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MAKING HEALTH CARE WORK FOR AMERICAN 

FAMILIES: THE ROLE OF PUBLIC HEALTH 

HEARING 

BEFORE THE

SUBCOMMITTEE ON HEALTH 

OF THE

COMMITTEE ON ENERGY AND 

COMMERCE 

HOUSE OF REPRESENTATIVES 

ONE HUNDRED ELEVENTH CONGRESS 

FIRST SESSION 

MARCH 31, 2009 

Serial No. 111–24 

( 

Printed for the use of the Committee on Energy and Commerce 

energycommerce.house.gov 


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COMMITTEE ON ENERGY AND COMMERCE 

HENRY A. WAXMAN, California, Chairman 

JOHN D. DINGELL, Michigan 

Chairman Emeritus 

EDWARD J. MARKEY, Massachusetts 

RICK BOUCHER, Virginia 

FRANK PALLONE, JR., New Jersey 

BART GORDON, Tennessee 

BOBBY L. RUSH, Illinois 

ANNA G. ESHOO, California 

BART STUPAK, Michigan 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

Vice Chairman 

LOIS CAPPS, California 

MICHAEL F. DOYLE, Pennsylvania 

JANE HARMAN, California 

TOM ALLEN, Maine 

JAN SCHAKOWSKY, Illinois 

HILDA L. SOLIS, California 

CHARLES A. GONZALEZ, Texas 

JAY INSLEE, Washington 

TAMMY BALDWIN, Wisconsin 

MIKE ROSS, Arkansas 

ANTHONY D. WEINER, New York 

JIM MATHESON, Utah 

G.K. BUTTERFIELD, North Carolina 

CHARLIE MELANCON, Louisiana 

JOHN BARROW, Georgia 

BARON P. HILL, Indiana 

DORIS O. MATSUI, California 

DONNA M. CHRISTENSEN, Virgin Islands 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

CHRISTOPHER MURPHY, Connecticut 

ZACHARY T. SPACE, Ohio 

JERRY MCNERNEY, California 

BETTY SUTTON, Ohio 

BRUCE L. BRALEY, Iowa 

PETER WELCH, Vermont 

JOE BARTON, Texas 

Ranking Member 

RALPH M. HALL, Texas 

FRED UPTON, Michigan 

CLIFF STEARNS, Florida 

NATHAN DEAL, Georgia 

ED WHITFIELD, Kentucky 

JOHN SHIMKUS, Illinois 

JOHN B. SHADEGG, Arizona 

ROY BLUNT, Missouri 

STEVE BUYER, Indiana 

GEORGE RADANOVICH, California 

JOSEPH R. PITTS, Pennsylvania 

MARY BONO MACK, California 

GREG WALDEN, Oregon 

LEE TERRY, Nebraska 

MIKE ROGERS, Michigan 

SUE WILKINS MYRICK, North Carolina 

JOHN SULLIVAN, Oklahoma 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 

MARSHA BLACKBURN, Tennessee 

PHIL GINGREY, Georgia 

STEVE SCALISE, Louisiana 

PARKER GRIFFITH, Alabama 

ROBERT E. LATTA, Ohio 

(II) 


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(III) 

SUBCOMMITTEE ON HEALTH

FRANK PALLONE, JR., New Jersey, Chairman 

JOHN D. DINGELL, Michigan 

BART GORDON, Tennessee 

ANNA G. ESHOO, California 

ELIOT L. ENGEL, New York 

GENE GREEN, Texas 

DIANA DEGETTE, Colorado 

LOIS CAPPS, California 

JAN SCHAKOWSKY, Illinois 

TAMMY BALDWIN, Wisconsin 

MIKE ROSS, Arkansas 

ANTHONY D. WEINER, New York 

JIM MATHESON, Utah 

JANE HARMAN, California 

CHARLES A. GONZALEZ, Texas 

JOHN BARROW, Georgia 

DONNA M. CHRISTENSEN, Virgin Islands 

KATHY CASTOR, Florida 

JOHN P. SARBANES, Maryland 

CHRISTOPHER S. MURPHY, Connecticut 

ZACHARY T. SPACE, Ohio 

BETTY SUTTON, Ohio 

BRUCE L. BRALEY, Iowa 

NATHAN DEAL, Georgia, 

Ranking Member 

RALPH M. HALL, Texas 

BARBARA CUBIN, Wyoming 

HEATHER WILSON, New Mexico 

JOHN B. SHADEGG, Arizona 

STEVE BUYER, Indiana 

JOSEPH R. PITTS, Pennsylvania 

MARY BONO MACK, California 

MIKE FERGUSON, New Jersey 

MIKE ROGERS, Michigan 

SUE WILKINS MYRICK, North Carolina 

JOHN SULLIVAN, Oklahoma 

TIM MURPHY, Pennsylvania 

MICHAEL C. BURGESS, Texas 


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C O N T E N T S 

Page 

Hon. Frank Pallone, Jr., a Representative in Congress from the State of 

New Jersey, opening statement .......................................................................... 1 

Hon. Nathan Deal, a Representative in Congress from the State of Georgia, 

opening statement ................................................................................................ 2 

Hon. Henry A. Waxman, a Representative in Congress from the State of 

California, opening statement ............................................................................. 4 

Prepared statement .......................................................................................... 5 

Hon. Joseph R. Pitts, a Representative in Congress from the Commonwealth 

of Pennsylvania, opening statement ................................................................... 9 

Hon. Gene Green, a Representative in Congress from the State of Texas, 

opening statement ................................................................................................ 9 

Hon. Anna G. Eshoo, a Representative in Congress from the State of California, opening statement .................................................................................... 13 

Hon. Janice D. Schakowsky, a Representative in Congress from the State 

of Illinois, opening statement .............................................................................. 15 

Hon. Michael C. Burgess, a Representative in Congress from the State of 

Texas, opening statement .................................................................................... 15 

Prepared statement .......................................................................................... 160 

WITNESSES

Richard E. Besser, M.D., Acting Director, CDC, Acting Administrator, Agency 

for Toxic Substances and Disease Registry ........................................................ 16 

Prepared statement .......................................................................................... 19 

Answers to submitted questions ...................................................................... 167 

Jonathan E. Fielding, M.D., M.P.H., Chair, Task Force on Community Preventive Services, Director and Health Officer, L.A. County Department 

of Public Health .................................................................................................... 33 

Prepared statement .......................................................................................... 36 

Heather Howard, J.D., Commissioner, New Jersey Department of Health 

and Senior Services .............................................................................................. 89 

Prepared statement .......................................................................................... 93 

David Satcher, M.D., Ph.D., Former U.S. Surgeon General, Director, Satcher 

Health Leadership Institute, Morehouse School of Medicine ........................... 99 

Prepared statement .......................................................................................... 101 

Barbara Spivak, M.D., President, Mount Auburn Cambridge Independent 

Physicians Association, Inc ................................................................................. 114 

Prepared statement .......................................................................................... 116 

Devon Herrick, Ph.D., Senior Fellow, National Center for Policy Analysis ....... 124 

Prepared statement .......................................................................................... 126 

Jeffrey Levi, Ph.D., Executive Director, Trust for America’s Health .................. 139 

Prepared statement .......................................................................................... 141 

SUBMITTED MATERIAL

Statement of the Human Rights Campaign, submitted by Ms. Baldwin ............ 162 


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(1) 

MAKING HEALTH CARE WORK FOR AMERICAN FAMILIES: THE ROLE OF PUBLIC 

HEALTH 

TUESDAY, MARCH 31, 2009 

HOUSE OF REPRESENTATIVES, 

SUBCOMMITTEE ON HEALTH, 

COMMITTEE ON ENERGY AND COMMERCE, 

Washington, DC. 

The subcommittee met, pursuant to call, at 10:06 a.m., in Room 

2232 of the Rayburn House Office Building, Hon. Frank Pallone, 

Jr. (chairman) presiding. 

Members present: Representatives Pallone, Dingell, Eshoo, 

Engel, Green, DeGette, Capps, Schakowsky, Baldwin, Matheson, 

Harman, Gonzalez, Barrow, Christensen, Castor, Sarbanes, Murphy of Connecticut, Waxman (ex officio), Deal, Whitfield, Shimkus, 

Pitts, Burgess, Blackburn, Gingrey, and Barton (ex officio). 

Staff present: Andy Schneider, Chief Health Counsel; Sarah 

Despres, Counsel; Tim Westmoreland, Consulting Counsel; Naomi 

Seiler, Counsel; Anne Morris, Legislative Analyst; Virgil Miller, 

Legislative Assistant; Jon Donenberg, Fellow; Camille Sealy, Fellow; Alvin Banks, Special Assistant; Alli Corr, Special Assistant; 

Miriam Edelman, Special Assistant; Lindsay Vidal, Staff Assistant; 

Aarti Shah, Minority Counsel; Ryan Long, Minority Chief Health 

Counsel; and Chad Grant, Minority Legislative Analyst. 

