[Senate Hearing 115-661]
[From the U.S. Government Publishing Office]
S. Hrg. 115-661
ENCOURAGING HEALTHY COMMUNITIES:
PERSPECTIVE FROM THE SURGEON GENERAL
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HEARING
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
ON
EXAMINING ENCOURAGING HEALTHY COMMUNITIES, FOCUSING ON PERSPECTIVE FROM
THE SURGEON GENERAL
__________
NOVEMBER 15, 2017
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
___________
U.S. GOVERNMENT PUBLISHING OFFICE
27-683 PDF WASHINGTON : 2019
COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
LAMAR ALEXANDER, Tennessee, Chairman
MICHAEL B. ENZI, Wyoming PATTY MURRAY, Washington
RICHARD BURR, North Carolina BERNARD SANDERS (I), Vermont
JOHNNY ISAKSON, Georgia ROBERT P. CASEY, JR., Pennsylvania
RAND PAUL, Kentucky AL FRANKEN, Minnesota
SUSAN M. COLLINS, Maine MICHAEL F. BENNET, Colorado
BILL CASSIDY, M.D., Louisiana SHELDON WHITEHOUSE, Rhode Island
TODD YOUNG, Indiana TAMMY BALDWIN, Wisconsin
ORRIN G. HATCH, Utah CHRISTOPHER S. MURPHY, Connecticut
PAT ROBERTS, Kansas ELIZABETH WARREN, Massachusetts
LISA MURKOWSKI, Alaska TIM KAINE, Virginia
TIM SCOTT, South Carolina MAGGIE WOOD HASSAN, New Hampshire
David P. Cleary, Republican Staff Director
Lindsey Ward Seidman, Republican Deputy Staff Director
Evan Schatz, Democratic Staff Director
John Righter, Democratic Deputy Staff Director
(ii)
C O N T E N T S
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STATEMENTS
WEDNESDAY, NOVEMBER 15, 2017
Page
Committee Members
Alexander, Hon. Lamar, Chairman, Committee on Health, Education,
Labor, and Pensions, opening statement......................... 1
Murray, Hon. Patty, Ranking Member, Committee on Health,
Education, Labor, and Pensions, opening statement.............. 3
Witness
Adams, Jerome, Vice Admiral, M.D., MPH, Surgeon General of the
Public Health Service, Washington, DC.......................... 12
(iii)
ENCOURAGING HEALTHY COMMUNITIES:
PERSPECTIVE FROM THE SURGEON GENERAL
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Wednesday, November 15, 2017
U.S. Senate,
Committee on Health, Education, Labor, and Pensions,
Washington, DC.
The Committee met, pursuant to notice, at 10:05 a.m., in
room SD-430, Dirksen Senate Office Building, Hon. Lamar
Alexander, Chairman of the Committee, presiding.
Present: Senators Alexander [presiding], Cassidy, Young,
Murray, Casey, Franken, Bennet, Whitehouse, Murphy, Warren,
Hassan, and Kaine.
Opening Statement of Senator Alexander
The Chairman. The Senate Committee on Health, Education,
Labor, and Pensions will please come to order.
Today, we're holding a hearing with the Surgeon General,
Dr. Jerome Adams, to hear his priorities on how to encourage
people to lead healthier lives. Senator Murray and I will each
have an opening statement. Then we'll introduce Dr. Adams.
After his testimony, Senators will each have 5 minutes of
questions.
When Dr. Adams and I met before his confirmation hearing, I
said to him that if, as Surgeon General, he threw himself into
one important problem with everything he has, he could have a
real impact on the lives of millions of Americans. At his
confirmation hearing, he said, ``I would make wellness and
community, and employer engagement a centerpiece of my agenda
if confirmed. Our health starts in the communities where we
live, learn, work, play, and go to school.''
Dr. Adams has said his first Surgeon General's Report will
focus on health and the economy. So it makes sense for that to
be his focus, because there is a remarkable consensus that
wellness--lifestyle changes like eating healthier and quitting
smoking--can prevent serious illness and reduce healthcare
costs. This is important because the United States spends about
$2.6 trillion treating chronic diseases. This accounts for more
than 84 percent of our healthcare costs--$2.6 trillion treating
chronic diseases, 84 percent of our healthcare costs.
Today, Dr. Adams will talk to us about what local
communities, businesses, and other organizations can do to
encourage people to live healthier lives, which will help
reduce healthcare spending on chronic diseases. The Cleveland
Clinic has said if you achieve at least four normal measures of
good health, such as a healthy body mass index and blood
pressure, and you see a primary care physician regularly and
keep immunizations up to date, you will avoid chronic disease
about 80 percent of the time.
At a hearing we held last month on wellness, I said that it
is hard to think of a better way to make a bigger impact on the
health of millions of Americans than to connect the consensus
about wellness to the health insurance that 178 million people
get on the job.
One of our witnesses last month, Steve Burd, talked about
an employee wellness program he implemented while CEO of
Safeway that has reduced the biological age of employees by 4
years.
He said, ``Given that 70 percent of healthcare spending is
driven by behaviors, employers can have a powerful impact on
both employee health and healthcare cost. Healthcare costs
continued to decline by 9 percent per year as Safeway with no
material changes to plan design. Safeway's health actuaries
reported this continued cost reduction was due predominately to
improved health status.''.
Many employers have developed similar wellness programs to
incentivize people to make healthier choices.
These programs may reward behaviors such as exercising,
eating better or quitting smoking, or offer employees a
percentage off their insurance premiums for doing things like
maintaining a healthy weight or keeping their cholesterol
levels in check.
Last month, we heard that while both employees and
employers benefit from lower healthcare costs, both also can
benefit in other ways when people live healthier lives.
Michael Roizen, the Chief Wellness Officer at the Cleveland
Clinic, told us, quote, ``The culture of wellness at the
Cleveland Clinic has generated remarkable results that have led
to shared benefits: healthier, happier employees, as well as
lower costs for their self-funded insurance program, and lower
costs for our employees and the communities and patients we
serve.'' In other words, a healthier workplace translates to
the greater community being healthier.
In recent years, a growing number of organizations and
communities have developed innovative programs to incentivize
individuals to engage in healthy behaviors.
For example, BlueCross BlueShield of Tennessee partnered
with local, state, and private organizations to fund community
level initiatives across the state, such as Fitness Zones in
Chattanooga, programs in rural counties to promote healthy
habits, and an interactive elementary school program to keep
kids moving. An overall healthy community is more economically
productive. There are fewer workplace accidents, less
absenteeism, and a higher rate of engagement.
At his confirmation hearing, Dr. Adams also said not all
national problems should have a response from Washington, DC. I
agree. We don't get any smarter flying to Washington each week.
Dr. Adams' motto as Surgeon General is, quote, ``Better health
through better partnerships,'' and I hope this Committee can be
one partner going forward.
I look forward to hearing how community level partnerships
and engagement can lead to healthier individuals, higher
quality healthcare, and lower healthcare costs.
Senator Murray.
Opening Statement of Senator Murray
Senator Murray. Thank you, Mr. Chairman.
Before we begin today's conversation, I do want to comment
on the decision by Senate Republicans to once again attempt to
raise families' costs and take away their healthcare, this time
to fund tax cuts for massive corporations and the rich, while
using the bipartisan agreement that Chairman Alexander and I
and Members of this Committee reached as nothing more than
political cover.
First, let's be clear about the policy. Tacking Alexander-
Murray onto the partisan Republican tax reform effort is like
trying to put out a fire with penicillin. It will not do
anything to help. The Alexander-Murray Bill was intended to
lower costs and stabilize the market, but millions of people
will still be left paying more and losing coverage if Senate
Republicans sabotage families' healthcare to help millionaires
and billionaires get more tax breaks they probably don't need.
Second, the way this was done, by sneaking devastating
healthcare changes into a partisan bill at the last minute, is
completely counter to the bipartisan spirit in which we worked
on this stabilization bill. Many of us agreed in the wake of
the partisan repeal efforts earlier this year that jamming
partisan policy through before anyone has a chance to see it is
absolutely not the right way to get things done. It is
especially disappointing to see this happen because in working
on our bill and reaching an agreement, we proved that we can
work under regular order and find common ground.
Finally, Mr. Chairman, I've said many times before how much
I appreciate your willingness to work across the aisle after
Trumpcare failed in July to try to get a result that actually
helps families rather than burdening them with higher costs and
causing millions to lose coverage. think the work that we and
this Committee are able to do together when we focus on what's
best for patients and families is exactly what people want to
see happening in Congress.
What Senate Republicans are proposing now is the exact
opposite and the wrong direction for families' health and
financial security. It would be deeply disappointing for people
who are looking to Congress for leadership, not partisanship,
if this latest partisan Republican effort undermined both the
policy and the spirit of the agreement that we were able to
reach.
Now, having said that, Dr. Adams, I do want to welcome you.
It's good to see you again, and I want to focus on this
hearing. As you know, several weeks ago, this Committee held a
hearing focused primarily on supporting health and wellness
through employee wellness programs. I, for one, was very
encouraged by our discussion on workplace wellness, as well as
on the importance of protecting workers' civil rights and
privacy. I'm glad that we're continuing that discussion today
by exploring the role of community prevention programs. Disease
prevention and health promotion is a critical part of improving
families' well-being, and we also know it can help yield better
health outcomes and lower costs.
Now, one thing I look forward to talking about more about
is the diverse role that stakeholders have in supporting
healthy communities. As I have said before, we all have an
important role to play in supporting health and wellness. That
means supporting public health at all levels, including
initiatives that promote physical activity, increase access to
healthy foods, expand on science-based ways to reduce tobacco
use, and a lot more.
Again, not only is this an important aspect of improving
the health of families, but it's also our local economies that
stand to benefit from the increased engagement of stakeholders
and businesses in partnership with government at all levels in
health promotion efforts.
This is something I know that you, Dr. Adams, are very
interested in, and I am encouraged that you are seeking input
on how the business community can do more to contribute to
community health.
Now, as you know, many businesses are already working hard
on this, and they are taking steps to invest in public health
efforts. It's something I've seen in my home State of
Washington, and I know it's happening in many states, where we
have businesses searching for ways to better support the health
and wellness of their workers, and where we have businesses
reaching out to our most at-risk populations of all ages, as
well as partnering with health departments and other partners
in the health community.
Needless to say, we want to encourage and build on these
efforts.
Now, I'm looking forward to today's discussion on how we
can continue to bring communities together to prioritize public
health. I am appreciative of your focus on this, Dr. Adams, and
I stand committed to working with you and all of my colleagues.
But I couldn't let a hearing about encouraging healthy
communities take place without pointing out that, on the whole,
it's hard to imagine what else the Trump Administration could
be doing right now to undermine the health of our communities.
I hope you agree that the following are all essential to
supporting public health and well-being: first, investing in
public health and prevention rather than slashing investments
in the Prevention and Public Health Fund; helping women get the
reproductive healthcare they need; supporting services that
allow people with disabilities and aging adults to remain in
their home and part of their communities; making sure people
struggling with opioid use disorders get comprehensive
healthcare coverage, including through Medicaid; and responding
effectively to urgent threats of disease and unsanitary
conditions in the wake of natural disasters like we've seen in
Puerto Rico and nationwide. Unfortunately, the Trump
Administration has failed profoundly in these areas and many
others.
As we move forward with these discussions, I want to be
clear. I will continue to urge the Trump Administration to
reverse its course and put the health and well-being of
children, women, and families ahead of politics. That certainly
includes any efforts to sabotage the bipartisan legislation
many of us in this Committee worked so hard to agree on in
favor of yet another partisan healthcare repeal effort that
will leave families paying more and losing coverage.
Mr. Chairman, before I close, I do want to submit a
statement by the American Association for Family Physicians for
the record. Thank you.
[The information referred to follows:]
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On behalf of the American Academy of Family Physicians
(AAFP) thank you for the opportunity to submit this Statement
for the Record for the U.S. Senate Health, Education, Labor,
and Pensions Committee's hearing, Encouraging Healthy
Communities: Perspectives from the U.S. Surgeon General.
The AAFP appreciates the Committee's interest in examining
health through the lens of community health. Consistent with
the World Health Organization's definition, the AAFP believes
that health is ``a state of complete physical, mental, and
social well-being and not merely the absence of disease or
infirmity.'' As the largest society of primary care physicians,
we are committed to helping patients achieve health and in
supporting initiatives that build healthy communities. It is
also our view that community health does not occur by
coincidence. Healthy communities develop through robust
research as well as investments from citizens, community-based
organizations, educational institutions, governments, and the
private sector.
