIN. Mr. President, I was deeply disturbed several weeks ago to learn of the White House's plan to strip $332 million in critical funding from the Prevention and Public Health Fund and to redirect that money to educating the public about the new health insurance marketplaces and other aspects of implementing the Affordable Care Act.

No one is more interested in ensuring the successful implementation of the health insurance exchanges than I am. I chair that committee. I was working with both Senator Kennedy and Senator Dodd in formulating these aspects of the Affordable Care Act. But it is ill-advised and shortsighted to raid the prevention fund, which is making absolutely critical investments in preventing disease, saving lives, and keeping women and their families healthy.

Last year they took $5 billion from the prevention fund. I will get to that in a moment. So, again, in their raiding of this prevention fund, not only is it a case of misplaced priorities, it is frankly an outrageous attack on an investment fund that is saving lives by advancing wellness and prevention initiatives in communities all across America.

A major purpose of the Affordable Care Act is to begin to transform our current sick care system into a genuine health care system, one that is focused on saving lives through a greater emphasis on wellness, prevention, and public health. I have been saying for 20 years or more that we do not have a health care system in America, we have a sick care system.

When you think about it, if you get sick, you can get pretty good care in America. We have the best surgeons and best cancer clinics. If you are sick, there is probably no better place in the world to be than in America to get cured. But what we are lousy at is keeping you healthy in the first place and preventing illness, preventing diseases, preventing chronic conditions.

Every expert acknowledges that we will never reduce health care costs or have a healthier and more productive society until we have a major focus on prevention. However, I have no choice but to conclude that when it comes to prevention and wellness, some people in this administration just do not get it.

The prevention fund already has been a giant step forward for public health in our Nation. Typically, prevention and public health initiatives have in the past always been an afterthought. This means that important community-based interventions often go unsupported. The prevention fund, as part of the Affordable Care Act, is making it possible for us to make national investments in evidence-based programs that promote physical activity, improve nutrition, and reduce tobacco use.

This is not the time to mention all of the many ways this fund is already making Americans healthier. I want to mention several representative investments that are happening right now.

The prevention fund is already investing $226 million to reduce chronic diseases, including diabetes and heart disease. Heart disease disproportionately affects women. In fact, it is the No. 1 cause of death for women in this country. Some 42 million women in America are currently living with some form of heart disease.

The World Health Organization estimates that a staggering 80 percent of heart disease, diabetes, and stroke could be prevented as a result of changes in smoking, nutrition, and physical activity alone.

Moreover, this investment by the prevention fund is not only saving lives, it is also saving money. Right now, heart disease costs our Nation about $440 billion a year--$440 billion a year in health care costs from heart disease alone.

Cigarette smoking kills an estimated 173,000 women a year. If current smoking rates persist, more than 6 million kids living in the United States today will ultimately die from smoking.

This year the fund is supporting a second round of the highly successful media campaign called ``Tips From a Former Smoker.'' It is estimated that last year's campaign will save $70 million annually based on just the smokers who successfully quit in reaction to this 12-week ad campaign. These ads are extremely powerful and effective. Within 2 days of the first ad appearing last year, the number of calls to our quit lines tripled. So mark my words, these ads are going to save lives. In fact, the second phase of this ad campaign is expected to inspire half a million quit attempts and to help at least 50,000 Americans quit smoking forever.

Now, that is the $93 million for the anti-tobacco education and support campaign. As I pointed out, over 6 million kids--if we do not do something about it, 6 million kids today in America will die from smoking.

Let's talk about the immunization program. The prevention fund is investing in immunization programs that protect kids and save billions of dollars in downstream costs. For every dollar spent on childhood immunizations, Americans save $16 by avoiding the costs of treating preventable diseases. Furthermore, by ensuring that all adults get recommended routine vaccines, we can prevent 40,000 to 50,000 deaths annually. So the $82 million that was cut for immunizations in the prevention fund by the action by the White House could have saved our Nation up to $1.3 billion in unnecessary health care costs. Again, this is the very definition of penny wise and pound foolish budgeting.

Investments from the prevention fund are not just at the national level, they are also at the community level. The fund is helping States, cities, and towns to implement evidence-based programs that meet their particular local needs.

For example, the State of Illinois has made improvements to its sidewalks and has marked crossings in order to increase levels of student physical activity for students going to school. Because of these improvements, the number of students who are walking to school has doubled. Not only is this good for their health, it is expected to save the school system about $67,000 a year on bus costs.

In Florida, the school board of Miami Dade County will soon implement the Play, Eat, Succeed project in order to reduce the prevalence of childhood obesity among students with disabilities and children in the Head Start Program. The project will focus on improving nutritional habits, increasing physical activity levels, and achieving a healthy weight.

In California, the Los Angeles County Department of Health has worked with more than 100 clinical teams to provide accessible clinical preventive services to control high blood pressure and cholesterol, reaching approximately 200,000 adults just in Los Angeles County alone.