OPENING STATEMENT OF HON. FRANK PALLONE, JR., A REPRESENTATIVE IN CONGRESS FROM THE STATE OF NEW JERSEY 

Mr. PALLONE. The hearing of the subcommittee is called to order. 

Today the subcommittee is meeting for the fourth hearing in the 

Making Health Care Work for American Families series. To date, 

we have heard about the failings of our current health care system, 

the need to increase access to care and improve our primary care 

work force, and the mechanisms that can make health care coverage affordable for all. In today’s hearing, however, we are going 

to explore a less often discussed, yet extremely vital aspect of 

health reform and that is public health. 

Health reform isn’t just about improving coverage and access. It 

is also about making our Nation healthier. We spend more than 

any other country on health care and still we have higher morbidity and mortality rates than any other industrialized Nation. 

More than half of our population suffers from at least one chronic 

condition, which not only increases our health care cost but also 


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lowers our productivity, and this is simply not sustainable especially in these difficult economic times. What is frustrating is that 

these diseases for the most part are preventable. Too many people 

are dying of illnesses such as cardiovascular disease, respiratory 

diseases, and diabetes-related illnesses, and if the current obesity 

epidemic continues on the path it is on now, we will see even further increases in many of these diseases. 

In my home State of New Jersey, 14 percent of our children are 

clinically overweight and this epidemic is obvious nationwide. A report conducted by the Trust for America’s Health in 2008 highlighted all potential problems these children will have to face during the course of their lifetime. Childhood obesity can lead to a 

myriad of health problems, including high blood pressure, Type II 

diabetes, joint problems, and depression, just to name a few. And 

this epidemic alone has the potential to cripple our health care system if we do not take measures to address it. Providing all Americans with health care coverage and improving access to care will 

address some of these issues. However, bolstering the public health 

system will be the vital component to making health care reform 

sustainable and to improving health outcomes. 

We must start investing in the prevention of these horrible diseases rather than just focusing on those who are already sick. This 

shift in our resource allocation could potentially save the system 

billions of dollars per year, not to mention the benefits to patients. 

Public health really means improving the quality of life for individual people, communities, and our society as a whole. Many of 

the federal, state, and local public health initiatives have already 

had huge impacts on out society’s health. Diseases that once were 

life threatening are now all by extinct thanks to vaccination efforts, 

for example. 

Smoke-free environments have already had an impact on the 

rate of smoke-related illnesses, and the community-based prevention initiatives supported by the Centers for Disease Control have 

already shown great results and increasing healthy lifestyle awareness and adherence. It is our responsibility in Congress to ensure 

that they have the resources they need to continue and expand the 

work that they are doing. In short, if I could sum up, public health 

ensures that individuals in communities are able to lead healthier 

lives. We will hear from witnesses today who have dedicated their 

lives to this noble goal, and I want to welcome all of them. I know 

we have two panels today. I want to thank everyone for coming. 

I especially wanted to mention our New Jersey Department of 

Health and Human Services Commissioner Heather Howard. She 

has worked on the Hill previously with then Senator Corzine, now 

Governor Corzine. It is wonderful to see you again, Heather, and 

all that you do, and I am looking forward to your testimony and 

that of all the others today. And I will start now by recognizing Mr. 

Deal for an opening statement. 

OPENING STATEMENT OF HON. NATHAN DEAL, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF GEORGIA 

Mr. DEAL. Thank you, Mr. Chairman. I too want to welcome both 

panels to our discussion here today, especially to thank Dr. Besser 

for being here and to congratulate him on his acting role as acting 


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director of the CDC, a facility which all of Georgians and all of the 

people of this country, I think, can be very proud of. Thank you for 

being here. And, also, Dr. David Satcher, who is here representing 

the Morehouse School of Medicine, another facility in my great 

State of Georgia that we are very proud of, and thank him for the 

continuing contribution that they make to the delivery of health 

care in our Nation. 

Today we will focus on the role of public health and disease prevention which are critical components of our Nation’s health care 

delivery system. From specialized research on infectious diseases, 

wellness, and prevention that is taking place at the CDE community outreach programs which promote health conscious behaviors, 

the role of the CDC in fulfilling the needs of the public is indeed 

substantial. As we move forward with health care reform this year, 

we must ensure that we continue to support those programs and 

activities which have proven to be successful. They provide a critical role, and we must ensure public health efforts are provided 

with the tools that they need to do the job well. In conjunction with 

these efforts, an equally important objective must be to incorporate 

incentives for individuals to make responsible choices about his or 

her health and thus adding value to prevention efforts in an avoidance of costly medical care in the future. 

The best way to ensure patients take proactive steps to improving their health, I think, is by taking their prescription medications 

as directed, by engaging in regular physical activity and by maintaining a healthy diet just to name a few. And it is well-placed incentives such as this that reward positive behavior and give individuals the opportunity to share in the savings generated by their 

prevention-minded efforts. The impact of establishing value-based 

incentives in the health care arena would take a significant positive step forward in maintaining healthy lives, not merely treating 

the sick once a condition presents itself. 

Another key component is coordination of patient care. All too 

often we hear of health care dollars being wasted by duplicative 

testing and unnecessary referrals, which are all a result of our silo 

system of health care delivery. Fortunately, with the incorporation 

of health information technology and patient electronic medical 

records and improved coordination among providers access to necessary information to administer the best care is vastly improved. 

Prevention efforts can be coordinated through the use of this technology. Home care can be assessed and patients can receive a continuum of care which our current system fails to support many 

times. 

Furthermore, as we continue to debate health care reform in the 

coming months, I hope we maintain focus on one of the most fundamental components of a well-performing health care delivery system, personal responsibility, giving patients and providers the freedom and responsibility to manage their care, not bureaucrats in 

Washington. It is critical to making improvements in our Nation’s 

health care delivery system. Again, Mr. Pallone, I thank you for 

holding the hearing today, and thank all of our witnesses and look 

forward to your testimony. I yield back. 

Mr. PALLONE. Thank you, Mr. Deal. Next is Chairman Waxman. 


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OPENING STATEMENT OF HON. HENRY A. WAXMAN, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA 

Mr. WAXMAN. Thank you very much, Mr. Chairman. Over the 

past month, we have had several hearings on health insurance and 

how to get it to all Americans, but as valuable as it is health insurance can’t do everything necessary to make our Nation healthy. 

Even if we make it possible for everyone to be insured, there will 

still be a major role for public health. Moreover, there will be an 

ongoing need for funding for these public health activities. I should 

begin by clarifying some basics. Public health includes many different things. It is working with groups and whole communities to 

improve health often more effectively than can be done between a 

provider and a patient. 

Fluoridation of water for a town is, for instance, vastly better 

than simply filling every citizen’s cavities. Exercise programs to 

prevent obesity are better than having to treat diabetes among people who become obese. It is tailoring health insurance and health 

care to prevent and diagnose disease early rather than simply 

treating it in its later stages. Immunization is always better than 

outbreaks. Screening for hypertension is better than simply waiting 

for strokes. It is providing for safety net services where the insurance market alone fails to do so. Community health centers, HIV 

service providers, and family planning clinics provide care to people 

who might not otherwise be able to find a provider. 

Health profession’s education programs can add to the primary 

care work force when the market might produce only specialists. 

And least glamorous, but critical, it is the infrastructure of daily 

disease control and health promotion. Closing down on sanitary 

restaurants is better than treating food poisoning. Compiling and 

studying epidemic trends can prevent major waves of disease. Public health is all of these things and more. It might be clear if I use 

an analogy. No community would be well served if all of its homeowners had fire insurance but there were no fire departments, firefighters, fire hydrants, or smoke detectors. That very well-insured 

town would still burn to the ground. Insurance is necessary but it 

is not sufficient. 

As we approach health reform, we must consider what aspects of 

the Nation’s health are based on public health and make these investments at the same time as we invest in coverage. We need to 

provide as firm a funding and organizational base for these services 

as we do for insurance because they are essential in making insurance efficient and productive and in making the Nation healthier. 

We will continue to debate insurance plans, Medicare Advantage 

health savings account and acute care on other days, but today’s 

hearing is about these public health activities that we seldom think 

about and we even more rarely provide for. I hope health reform 

will make us change that. Thank you very much, Mr. Chairman. 

[The prepared statement of Mr. Waxman follows:] 


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Mr. PALLONE. Thank you, Chairman Waxman. The gentleman 

from Pennsylvania, Mr. Pitts. 