Primary Care is Associated With Healthier Communities
The AAFP acknowledges that physicians play an important
role in community health, both as clinicians, but also as
community partners who understand that what takes place outside
of the doctor's office (the social determinants of health)
impacts patients' health and the health of a community. Still,
primary care (comprehensive, first contact, whole person,
continuing care) is the foundation of an efficient health
system. It is not limited to a single disease or condition, and
can be accessed in a variety of settings. Primary care (family
medicine, general internal medicine and general pediatrics) is
provided and managed by a personal physician, based on a strong
physician-patient relationship, and requires communication and
coordination with other health professionals and medical
specialists. The benefits of primary care do not just accrue to
the individual patient.
Primary care also translates into healthier communities.
\1\ For instance, U.S. states with higher ratios of primary
care physician-to-population ratios have better health
outcomes, including lower rates of all causes of mortality:
mortality from heart disease, cancer, or stroke; infant
mortality; low birth weight; and poor self-reported health.
This is true even after controlling for sociodemographic
measures (percentages of elderly, urban, and minority;
education; income; unemployment; pollution) and lifestyle
factors (seatbelt use, obesity, and smoking). \2\
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\1\ Shi L, Macinko J, Starfield B, Politzer R, Wulu J, Xu J.
Primary Care, Social Inequalities, and All-Cause, Heart Disease, and
Cancer Mortality in U.S. Counties, 1990. American Journal of Public
Health. 2005a;95:674-80.
\2\ Shi L, The relationship between primary care and life chances.
J Health Care Poor Underserved. 1992 Fall; 3(2):321-35
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The dose of primary care can even be measured--an increase
of one primary care physician per 10,000 people is associated
with an average mortality reduction of 5.3 percent, or 49 fewer
deaths per 100,000 per year. \3\ High quality primary care is
necessary to achieve the triple aim of improving population
health, enhancing the patient experience and lowering per
capita costs. \4\
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\3\ Macinko J, Starfield B, Shi L. Quantifying the health benefits
of primary care physician supply in the United States. Int J Health
Serv. 2007;37(1):111-26.
\4\ Shi L, Starfield B, Primary care, income inequality, and self-
rated health in the United States: a mixed-level analysis. Int J Health
Serv. 2000; 30(3):541-55.
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Patients, particularly the elderly, with a usual source of
care are healthier and have lower medical costs because they
use fewer health care resources and can resolve their health
needs more efficiently. \5\ In contrast, those without a usual
source of care have more problems getting health care and more
often do not receive appropriate medical help when it is
necessary. \6\ Patients who gain a usual source of care have
fewer expensive emergency room visits, unnecessary tests and
procedures. They also enjoy better care coordination. \7\ We
believe it is in the national interest to support programs with
the potential to help improve patient access for this
population.
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\5\ Gilfillan, R. J., Tomcavage, J., Rosenthal, M. B., Davis, D.
E., Graham, J., Roy, J. A., & ... Steele, J. D. (2010). Value and the
Medical Home: Effects of Transformed Primary Care. American Journal of
Managed Care, 16(8), 607-615
\6\ Ibid.
\7\ Liaw, W., Jetty, A., Petterson, S., Bazemore, A. and Green, L.
(2017), Trends in the Types of Usual Sources of Care: A Shift from
People to Places or Nothing at All. Health Serv Res. doi:10.1111/1475-
6773.12753
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The Nation's Primary Care Shortage is a Community Health Issue
The current physician shortage and uneven distribution of
physicians impacts population health. A U.S. Centers for
Disease Control and Prevention study indicated that patients in
rural areas tend to have shorter life spans, and access to
health care is one of several factors contributing to rural
health disparities. \8\ The report recommended greater patient
access to basic primary care interventions such as high blood
pressure screening, early disease intervention, and health
promotion (tobacco cessation, physical activity, healthy
eating). \9\ The findings highlighted in the CDC's report are
consistent with numerous others on health equity, including a
longitudinal study published in JAMA Internal Medicine,
indicating that a person's zip code may have as much influence
on their health and life expectancy as their genetic code. \10\
Therefore, it is imperative that physician care is accessible
for all.
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\8\ Moy E, Garcia MC, Bastian B, et al, Leading Cause of Death in
Nonmetropolitan and Metropolitan Areas - United States, 1999 - 2014,
MMWR, Surveil Summ, 2017; 66 (No.SS-1); 1-8. DOI: https://www.cdc.gov/
mmwr/volumes/66/ss/ss6601a1.htm
\9\ MMWR, 2017
\10\ Dwyer-Lindgren L, Bertozzi-Villa A, Stubbs RW, Morozoff C,
Mackenbach JP, van Lenthe FJ, Mokdad AH, Murray CJL. Inequalities in
Life Expectancy Among US Counties, 1980 to 2014Temporal Trends and Key
Drivers. JAMA Intern Med. 2017;177(7):1003-1011. doi:10.1001/
jamainternmed.2017.0918
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The current primary care physician shortage and its
maldistribution remain significant physician workforce
challenges. An Annals of Family Medicine study \11\ projects
that the changing needs of the U.S. population will require an
additional 33,000 practicing primary care physicians by 2035. A
2017 Government Accountability Office (GAO) report indicates
that physician maldistribution significantly impacts rural
communities. \12\ The patient-to-primary care physician ratio
in rural areas is only 39.8 physicians per 100,000 people,
compared to 53.3 physicians per 100,000 in urban areas. \13\
According to GAO, one of the major drivers of physician
maldistribution is that medical residents are highly
concentrated in very few parts of the country. The report
stated that graduate medication education (GME) training
remained concentrated in the Northeast and in urban areas,
which continue to house 99 percent of medical residents. \14\
The GAO also indicated that while the total number of residents
increased by 13.6 percent from 2001 to 2010, the number
expected to enter primary care decreased by 6.3 percent. \15\
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\11\ http://www.annfammed.org/content/13/2/107.full
\12\ U.S. Government Accountability Office, May 2017, GAO 17-411,
http://www.gao.gov/assets/690/684946.pdf
\13\ Hing, E, Hsiao, C. US Department of Health and Human
Services. State Variability in Supply of Office-based Primary Care
Providers: United States 2012. NCHS Data Brief, No. 151, May 2014
\14\ GAO, 2017
\15\ Ibid
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Primary care workforce programs, such as the Teaching
Health Center Graduate Medical Education Program and the
National Health Service Corp Program, are essential resources
to begin to increase the number of primary care physicians and
to ensure they work in communities that need them most. The
THCGME program appropriately trains residents who then stay in
the community. THCGME residents are trained in delivery system
models using electronic health records, providing culturally
competent care, and following care coordination protocols. \16\
Some are also able to operate in environments where they are
trained in mental health, drug and substance use treatment, and
chronic pain management. \17\ Residents who train in
underserved communities are likely to continue practicing in
those same environments. \18\
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\16\ Candice Chen, Frederick Chen, and Fitzhugh Mullan. ``Teaching
Health Centers: A New Paradigm in Graduate Medical Education.''
Academic Medicine: Journal of the Association of American Medical
Colleges 87.12 (2012): 1752-1756. PMC. available at https://
www.ncbi.nlm.nih.gov/pmc/articles/PMC3761371/
\17\ David Mitchell, Residency Directors Tout Benefits of Teaching
Health Center GME Program, AAFP News, (September 6, 2013), available at
http://www.aafp.org/news/education-professional-development/
20130906thcroundtable.html
\18\ Elizabeth Brown, MD, and Kathleen Klink, MD, FAAFP, Teaching
Health Center GME Funding Instability Threatens Program Viability, Am
Fam Physician. (Feb. 2015);91(3):168-170. Available at http://
www.aafp.org/afp/2015/0201/p168.html
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American Medical Association Physician Masterfile data
confirms that a majority of family medicine residents practice
within 100 miles of their residency training location. \19\ By
comparison, fewer than 5 percent of physicians who complete
training in hospital-based GME programs provide direct patient
care in rural areas. \20\ Thus, the most effective way to
encourage family and other primary-care physicians to practice
in rural and underserved areas is not to recruit them from
remote academic medical centers but to train them in these
settings. Similarly, the National Health Care Corps (NHSC)
offers financial assistance to recruit and retain health care
providers to meet the workforce needs of communities across the
Nation designated as health professional shortage areas
(HPSAs). The NHSC is vital for supporting the needs of our
Nation's vulnerable communities. The AAFP believes building the
primary care workforce is an important return on investment. We
also believe that workforce programs help ensure high quality,
efficient medical care is more readily available. By reducing
physician shortages and attracting physicians to serve in
communities that need them, these programs also help improve
the way care is delivered and help meet the Nation's health
care goals.
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\19\ E. Blake Fagan, MD, et al., Family Medicine Graduate
Proximity to Their Site of Training, Family Medicine, Vol. 47, No. 2,
at 126 (Feb. 2015).
\20\ Candice Chen, MD, MPH, et al., Toward Graduate Medical
Education (GME) Accountability: Measuring the Outcomes of GME
Institutions, Academic Medicine, Vol. 88, No. 9, p. 1269 (Sept. 2013).
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Disease Prevention and Population Health
Mental Health and Substance Use Issues
Family physicians have traditionally focused on treating
the whole patient, and recognize the mind, body and spirit
connection. Promotion of mental health, diagnosis and treatment
of mental illness in the individual and family context are
integral components of family medicine. Mental health is also
fundamental for patient and health and community well-being.
The AAFP believes that access to increased mental health and
substance use funding is a national imperative. According to
SAMHSA's 2014 National Survey on Drug Use and Health (NSDUH),
an estimated 43.6 million (18.1 percent) Americans ages 18 and
up experienced some form of mental illness. \21\ In the past
year, 20.2 million adults (8.4 percent) had a substance use
disorder. Of these, 7.9 million people had both a mental
disorder and substance use disorder. \22\
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\21\ Substance and Mental Health Services Administration, https://
www.samhsa.gov/disorders
\22\ SAMHSA, Substance Use and Mental Health Disorders
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Social factors, such as early life experiences, poverty,
racial and ethnic minority status, and exposure to violence,
put patients at greater risk of developing mental illnesses.
Mental illness is associated with increased occurrence of
chronic diseases such as cardiovascular disease, diabetes,
obesity. \23\ Research found that among elderly patients with
high depressive scores, the risk of coronary heart disease
increased 40 percent while the risk of death increased 60
percent compared with elderly patients with the lowest mean
depressive scores. \24\
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\23\ AAFP, Mental Health Care Services by Family Physicians,
\24\ Ibid
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The AAFP commends Congress mental health reform efforts,
but there is still significant progress needed to fully
implement the Mental Health Parity and Addiction Equity Act and
to eliminate barriers for primary care and behavioral health
integration. People with mental or substance abuse disorders
were more likely to get treatment from a primary care
physician/nurse or other general medical doctor. \25\ We urge
continued progress to address this issue.
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\25\ Ibid
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The AAFP shares the administration's commitment to
addressing the Nation's opioid crisis through public education,
substance use treatment, overdose prevention, and improved
prescription drug monitoring. In 2015, the AAFP joined partners
in the public and private sector in announcing a unified effort
to address the Nation's epidemic of opioid abuse and heroin
use. The AAFP, along with the more than 40 stakeholder groups,
pledged to increase opioid abuse prevention, treatment, and
related activities. Over the next few years, medical and health
stakeholders have committed to having more than 540,000
physicians and health care professionals complete opioid
prescriber training in the next 2 years; double the number of
physicians certified to prescribe buprenorphine for opioid use
disorder treatment--from 30,000 to 60,000--in the next 3 years;
double the number of clinicians who prescribe naloxone; double
the number of physicians and health care professionals
registered with their State Prescription Drug Monitoring
Programs in the next 2 years; and, reach more than 4 million
physicians and health care professionals with awareness
messaging about opioid abuse.
Chronic Diseases
Chronic diseases are the leading causes of mortality and
morbidity in the United States adult population. According to
the CDC, the leading chronic conditions are heart disease,
cancers, stroke, obesity, diabetes, and arthritis. \26\ As of
2012, about half of all adults-117 million people-had one or
more chronic health conditions. \27\ One in four adults had two
or more chronic health conditions and seven of the top 10
causes of death in 2014 were chronic diseases. \28\ Two of
these chronic diseases-heart disease and cancer-together
accounted for nearly 46 percent of all deaths. \29\ These
conditions are mostly preventable; therefore, it is vital that
as a country we invest in preventive health efforts.
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\26\ CDC, Chronic Diseases, https://www.cdc.gov/chronicdisease/
overview/index.htm
\27\ Ibid
\28\ Ibid
\29\ Ibid
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Preventive health is essential for adults, especially with
the aging of the U.S. population. By the year 2050, the number
of people 65 years of age and older will nearly double
increasing the population of Medicare patients, 82 percent of
whom have chronic health conditions. \30\ As a country, we will
only succeed at caring for this population by strengthening
primary care, a specialty that is highly skilled in addressing
the needs of patients with chronic diseases and multiple
conditions. Better chronic care management is associated with
fewer trips to the hospital and appropriate utilization of less
expensive medical care. \31\ Making strides in this area will
require a serious commitment to patient education, health care
access, and community support.