In my State of Iowa, the Black Hawk County Board of Health is working with the local agency on aging to implement the Better Choices, Better Health Program. This initiative is designed to help individuals who are living with chronic conditions to find practical ways to self-manage pain, fatigue, and to make healthier nutrition and exercise choices, to set realistic goals, to understand treatment options and communicate with family and health care providers about their condition.

I mention all of these to show that the prevention fund is not just top-down from Washington; we are trying to encourage communities, cities, towns, counties, and, yes, some States to do work on their own, to come up with innovative ideas on how to encourage people to live healthier lives, to prevent smoking, to, for instance, get more kids to walk to school. And this is a big problem. A lot of kids in America can walk to school, but they do not have sidewalks, they do not have safe passages to school, so they take a bus. Simple things like that are done at the local level with the prevention fund, and when local levels experiment and do things like this and they find that they work, then other people adopt it. To me, this is one of the key elements of the prevention fund. It is sort of letting a thousand flowers bloom, getting more ideas out there from people at the local level on what they can do, how they can buy into this.

What can they do, and how can they buy into this to have a good prevention and wellness program on the local level?

Let's look at the return on investment. We always wonder about the return on investment for the kind of money we spend in government. The prevention fund all across America is investing in proven locally developed programs, as I mentioned, that promote health and wellness, and they save lives. Not only is this improving our health outcomes but it will save us money.

According to a study by the Centers for Disease Control and Prevention, the National Diabetes Prevention Program to prevent or delay nearly 885,000 cases of type 2 diabetes would save our health system about $5.7 billion over the next 25 years. The National Diabetes Prevention Program is a public-private partnership of health organizations that work together to prevent type 2 diabetes to life style change programs right in our home communities. Given that in 2007 diabetes alone accounted for about $116 billion in direct medical costs, it is all the more critical that we continue to invest in proven programs such as this.

I want to point out that for these investments, for every dollar we put in a childhood immunization series, it has been proven we saved $16.50. Yet if I am not mistaken, the White House is taking about $85 million out of this fund--penny wise and pound foolish.

Tobacco control programs: For every $1 we invest, we are saving $5. Chronic disease prevention: For every $1 we spend, we save $5.60. For workplace wellness programs: $3.27 for every $1 we spend. Any way you look at it, in all of these programs, just the return alone--not mentioning the productivity of people who are healthier, who don't smoke, who don't have chronic illnesses--their productivity is much higher than those who have chronic illnesses.

The list goes on and on. The Trust for America's Health released a study showing that a 5-percent reduction in the obesity rate could yield more than $600 billion in savings on health care costs over 20 years. Again, this is from the Trust for America's Health. A 5-percent reduction in the obesity rate, 5 percent only, could yield more than $600 billion in savings on health care costs over 20 years.

Studies such as this confirm what common sense tells us. Your mother was right; prevention is the best medicine for our bodies and for our budgets alike. That is why nearly 800 organizations have spoken against misguided efforts to slash or eliminate the prevention fund.

Despite ill-advised efforts to cut or eliminate the prevention fund, most Americans understand what is at stake. Prior to creation of the prevention fund, for every dollar spent on health care, 75 cents went to treating patients with chronic diseases, while only 4 cents was spent on efforts to prevent those diseases. Again, before the Affordable Care Act, 75 cents of every health care dollar was spent on treating you after you got sick. Only 4 cents was spent on preventing those diseases.

This chronic underinvestment has had devastating consequences. Nearly half of American adults have at least one chronic condition. Two-thirds of the increase in health care spending between 1987 and 2000 was due to increased prevalence of chronic diseases.

We had a briefing from three highly acclaimed medical practitioners 2 or 3 weeks ago, and they pointed out that two-thirds of the money we spend in Medicare goes for treating chronic illnesses--two-thirds.

When we talk about the money we are spending on Medicare and how do we control Medicare costs, some people say we have got to make it tougher for people to get Medicare or you have got to cut down on Medicare, when the answer is staring us right straight in the face: prevention and wellness programs. For elderly people who do have a chronic condition, there are interventions that will save us money and make their lives better through prevention and wellness programs. We know that. There are evidence-based programs which are proven to work.

The prevention fund gives us an unprecedented opportunity to bend the cost curve by jumpstarting the transformation of America into a true wellness society, a society that focuses on preventing disease, saving lives and saving money.

As I said, the fund is doing both; it is saving lives and saving money. To slash this fund as the White House intends to do is bad public policy and bad priorities. To take money from the prevention fund is to cannibalize the Affordable Care Act in ways that will both cost us money and lives. I think it is a violation of both the letter and the spirit of this landmark law. Again, one more time, we know prevention saves lives.

Cancer deaths: About 567,000 people die from cancer annually in the United States. Fifty percent of those are preventable and much cheaper than all the long-term care costs, not to mention the devastation that happens in families' lives when a parent is lost to cancer.