OPENING STATEMENT OF HON. JOSEPH R. PITTS, A REPRESENTATIVE IN CONGRESS FROM THE COMMONWEALTH 

OF PENNSYLVANIA 

Mr. PITTS. Thank you, Mr. Chairman. I would like to thank you 

for convening this hearing. Within the larger context of health care 

reform, I think it is important for us to focus on two areas, chronic 

illnesses, which account for a major portion of health care expenditures, and prevention and wellness activities. There is a place for 

government programs and community services but if we are truly 

serious about reining in health care cost and transforming how we 

deliver health care in this country, I believe that we must focus on 

personal responsibility for lifestyle and health choices. We should 

empower citizens to change their behavior and incentivize responsible choices. There are great successes in the private sector such 

as the grocery chain, Safeway, which has cut its health care cost 

by covering all preventive care services appropriate for a patient’s 

age group. 

It offers other benefits such as a 24-hour hot line staffed by registered nurses, services to help people manage chronic conditions, 

and incentives designed to promote healthier lifestyles. Where 

there are barriers to small group plans offering incentives such as 

these, we should re-evaluate current law and make necessary 

changes. Also, patients must be more involved in their own care 

and treatment. Health savings accounts can play a key role in active patient participation. We know that when people’s own money 

is on the line they make wiser decisions. Mr. Chairman, I look forward to hearing the thoughts and testimony of our witnesses today, 

and I thank you and yield back my time. 

Mr. PALLONE. Thank you. The gentleman from Texas, Mr. Green. 

OPENING STATEMENT OF HON. GENE GREEN, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF TEXAS 

Mr. GREEN. Thank you, Mr. Chairman, for holding this fourth 

hearing today on the health care reform and the role of public 

health. Disease prevention and good health promotion are important community issues we all support. Sadly, Congress has allowed 

the funding for disease prevention and community health programs 

to fall flat over the years, and we have not made much of an investment in prevention and wellness programs or disease prevention programs. The lack of funding for prevention and wellness and 

disease prevention programs is especially troubling in districts like 

mine where you rely on community-based prevention programs because of our population. 

The Houston area is an international city and state where we 

have some of the highest rates of tuberculosis in the Nation and 

need a very strong disease prevention program. Houston has the 

third largest Hispanic population in the country, and I represent 

an area that is 65 percent Hispanic in a medically underserved district. Unfortunately, most minority populations have higher rates 

of disease like diabetes, cervical cancer, HIV AIDS, and heart disease in our community. In fact, Mexican Americans are twice as 


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likely as Anglos to be diagnosed with diabetes. These diseases are 

mostly preventable but lack of access to care is still a barrier to the 

minority communities, and part of that probable cause to the many 

health problems for the Hispanic community as a whole. We rely 

on programs at the YMCA for our children who participate in 

sports to help reduce our obesity levels in children. We also rely on 

partnerships in our community health centers in the hospital district to monitor and help treat diabetes in our population. 

These programs are crucial in reducing our high diabetes and 

obesity rates. I am particularly pleased the American Recovery and 

Reinvestment Act included funding for prevention and wellness 

programs. These programs are key to reducing rates of chronic diseases in our communities. I would hope any health reform package 

we work on in this committee will take into account the importance 

of prevention, wellness, and data monitoring in disease prevention. 

Thank you, Mr. Chairman. I yield back my time. 

Mr. PALLONE. Thank you, Mr. Green. The gentleman from Georgia, Mr. Gingrey. 

Mr. GINGREY. Mr. Chairman, I am going to waive my opening 

statement. 

Mr. PALLONE. The gentleman from Kentucky, Mr. Whitfield. 

Mr. WHITFIELD. Mr. Chairman, thank you very much for holding 

this hearing, and we look forward to the testimony of the witnesses 

today. I would just point out that it is my understanding that less 

than 3 percent of all money spent by the federal government in 

health care is used for public health activities. And I know that in 

Kentucky for every 6 people admitted to the hospital in Kentucky 

last year one of them was admitted because of diabetes, so this 

whole issue of prevention has to be a vital part in our reform, and 

I look forward to working with the committee in addressing that 

issue. Thank you. 

Mr. PALLONE. Thank you. Our subcommittee vice-chair, Mrs. 

Capps. 

Mrs. CAPPS. Thank you, Chairman Pallone. And I am so pleased 

that we are addressing public health needs in our hearing today as 

we endeavor to bring real health reform to Americans. It is in my 

DNA as a public health nurse that an ounce of prevention is worth 

a pound of cure. In my home State of California and throughout 

our country there needs to be a major shift in how we address 

health care. Instead of just talking about treating illnesses, we 

need to talk about preventing it as often as we can and educating 

and promoting healthy behaviors and decision making. We need to 

talk about the role that the public health community will play in 

achieving that goal, so I look forward to our witnesses. I welcome 

our first panel and know that we are going to have a lively discussion today. I yield back. 

Mr. PALLONE. Thank you. The gentlewoman from Tennessee, 

Mrs. Blackburn. 

Mrs. BLACKBURN. Thank you, Mr. Chairman, and welcome to our 

witnesses. We are looking forward to the hearing today. And, Dr. 

Besser, I want to thank you for your testimony and point out one 

thing that I think is so important that we focus on. When you say 

we are not achieving an acceptable return for the investment we 

made on health care despite spending more than any other nation, 


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and I think it does point out the importance of personal responsibility. We have some good pilot projects that have taken place in 

some of our states. Some of them have been successful. Some have 

not, but it does give us some good evaluated data and outcomes 

that we can look at, lessons that should have been learned, and I 

think it also points out how one size does not fit all in health care 

delivery. And I look forward to the testimony and the discussion 

today. Thank you, Mr. Chairman. I yield back. 

Mr. PALLONE. Thank you. The gentleman from Utah, Mr. Matheson. 

Mr. MATHESON. Well, thank you, Mr. Chairman. I concur with 

what our full committee chairman said that while access is an important issue, we also need to look for ways to reform our system 

to make it more efficient and preventive care and the public health 

system clearly create a venue where there are great opportunities 

to make more progress in this regard. If we don’t find a way to 

make our system more effective for all the money we are putting 

into it, we are kidding ourselves. We have to find a way to be more 

efficient, find a better system than we have right now because we 

spend more than anyone in the world. We are not getting the best 

outcomes. And if we increase access for America into the current 

system it drives us off a financial cliff that much more quickly. 

This is a very important hearing today because this panel can 

give us some good ideas about where we can improve on important 

front end investments to have long-term benefit to our country. I 

yield back, Mr. Chairman. 

Mr. PALLONE. Thank you. The gentlewoman from California, Ms. 

Harman. 

Ms. HARMAN. Thank you, Mr. Chairman, and thank you again 

for holding all of these thoughtful hearings. I want to recognize one 

of our witnesses this morning, Dr. Jonathan Fielding, who is the 

director of LA County’s Department of Health, and who is a dear 

and valued advisor to me on health care issues. He oversees one 

of the Nation’s largest public health departments and is charged 

with protecting LA County residents, especially in the realm of 

emergency preparedness, something always on the mind of this 

lawmaker. I just want to focus for 25 seconds on the need for developing surge capacity in our country as we consider health care reform. 

The only level 1 trauma center near LAX and the ports of LA 

and Long Beach, both top terror targets, which could be attacked 

simultaneously, is Harbor UCLA Hospital, a first class teaching 

hospital. Harbor’s emergency room was cited for overcrowding and 

no terror attacks have even been contemplated yet. It has tried to 

address this problem but I worry that we are not ready and that 

should something like this happen in any city in America or near 

simultaneously in many cities in America, we won’t be ready so 

this has to be part of health care reform. Level 1 trauma centers 

will have to take care of huge numbers of victims should we have 

near simultaneous terror attacks. And just as we think about the 

rising waters in Fargo, North Dakota, let us think about the rising 

numbers of people who will need health care and we are not ready. 

Thank you, Mr. Chairman. 


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Mr. PALLONE. Thank you. The gentlewoman from the Virgin Islands, Mrs. Christensen. 

Mrs. CHRISTENSEN. Thank you, Mr. Chairman. Also coming from 

the Homeland Security Committee like Ms. Harman, we have been 

calling for more attention and funding to our public health system 

for the past 6 years, and also the issue is terrorism my interest is 

also in enabling the system to fulfill its responsibility to protect the 

public health every day and particularly in poor communities 

where it is most neglected and deficient. Homeland Security still 

has a role but the President’s vision and determination provides us 

with an opportunity to ensure that the public health system in our 

country is strong and intact everywhere because it will only be as 

strong as its weakest link. As we approach reform strengthening 

public health in its broadest definition and eliminating health disparities must go hand in hand with expending coverage. 

And while prevention and individual care will produce some savings but mostly through a healthier, happier, and more productive 

and competitive populous as we heard at the last hearing it is primarily through community prevention approaches, public health 

approaches, that we will reap the most savings, reduce our Nation’s 

soaring health care costs, and recapture our role of leadership as 

we improve our health standing among the nations of the world. 