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\30\ Tricia Neuman, Juliette Cubanski, Jennifer Huang, Anthony
Dominco, Kaiser Family Foundation, Report, Rising Cost of Living Longer
(January 2015), accessed online at:http://kff.org/medicare/report/the-
rising-cost-of-living-longer-analysis-of-medicare-spending-by-age- for-
beneficiaries-in-traditional-medicare/
\31\ Reid B. Blackwelder, MD, Leaders Voices Blog, (October 2014),
We're Doing Our Part to Keep SGR Issue On Congress' Radar, http://
blogs.aafp.org/cfr/leadervoices/entry/we--re--doing--our--part
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Programs, such as those that increase access to healthy
foods and to increase opportunities to walk through
improvements to the built environment have the capacity to help
lower the risk of disease such as heart disease, stroke, and
diabetes.
Tobacco use is the single largest cause of preventable
disease in the United States. Cigarette smoking kills more than
480,000 Americans each year, with more than 41,000 of these
deaths from exposure to secondhand smoke \32\ The AAFP supports
these initiatives through its Tar Wars Program, a community-
based effort to encourage family physicians to educate school-
age youth about the dangers of smoking. The program began and
has been particularly supportive of programs to reduce smoking
and to increase access to cessation programs. The AAFP has also
supported the Family Smoking Prevention and Tobacco Control
Act's full implementation, including efforts to restrict
adolescents from using tobacco programs. The AAFP supports
restrictions on the sales of specialty and flavored tobacco
products, regulations on electronic nicotine delivery devices,
and prohibits on the sale of tobacco products for those under
21 years of age.
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\32\ CDC, https://www.cdc.gov/tobacco/campaign/tips/resources/
data/cigarette-smoking-in-united-states.html
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Immunization and Infectious Diseases
Immunizations are a 21st century public health success, yet
42,000 adults and 300 children in the United States die each
year from vaccine-preventable diseases. \33\ A 2016 report
published in Health Affairs indicates that the economic costs
of vaccine-preventable disease for adults is between $4.7
billion and $14 billion per year. \34\ Although vaccines are
available in many different locations, such as pharmacies and
in workplaces, primary care physicians play an important role
as immunizers. The doctor-patient relationship can be
instrumental in helping patients overcome their hesitancy or
educating them when new immunizations are recommended.
---------------------------------------------------------------------------
\33\ Office of Disease Prevention and Health Promotion, Healthy
People 2020, https://www.healthypeople.gov/2020/topics- objectives/
topic/immunization-and-infectious-diseases
\34\ Modeling The Economic Burden Of Adult Vaccine-Preventable
Diseases In The United States. Health Aff (Millwood). 2016 Nov
1;35(11):2124-2132. Epub 2016 Oct
---------------------------------------------------------------------------
Doctors also understand patients' medical histories and
risk factors. For example, primary care physicians can help
diabetes mellitus patients understand how the condition
compromises their immune system and why their vaccinations
should be up-to-date. Health experts also agree that global
cooperation is an important value, but it is also important
note that infectious disease knows no boundaries. The AAFP
supports programs that increase access to vaccines, such as the
CDC's Section 317 Immunization Grant program. The program
provides funding to states to immunize underserved populations.
The AAFP also supports policies to improve immunization
information system interoperability to allow physicians to
access state data bases and to allow for better interstate
communication.
The AAFP recognizes the importance of addressing the spread
of antibiotic resistant bacteria. AAFP has committed to
reducing the use of unnecessary antibiotics in medicine, but
there is still significant progress needed within animal
agriculture. Currently, 70 percent of the antibiotics used in
the US are used for food-producing animals. It is our hope that
progress continues under the U.S. Food and Drug
Administration's current initiatives to reduce the over-
utilization of antibiotics in animals.
Child Health
Disease prevention is an import issue for pediatric
populations. Children are not little adults, which means that
their health needs are unique. Most children are healthy and
spending on this population represents a small portion of
overall healthcare investments, but supporting child well-being
can ensure that our Nation has a healthier future. Initiatives
that build health early in life include pro-conception care,
home visiting, early nutrition, vaccine access, health care,
child care, and early education. Medicaid is particularly vital
for children because it provides coverage for such a large
proportion of the child population (close to one in three US
children are covered by Medicaid or CHIP). Child patients with
Medicaid coverage are also entitled to any benefit that is
``medically necessary,'' which includes hospital care,
physician services immunizations and early, periodic,
screening, diagnostic, and treatment (EPSDT) for those under
the age of 21 \35\ Medicaid also covers family planning, and
other maternal health services for women across the country.
Medicaid is also the predominant source of health coverage for
children in the foster care system. These are among the most
vulnerable children in society because of their unique social
and emotional needs.
---------------------------------------------------------------------------
\35\ Kaiser, Medicaid Benefits, 1997, https://
kaiserfamilyfoundation.files.wordpress.com/2013/05/mrbbenefits.pdf
---------------------------------------------------------------------------
Violence prevention is an important child health and
lifespan issue. \36\ An estimated 702,000 children were
confirmed by child protective services as being victims of
abuse and neglect in 2014. \37\ At least one in four children
have experienced child neglect or abuse (including physical,
emotional, and sexual) at some point in their lives, and one in
seven children experienced abuse or neglect in the last year.
\38\ Children who have suffered abuse or neglect may develop a
variety of short-or long-term behavioral and functional
problems including conduct disorders, poor academic
performance, decreased cognitive functioning, emotional
instability, depression, a tendency to be aggressive or violent
with others, post-traumatic stress disorder (PTSD), sleep
disturbances, anxiety, oppositional behavior, and others \39\
---------------------------------------------------------------------------
\36\ AAFP, Violence Position Paper, http://www.aafp.org/about/
policies/all/violence.html
\37\ CDC, Child Abuse and Neglect, https://www.cdc.gov/
violenceprevention/childabuseandneglect/index.html
\38\ Ibid
\39\ Holbrook TL, Hoyt DB, Coimbra R, Potenza B, Sise M, Anderson
JP. Long term trauma persists after major trauma in adolescents: new
data on risk factors and functional outcome. J Trauma. 2005;58 (4):764
-771
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According to the landmark Adverse Childhood Experience
Study (ACES), children who are exposed to traumatic life
experiences are more likely to experience adult diseases later
in life. \40\ The Among those adults who had experienced the
highest levels of childhood trauma and thus had the highest
``ACES'' score, those individuals were: five times more likely
to have been alcoholic; nine times more likely to have abused
illegal drugs; three times more likely to be clinically
depressed; four times more likely to smoke; 17 times more
likely to have attempted suicide; three times more likely to
have an unintended pregnancy; three times more likely to report
more than 50 sexual partners; two times more likely to develop
heart disease; and two times more likely to be obese. \41\
---------------------------------------------------------------------------
\40\ Felitti VJ, Anda RF, Nordenberg P, et al. Relationship of
childhood abuse and household dysfunction to many of the leading causes
of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J
Prev Med. 1998;14 (4):245 -258
\41\ Jones R, Flahery EG. Clinicians' Description of Factors
Influencing Their Reporting of Suspected Child Abuse: Report of the
Child Abuse Reporting Experience Study Research Group. Pediatrics.
2008;122(2):259-266
---------------------------------------------------------------------------
Violence prevention is not only a child health issue, as
many children survive violence in the home that has impacts
across their lifespan. It is important to invest in initiatives
that reduce violence and promote child well-being such as
domestic violence prevention, parenting education, evidence-
based home visiting, and early childhood support. Furthermore,
there is a growing movement within the medical community to
address these issues, like toxic stress, and to help patients
access mental health and trauma-informed services. In addition,
gun safety policies have the potential to decrease accidents
and violence that result in thousands of injuries,
disabilities, and deaths each year. The AAFP supports research
and common-sense policies, such as improved background checks,
to reduce the risk individuals may pose to themselves or to
others within their communities.
Equity and Health Barriers
The mission of the AAFP is to improve the health of
patients, families, and communities by serving the needs of
members with professionalism and creativity. In their patient-
centered practices, family physicians identify and address the
social determinants of health for individuals and families,
incorporating this information in the bio psychosocial model to
promote continuous healing relationships, whole-person
orientation, family and community context, and comprehensive
care. Social determinants of health are the conditions under
which people are born, grow, live, work, and age. To that end,
the AAFP established its Center for Diversity and Health Equity
to provide opportunities to become a more thoughtful and
visible leader for diversity and health equity.
Race or ethnicity, sex, sexual identity, age, disability,
socioeconomic status, and geographic location all contribute to
an individual's ability to achieve good health. Experts agree
that successfully achieving measurable outcomes is possible
with a ``health in all policies'' strategy that examines the
multiple factors that contribute to or detract from a patient's
health. We must seek to understand how issues such as race,
ethnicity, sex, age, disability, economic status, and
geographic location influence health, but also acknowledge that
access to housing, safe drinking water, and clean air also
impact our patients.
The AAFP believes Federal, state, and local policymakers
should acquaint themselves with these social determinants of
health and embrace equality as vital to community health.
Policy makers should also eliminate barriers that prevent
individuals from accessing the care, information, and social
supports that they need to reach optimal health. One barrier
that raises concerns for health equity is the persistent
passage of Federal laws that interfere with the doctor/patient
relationship. These efforts often manifest in policies that
create barriers for women's ability to access contraception and
abortion. The AAFP opposes legislative interference in the
doctor/patient relationship its replacement of scientific
evidence and its undermining of patient autonomy.
The AAFP is also concerned about the state of Federal
funding and the implications for patients' health, safety and
access to care. Growing Federal funding cuts potentially create
a domino effect of damage that ultimately will harm the health
of America on both an individual and community-wide basis.
Reducing funding for agencies that oversee the health care
industry--17 percent of the U.S. economy--destabilizes the
foundation of services on which patients depend. Damage to one
agency can impact the viability and effectiveness of others.
The system is only as strong as the agencies and programs that
undergird it. The AAFP encourages Congress to ensure stability
of programs that are foundational to an effective, efficient
health care system.
Health care access is also a significant barrier,
especially for low-income individuals. The AAFP first adopted a
policy supporting health care coverage for all in 1989. For the
past 28 years the AAFP has advanced and supported policies that
would ensure a greater number of Americans had health care
coverage. The AAFP appreciates the bipartisan support for the
Medicare Access and CHIP Reauthorization Act's (MACRA) landmark
reforms that have the potential for improving patient care
outcomes by emphasizing value over fee-for-service. We welcome
the opportunity to work with policymakers to evaluate MACRA's
implementation process. enactment and the potential to improve
patient outcomes.
It is also important to acknowledge that passage of the
Patient Protection and Affordable Care Act represented a sea
change for millions of patients. We are pleased the Committee
has engaged in bipartisan hearings on how to improve individual
market as well as proposals to maintain the cost-sharing
reduction payments. Medicaid expansion and the law's Essential
Health Benefits were particularly important for vulnerable
populations. Medicaid assists the most vulnerable patients who
are members of minority groups, homeless, formerly
incarcerated, foster and former foster youth, mentally ill,
addicted, and military families. Insurance coverage rates among
minorities are lower than rates among the non-Hispanic white
population. \42\ Minorities experience disproportionate rates
of illness, premature death, and disability compared to the
general population. \43\ In addition, virtually all of the
estimated individuals nationally who are homeless could be
eligible for Medicaid. Many in this population would benefit
from the mental health and addiction treatment requirement
included under the law. \44\ Forty percent of our Nation's
veterans who are under 65 years of age have incomes that could
qualify them for Medicaid under the ACA's expanded coverage.
\45\ In general, family members of veterans are not covered by
the Veteran's Administration, but may seek coverage through
Medicaid or the marketplace. \46\ Many patients in this
category are unaware that they qualify for health benefits.
---------------------------------------------------------------------------
\42\ Center for Health Care Statistics (CHCS), Reaching Vulnerable
Populations Through Health Reform, April 2014, available at--http://
www.chcs.org/media/Vulnerable-Populations--April-2014.pdf
\43\ Center for Health Care Statistics, April 2014
\44\ Id.
\45\ Id.
\46\ Id.
---------------------------------------------------------------------------
A New England Journal of Medicine article indicates that
the law's coverage expansion was associated with higher rates
of having a usual source of care, greater access to primary
care access, and, higher rates of preventive health screenings.
\47\ Anecdotal evidence among family physicians also reveal
that health care access is saving lives and improving patient
health for those who are accessing much-needed care for chronic
diseases or detecting conditions in the initial stages. Again,
achieving optimal health does not occur by accident. Realizing
the vision of healthy communities, like other national
priorities, requires that we identify goals, invest resources,
and eliminate barriers, especially for vulnerable citizens.