Preventable diseases, heart disease, diabetes, and stroke: About 796,000 people die from heart disease, diabetes, and stroke annually in the United States. Eighty percent of those are preventable. Yet we are going to cut money from the prevention fund? It doesn't make sense.

Prior to the Senate adjourning for this last recess, I put a hold on Ms. Marilyn Tavenner's nomination to serve as the Administrator for the Centers for Medicare and Medicaid Services. Ms. Tavenner, in her role as Acting Administrator, signed a directive in March that channeled critical funds away from prevention. I must say, as the chairman of the committee, and as the author of the prevention fund in the Affordable Care Act, I was never notified until the decision had been made. I was not consulted. No one was. It was just sort of signed away.

Again, I want to make it very clear the hold I put on Ms. Tavenner was not a secret hold. In fact, I don't believe in secret holds. Too often people put on secret holds and you don't know who is doing it. I would never do that. I issued my hold publicly. Why? In order to heighten public awareness of this administration's ill-advised policy decision to cut prevention money and hopefully to get the White House to start to reconsider. I wanted to give people in the White House the chance to understand that their assault on the prevention fund is shortsighted, destructive, and perhaps suggests other sources of funding for implementing and overseeing the marketplace.

Last year the administration, as I said, approved a $5 billion--and I am correct here--a $5 billion cut to the fund as part of the middle-class tax bill. That was last year. I thought after that we had an agreement that was not going to happen again, the clearer cut agreement.

Now the administration has made it clear they intend to move forward with even more cuts--$332 million this year--to the prevention fund. What we are seeing from the administration is, at best, mixed signals and, at worst, a betrayal of the letter and spirit of the Affordable Care Act.

I repeat, these are bad policy choices. This choice to take money out of the prevention fund will have negative serious consequences for the future health of the American people.

Again, I don't know and I am unsure as to who is giving advice to the President, but I want to say to President Obama, I think you are getting bad advice, bad advice on where the money is coming from and how it is affecting the prevention fund, and there are other sources of funding for the marketplace other than the prevention fund.

I want to make it clear I don't want to interfere with the important work of the Centers for Medicare and Medicaid Services. I also happen to believe Ms. Tavenner is very well qualified and strongly qualified to be the next Administrator. I believe it is urgent to have an effective leader at the helm of CMS as we enter a critical stage in implementing the Affordable Care Act.

Accordingly, I am removing my hold on her nomination. However, as I do so, I repeat, it is deeply disappointing and disturbing that the White House once again is raiding the Prevention and Public Health Fund.

I would hope Ms. Tavenner, in her future role as the head of the CMS, will understand that while she works for the President, advice and consent of the U.S. Senate might be something worth considering in her future actions. I hope and expect again that the White House will respect the intent of Congress in creating the prevention fund, not as an afterthought but as a critical feature of the Affordable Care Act--every bit as critical as the exchanges, the marketplace, and everything else.

I hope the administration will join us in fighting for the prevention fund and in making smart, evidence-based investments in prevention and wellness. This is what real health reform is about. It is not about how you pay the bills. If all we are going to do in the Affordable Care Act is jiggle around on how we pay the bills, we are sunk. Real health reform is about changing our society away from a sick-care system to a true health care system, keeping people healthy, promoting wellness, having prevention programs at every level of society, in our schools, in our workplaces, and in our communities from the earliest moments of life, immunization programs. This is for those who are elderly, who may have a chronic condition but who can control that, at less cost and with healthier lives through good prevention and wellness programs. That is what true health reform is about, and it is our best bet for creating a healthier and more prosperous Nation. To that important end, the Congress and the White House should not be working at cross purposes. We should be working together. I say we must rededicate ourselves to the great goal of creating a reformed health care system that has a major focus on prevention and wellness, not just for a few but for all Americans. That is what the intention was of the Prevention and Public Health Fund.

As I say again, and I say very clearly, I don't know who is advising the President, but I think the President is getting bad advice. I understand the President has a lot on his plate, everything from Syria to Afghanistan--a lot. I understand that.

I hope that those in the White House who are advising the President would take a closer look and find some way of replenishing that $332 million and hopefully making some ironclad agreements that they are not going to raid the fund again next year.

I thought we had an agreement that last year was it, that $5 billion was it. I thought we had that agreement. I was operating under that assumption. Will we take more money out of the prevention fund again next year too to meet some exigency that may come up? That is what has been wrong with our sick-care system in the past. We are so focused on paying today's bills we don't focus on the future and how to keep people healthy. We just pay today's bills, keep paying the bills and paying the bills. Like clueless dodos, we wonder why health care costs are skyrocketing.

It is because we don't focus on keeping people healthy in the first place.

So I will remove my hold on Ms. Tavenner, but I hope the administration will find a way to replenish that $332 million this year and make a firm commitment to not raiding this fund in the future.


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