So welcome to all of our panelists. Thank you for your leadership, 

and I look forward to the testimony. 

Mr. PALLONE. Thank you. Our chairman emeritus, Mr. Dingell. 

Mr. DINGELL. Thank you. I commend you for this hearing. I ask 

unanimous consent to put my entire statement into the record. 

Mr. PALLONE. Without objection, so ordered. 

Mr. DINGELL. It is an excellent one and it bears considerable attention, I hope everyone will understand. But your holding of this 

hearing is extremely important. There are significant benefits from 

public health investments and that includes investments in prevention. The American Recovery and Reinvestment Act of 2009 allocated a billion dollars for prevention and wellness, and even though 

the Congressional Budget Office has been hesitant on cost savings 

and prevention measures non-partisan studies have shown significant health cost savings from public health spending. According to 

the Trust for America’s Health private insurers and individuals 

could save more than $9 billion annually within 5 years if we 

would just spend $10 per person on public health. 

I would urge, Mr. Chairman, that this hearing be used as a 

mechanism to enlighten the Congressional Budget Office and 

doubters about the need for the kind of prevention and wellness 

concerns that you are showing in having this hearing. With that, 

I yield back the balance of my time. 

Mr. PALLONE. Thank you, Mr. Dingell. Thank you, Chairman 

Dingell. Next is the gentleman from Connecticut, Mr. Murphy. 

Mr. MURPHY of Connecticut. Thank you very much, Mr. Chairman. I join my colleagues in looking forward to the testimony on 

this very important subject. I hope today that we explore a number 

of subjects but at the very least these two. First, as Mr. Pitts has 

pointed out, there are enormous opportunities to look at the private 

sector for the work that they have done in public health. In my district the company, Pitney Bowes, has been a leader in this respect. 


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I hope that we talk about both the opportunities for public health 

within the private context but also the limitations. It works well 

if you are at a large employer but relying on the private sector 

certainly has limitations for those people who work for smaller employers or who have individual insurance. 

Second, I hope that we will be able to explore who is doing it 

right out there and who is doing it wrong. In Connecticut, we have 

done a wonderful job of using public funds to pay for breast cancer 

and cervical cancer screenings. And I think one of the things that 

we need to talk about is how we go out to different either political 

subdivisions or private employers who have done this right, get 

that information disseminated out to others so that we can standardize best preventive practices across this great country. Thank 

you, Mr. Chairman, for the hearing today, and I yield back my 

time. 

Mr. PALLONE. Thank you, Mr. Murphy. The gentlewoman from 

California, Ms. Eshoo. 

OPENING STATEMENT OF HON. ANNA G. ESHOO, A REPRESENTATIVE IN CONGRESS FROM THE STATE OF CALIFORNIA 

Ms. ESHOO. Thank you, Mr. Chairman, for continuing on with a 

series of hearings relative to health care to help shape our thinking 

on I think one of the most long awaited bills by the American people, and that is to reshape our entire health care system. I am very 

pleased that we are focusing on public health. Public health has a 

long arm. It has a long reach. And I think it is one of the areas 

of health care that might be the most taken for granted in the entire system in the country. I came to understand and appreciate 

the role that public health plays before I came to Congress when 

I was in county government on the board of supervisors in San 

Mateo County in California, and whether it was on the prevention 

side for the county or on the side that had to react to say the removal of dangerous things off the shelves or markets, they moved 

very swiftly and in a very limber way to protect the public. 

I have often wondered why we have not progressed over the 

years to strengthen public health. And just as a physician would 

say to a patient, you can’t starve yourself in order to lose weight, 

that is exactly what has happened to the public health system in 

our country. We have not funded it properly for it to go forward 

and do the magnificent work that it is capable of that it already 

has done and the role that we want it to play. So this is more than 

appropriate to have this hearing. I look forward to hearing from 

the very distinguished witnesses that are at the forefront of the 

public health system and our country, and I look forward to a bill 

that is going to strengthen the arm, that long arm that has a great 

reach to the American public to prevent bad things from happening, and when we do that we promote wellness at the same 

time. 

And what I hope we will also look at, Mr. Chairman, in terms 

of policy, and that is that I think in one fell swoop we could do so 

much in terms of obesity if we look at what food stamps will actually buy and pay for. If we continue to allow food stamps to buy 

junk and bad foods in the supermarkets or the small markets in 


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the neighborhoods in the areas where poor people live then it is the 

federal government that really is promoting the worst. We can’t 

just beat our chests about obesity in our country. We should just 

do something policy wise that really overnight could revolutionize 

what poor people ingest and what they buy with the food stamps 

that we provide. So thank you very much. 

Mr. PALLONE. Thank you. The gentleman from Texas, Mr. Gonzalez. 

Mr. GONZALEZ. I waive opening. 

Mr. PALLONE. Thank you. Next is the gentlewoman from Florida, 

Ms. Castor. 

Ms. CASTOR. Thank you, Mr. Chairman. Bolstering our public 

health prevention and wellness initiative simply must be a lynch 

pin of our health care reform effort. Many community based prevention initiatives are working well already. We all have participated or know about them in childhood obesity or smoking cessation or diabetes screening. But I think it will take our renewed 

efforts in this health care reform effort, a modernization, additional 

resources that will ultimately help make Americans healthier. I 

want to thank all of the witnesses. Your testimony is very good. I 

trust that we will incorporate a lot of your recommendations into 

the health care reform effort that Americans are clamoring for. I 

yield back. 

Mr. PALLONE. Thank you. The gentleman from Maryland, Mr. 

Sarbanes. 

Mr. SARBANES. Thank you, Mr. Chairman, for holding the hearing. I am looking forward to the testimony today. Last year in the 

Ed and Labor Committee we had a hearing on the pension system 

in America, and a number of us questioned the premise of the 

hearing because we didn’t believe there was actually a system in 

place but more of a patchwork arrangement. And I notice that this 

doesn’t—the name of this hearing talks about the role of public 

health. It doesn’t assert necessarily the public health system. And 

I would question whether we really have a system in place. I think 

we have strong public health advocates across the country and 

places where it is working very well. But to suggest that we have 

a system, I think, is a poor diagnosis, frankly. 

And one of the hopes I have for the health care reform effort that 

is under way is that we will emerge from this debate with a public 

health system in place. Many have critiqued the way we approach 

health in this country as having developed a sick care system rather than a health care system. Obviously, prevention is critical to 

changing that orientation, and public health is critical to that. So 

I look forward to your testimony. I am particularly interested in 

this notion of place-based initiatives. In other words, what do you 

do in schools, what do you do in clinics, what do you do in employment, in work places, and so forth, going to where people are to 

provide the kind of prevention, wellness, and fitness services that 

really will represent a true public health system is absolutely fundamental. So I look forward to your testimony. I thank you, Mr. 

Chairman. I yield back my time. 

Mr. PALLONE. Thank you. Ms. Schakowsky. 


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OPENING STATEMENT OF HON. JANICE D. SCHAKOWSKY, A 

REPRESENTATIVE IN CONGRESS FROM THE STATE OF ILLINOIS 

Ms. SCHAKOWSKY. Thank you, Mr. Chairman. I do want to assert 

the centrality of a public health infrastructure but we certainly do 

need to do more to help bolster it and create it. I am going to soon 

reintroduce the Health Promotion First Act, which I first sponsored 

last Congress with bipartisan support including members from this 

committee. My bill recognizes that we need to improve research 

into health promotion, coordinate activities across agencies, and develop a strategy to improve public health. I want to mention two 

specific areas of concern to me. It has been mentioned before, but 

we need to reduce obesity among children and across all populations. 

A small example. There is an organization called Mainstay in Illinois where I am from, estimates that Illinois could save over $160 

million a year by adjusting obesity in people with developmental 

disabilities who live in group homes, a setting really amenable to 

that kind of effort. STDs, we all were shocked, I think, or some 

anyway, earlier this month when the D.C. health department reported over 3 percent of the city’s population, 7 percent of African 

American men, infected with HIV AIDS. Local experts put that 

number closer to 5 percent because of under reporting. And we 

have measures today that would help to stop STD transmission 

that need to be implemented. 

And, finally, it is hard to overstate the importance of increasing 

public health resources for research, public education, and treatment. Our public health work force is being stressed to its breaking 

point, and we have to do all that we can to repair that as well. So 

I thank you, Mr. Chairman, and I look forward to hearing from our 

witnesses. Yield back. 

Mr. PALLONE. Thank you. The gentleman from Texas, Mr. Burgess. 