---------------------------------------------------------------------------
\47\ Benjamin D. Sommers, M.D., Ph.D., Atul A. Gawande, M.D.,
M.P.H., and Katherine Baicker, Ph.D., N Engl J Med 2017; 377:586-593
---------------------------------------------------------------------------
Conclusion
The AAFP appreciates the opportunity to share these
comments on community health and welcomes the opportunity to
work with policymakers to achieve positive outcomes on these
and other policies. For more information, please contact Sonya
Clay, Government Relations Representative, at 202-232-9033 or
[email protected].
------
The Chairman. Thank you, Senator Murray. It will be
included.
I'm pleased to welcome the Surgeon General, Dr. Jerome
Adams, to today's hearing. He oversees the U.S. Public Health
Service Commissioned Corps, a group of over 6,500 public health
professionals working throughout the Federal Government for the
advancement of public health.
Dr. Adams previously served as the Indiana State Health
Commissioner. Before that, he served as Staff Anesthesiologist
and Assistant Professor of Anesthesia at the Indiana University
School of Medicine. He holds a B.S. in biochemistry, a B.A. in
biopsychology from the University of Maryland, Baltimore
County; a Master's in Public Health from the University of
California at Berkeley; and an M.D. from the Indiana University
School of Medicine, where he also completed his anesthesia
residency.
Welcome again, Dr. Adams. We appreciate you summarizing
your testimony in about 5 minutes. That'll leave more time for
questions.
Welcome.
STATEMENT OF VICE ADMIRAL JEROME ADAMS, M.D., MPH, SURGEON
GENERAL OF THE PUBLIC HEALTH SERVICE, WASHINGTON, DC
Dr. Adams. Absolutely. Thank you so much. It is good to be
here again. It's a little bit lonelier up here than what it was
the last time I was here. But I'll tell you, it's good to be
back. I'd like to thank Chairman Alexander, Ranking Member
Murray, and Members of the Senate HELP Committee for hosting
these very important hearings on the topic of wellness.
I'm going to sidetrack just for a little bit and go over my
time just for a bit, because I have to say to each and every
one of you thank you so much for confirming me. Thank you so
much for being willing to work with me, both to the Senators
and to all of the staffers.
I was coming in the building this morning and I was reading
about Senator Dirksen. He was beloved by all of his colleagues,
and I think that the HELP Committee really epitomizes the
bipartisan--from my point of view, health is nonpartisan--
nature of how we need to look at problems. I want to say thank
you so much for your support getting me here, and I look
forward to your support moving forward.
Back to my testimony. The United States is the undisputed
global leader in medical research and medical care. However,
despite spending over $3.2 trillion annually on healthcare, we
continue to rank below many countries in life expectancy and in
other important indicators of health. Chronic diseases like
heart disease, cancer, diabetes, and lung disease are the
leading causes of death and disability in the United States and
among the most costly. Yet we know they are preventable.
While there's been some stabilization in mortality from
most chronic diseases, we are now facing an unprecedented
number of lives lost due to suicides and drug overdoses largely
involving prescription or illicit opioids. These so-called
deaths of despair are affecting all Americans across the
country and are brought on in part by a lack of hope and a lack
of opportunity. This is why it is so important that the
President called for the declaration of the opioid crisis as a
public health emergency. At HHS, we are committed to using all
possible resources to attack this epidemic head-on.
Not only is the opioid epidemic impacting our families and
communities, but it is also taking a significant toll on our
economy. The economic burden of the opioid crisis is $78.5
billion, with a B, in healthcare, law enforcement, and lost
productivity.
There is good news, however. Research showed that for each
dollar invested in evidence-based prevention programs, up to
$10 is saved in treatment costs. Furthermore, these prevention
programs have also been shown to prevent high school
delinquency, teen pregnancy, school dropout, and violence. We
can turn the tide.
Effective public health interventions and policies that
target chronic diseases and deaths of despair lead to a
healthier population with lower healthcare spending, less
school and workplace absenteeism, increased economic
productivity, and an improved quality of life. What's the key
to effectiveness and efficiency? Well, scientists have found
that the conditions in which we live, learn, work, and play can
have an enormous impact on our health long before we ever see a
doctor.
A community suffering from poor health is all too often a
home to local businesses with workforce shortages and work-
related illnesses and injuries. There are declines in
productivity and issues with workforce recruitment and
retention, which lead to decreased profitability. Productivity
losses as a result of employees who don't come to work or who
work while sick, cost U.S. employers more than $225 billion
annually. This equates to almost $1,700 per employee per year
due to our country's unwellness.
As I travel around the country, I constantly hear that
businesses are struggling to fill open positions because
applicants are unable to pass a drug test. Businesses that
recognize addiction as a chronic disease and help their
employees access treatment avoid the high cost of termination,
recruitment, and retraining new staff. Businesses that
recognize the downstream cost of community inactivity, poor
nutrition, and tobacco use demonstrate lower healthcare costs
and boast larger profits.
While the government must play a role in prevention and
treatment, we cannot do it alone, as Senator Alexander
mentioned. The business sector is a critical partner in helping
achieve gains in the wellness of all Americans. The private
sector pays for about half of total healthcare spending in the
United States.
But rather than viewing health merely as an insurance
expense to be controlled, more companies are seeing the
building of a community culture of health as a true business
opportunity. Why? Because mental, physical, and economic health
in communities are strongly and inextricably correlated.
Healthier communities tend to be more economically prosperous,
and more prosperous communities tend to be healthier.
Improved community conditions for health, such as clean and
safe neighborhoods, access to healthy food options, and
opportunities for exercise and physical activity can help
influence positive health behaviors and lead to a more
productive and a more profitable workforce. While workplace
wellness programs are fortunately becoming more prevalent
amongst corporations--and a lot of the initial testimony that
you had previously focused on those--the most innovative
businesses are implementing initiatives that go well beyond an
onsite focus on employees to incorporating community health as
a whole.
For example, Target is putting wellness at the center of
its corporate social responsibility strategy, investing $40
million in more than 50 nonprofits which focus on increasing
the physical activity and healthy eating habits of local
children and their families. GSK, Costco, Cummins, and many
others have invested in their communities as a means of
investing in their most valued asset, their employees.
In closing, I'd say that recognizing the role of wellness
in our country's safety, security, and prosperity is why I'm
focusing my term as Surgeon General on better health through
better partnerships. This means we will strengthen ties with
existing public health and healthcare partners. But it also
means we will forge new partnerships with the business, law
enforcement, education, and defense sectors, as well as the
religious, faith-based, and other community organizations and
sectors.
For this reason, my signature report will focus on the
intersection between health and the economy, how businesses are
able to thrive by investing in the health of their employees
and communities. Achieving wellness at the community level is
paramount to eliminating chronic disease, improving quality of
life, reducing healthcare costs, and increasing life
expectancy. By working together across the public and private
sectors, I am confident that we will achieve HHS's goal of
healthier people, stronger communities, and a safer Nation.
With that, I'm happy to take your questions.
[The prepared statement of Dr. Adams follows:]
------
prepared statement of jerome m. adams
Value of Wellness
I would like to thank Chairman Alexander, Ranking Member
Murray, and Members of the Senate HELP Committee for hosting
hearings on the topic of wellness.
The U.S. is the global leader in medical research and
medical care. However, there are reasons for concern. Despite
spending over $3.2 trillion annually on healthcare--which is
significantly more than any other country--we continue to have
room for improvement when it comes to life expectancy and other
indicators of health.
Chronic diseases--like heart disease, cancer, diabetes, and
chronic obstructive pulmonary disease (COPD)--are the leading
cause of death and disability in the U.S. and among the most
costly, yet these afflictions may be preventable. The World
Health Organization reports that at least 80 percent of all
heart disease, stroke, and type 2 diabetes and up to 40 percent
of cancer could be prevented if people ate better, engaged in
more physical activity and ceased to use tobacco. \1\
---------------------------------------------------------------------------
\1\ Preventing chronic diseases: a vital investment, World Health
Organization, 2005, http://www.who.int/chp/chronic--disease--report/
full--report.pdf;Noncommunicable diseases country profiles, World
Health Organization, July 2014, http://www.who.int/nmh/publications/
ncd-profiles-2014/en/
---------------------------------------------------------------------------
While there has been some stabilization in deaths from some
chronic diseases, we are now facing unprecedented increases in
deaths due to suicide, liver cirrhosis from alcohol
consumption, and drug overdoses, largely due to overdose deaths
involving prescription or illicit opioids. The President
recently called upon Acting Secretary Hargan to declare the
opioids crisis plaguing our communities a nationwide Public
Health Emergency. These so-called deaths of despair are
affecting all Americans across the country, and are brought on
in part by a lack of hope and opportunity. The opioid epidemic
impacts our families and communities, and it is taking a toll
on our economy. The economic burden of the prescription opioid
crisis is $78.5 billion in healthcare, law enforcement, and
lost productivity. The good news is that research shows that
for each dollar invested in evidence-based prevention programs,
up to $10 is saved in treatment for alcohol or other substance
misuse-related costs. \2\ These prevention programs go beyond
preventing or lowering the risks of addiction--they also have
been shown to prevent delinquency, teen pregnancy, school
dropout, and violence. \3\
---------------------------------------------------------------------------
\2\ Facing Addiction in America: The Surgeon General's Report on
Alcohol, Drugs, and Health, Office of the Surgeon General, U.S.
Department of Health and Human Services, November 2016, https://
addiction.surgeongeneral.gov/
\3\ Facing Addiction in America: The Surgeon General's Report on
Alcohol, Drugs, and Health, Office of the Surgeon General, U.S.
Department of Health and Human Services, November 2016, https://
addiction.surgeongeneral.gov/
---------------------------------------------------------------------------
Effective public health interventions and policies that
target deaths of despair and chronic diseases lead to a
healthier population with lower health care spending, less
school and workplace absenteeism, increased economic
productivity, and an improved quality of life.
By investing in the prevention and treatment of the most
common chronic diseases, one estimate shows the U.S. could
decrease treatment costs by $218 billion per year and reduce
the economic impact of disease by $1.1 trillion annually. \4\
---------------------------------------------------------------------------
\4\ An Unhealthy America: The Economic Burden of Chronic Disease--
Charting a New Course to Save Lives and Increase Productivity and
Economic Growth, Milken Institute, 2007, http://
assets1b.milkeninstitute.org/assets/Publication/ResearchReport/PDF/
chronic--disease--report.pdf
---------------------------------------------------------------------------
Scientists have found that the conditions in which we live
and work have an enormous impact on our health, long before we
ever see a doctor. Wellness starts in our families, our schools
and workplaces, in our playgrounds and parks, and in the air we
breathe and the water we drink.
Wellness and the Business Sector
Productivity losses as a result of employees who don't come
to work, or work while sick, cost U.S. employers $225.8 billion
annually, or about $1,685 per employee each year. For example,
obesity and obesity-related illnesses, like diabetes, cost the
Nation over $153 billion per year in lost productivity. \5\
---------------------------------------------------------------------------
\5\ Stewart WF, Ricci JA, Chee E, Morganstein D. Lost productive
work time costs from health conditions in the United States: results
from the American productivity audit. J Occup Environ Med.
2003;45(12):1234-1246
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As an administration, we are focused on the opioid crisis
currently impacting our country, and with good reason.
Prescription opioid addiction and non-fatal overdoses cost
$20.4 billion in lost productivity in 2013. \6\ According to
the National Safety Council, a worker with a substance use
disorder is not as productive, is more likely to make a
mistake, and may take twice as many sick days. Companies that
recognize addiction and support their staff have found that
employees in recovery have lower turnover rates, are less
likely to miss work, and are less likely to be hospitalized and
have fewer doctor visits.
---------------------------------------------------------------------------
\6\ Florence, Curtis S., Chao Zhou, Feijun Luo and Likang Xu.
``The Economic Burden of Prescription Opioid Overdose, Abuse, and
Dependence in the United States, 2013.'' Medical Care 54 10 (2016):
901-6
---------------------------------------------------------------------------
A community with poor health results in local businesses
with workforce shortages; absenteeism; presenteeism, when
workers are on the job but are not fully functioning due to
illness or other medical conditions; work-related injuries and
illnesses; declines in productivity and profitability; and
issues with workforce recruitment and retention. As I travel
around the country, I have heard that businesses are now
struggling to fill open positions because applicants are unable
to pass their drug tests. Businesses that recognize addiction
and help employees get into treatment allow employers to keep
valued employees. Furthermore, employers also avoid the high
costs of termination, recruitment, and retraining new staff.
The business sector is a critical partner in helping
achieve gains in the wellness of Americans. The private sector
pays for about half of total healthcare spending in the United
States. Rather than viewing health merely as an insurance
expense to be controlled, more companies are seeing the
building of a health culture as a business opportunity.
After CVS removed tobacco products from store shelves and
renamed itself CVS Health, new revenues more than made up for
lost sales while also reducing the purchases of cigarette packs
by at least 95 million at ``all retailers'' by at least 95
million at ``all retailers.''by at least 95 million at ``all
retailers.'' \7\ General Dynamics Bath Iron Works, a large
full-service shipyard in Maine employing over 6,000 employees,
extended a successful in-house diabetes prevention initiative
into the wider community. It expects to cut participants'
future healthcare costs over five years by 60 percent on
average.
---------------------------------------------------------------------------
\7\ CVS; Forbes, 2015
---------------------------------------------------------------------------
The health and economy of communities are often strongly
correlated. Healthier communities tend to be economically more
prosperous and vice versa. Improved community conditions for
health, such as clean and safe neighborhoods, access to
healthful food options, and opportunities for exercise and
physical activity, can help positively influence health
behaviors and lead to a more productive workforce.
Several businesses are implementing health initiatives that
go beyond workplace wellness programs to support community
health. For example, Target is putting wellness at the center
of its Corporate Social Responsibility strategy, having
invested $40 million dollars in more than 50 non-profit
organizations around the U.S., which focus on increasing the
physical activity and healthy eating habits of children and
their families in local communities.
Wellness and National Security
As a United States Public Health Service (USPHS)
Commissioned Corps officer and member of the uniformed
services, I know that wellness is at the heart of the safety
and security of our Nation. It is estimated that seven in ten
youths (ages 17-24) would fail to qualify for military service
due to obesity, educational deficits, or behavioral health
issues/criminal history. \8\
---------------------------------------------------------------------------
\8\ Unfit to Serve, CDC infographic; Ready, Willing, and Unable to
Serve, Mission: Readiness Report, 2009
---------------------------------------------------------------------------
In order to ensure a strong national defense, we need to
ensure threats to service member recruitment, retention,
readiness, and resilience are mitigated. As Surgeon General, I
am working to bring awareness to this issue by publicizing my
annual physical fitness test for the USPHS, which evaluates
four key components of fitness: cardiorespiratory endurance,
upper body endurance, core endurance, and flexibility. I will
be working with members of the PHS Commissioned Corps, National
Guard, and other Department of Defense reserves to work with
local schools in order to implement evidence-based programs to
increase physical fitness. Not just because our youth deserve
to be healthy, but also for their educational benefit and the
benefit of teachers and their classrooms as well. Research
demonstrates that students who engage in physical activity have
greater attention spans in class and higher test scores in
addition to the health benefits.
Surgeon General Priorities
Recognizing the role of wellness in our country's safety,
security, and prosperity is the reason I will focus my term as
Surgeon General on ``Better Health through Better
Partnerships.'' This means we will strengthen ties with
existing public health and healthcare partners, while forging
new partnerships with the business, law enforcement, education,
and defense sectors, as well as religious and faith-based, and
other community organizations.
It is for this reason I have decided my signature Surgeon
General's report will focus on the intersection between health
and the economy, and how businesses are able to thrive by
investing in the health of their employees and communities. By
partnering with non-traditional sectors and helping them
recognize their role in wellness at the community level, we
allow everyone to have a fair chance for good health and
opportunities for better health choices. Achieving wellness at
the community level is paramount to eliminating chronic
disease, improving quality of life, reducing healthcare costs,
and increasing life expectancy. By investing in communities, we
can ensure the U.S. Department of Health and Human Services'
goal of healthier people, stronger communities, and a safer
Nation.
------
The Chairman. Thank you, Dr. Adams. We'll now begin a 5-
minute round of questions, and I'll start.
Senator Murray mentioned the tax bill, and I'll briefly
comment on that before I go to wellness. Senator Murray knows
how much I respect her leadership and the work we did most
recently on the Alexander-Murray legislation, which has growing
support in both the Democratic and Republican sides of the
Senate and I think the House, and, hopefully, eventually with
the President.
But it's in a different bill in a different committee. It's
in the Tax Reform Bill, and it cannot--the Alexander-Murray
proposal, under the rules of the Senate, cannot be made a part
of the Tax Reform Bill. It has to stand on its own. It'll be
considered separately and must be considered separately. I
imagine there will be other provisions in the Tax Reform Bill,
as it makes its way through the Finance Committee today, that
Democratic Members of the Senate don't like, and they'll have a
chance to vote against those provisions.
No. 2, the Tax Reform Bill is moving through committee.
It's being amended this week, or amendments are being offered.
It will go to the floor, where there'll be an unlimited number
of amendments that can be offered.
No. 3, it's true that if the individual mandate is repealed
in 2019, the Congressional Budget Office has said that rates
could go up 10 percent in that year, but that the markets would
be stable during the decade. The Congressional Budget Office
has also said that, quite aside from that, if we don't pass
Alexander-Murray with the cost-sharing provisions that we'll
have a 20 percent increase in rates this year, and that
increase will go up to 25 percent in 2020.
I know there are differences of opinion about what the
Finance Committee is doing. My only point is that's a different
committee, a different bill, and the work we did on Alexander-
Murray can't be considered as a part of the Tax Reform Bill
under the rules of the Senate.
Senator Murray. Mr. Chairman, could you just yield to a
question?
The Chairman. Sure.
Senator Murray. Do you agree with me that the Alexander-
Murray Bill was not designed to deal with the disruption in the
marketplace, though it increased costs by 10 percent, as you
just identified, where more people lose their coverage under
the individual mandate repeal?
The Chairman. Well, it was designed to deal with disruption
in the marketplace. The CBO found that repealing the individual
mandate will not create instability in the market. It will
raise rates 10 percent.
Senator Murray. But our bill was never designed--we did not
have hearings, we did not have input, we did not have any
discussion about what the marketplace would look like if the
individual mandate was repealed.
The Chairman. Well, no, we didn't, because the individual
mandate is a tax, and that's not in our jurisdiction.
Senator Murray. Yes. My point is that our bill was not
designed to----
The Chairman. It's in the Finance Committee's jurisdiction.
Senator Murray.----deal with the current provision that's
being proposed.
The Chairman. Well, our bill is in this Committee, and it's
one set of issues, and if it doesn't pass, we'll have a big
increase in premiums, the CBO has said. The Finance Committee
is working on another bill, which our bill can't be a part of
under the rules of the Senate.
Dr. Adams, in our last wellness hearing, someone suggested
that there might be a wellness program for the Department of
Health and Human Services since it has 80,000 employees and
millions of people work across all the Federal agencies. Would
such a pilot program--does one exist, a wellness program now
for HHS? Would it be possible to have one?
Dr. Adams. Well, I certainly appreciate that question,
Chairman, and I can tell you that the Department of Health and
Human Services has a number of wellness programs for their
employees. We offer free gym memberships. We offer free flu
shots. We have a variety of healthful food options. When you go
to the cafeteria, and when you're wearing the uniform, and you
walk in----
The Chairman. But I mean the kind that the Cleveland Clinic
has, where it's a structured program, where employees are given
incentives and opportunities to have reduced--some benefits for
an improved lifestyle. Do you have that?
Dr. Adams. Well, I certainly think that Cleveland Clinic is
the ideal, and there's an opportunity for us to grow at HHS and
to become even better at incentivizing healthy behaviors. The
answer to your question, very directly, sir, is we have a
number of programs, but we could do better, and we need to look
at examples such as the Cleveland Clinic, and then take that to
all of our corporations and businesses across the country.
The Chairman. Well, models and pilot programs sometimes set
good examples. The bully pulpit is a good way to lead, rather
than mandates from Washington sometimes. Another example of
that is the Malcolm Baldrige National Quality Improvement Act
of 1987 that was created to encourage businesses, nonprofits,
and others to compete for performance-based awards to improve
the quality of what they were doing.
I knew David Kearns very well. I recruited him to be the
Deputy Secretary of the Department of Education in 1991. He was
the CEO of Xerox, and Xerox is one of the companies that had
gone through the Baldrige competition and won it. Companies all
over America signed up for that and improved their quality
without any Federal orders to do it. That was the incentive,
the honor of it all.
I wondered if you had ever considered a Baldrige type award
for wellness for employers who want to improve the lifestyle of
their employees.
Dr. Adams. Senator, I think that is a wonderful idea. The
states that have been really innovative in this arena have had
awards sponsored by their local chambers of commerce to
recognize businesses that are not only doing onsite workplace
wellness but also reaching out into the communities. I think
the more we can highlight those programs, the more we can
applaud folks for doing what we know is the right thing, the
better. I think that's wonderful idea.
The Chairman. Thank you, Dr. Adams.
Senator Murray.
Senator Murray. Your testimony speaks to the critical role
that employers can have in supporting the health and well-being
of their communities and employees. Now, as you know, the Trump
Administration recently took the extreme action of allowing
practically any employer or university to claim a religious or
morale exemption to avoid covering birth control for their
employees without ensuring they have an alternative source of
coverage.
Rather than promoting the health of their workers, that
would actually allow employers to prevent female employees from
having coverage through their employer sponsored insurance that
is required today under the ACA, taking away, actually,
healthcare options for millions of women nationwide and
undermining their economic well-being. I wanted to ask you, do
you agree that having access to birth control is critical to
the health of women across our country?
Dr. Adams. Senator, I believe that women's health and
family planning are extremely important parts of health and
wellness in our communities, and I hope that the folks here in
this room can come together and help institute reasonable laws,
and at HHS, we're always searching to come up with reasonable
compromises that are acceptable to communities and states to be
able to emphasize women's health.
Senator Murray. Do you believe that's an appropriate way
for employers to influence healthcare decisions of their
employees?
Dr. Adams. I'm sorry, believe what is appropriate?
Senator Murray. The new mandate--or the new rule from the
Administration that pretty much says any employer or university
can opt out. Is that an appropriate way if employers opt out?
Dr. Adams. I certainly appreciate the question, Senator,
and when I am talking to folks about health, there's the
science, but the science has to be implemented as one variable
into a complicated policy equation. What I've found is that
mandates rarely are accepted by the community and by the people
who we're trying to help. As Surgeon General, what I want to do
is make sure folks understand the science, and I believe what
we're trying to do is give corporations the flexibility to
determine what is best for their employees. I want to make sure
I'm there to help them understand what the science says.
Senator Murray. Thank you. My point is that if we are
telling employers that they can decide how a woman's healthcare
can be covered, and in a hearing where we're talking about
employers helping the well-being of their employees, that seems
really at odds with me.
Now, as you've heard today, there are many promising
examples where private sector engagement can improve both
health and economic growth at local levels. We've seen that in
some of the most successful initiatives that involved efforts
where the private sector investments complement our Nation's
public health backbone. One great example of that is in my home
State of Washington where child care providers, public water
system operators, residential property managers, and others are
working with their state health department to eliminate
childhood lead exposure.
Now, this would not be possible without state and local
public health departments, which provide the services and
infrastructure to protect kids from lead poisoning, which is
why the private sector can't and should not be expected to go
it alone. Whether we're talking about lead poisoning prevention
or combating heart disease, our public health system really
depends on sustained Federal funding from CDC and others. Yet
time and again, we have had to fight back proposals from this
Administration that would slash Federal funding for public
health.
In your written testimony, you spoke to the value of
investing in prevention. Do you think Federal funding for CDC
supported state, local, tribal, and territorial public health
programs is adequate?
Dr. Adams. Ma'am, as a public health advocate, I always
want more money for public health. I also realize that tax
revenues that come in from increased businesses in a society
also can contribute to state and local funding for public
health, and I think that's a complicated policy equation that
doesn't fall under my purview.
What I want to do is make sure folks understand we need to
invest in prevention and public health. We need to make sure
that that total number continues to increase, and that's going
to come from private, that's going to come from Federal, that's
going to come from state. But, ultimately, it does need to
increase if we're going to lower our costs in the long term.
Senator Murray. Okay. I just have a half a minute left. But
we all know the opioid epidemic is going to take long-term
sustained investments in prevention and treatment and recovery.
As Surgeon General, I know you're less directly involved with
on-the-ground response to the opioid epidemic than you were as
a state health commissioner. But you do have a unique ability
to speak to the country about how community stakeholders must
come together.
I wanted to ask you how you're using your role as Surgeon
General to help communities overcome some of the divisive
issues, like needle exchange, so they can really address the
opioid crisis.
Dr. Adams. Well, thank you so much for that question. One
of the things that I've already done is participated in a forum
for the HHS Neighborhood and Faith-Based Partnerships Division.
I'm reaching out to those communities and helping folks
understand that sometimes controversial interventions that are
scientifically based can and should be considered in the
toolkit when you're looking at how to respond to the opioid
epidemic.
I met with Chief Justice Loretta Rush just last night, the
Chief Justice of Indiana. She's heading up the Judicial Opioid
Task Force, and we're looking at ways to bring in the judicial
community for diversion programs or pre-trial programs. We've
also reached out to the police and the law enforcement
community. I was in Atlanta last week and met with the sheriff
down there, and we talked about ways to decrease violence by
making sure folks get access to treatment.