Mr. BURGESS. Thank you, Mr. Chairman. In the interest of time, 

I have a statement that I will submit for the record. I am just very 

pleased to hear from our witnesses today. I am particularly looking 

forward to hearing from Dr. Satcher, and recognize his work that 

he has done on behalf of Alzheimer’s patients in this country. Certainly, genomic medicine is a game changer. In medicine we are indeed on the threshold of a transformational time where it will be 

possible to identify individuals at risk, and now with newer 

monoclonal antibodies perhaps be able to offer some treatment options prior to the clinical manifestations of the disease, so this will 

become a much more long-term management problem and ultimately there are significant savings in our system that can be 

gathered by this type of activity. So, Dr. Satcher, we are grateful 

to you for your service and your work on that behalf. With that, 

Mr. Chairman, I will yield back the balance of my time. 

[The prepared statement of Mr. Burgess follows on p. 160.] 

Mr. PALLONE. Thank you. The gentlewoman from Wisconsin, Ms. 

Baldwin. 

Ms. BALDWIN. Thank you, Mr. Chairman, and before I begin, I 

would like to request unanimous consent to submit for the record 


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testimony prepared by the Human Rights Campaign that addresses 

the issue of access to health care for LGBT Americans. 

Mr. PALLONE. Without objection, so ordered. 

[The information appears at the conclusion of the hearing.] 

Ms. BALDWIN. Thank you, Mr. Chairman. If we are going to meet 

the serious public health care challenges of today and tomorrow, 

we must help our states respond to these challenges. Many parts 

of our state and local public health system are fragmented and outdated. With my colleague on this committee, Congressman Terry, 

I sponsor the Strengthening America’s Public Health Systems Act, 

a bill specifically that focuses on public health infrastructure. It invests in state labs of hygiene, improves surveillance and reporting 

systems and empowers the future public health work force. We also 

must rely on evidence-based prevention efforts and fully fund our 

federal agencies so that they can conduct community-based interventions to prevent diseases like HIV. 

If we can more closely align federal funding with recommendations of the U.S. preventive services task force and the task force 

on community preventive services, I think we can see a real return 

on our investment in public health, a critical part of comprehensive 

health care reform. And, thank you, again, Mr. Chairman, and to 

our witnesses for this hearing and your testimony today. 

Mr. PALLONE. Thank you. And I think that concludes the opening 

statements by the members of the subcommittee, so we will now 

turn to our first panel. First of all, welcome. We have with us today 

on my left Dr. Richard Besser, who is Acting Director of the CDC, 

and Acting Administrator of the Agency for Toxic Substances and 

Disease Registry. And we also have Dr. Jonathan Fielding, who is 

Chair of the Task Force on Community Preventive Services, Director and Health Office of the Los Angeles County Department of 

Public Health. And, again, thank you for being here. We have 5- 

minute opening statements. They become part of the hearing 

record. And I will start with Dr. Besser. 

STATEMENTS OF RICHARD E. BESSER, M.D., ACTING DIRECTOR, CDC, ACTING ADMINISTRATOR, AGENCY FOR TOXIC 

SUBSTANCES AND DISEASE REGISTRY; JONATHAN E. FIELDING, M.D., M.P.H., CHAIR, TASK FORCE ON COMMUNITY PREVENTIVE SERVICES, DIRECTOR AND HEALTH OFFICER, L.A. 

COUNTY DEPARTMENT OF PUBLIC HEALTH 

STATEMENT OF RICHARD E. BESSER, M.D. 

Dr. BESSER. Good morning. I am Richard Besser, and I am honored to be serving as the Acting Director for the Centers for Disease Control and Prevention at the time our national focus turns 

to ways we can improve our health system. As a practicing pediatrician and leader of the Nation’s principal prevention agency, I 

recognize both the urgency of solving the problems in our health 

system and the opportunities we have to improve the health of 

Americans as we do so. I would like to thank Chairman Pallone, 

Ranking Member Deal, Chairman Waxman, and members of the 

subcommittee for your support of prevention and public health, and 

for holding this important hearing today to turn the spotlight to 

the role of prevention and wellness in health reform. 


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Today, it is evident that our health system is not fully achieving 

its primary goal, protecting and improving our health. If our vision 

for health reform is too narrow, we still won’t achieve our ultimate 

goal of health for all Americans. For too long, in discussions of 

health reform, health care delivery and public health approaches 

have been treated separately, as if they were disconnected and mutually exclusive systems. With a discussion of health reform currently a focus for the Nation, it is time instead to start talking 

about solving our national health needs through a comprehensive 

system that seamlessly integrates health care delivery, prevention, 

and public health. 

CDC and our public health partners are already working to create these connections, connections between patients, providers, and 

public health officials. By creating more seamless integration between clinical care, which focuses on the health of a single person, 

and the public health system, which focuses on the health of an entire community or population, a truly reformed health system could 

increase access to needed health care services in the short term, 

and reduce demand for treatment services through prevention over 

time. For Americans to truly be healthier, we must not only have 

access to treatment when sick, but they should receive recommended screenings to detect the risk of disease early, have access to evidence-based interventions to prevent disease and injury 

before they occur, be supported by care systems that minimize progression of disease once it occurs, and live, work, and play in environments that promote healthy choices and behaviors. 

We move into a health reform discussion with strong evidence 

that prevention and public health interventions work, both in communities and health care settings, preventing illness, increasing 

years of healthy living, improving work or productivity, and often 

saving health care costs. While much remains to be done to improve our evidence base, we have clear documentation of the success of these approaches. My written statement draws example 

from immunization, tobacco prevention and cessation, community 

interventions to prevent and reduce obesity, and interventions that 

reduce health disparities, prevent the spread of HIV, reduce the 

impact of health care associated infections, and prevent costly and 

disruptive falls among older adults. 

We are pleased to be able to work closely with Dr. Fielding and 

the task force on community preventive services, which has conducted exacting reviews of the evidence and success to help guide 

our programmatic and policy interventions, something that will be 

particularly critical in a reformed health system. I am also happy 

that the committee will have the opportunity to hear from other 

public health leaders to help assess the value that can be delivered 

from these types of interventions. We are anxious to continue and 

accelerate this work with funding provided to HHS under the 

American Recovery and Reinvestment Act to address immunization, health-care associated infections, and prevention and 

wellness. 

Turning to what can be done to advance the public’s health 

through reform of our Nation’s health system, it is our goal that 

all Americans live in communities that create positive opportunities for health, including opportunities for physical activity and acVerDate Mar 15 2010 01:39 Mar 02, 2012 Jkt 067821 PO 00000 Frm 00023 Fmt 6633 Sfmt 6633 E:\HR\OC\A821.XXX A821

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cess to healthy food choices, live in communities that provide greater access to effective, evidence-based clinical and community prevention interventions, provide effective support for management of 

health conditions, starting with costly chronic diseases, so that the 

consequences, both cost and health, are minimized, and protect citizens from harm, including from tobacco use, environmental hazards, contaminated food, hazardous work sites, risk of injury, and 

unsafe medical practices. 

We can put prevention to work across America. This can be accomplished through a broad, national prevention agenda through 

which we will need to provide tools and support the individuals to 

enable them to take responsibility for their own health, provide 

solid evidence upon which personal community, and policy decisions that promote prevention and wellness can be made, ensure 

rigorous tracking, monitoring, and evaluation so that we can measure performance and ensure accountability, more effectively support state and local health agencies with the tools and technical 

support to achieve positive health outcomes in communities across 

the United States, tailor interventions to reduce health disparities 

and improve health outcomes for populations most at risk, use policy levers to improve health, including those in areas not traditionally recognized as health-related policies, such as food, education, 

and transportation to create greater opportunities for physical activity and improved nutrition, address the health crisis caused by 

tobacco use through policy interventions, as well as comprehensive 

tobacco control programs, and reform the delivery system to promote a more seamless integration of individual, clinical, mental 

health, and community approaches that in combination can make 

us healthier. 

Mr. Chairman, and members of the committee, the problems in 

the health system remain a fundamental concern of families, communities, businesses, and policymakers. A deepening recession 

adds urgency to already recognized shortcomings in the current 

health system. I share the President’s commitment to reform that 

makes health care affordable and accessible, and I look forward to 

working with the subcommittee to help make prevention a practical 

reality as part of this national health reform effort. Thank you very 

much. 

[The prepared statement of Dr. Besser follows:] 


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Mr. PALLONE. Thank you. Dr. Fielding. 

STATEMENT OF JONATHAN E. FIELDING, M.D. 

Dr. FIELDING. Chairman Waxman, Chairman Pallone, Ranking 

Member Deal, members of the committee, ladies and gentlemen, 

thank you very much for the opportunity to talk with you today. 

My name is Jonathan Fielding. I am Director of Public Health for 

Los Angeles County, and I chair the Community Preventive Service 

Task Force, and also chair the Secretary’s Committee on 2020 Objectives for the Nation. And I am here today to talk about a very 

well-developed tool and process that tells us what policies and what 

programs have been proven to improve the health of the U.S. population and how to assure this and that we use this information to 

increase our national productivity, particularly important in these 

economic times. 

As a background, health reform is very important to assure everybody has access to quality, affordable health care. However, the 

World Health Organization ranked the health system of the United 

States 37th in the world despite the fact that we spent 50 percent 

more of our GDP on health care than any other country. We need 

to pair health care reform with health reform, which requires 

changes in personal habits that relate to health and underlying 

causes of preventable health problems. The majority of the incredible, unprecedented 37-year gain in life expectancy during the 20th 

Century occurred because largely we had policies and programs 

urged by the public health community, including purer food and 

water, better environmental protection, occupational health laws, 

improved housing standards, better nutritional standards, and 

more sanitary waste disposal, as well as a general increase in the 

standard of living. 

But serious opportunities to improve health and reduce the terrible disparities in health among subgroups remain. Today, 1⁄3 of 

all deaths in the United States are caused by tobacco use, physical 

inactivity, poor nutrition, and abuse of alcohol and other substances. In addition, we increasingly understand that poor education, low income, problems in our physical and social environments are the underlying causes of many diseases, and we have opportunities not only at the retail level, which is what we do in the 

health care system, but to work wholesale, which is working at the 

determinants of health in all of us where working on one can affect 

many diseases. 

Fortunately, we are learning what works to keep Americans 

healthy, to make improvements in their health behaviors, and to 

address the underlying causes of ill health in the physical and social environment. This progress is due to the work of great CDC 

staff with the independent external task force that I chair that develops the guide to community preventive services. We do systematic reviews and make recommendations that are based on the best 

evidence. Over 200 reviews and recommendations have been completed and we know that these recommendations make a difference. For example, our recommendation to reduce blood alcohol 

concentration limits for drivers to 0.8 helped to spur congressional 

legislation to limit access to transportation funds to states that perVerDate Mar 15 2010 01:39 Mar 02, 2012 Jkt 067821 PO 00000 Frm 00039 Fmt 6633 Sfmt 6633 E:\HR\OC\A821.XXX A821

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mitted higher alcohol level. That contributed not only to safer roads 

but we saved many lives. 

The recommendation can also assist HHS in determining the 

best use of the Recovery Act funds. For example, to prevent smoking and increase cessation the guide has shown that social marketing campaigns are very effective. A public-private partnership 

could rapidly apply the Recovery Act resources to a national tobacco media campaign that could substantially reduce the one behavior, smoking, that causes the greatest number of preventable 

deaths. The guide also provides essential recommendations for how 

the health care system can increase its efficiency and effectiveness. 

Its companion clinical guides tells us what preventive services individuals should receive like mammography, while the community 

guide tells us how the health care system can most efficiently and 

effectively organize itself and deliver the services that maximize 

uptake continuity and health impact. 

Nonetheless, we face major challenges. First, because of insufficient core funding the 210 completed reviews and accompanying 

recommendations represent only a fraction of the highest priority 

opportunities and topics identified. Second, the recommendations 

are of little value if they are not used. The guide has been passively disseminated so awareness of its recommendation remains 

low and they have not become part of standard practice. Third, the 

guide often finds insufficient evidence to make a recommendation 

because the needed studies that could answer that question have 

not been done. One major gap is lack of information on how to reduce health disparities. 

Another priority opportunity is to quantify the health effects of 

decisions that are outside the health sector such as an education 

and transportation and criminal justice. Health impact assessment 

is an effective tool for such analyses that could basically help every 

congressional committee understand how the decisions they are 

considering would effect the health of all of their constituents. I 

have four recommendations for your consideration. First and foremost, the guide to community preventive services needs full, financial, and personnel support. A one-time infusion of $50 million 

would allow us to provide recommendations for all the high priority 

topics and intervention needed by communities within 3 years. 

These resources would also allow us to rapidly and efficiently expand and proactively disseminate the recommendations so they become standard practice for users in both the public and the private 

sector. The ongoing work of the task force will require $15 million 

annually on a continuing basis so that we can keep the recommendations current, assess the effectiveness of new policies and 

programs and continue active dissemination to assure that these 

recommendations are being followed and to evaluate to make sure. 

Second, the major gaps in evidence need to be filled with robust, 

targeted, funding for research with CDC as the lead agency. Third, 

we need support to use the best science to address the health effects where many disciplines need to interact. 

Global warming is one example and other policy issues through 

health impact assessment and other novel approaches. Fourth, the 

guide and these initiatives need evaluation to make sure recommendations are being implemented and determine if the exVerDate Mar 15 2010 01:39 Mar 02, 2012 Jkt 067821 PO 00000 Frm 00040 Fmt 6633 Sfmt 6633 E:\HR\OC\A821.XXX A821

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pected health improvements are being realized. Finally, Healthy 

People 20–20 currently under development will provide health objectives for our Nation. These objectives need to be fully informed 

by the guide recommendation and results of the studies that we 

have looked at so that the objective set can be realistic and based 

on the best evidence. These two major initiatives need to be tightly 

linked to maximize the value of both. Thank you again for providing the opportunity for me to talk with you, and I look forward 

to discussing these issues and responding to your questions. 

[The prepared statement of Dr. Fielding follows:] 


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Mr. PALLONE. Thank you, both of you. We will start with our 

questions, and we generally have 5 minutes from each member, 

and I will start with myself. I tend, and I guess most people, tend 

to look at prevention sort of from two perspectives. One is what we 

call clinical preventive services delivered by physicians and other 

practitioners during a patient’s visit, and that is why we emphasize, you know, in health care reform we want everybody to be able 

to see a doctor on a regular basis, and whether it is a school-based 

clinic covered in your insurance that that is an important part of 

prevention, that you can see somebody who can review your situation and give you care without having to get sicker and go to a hospital or emergency room. 

And the other thing is the community-based prevention like education campaigns, and these things are very important. I am going 

to use my kids as an example, and I hate to do that sometimes but 

it is the easiest thing for me. I do think that like education campaigns about, for example, not smoking are very effective. I mean 

I find that they see smoking as a very bad thing like almost socially unacceptable. And I think a lot of that has had to do with 

the campaigns. But I also question the limits of what we can do 

in these two categories because it just seems that so much of prevention is personal and individual. And, again, I will use my kids 

as an example. You know, they just want to watch TV. They want 

to play videos. In the old days, and I am really dating myself, you 

would be in the neighborhood and you would go out and play on 

the street or in the back yard. Today it is like watching the videos, 

watching TV, and, unfortunately, as members of Congress you are 

not with them every day so on the weekend I will try to get them 

out of the house but it is very tough. 

And the same thing is true with foods, you know, They want to 

go to McDonald’s and the fast food places. Even if we are going out 

to eat, it is hard to get them to go to any place but fast foods and 

so my point is there is no question that these community-based 

prevention things like education with no smoking are effective, but 

it just seem to me we are losing the battle. And, I don’t know, can 

we spend enough money on these educational campaigns, for example, to really make a difference? I mean, obviously, the smoking is 

a good example of that if I can use my own children, but it just 

seems like we are doing—we are spending some money on things 

like anti-smoking initiatives and other things, but it is not anywhere near as effective as all the promotional and advertising activity that takes them in the other direction in terms of their lifestyle. 

So I just wanted to comment. You just think we need to just 

spend a lot more money or is there actually something we can do 

about personal life style? My question is very general, gentlemen. 

Dr. BESSER. Thanks very much for that comment and question, 

Mr. Chairman. And you raise a very challenging question, how do 

you change behavior. When we are talking about things like smoking, you are talking about things like obesity, how do you work to 

help support an individual to make those changes. And educational 

campaign is part of that, but when you are looking at behavior 

change, we try and look at it in a more comprehensive way. Educating and informing is part of that. But what can you do to supVerDate Mar 15 2010 01:39 Mar 02, 2012 Jkt 067821 PO 00000 Frm 00067 Fmt 6633 Sfmt 6633 E:\HR\OC\A821.XXX A821

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port that individual? I volunteer in a clinic in Atlanta, and I have 

just been astounded by the increasing number of children I see who 

are obese, and I talk to that child about activity and why aren’t you 

going outside and playing and engaging in sports programs. 

Mr. PALLONE. Doctor, not to interrupt you, but I am very active 

with Native American issues. 

Dr. BESSER. Yes. 

Mr. PALLONE. And the more I go to the different reservations and 

meet the tribes, the more I see younger and younger kids with the 

adult onset diabetes. I mean 20 years ago you would find somebody 

who was maybe 21. Now you find kids that are 10 or 11 years old. 

Dr. BESSER. There is an epidemic of diabetes taking place in this 

country, and we are seeing it younger and younger. American Indian populations, Latino populations, it is absolutely out of control, 

and if we are going to handle the problem of ever increasing health 

care costs prevention has to be part of that. But the children I am 

seeing, when they go to school they don’t have access to physical 

education programs. When they come home, they are not in communities that encourage physical activity. When they go to a fast 

food restaurant, there is no posting of nutritional information to 

allow families to make healthy choices. 