That's why, again, my motto is better health through better
partnerships. Einstein said the definition of insanity is doing
the same thing and expecting a different result. We've got to
break out of our siloes. We've got to start speaking languages
that resonate, including the language of business, including
the language of the faith-based community, and an understanding
for where they are, and we've got to meet people where they
are.
Senator Murray. Thank you very much.
Dr. Adams. Thank you to you and your staff. You have been a
tremendous help. Please share with me your examples from
Washington, because we want folks to know you all are doing
some great work out there.
The Chairman. Thank you, Senator Murray.
Senator Cassidy.
Senator Cassidy. Hey, Dr. Adams.
Dr. Adams. Hello.
Senator Cassidy. I'm going to follow-up on what Senator
Murray just said, because you're also a pain doc.
Dr. Adams. I am.
Senator Cassidy. If there's something that unites us, it's
we've got to do something about opioids. It appears that
overprescribing by physicians and dentists is part of what's
driving the opioid epidemic. This may be in your current
position, or it may be in your state position, or it may be in
your pain doc position. But is there anything that we could do,
legislatively, that you could specify that would help with this
opioid epidemic, from any of the hats you have worn?
Dr. Adams. I certainly appreciate that. I want to highlight
one of the things we're doing at HHS, and that's the Committee
on Alternatives for Pain Management, and we're going to have
our first meeting either in late December or early January.
Thank you all for giving us the opportunity to come up with
those opioid alternatives.
But something that all of you can do--you can invite me to
your communities to help speak about wellness and the economy.
Why does that matter, and why is that an answer to your
question? Because I framed these in my opening testimony as
deaths of despair. If you ultimately want to get upstream,
we've got to make sure communities are more prosperous so that
people don't lose hope. If they can see that there's an
opportunity to go to something else besides self-medicating,
ultimately, that's the most upstream that we can go.
Senator Cassidy. That Princeton study by Anne Case, the
Death of Despair--from Despair, specifically, middle-aged white
males, but now also other groups--if you will, tracing that
opioid epidemic back to if the folks have no vision, they
despair.
Dr. Adams. Absolutely. As I said, a healthier community is
more prosperous, and a more prosperous community is, in turn,
healthier and is not going to suffer as much from the opioid
epidemic or cancer or diabetes or what-have-you.
Senator Cassidy. We actually address opioids not
collaterally, but as part of an overall approach. Now, we spoke
beforehand about some of the stuff you've done--were involved
with in Indiana----
Dr. Adams. Yes.
Senator Cassidy.----and with some of the preventive
programs that we previously heard about from business have been
implemented for folks who are not--through business. Can you
elaborate on that? Again, what can we take as guidance from
what you all have done successfully to bring better health to
groups who, statistically, are more likely to suffer from
chronic illness?
Dr. Adams. Well, we know a lot of our folks who suffer from
chronic illness, who suffer from infant mortality, who suffer
from the opioid epidemic are covered by Medicaid. I don't want
to go too far down the rabbit hole here, but I will say that in
Indiana, with our Healthy Indiana plan, we've been able to
incentivize wellness and healthier behaviors----
Senator Cassidy. How did you do that, may I ask?
Dr. Adams. Well, we have a health savings plan, and folks
pay a deductible each year. They get a discount on their
deductible if they participate in wellness activities that have
been scientifically validated, like getting your colon cancer
screening, like getting your breast cancer screening, like
participating in immunizations.
We found that by having a program that gave the state the
flexibility to experiment--you mentioned pilot programs, sir--
to be able to do that in an innovative way, giving the state
the flexibility, we've been able to increase the participation
in wellness initiatives by folks who people did not believe
would do it. I can tell you I lived through it. Folks didn't
believe it was going to work.
Senator Cassidy. Just to put a point on it--because my
experience as a physician was working in a hospital for the
uninsured, which just socioeconomically tended to be poor--
there's always a kind of bias that folks such as you and I are
speaking of who are not sophisticated enough to respond to such
incentives or otherwise have obstacles which do not allow it,
and you're saying, absolutely, they will respond appropriately
in their self-interest in a way which isn't mandated, because
I'm not--believe me, the American people hate to be told to do
anything, but they love being incentivized, and they responded
to incentives.
Dr. Adams. You said two things there, sir, that I want to
draw out. You said that people believe that they can't or
they're not sophisticated enough to do it. That is absolutely
false. If we set up a program that incentivizes them, they will
respond to those----
Senator Cassidy. By the way, the same incentives as I would
have through the workplace incentive program.
Dr. Adams. Exactly. There's something else you said, too,
though, that I think is very important. You mentioned
obstacles. If we're going to do this, we need to make sure
folks are aware of the real obstacles people face in terms of
being healthier. I talk about my kids all the time. I live in a
nice neighborhood. We've got sidewalks. We've got--nobody
smokes. There's grocery stores right down the street. That's
very different than the community where I work. I work in a
hospital with a lot of people who are uninsured.
Again, it's not as easy as saying go out and exercise when
there's not complete streets. It's not as easy as saying eat
healthy when there's only fast food restaurants. We have to
take those obstacles into account, and there are a lot of great
programs that mesh the two, and I hope that that's what you all
can do as Senators from some very different ways of thinking. I
hope you all can come together, and we can help promote the
best practices.
Senator Cassidy. Thank you, Doctor, and I yield back.
The Chairman. Thank you, Senator Cassidy.
Senator Warren.
[No verbal response.]
The Chairman. Oh, she's not here.
Senator Hassan.
Senator Hassan. Thank you, Mr. Chair, and thank you,
Ranking Member Murray, and welcome, Doctor.
Before I get to my questions, I do want to say how
disappointed I am about reports that Republicans are now
threatening to use their tax bill to pursue a partisan goal of
repealing health coverage. The Trump Administration's sabotage
attempts are already raising healthcare premiums and squeezing
hard-working people in New Hampshire and across the country,
and this partisan plan would cause healthcare premiums to rise
an additional 10 percent a year in the individual market and
about 10 percent through most of the budget window that the tax
bill deals with, all to give tax breaks to corporate special
interests and the wealthiest few.
Instead of raising costs, we should be working together to
pass the bipartisan stabilization package led by Senators
Alexander and Murray that would lower costs. If Republicans
move forward with their plan on the tax bill, the efforts of
the Alexander-Murray Bill are for naught, because we are going
to destabilize it in a different committee, in a different
room, while also taking away health insurance, according to the
CBO, from approximately 13 million people, which gets me to the
point of this morning's hearing, which is it is very hard to
promote wellness when people can't get primary care because
they don't have insurance coverage, or where Medicaid expansion
is threatened, and it's very hard to talk about wellness when
people can't afford care and can't get care.
I hope very much that the group that is crafting this tax
bill will decide not to try to repeal the individual mandate
and cause premiums to go up and rip care away from people.
I do have a number of questions about wellness efforts. But
I did also want to just comment a little bit on the discussion
that we've already had on the opioid epidemic, because I
appreciate your work very much. You know that New Hampshire has
been one of the hardest hit states in the country. We all share
a bipartisan commitment to addressing the opioid crisis.
I was encouraged by the President's commission's
recommendations. There are a number of things that are
evidence-based that a lot of us have been doing in our states.
But we are still waiting for the Administration to actually
identify what implementing those recommendations is going to
cost, and then identifying a number that we could all work to
appropriate to get treatment and prevention efforts and
recovery efforts out into our community.
I hope very much that you will urge the Administration to
actually identify what it would cost. Some of us have a bill
that says let's start with $45 billion, which was an amount
that friends on the other side of the aisle agreed would be an
appropriate start this summer, and I think we really need to
focus on getting resources to our communities. With an epidemic
of this scope, this size, it does not seem to me that not
spending additional dollars on it is going to do the trick.
So I hope very much that you will be a voice for that. Can
I have your commitment to helping the Administration identify
real resources?
Dr. Adams. You absolutely do. HHS has its foot on the gas,
and we are not taking it off until we start to see some
progress. I promise you that.
Senator Hassan. Thank you. One other quick point that I
would just ask you to think about, going back to Senator
Murray's discussion on coverage for birth control. I cannot
imagine that if an employer told male employees that they could
not have certain kinds of healthcare that men would tolerate
it.
I really do believe that it is totally inappropriate for
any employer to tell any employee how they can spend or apply
healthcare coverage. That should be between the employee and
her doctor, and if she needs access to birth control, and she
is working and getting the benefit an employer-sponsored health
insurance coverage, she should be able to make healthcare
decisions without interference from her employer, and I just
hope you will take that position into account.
Dr. Adams. Thank you very much for that, Senator. Again,
family planning is critically important to wellness. We also
have to factor in the employers and the faith-based community,
where some of those objections come from. I can promise you I
will always be there to tell folks about the science, and the
science says family planning is an important part of wellness.
Senator Hassan. Thank you. Birth control also treats women
for conditions other than family planning.
Last issue--we are seeing in the annual sexually
transmitted disease surveillance report that STD rates have
increased by more than 2 million cases in 2016. What can
communities do to address the rising rates of STDs and how
should the Federal Government assist with these efforts?
Dr. Adams. Well, HHS is focused on that. The CDC is focused
on that. I was just down there last week talking with
individuals. But it all, again, comes back to wellness. There
are folks who are engaging in activities that are leading to
increased transmission of sexually transmitted diseases for
reasons due to lack of education, lack of opportunity.
I think that if we can invest in wellness from both a
Federal and a private point of view, you will see lower STD
rates. You see that in communities that are more prosperous,
the STD rates are lower. How can we engage businesses to
participate in what we know are proven public health
interventions and are a definite health problem.
Senator Hassan. Thank you, and thank you, Mr. Chair, for
your indulgence, and thank you Dr. Adams.
The Chairman. Thank you, Senator Hassan.
Senator Young.
Senator Young. Dr. Adams.
Dr. Adams. Hello.
Senator Young. I enlisted in the United States Navy as a
Seaman Recruit. It took me a decade in the military. I finally
became an O3, a Captain in the U.S. Marine Corps, and here you
sit as a Vice Admiral in the Navy, and I couldn't be happier.
You're going to be a great Surgeon General.
I'd like to ask you some questions related to evidence-
based prevention programs. You touched a bit on it earlier--the
Indiana model with respect to our Medicaid program, targeting
people of modest means. There's certainly some evidence-based
prevention programs that were put to use there.
But you've indicated in your testimony that for each dollar
invested in some of these programs, we can see $10 saved in
treatment on mental health issues, on alcohol abuse challenges.
What specific programs would you like to bring to light in this
Committee and all who are watching, whether it's in the public
realm or in the private sector, that you think have been
incredibly impactful and ought to be scaled up nationally?
Dr. Adams. Well, I certainly appreciate that question, and
again, it's partnerships. It's collaboration between the
private and the public entities. We know that in South
Carolina, Nikki Haley, when she was Governor there, shepherded
a program that was a public-private partnership to address
infant mortality, and they've seen their infant mortality
metrics improve.
Senator Young. Was that the Nurse-Family Partnership?
Dr. Adams. That was involving Nurse-Family Partnership,
absolutely, and we've invested in Nurse-Family Partnership in
Indiana also under my tenure as Health Commissioner there. We
know that every $1 invested in biking and walking trails can
return benefits up to $12, and for every $1 invested in food
and nutrition, there's a $10 return in healthcare costs.
How do we get companies to invest in community building?
We've seen this, and again, in Indiana--as Health Commissioner,
I keep referring back--we built bike trails there throughout
the city, and it actually improved the economy, and it also
improved the health of individuals because they were able to
participate in physical activity.
Senator Young. Now, the things you mentioned--they strike
me as powerful. They intuitively seem to advance health and
wellness. Have they been rigorously evaluated? For example, you
cite bike trails. Do we know that bike trails increase health
and wellness, or is there just a correlation between the
existence of bike trails and healthy persons who live in the
surrounding area, which is not causal, per se?
Dr. Adams. Well, there's two things I would say there.
There is a fair amount of evidence that investing in wellness
increases prosperity. The web-based diabetes prevention program
lowers 5-year risk for diabetes by 30 percent, stroke by 16
percent, and heart disease by 13 percent, and that's a program
that Costco actually put in place. HEB Supermarket chain did
research on their investments in wellness and found that their
healthcare costs were less than half of the national average.
There is evidence out there. But what I want to say to you
all is that's why it's so critically important that I'm able to
do the Surgeon General's Report on health and the economy,
because we want to compile the evidence that exists showing the
links between health and the economy, and we want to give the
businesses and the public health entities in your state the
tools to be able to say, ``This is evidence-based. We want to
replicate this in our communities.''
Minnesota is doing a great job, and Senator Franken didn't
show on me again, so you tell him I miss him. Tell him he's got
to get here next time. They're doing some great work there with
Target and with the other businesses in their communities to
promote health and wellness.