When we think about these problems, there are things that we 

can do on a policy level. There are things we can do on a community level. There are things we can do to help their clinician provide them with counseling, and there are things that we can do to 

help that individual make healthy choices. But it has to be a concerted effort not just focused on that individual. The public health 

solutions are the long-term solutions to many of these problems. 

Mr. PALLONE. I just think we need to do so much more. I don’t 

know if it is money or whatever it is to counteract the trend that 

we have no idea how much effort it is going to take and—go ahead. 

Dr. BESSER. I think resources is part of it, evidence is part of it. 

As Dr. Fielding was saying, the more we know what works from 

various pilots in communities the more we can expand that to 

other communities. There is definitely a gap in research in many 

areas of the most effective ways to change behavior. We are very 

excited about the resources that are going into comparative effectiveness research on the clinical side, but we clearly feel that there 

needs to be more work done on comparing different interventions 

on the community level to see which ones give you the best bang 

for the buck. 

Dr. FIELDING. Let me just mention a couple of things. With medicine, we are kind of taught that there is a single answer to a single 

problem. It is kind of one to one. When you take the issue as complex as obesity there isn’t a magic bullet. You need to do a variety 

of things. Some of those are policies, as Dr. Besser said. Menu labeling, for example. I worked very hard with others in California 

to get menu labeling in the fast food restaurants right up on the 

order board. That is going to happen in the next 2 years. And so 

you and I as parents are going to look at that and say you want 

what? How many calories does that have? And, by the way, there 

is some confounding information. When you look at that, you 

wouldn’t know that there is a yogurt shake that actually has over 

1,000 calories. Oh, it is yogurt, you know, how bad can it be. So 


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part of it is changing consumer information. Part of it is changing 

the opportunities in the school. 

We have worked with the school system in Los Angeles County 

to increase physical activity but again the funding is being cut so 

it is tough. Now we have changed the food in the vending machines 

there so there is not junk food available in the vending machines. 

But there is also an aggregation of fast food restaurants that are 

near high schools where kids go out from school and in fact buy 

that instead of eating the food that is available in school. So we 

have to take a variety of approaches. One thing is very clear that 

I as a physician talking to a patient is not the only answer. It is 

not going to be the whole problem solver for obesity. The same way 

with tobacco control. We know that physician very brief advice in 

a standardized way the research has shown that can be effective. 

That is not enough. 

You reference the truth campaign, which has been very effective 

by the American Legacy Foundation. But that requires tens of millions of dollars a year. Now one of the opportunities would be the 

federal government to say as part of the recovery act, we are going 

to put substantial dollars, match that with what is already available from the American Legacy Foundation, and do not only the 

prevention through truth but become an X like program which is 

the cessation program tied to quit lines. So there have to be a variety of mechanisms. No one is going to do it, and that is why it is 

confusing because it is not the medical paradigm. We need a very 

strong public health infrastructure with states and local public 

health agencies taking the lead in convening and letting people 

know the evidence and in working across the aisle. 

Mr. PALLONE. Thank you. I know I went too long here. Mr. Deal. 

Mr. DEAL. Thank you. Thank you both for your testimony. You 

know, there are categories that we can look at. One category is 

whether we know enough to know to do the right thing. For adults, 

most of us probably know what we ought to do. We just don’t do 

it. But for children, they are in the formative stages, and I am concerned about the things that the government can and can’t do, 

things government should or shouldn’t do. And for adults pretty 

much there is a freedom of choice there that government has very 

little ability to change other than maybe to educate, but in children 

I think it is a different area. 

And I agree with what my colleague, Ms. Eshoo, brought up in 

her opening statement about the food stamp programs, and I want 

to enumerate a couple of things here and ask you if you all have 

looked at these things, and they primarily relate to children. Of 

course, I am a big proponent for recess. I have a theory that when 

recess went out obesity went up, but in Atlanta you mentioned, and 

my understanding is the school board in Atlanta has now made a 

decision to do away with the physical education classes because 

they had to use the time to meet the academic requirements that 

the state has imposed and maybe even we have imposed from the 

federal level down. 

Things like school nurse programs, things like putting restraints 

on what products can be used with food stamp purchases, which I 

understand we do have some restraints in the WIC program already, things like the school lunch program. Now I know most 


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school lunch programs now have a salad bar. That is for the teachers primarily. It is not the students who are utilizing it. What are 

we doing, what can we do, what can we do in those environments 

because for children the majority of the time that anybody other 

than their parents have control over is in a school environment. 

Would you all address that as it relates to children and either what 

they eat in the school lunch program, what many of them eat as 

a result of food stamp purchases, et cetera? 

Dr. BESSER. I think this relates to the concept of health in all 

policies, and how do we look to ensure that we are promoting 

health or not by implementing policies promoting un-health 

through what takes place. Your comments about requirements, 

education requirements, and their impact is a really telling one. 

The reason that classes were increased was to try and improve the 

academic qualifications of students coming out of school. But we do 

know that students learn better when they are physically active, 

and the untoward consequences of some of those policies was 

squeezing physical education out of schools. We need to be able to 

look at that, and as public health practitioners we need to ensure 

that we have linkages, not just within the Department of Health 

and Human Services, but across government so that we are looking 

at how do you promote health in these other areas. 

The idea of a health impact assessment when policies are moving 

forward is very attractive because it would force us to say, OK, as 

we are looking to construction project, we are looking for new 

roads. Well, does that road project have sidewalks? Does it have bicycle lanes? Does it have things that actually could encourage people to be physically active or is that something that was not considered as part of that. The more creative we are and the more we 

are able to look at things that don’t necessarily require new dollars 

the more effective we are going to be at building healthy communities that promote health for children and the entire population. 

Dr. FIELDING. I think you are absolutely right. The WIC program 

has made important strides that can be emulated for the broader 

food stamp program, the SNAP program, but in the schools we 

changed the vending machines so they only have healthier snacks 

and taken out the soda, which has a lot of calories that kids—— 

Mr. DEAL. You have to be careful about that with Coca Cola in 

Atlanta as does Dr. Besser. 

Dr. FIELDING. Well, my guess is Coca Cola probably makes more 

on the water they sell than on the Coke so maybe it helps—— 

Mr. DEAL. They have made a concerted effort as an organization 

to deal with that. 

Dr. FIELDING. Exactly, so I think the large beverage manufacturers, they have a very broad range so whether it is A or B they certainly can do as well. But also the food that is served, a lot of that 

is bought through USDA so what percentage fat can that food be, 

what about portion size. You have people in the cafeteria who we 

have had to teach not to give huge amounts on a plate. There is 

also issues of plate waste. We can serve vegetables but what if kids 

don’t eat them. So part of it is what we can do externally. Part of 

it is what has to be done in the family. In school, for example, 

physical activity needs to be real physical activity. As an example, 

playing softball or playing baseball, most people are sitting around. 


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They are standing. Well, what if everybody ran around the bases 

every time somebody got a hit? That is the way to change the 

game, if you will. 

And the same way out of school. We have to make sure that kids 

have a safe environment in which to play. Are schools available 

after hours? What about those general after school programs? Is 

there lighting in neighborhoods? So you can’t separate these. And 

then parents. For example, as Chairman Pallone said, you know, 

what about the kids watching television? Well, they are spending 

too much time in front of the screens. Well, some parents may say, 

you know, there is a limit on how much you can do or you can only 

do it after you have done some physical activity. Not easy for us 

as parents but we have to take charge of part of that ourselves. 

Mr. DEAL. Thank you both. 

Mr. PALLONE. Chairman Waxman. 

Mr. WAXMAN. I want to ask a question for both of you. In a little 

while, we are going to hear from Dr. Satcher, and he notes in his 

written testimony that racial and ethnic health disparities result in 

at least 83,500 excess deaths among African Americans each year. 

That is simply unacceptable. We have to address it in health reform. My question is what contribution can public health make to 

reducing racial and ethnic health disparities? Are there specific 

clinical preventive services that will reduce disparities if we cover 

them in health reform? Are there specific community-based preventive services that will reduce disparities if we fund them in health 

reform? Dr. Besser, why don’t we start with you? 

Dr. BESSER. Thank you, Mr. Chairman, for that question. I think 

that your comment that this is unacceptable is right on target. It 

is absolutely unacceptable the degree of disparities we see in 

health. CDC has undertaken a number of initiatives to try and address racial and ethnic disparities, but not on the scale that they 

need to be done. There is a program at CDC called REACH, which 

is racial and ethnic approaches to community health that has been 

done in a number of communities to specifically address within 

those communities the racial and ethnic disparities that occur. 