Senator Young. It's great that you're looking nationally,
clearly, at various examples in the private realm and also in
the public sector. I think it's really important as you compile
your Surgeon General's Report that we ensure--we indicate the
level of certainty we have about the effectiveness of these
different interventions and policy approaches. That is, have
things been studied using the gold standard of evaluation,
randomized control trial across multiple sites, or, instead, do
we just have sort of a decent level of confidence, based on
some longitudinal study that something is working well?
If we have a very high level of confidence, I think those
are the programs we're more inclined, as government officials,
to invest in and to scale up. I say, we, meaning not just the
Federal Government, but also state and local authorities. They
need to begin maybe stepping up in a health prevention and
wellness way that they haven't in the past.
The last point I'd like to make, with the Chairman's
indulgence, is some of the answers here may lie in behavioral
science. If we can change the choice architecture people have,
if we can organize our policies and also perhaps even our
physical environment in a way that makes people more inclined
to make individual choices in furtherance of the health
outcomes that they want, then that could be very, very
powerful. I hope you'll be consulting with behavioral
scientists as you put together that report and work with this
Committee.
Thank you.
Dr. Adams. Behavioral scientists, health economists--we
want to make sure we bring everyone into the fold. To your
point about the evidence, that is why it is so critical that I
have your support for the Surgeon General's Report, because
that's what we want to do. We want to look at it and say,
``This is top tier. Go with it.'' This one, maybe not so.
At HHS, in regards to the opioid epidemic, with your
indulgence, sir, we're evaluating 42 different evidence-based
programs to respond to the opioid epidemic, because right now,
folks are throwing spaghetti at the wall to see what sticks,
and we want to make sure we're funding the most evidence-based,
the best programs, in order to be able to most efficiently and
effectively tackle the opioid epidemic.
Senator Young. I look forward to working with you, Vice
Admiral. Thank you.
Dr. Adams. Thank you.
The Chairman. Thank you, Senator Young.
Senator Murphy.
Senator Murphy. Thank you very much, Mr. Chairman.
Good to see you, Dr. Adams, again.
Mr. Chairman, you're hearing our frustration about the way
in which this tax bill has turned into a healthcare bill in the
last 48 hours. I was so proud of this Committee when we held, I
think, three or four hearings to study how we could stabilize
the individual market and so proud of how you and Senator
Murray worked together to develop that plan.
But the impact of Alexander-Murray, should it pass, or had
it passed, will be dwarfed by the impact of repealing the
individual mandate, and it is potentially going to come up for
a vote in the U.S. Senate without a single hearing in this
Committee, maybe a markup in the Finance Committee, but no
serious attempts to understand what the impact is.
CBO admitted that it's very hard to understand what happens
when the mandate disappears. It could be catastrophic in the
sense that if you keep the requirement that plans continue to
price without respect to medical acuity, but you don't require
that people buy insurance, the rational individual would not
buy insurance until they become so sick that they need care,
knowing that they'll never pay any more for it. A rational
healthy person simply would not buy insurance with the
protection in place and no mandate. At the very least, CBO says
that premiums are going to go up 10 percent compounding, year
over year, simply because of the piece of legislation that the
Senate is potentially going to pass.
The reason I say that this bill is becoming a healthcare
bill instead of a tax bill is because from what we understand,
the individual income tax relief, which will help about two out
of every three middle class families, is temporary. It
disappears in 7 years, and by 7 years from now, premiums will
have doubled, according to CBO, because of the repeal of the
individual mandate.
7 years from now, an average family will get almost no
individual income tax relief, because their tax cuts will have
expired, and their premiums will be potentially $10,000 higher
than they are today, according to CBO. Seven years from now, a
doubling of annual premiums for the average family will mean an
increase in cost of $10,000.
To most middle class families, yesterday, this bill stopped
being a tax bill and started being a healthcare bill, and this
Committee, again, is not reviewing it.
Dr. Adams, thank you for being here. I have one question
for you. Dangerous neighborhoods are not healthy neighborhoods.
What we know about the biology of trauma and toxic stress is
that if you're walking to school every day fearing for your
life, if you live in a neighborhood in which gun shots are your
bedtime music, as is the case in a lot of neighborhoods in this
country, your brain is bathed in adrenalin and cortisol, which,
from what I understand, fundamentally alters the way in which
your brain works.
As we're talking about trying to build healthy communities,
how important is it to make sure that we're building safe
communities? Because if kids fear violence, if they fear gun
homicides, then all of the work we do to build resources and
healthcare equity doesn't really matter because their brains
have been altered. I know you've thought a lot about this, have
done a lot of work around this issue. Talk about the connection
between safe communities and healthy communities.
Dr. Adams. Thank you so much for bringing up that point,
because community safety is a critical part of wellness. I'll
give you a quick example. I was in Atlanta last week, and the
East Lake Community in Atlanta had some of the highest high
school dropout rates, some of the worst crime, some of the
lowest employment rates in the Nation.
They brought together multiple different sectors, different
partners, around the idea of economic wellness and
productivity, and now, they are above the state average for
high school completion, their crime rates have gone down, and
they've become a more prosperous and a safer community, which
leads back to the point that I originally made that health and
the economy are intimately connected, and embedded in that is
safety. If you're a more prosperous community, you're going to
be a safer community and a healthier community, and vice versa.
Senator Murphy. When we talk about gun violence, we tend to
think of the impact as being on the victims and on the victims'
immediate close set of friends and family. But the fact of the
matter is the impact in these neighborhoods is felt by everyone
who has this fight or flight mechanism that sets off in their
brain. It's a public health issue, and I appreciate your
comments on that.
Thank you, Mr. Chairman.
Dr. Adams. Thank you, sir.
The Chairman. Thank you, Senator Murphy.
Senator Warren.
Senator Warren. Thank you, Mr. Chairman. I echo my
colleague's concerns about yesterday's decision by the Senate
Republicans to use their tax bill to rip healthcare coverage
away from 13 million Americans. Republicans have apparently
decided that it is not enough for their tax bill to raise taxes
on millions of middle class families. Now it will also raise
insurance premiums on millions more and take away healthcare
coverage from people who desperately need it.
Insurers, doctors, hospitals, patient groups--they have all
been crystal clear. This will destabilize the insurance market,
and it will hurt people, plain and simple. Republicans should
not use their tax bill as a way to take away people's health
insurance.
Dr. Adams has come here to talk about an important topic,
and I want to take an opportunity to ask him some questions
about this. When it comes to health outcomes in this country,
there are some really clear patterns. Life expectancy is lower
for black Americans than for white Americans, lower for people
without a high school degree than for those who complete
college, lower for people at the bottom of the income
distribution than those at the top. Because where we live is
often segregated by these same factors, one recent study found
a 20-year difference between counties with the highest and
lowest life expectancies in America. That is deeply shocking.
Dr. Adams. We've seen that even in Indiana.
Senator Warren. That is deeply shocking in America. These
disparities are persistent, but for decades, the story has been
that all groups are living longer. Unfortunately, we're seeing
some worrying new trends on that front. The CDC recently
reported that the death rate so far in 2017 is up compared with
last year, and research suggests that death rates are flat or
even increasing for middle-aged white Americans who have not
graduated from college.
Dr. Adams, what do we know about what might be driving this
troubling shift in mortality rates in America?
Dr. Adams. Well, again, we had a discussion earlier about
deaths of despair, and the reality is that when you look at the
communities where those death rates are going up for middle-
aged white Americans, there is a lack of hope and there is a
lack of opportunity.
Hello, Senator Franken. How are you, sir?
Senator Franken. Very good. How are you?
Dr. Adams. I'm well.
What we want to do is we want to make sure we're engaging
the business sector, the faith-based community sector, the
people in those communities who can provide that hope and
opportunity, because that's the only way we're going to turn
this around. We're not going to turn it around simply by
looking at it as a medical problem or a health problem. We've
got to look at it as a hope and an opportunity problem.
Senator Warren. I see this as health and economic security
go hand in hand, that having a good job with decent pay and
health insurance means that if somebody gets sick, they can
still go to the doctor and they can have a few months cushion
until they get back on their feet. If addiction hits someone in
the family, there's a better chance of accessing treatment.
But if someone is injured on the job because their employer
isn't following the law, or they can't get a hernia surgery
because they don't have health insurance, or their paycheck
barely covers their monthly rent, then--I'll be blunt about
this--their chances of staying healthy and free from chronic
pain simply aren't as good.
Dr. Adams. They're a higher cost to their employers often.
Senator Warren. That's exactly what I want to go to. Do you
agree that improving health outcomes in this country and
addressing these disturbing trends that we're talking about is
going to take economic policies as well as public health
policies?
Dr. Adams. I think it's going to take economic policies,
both in the private and the public sector, and I think that as
public health advocates, we need to do a better job of helping
corporations and businesses understand that connectivity so
that they invest in their communities and their employees up
front instead of paying on the back end for workplace
accidents, for higher healthcare costs, for retraining people
when they've got to fire the person who doesn't show up for
work, or they just don't come back anymore.
Senator Warren. Good. Well, I really appreciate your
comments on this. These are very serious problems, literally
life and death, and we're not going to solve them with any one
hearing or any one policy. But we need to underline that a
person's chances of growing up healthy or staying healthy or
getting help when they need it should not depend on their zip
code, and help should not be reserved for the wealthy few and
the well connected. It means we have to be willing to fight for
fair economic policies and an effective safety net as well as
good public health programs.
Dr. Adams. That's not just on the Federal level, but it's
got to be on the private and on the state level also to make
sure we have a comprehensive package of policies that put
people in the best position for better health and communities
in the best position for economic prosperity.
Thank you.
Senator Warren. Thank you.
The Chairman. Thank you, Senator Warren.
Senator Whitehouse.
Senator Whitehouse. Thank you, Mr. Chairman.
Welcome, Dr. Adams.
Dr. Adams. Good to see you again.
Senator Whitehouse. Good to see you again. First of all,
thank you for mentioning CVS in your testimony. CVS is
headquartered in Woonsocket, Rhode Island, and we're very proud
of that company, and we're particularly proud of that company's
decision to take cigarettes out of its stores, all of its
stores, and indeed, they quit the United States Chamber of
Commerce when it was discovered that the United States Chamber
of Commerce was attacking tobacco regulations around the world.
They have really dialed in on the health concerns about
tobacco, and I think your recognition of that is a very nice
thing for them and for Rhode Island. I appreciate that.
Dr. Adams. Even though they took an initial hit, they
actually are more profitable because they made a healthy
decision. I think that's important for folks to understand.
This wasn't just something that benefited the health of folks
and it wasn't just a philanthropic endeavor. It was something
that actually made economic sense for them to do in the long
run, and that's what we want folks to understand and why the
CVS story is so powerful.
Senator Whitehouse. You also mentioned the discrepancy
between the amount we pay for healthcare in this country and
the outcomes that we get. You mentioned life expectancy, but
there are plenty of metrics. I always have in my mind the graph
of the OECD countries that shows the chart of them measured by
life expectancy and by per capita cost, and America is like way
out here, highest per capita cost by a ton over all of our
competitors, and yet for all that extra money we're not getting
gains. We're below the midpoint of the pack, as I recall, lined
up with Croatia and Greece for life expectancy.
What's interesting to me about that is that it suggests
that there's real opportunity for good bipartisan work to be
done here in this Committee to try to cure that problem, and,
instead, we seem to be in this relentless groundhog day horror
fight trying to undo healthcare for Americans, and to hell with
the collateral damage in individual Americans' lives, and it's
frustrating because I think we could be much more productive
than this endless repeal and replace zombie that keeps coming
out of the grave to no good that anybody can identify other
than the political good, I guess, of putting the Affordable
Care Act up as a sort of political trophy for the big
Republican donors. The whole thing is very frustrating.
But I want to focus on one particular area, because you
spoke with a lot of passion about this when you and I met in my
office, and that is the area when people are getting to the end
of their life, when they have very advanced illnesses. As you
know, there's a group called CTAC, the Coalition of Transformed
Advanced Care, that is engaged with a lot of the business
community, big business community leaders, to try to provide a
better way of managing that time.
In Rhode Island, we've done a lot of work that I told you
about to try to take better care of people who are in that
period of their lives. Very often, what we see, tragically, is
that somebody who wants to be treated a certain way doesn't get
that choice honored, partly because we haven't actually
documented what their choice should be well enough and partly
because the healthcare machinery just grabs them and grinds
them along, and by the time you've been able to intervene, it's
too late and they've had procedures they didn't want, and
they've been in the ICU when they didn't want to be, and they
weren't at home where they did want to be, and all of those
things have gone wrong.
In many respects, I think, the way we pay drives the care
we get, and I encourage you to continue looking at ways that
you can be an advocate for people suffering advanced illness in
their last months of life who, I think, are very often
casualties of our healthcare system because their voices simply
aren't heard. I'd renew my invitation to you to come up to
Rhode Island and let me show you what we're doing. You said you
were interested in doing that when we met, and I renew the
invitation today. If you could respond to that point.
Dr. Adams. Absolutely, sir. I'm looking forward to coming
up there. I've been in touch with your health commissioner
constantly.
By focusing on end of life care, we will be able to save
tremendous dollars in terms of healthcare costs. But I'm going
to show you an amazing display of message discipline. I'm going
to show you how that fits into wellness. Folks who are
healthier, who live a lifestyle of wellness, are going to not
only live longer, but they're going to live healthier, they're
going to have less healthcare cost, and they're not going to
spend that much money on end of life care.
But as you mentioned, just as importantly, part of wellness
is having a plan for how you want to die. If it's going in and
talking to your primary care physician about what you want and
making sure it's documented in a way that folks understand and
that can be communicated when the time actually comes. Even
this, when you move upstream, comes back to focusing on
wellness and making sure we're concentrating on that as a
community instead of waiting until someone gets that terminal
illness and then trying to sort it all out on the back end
financially and philosophically.
Senator Whitehouse. My time has expired. Thank you, Mr.
Chairman.
The Chairman. Thank you, Senator Whitehouse.
Senator Kaine.
Senator Kaine. Thank you, Mr. Chair, and thank you, Dr.
Adams.
Dr. Adams, Indiana, under the Affordable Care Act, chose to
expand--to embrace the Medicaid expansion designed in its own
way. Isn't that correct?
Dr. Adams. We got a waiver to actually accept the Medicaid
expansion funding through the ACA to expand our Healthy Indiana
plan.
Senator Kaine. Has the uninsured rate in Indiana come down
fairly significantly because of that and also because of
Obamacare subsidies that Indianans have been able to avail
themselves of?
Dr. Adams. We've been able to increase access to over
400,000 people, and it's important to understand that the
Healthy Indiana plan was also a partnership between the public
and the private entities, which is why I keep saying
partnerships are so critically important----
Senator Kaine. Do you know, sitting here, what the
reduction in the uninsured rate was, like pre-Affordable Care
Act, and post-Affordable Care Act, when you include both the
Obamacare subsidies to Indianans and the expansion of Medicaid
that Indiana did?
Dr. Adams. I can get you those specific numbers.
I know I worked at a county hospital, and our uninsured
rate went down significantly, and again, 400,000 is the number
of folks who we've been able to increase access to coverage to.
Senator Kaine. In your opinion, is Indiana a healthier
community? The title of this hearing is Investing in Healthy
Communities. Is Indiana a healthier community because fewer
people are uninsured today?
Dr. Adams. Indiana is a healthier community because we were
given the flexibility to be able to design our own state
program and actually implement it in a----
Senator Kaine. Which many states have done under the
Affordable Care Act. Correct?
Dr. Adams. Yes, sir.
Senator Kaine. You do believe that Indiana is a healthier
community today as a result of both the Medicaid expansion that
you designed and other aspects of the Affordable Care Act?
Dr. Adams. I believe we're a healthier community today,
sir.
Senator Kaine. Would you say, generally, for purposes of
the report that you're doing, looking at what makes a healthier
community, that, all things being equal, as a general matter,
the lower percentage of people who are uninsured, the healthier
the community is?
Dr. Adams. Yes, I would agree with that.
Senator Kaine. You might find an exception here or there.
But as a general matter, reducing the uninsured rate would be
one sign of a community that is likely to be a healthier
community.
Dr. Adams. I would agree with that, sir.
Senator Kaine. There's surveys every year that get put out
by groups like United Health Association that rank the
healthiest and least healthy states in the United States. In
the most recent version that I've seen, the 10 healthiest
states in the United States all have done the Medicaid
expansion, and of the 10 least healthy states in the United
States, only four have done the Medicaid expansion, and I think
that's additional evidence of the proposition that you're
testifying to today.
I'll just add my own concern about what's happening in the
Finance Committee now. If, as you testify and as the statistics
would seem to suggest, one evidence of being healthier is
reducing the percentage of uninsured, why would we want in a
tax bill to do something that would increase the number of
uninsured? It suggests that tax is more important than people's
health. A tax break to some at the top is more important than
people's health.
It's kind of a left hand-right hand problem. We're here in
the HELP Committee trying to do things that improve people's
health, and you're testifying about healthy communities with
some great testimony, and it would seem from the statistics and
Indiana's own experience that if you reduce the uninsured rate,
you're going to have healthier communities. That's the purpose
of the hearing. But in the Finance Committee today, there's
going to be an action taken that would reduce the number of
people in this country by potentially 13 million who have
health insurance. I just don't get it.
Let me ask you this, switching gears. We had a hearing
about 2 weeks ago, and we had a number of witnesses, including
Francis Collins from NIH, a really great leader, a Virginian--
I'm a little proud of him for that reason--and I asked him this
question, and I would be curious as to your answer about this
question.
If we were to set a goal as a Nation, like a big goal, and
say we want to be addiction free by 2030, is the state of our
knowledge about addiction, is the state of our treatments and
technology such that we could make that kind of a bold
statement, like John F. Kennedy said we're going to be on the
moon at the end of the decade? Could we make that kind of a
bold commitment if we really put our minds to it? Do you, as
Surgeon General of the United States, think we can meet that
goal?
Dr. Adams. I wouldn't only say that we can. I would say
that we must. We never would have gotten to the moon, even
though folks didn't believe it was possible, unless JFK
declared that we were going to do so. We are not going to solve
this crisis unless we are definitive that it's an absolutely
must that we achieve that goal, and I'm confident that we can
if we work toward better partnerships.
If I may, to your point earlier, I don't want to debate
your point. It's clear that higher insurance rates correlate
with healthier communities.
Senator Kaine. Higher percentages of people with insurance.
Dr. Adams. Yes. But there is primary, secondary, and
tertiary prevention, and you're talking about tertiary
prevention. As a public health advocate, I would be remiss if I
did not say that we can focus all we want on healthcare, but as
long as we're over-consuming it because of a lack of wellness,
we aren't going to solve the problem.
The states that you mentioned that are in the top 10 and
the states that you mentioned that are in the bottom 10--they
were in the top 10 and the bottom 10 before the Affordable Care
Act. Why? Because they are states who invested in wellness and
health and had their communities--Senator Franken and I talked
a lot about Minnesota before you came, doing a great job there
of engaging the corporations and the businesses in health, and
Minnesota has been in that top in terms of health outcomes. I
think it's important that we always remember we need to focus
on wellness and that healthcare and health insurance coverage
is one part of the equation, but it's not going to solve the
problem if we don't focus upstream and keep----
Senator Kaine. But you would agree with me, though, that
the percentage of people with health coverage is a pretty
important component of the health of a community.
Dr. Adams. I would agree with you that the science shows
that in communities that have higher rates of coverage, they
tend to be healthier than ones that don't.
Senator Kaine. Right. Thank you very much.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Kaine.
Senator Franken.
Senator Franken. Yes, I definitely agree with that, and in
Minnesota, we have--we cut in half the numbers that were
uninsured. I'm glad that you brought up the National Diabetes
Prevention Program in your testimony or at some point earlier.
I'm sorry----
Dr. Adams. I was giving you shout-outs left and right,
Senator.
Senator Franken. That's what I understand, including
mentioning that I didn't show on you again. Let me explain. I
really wanted to be at your confirmation hearing. The day of
that confirmation hearing, I was at Arlington Cemetery speaking
at--I spoke at the funeral of Captain Luis Montalvan, who was
an inspiration to me on--he had a dog, a service dog, and we
can talk about the service dog program at some point. But I'm
really sorry I wasn't able to be there, but I was doing
something else.
Dr. Adams. No, thank you for that. One of the honors of my
life was marching in the New York City Veterans Day parade this
past weekend. It's extremely important that we honor our
veterans for their service, and thank you for that.
Senator Franken. He was a friend of mine.
I do want to mention this, in the finance bill, this idea
of taking away the mandate. We know what the results of that
would be, and it would be antithetical to what you're talking
about. The more people insured, the healthier we are. We know
that. We saw a survey study in JAMA about the benefits of
more--that we've had because of the Affordable Care Act and
more people insured.
To me--and another thing that that does, which is inserting
that into a tax bill, I think is just--it's not helpful. It
poisons the well on cooperation on healthcare and the wonderful
compromise that the Chairman and the Ranking Member came up
with. I just would hope that the--we've been shut out of so
many things, and it hasn't--there hasn't been a good result
because of that. The best results, to me, are when we do things
in a bipartisan way, which the Chairman does.
But I want to move on to something that we do in Minnesota.
You highlight that in the U.S., we spend more on healthcare
than any other country, around $3.2 trillion each year, and in
many cases twice the amount that other countries that cover
everybody, and yet there's so much more that needs to be done
to improve our outcomes. It's estimated that 50 percent of
costs are used by just 5 percent of the population, and
according to a piece in the Journal of the American Medical
Association, an overwhelming portion of these top healthcare
users are poor and housing insecure.
Recognizing the connection between housing and health, some
healthcare organizations have begun working to address housing
needs in order to improve the overall health of their patients.
In Minnesota, Hennepin Health, an accountable care organization
in the Twin Cities, developed a program that paired healthcare,
housing, and social services. Just 1 year after participants in
the program were placed in supportive housing, Hennepin Health
saw significant reductions in emergency room visits,
hospitalizations, and psychiatric care.
A study on a similar program in Los Angeles found that
government spending was 79 percent lower for people in
supportive housing than for people who were homeless.
Vice Admiral Adams, what will you do to encourage
healthcare providers and other stakeholders to work together to
deliver healthcare interventions that are paired with housing
and other social supports?
Dr. Adams. Senator, thank you so much for that question. I
have been in touch with Secretary Carson. I think we have a
tremendous opportunity having a physician as head of HUD, and
he and I both firmly believe housing is health. We know one of
the No. 1 predictors of whether or not you're going to be
successful in recovering from addiction is whether or not
you've got permanent supportive housing to go back into.
We know that you're not going to take your diabetes
medication or your hypertension medications or get your
screenings if you're worried about where you're going to sleep
that night. Housing is absolutely health, and I think that the
folks who represent the housing community need to be at the
table when we're discussing how we build a healthier community.
With a bit of your indulgence, Senator Alexander, I would
be remiss if I did not say that I detected an insinuation from
several folks that the current administration is against
coverage for folks. I do agree that there is a direct link
between the health of a community and the number of people who
are insured. The administration is not against people being
insured. We have a different mindset about how we can achieve
that.
I can tell you that in Indiana, folks did not believe we
would be able to increase coverage to people through our
Healthy Indiana plan. Folks didn't believe it. We were able to
expand coverage to over 400,000 people. This administration is
not anti-coverage. It's about giving states the flexibility to
decide how that coverage is going to be delivered, and I think
that's an important distinction without going too far down that
rabbit hole, because, again----
The Chairman. We need to wrap up, Dr. Adams.
Senator Franken. Can I just respond to that in one little
way?
The Chairman. Yes.
Senator Franken. In Indiana, you took Medicaid expansion,
didn't you?
Dr. Adams. Sir, we got a waiver to actually expand our
Healthy Indiana plan utilizing funds that were made available
through the Affordable Care Act by a waiver.
Senator Franken. Exactly. I mean, funds were made available
through the Affordable Care Act. You got a waiver, which was
part of the structure of the Affordable Care Act. When--you
can't have it both ways.
Dr. Adams. But the administration's plans for healthcare
reform that have been put out here so far--each of them--and I
know because I'm in touch with the Governor of Indiana--would
still allow us to continue our Healthy Indiana----
The Chairman. We're well over time, and I have to go to a
markup with----
Senator Franken. I know, but every plan offered by the
administration and by the Republicans--CBO has scored every one
of them for, in many cases, tens of millions of Americans--
fewer having insurance, and you know that. You have to know
that.
Dr. Adams. I know we need to focus on wellness, and I look
forward to working with all of you all to focus on wellness
because----
Senator Franken. That was not responsive to what I just
asked you.
The Chairman. Okay. Thank you, Senator Franken.
Dr. Adams, thank you for being here for the hearing and for
your suggestions and for your service to our country.
Senator Murray, do you have other things you'd like to say?
Senator Murray. Well, Mr. Chairman, I do want to just say
that if you don't have access to insurance because the
insurance market has collapsed, that's no healthcare coverage
for a lot of people. That is why we are deeply concerned on
this side.
But, Dr. Adams, I do want to thank you for your hearing
testimony today. We want to work with you on healthy outcomes,
lower healthcare costs for families. We are concerned about and
deeply opposed to the proposal because it will increase costs,
and when it increases costs, then people don't have access. I'm
very deeply concerned about this administration's long-time
activity to actively undermine the healthcare of our
communities, and we will continue to focus on that.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Murray.
The hearing record will remain open for 10 days. Members
may submit additional information for the record within that
time if they would like.
Thank you for being here. The Committee will stand
adjourned.
[Whereupon, at 11:27 a.m., the hearing was adjourned.]
[all]