Where this program has been enacted, we have seen a removal 

of the disparity in rates of mammography among African American 

women. We have seen removal of disparity in the rates of blood 

pressure screening for African American men, an increase in the 

use of blood pressure medication. We have seen a decrease in 

smoking among Asian American men. We know how to address 

these disparities, and again it takes a community approach. It is 

not a one size fits all approach. 

And with appropriate scale up of these programs, I think that we 

can see the removal of a lot of these disparities. We have seen it 

in immunization programs where you have seen universal immunization. You have seen elimination or at least a closing of many of 

those disparities, and it is time for us to ensure that those programs are available to all of our communities. 

Dr. FIELDING. Thank you very much. As your constituent, I am 

happy to add a couple of thoughts. First of all, we are not going 

to get to parity in terms of health unless we address some of the 

underlying determinants. I was asked the other day at a RAND 

conference, what is the single thing you would do to improve the 


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health of the American people particularly focused on reducing disparities, and I said increase the graduation rate from high school 

for a number of minority groups. They are very poor in Los Angeles 

as in other parts of the country, and the differences in health that 

come along with that are substantial. The issues of transportation, 

the issues of access to nutritious foods, fruits and vegetables. 

Mr. WAXMAN. Well, how would you address this, in a communitybased way or would you do it in a clinical way? I know that you 

can solve all the world’s problems and it would change the disparities but if we are doing health reform, what do you recommend we 

do in health reform? Should we provide money for community programs? Should we provide certain clinical practices for those who 

are going to now be insured if we get a health reform bill through? 

Dr. FIELDING. Yes, I think that, as you suggest, Mr. Chairman, 

at all levels in a health care reform system, you want to make sure 

that there are not only the ability but the incentives so that the 

providers have incentives to make sure that there are not disparities in terms of the access to services, but we also know that we 

have to use a lot of efforts. It is not simply that one has to have 

services accessible. They have to use them. And so one of the 

things we do in the community guide is to develop interventions 

which basically help people to use the services. And with different 

groups that may be different so for one group it may be that recall 

reminders make a difference. For another group it may be that you 

need to call their cell phones. 

For another group it may be that they have to have a case manager. It is trying to understand that that we are trying to do in the 

community guide working with the clinical guide, so I think the opportunity for all of those should be included in health system reform but we also, if we are going to reduce disparities, need to 

focus on the core of public health and the underlying problems. For 

example, in Los Angeles County African American men and women 

have a 25 percent smoking rate. The average rate in Los Angeles 

County is 14 percent. So we need programs, for example, social 

marketing programs that are particularly focused on the African 

American population there on tobacco. 

We need programs on obesity for Latinos as well as African 

Americans, so I think it needs to be a combination of what can go 

in the health care reform and the other parts of health reform that 

are outside the strict health care system. 

Dr. BESSER. Chairman Waxman, if I could add to that. I think 

that it also ties into comments that were made by many members 

about the importance of a strong state and local public health system. In a community you need to have a public health infrastructure, epidemiologists and public health specialists, who can look at 

what are the risk factors in that particular community and address 

those. It is not a one size fits all, and those in the community, as 

Dr. Fielding is saying, in a community that got higher rates of 

smoking in one particular population, they have to look at what is 

driving that, who the community leaders are, and how you build 

a public health program that targets the drivers in that particular 

community, and to do that you need a strong, local public health 

system. 

Mr. WAXMAN. Thank you, Mr. Chairman. 


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Mr. PALLONE. Thank you. Our ranking member, Mr. Barton. 

Mr. BARTON. Thank you, Mr. Chairman. One of the things that 

we can do to promote congressional health would be to stop scheduling simultaneous subcommittee hearings of this committee, 

which causes—but I guess it does promote de-obesity because it 

makes us run back and forth, up and down the stairs. I just have 

one question for this distinguished panel, and it is the idea of universal coverage. The President has said that every American 

should have health care insurance and you almost have to have— 

you don’t have to but you almost have to have a mandate that 

every American has to have it, so my question is should that be 

an individual mandate or should it be some sort of a universal 

mandate that if you are not covered under a group plan there be 

a national kind of a backup fail safe plan for any individuals that 

don’t have group coverage, so could you two gentlemen give us your 

ideas on how to get universal coverage for every American regardless of their employability and employment status? 

Dr. BESSER. Thank you very much for that question. From a public health perspective, and that is the hat I wear and where my expertise lies, the critical factor is access to care and ensuring as a 

Nation that we move to a point where everyone has access to care 

and that care is not just being delivered in emergency rooms when 

people are sick. And I think there are many ways to get there. 

Which way we get there, I think is not one where CDC has the expertise. One thing that we hopefully over time will be able to bring 

more light to is the impact particular insurance or particular systems may have on an individual’s health. We collect a lot of information on the health status of Americans through various surveys 

and one is the national health interview survey. 

And through that survey, we are now starting to collect information about type of insurance, type of insurance plan, whether it is 

a health savings plan or such so that over time we should be able 

to look at does that particular type of system have an impact on 

health drivers. 

Dr. FIELDING. Sir, I don’t know which is the best way to get 

there. I think what is important is that there be however you get 

there a core of services which is going to contribute to health because health then allows us to be more competitive, more productive as a Nation by reducing preventable problems. I think if we 

focus on that aspect there are probably a number of ways to get 

there but providing the emphasis on what we can do within that 

system and then working together with public health is probably 

our best opportunity to improve the health of every American and 

to reduce disparities at a time when unfortunately our health is 

not as good as that of our trading partners in many cases. 

Mr. BARTON. Thank you, Mr. Chairman. 

Mr. PALLONE. Mr. Dingell. 

Mr. DINGELL. Thank you, Mr. Chairman. This question is to Dr. 

Fielding and Dr. Besser. Question, public health has a cost benefit 

to the society, does it not, yes or no? 

Dr. FIELDING. Yes, it has a very substantial benefit to society, 

sir. 

Mr. DINGELL. Dr. Besser. 

Dr. BESSER. Yes, sir, I would agree with that. 


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Mr. DINGELL. All right. Now the reason for that question is the 

dealings in this committee with national health insurance or getting a program which will cover every American, that cost benefit 

may get dropped out of the equation because of the Congressional 

Budget Office which has a rather stingy attitude of quantifying 

things which they view as being unquantifiable. How do we then 

see to it that we get this question resolved in a way which is quantifiable so that we can get some discernable, visible, and calculable 

benefits to the society from public health so that we can get CBO 

to give us a proper estimate of savings and benefits that could be 

achieved by public health service, by CDC and other entities which 

work towards this end? Starting first with Dr. Fielding and then 

Dr. Besser. 

Dr. FIELDING. Thank you very much. A very important question, 

Chairman. I think several things. First of all, you will hear from 

Jeff Levi from Trust for America’s Health the kind of studies that 

they have done suggest a very good return on investment for some 

of the things we could do in public health. It is clear to me that 

we are not going to get where we need to with the national system 

of strong local public health and state public health unless the federal government is a partner with the states and localities, unless 

there is a sustainable amount of money that goes to make sure 

that the spine of public health is strong. 

With respect to the Congressional Budget Office with which I 

have had some discussions as well, I think that they tell me that 

the Congress is asking them to look very narrowly, and I don’t 

think that looking narrowly answers the question. What they need 

to look at is the value. What is the relative value of different kinds 

of investments, and I think if you look at the relative value you get 

better. 

Mr. DINGELL. That is an outfit, Doctor, that sometimes knows 

the cost of everything and the value of nothing and they have great 

difficulty in converting value to cost that is discernible and can 

then be included as justification in the legislation. I am asking 

your help about how do we get this quantification step done. And 

remember my time is running. 

Dr. FIELDING. OK. What I am suggesting is that we look not only 

at the dollar savings in a very short period of time to the federal 

government, but we do two things—— 

Mr. DINGELL. Let me put it to you this way, Doctor. If we had 

Black Death there would be a—to spring back, we would all of a 

sudden have a very major cost to the society. AIDS has a very 

major cost to the society. If tuberculosis were to come back and 

break loose in the society, we would have a cost. How do we quantify these things and how do we request quantification from CBO 

so that they will give us something that will be useful in this discussion? 

Dr. FIELDING. We can quantify the cost of epidemics in terms of 

health care costs, in terms of productivity loss, in terms of cost to 

the Social Security system and the like. That is easy. What is hard 

to know is what exactly it takes to prevent those because it comes 

from a number of different places. I think if we ask the CBO to 

look at what is the health benefit for a dollar invested in alternative ways, that is what I mean by value. Instead of just saying 


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what is the dollar back, what is the health value? We are spending 

right now $1 out of every $6 in this country on health care. We 

don’t know in many cases what the value of those dollars is. We 

need to compare that with the value of public health. 

Mr. DINGELL. If you give preventive care, you could shrink those 

numbers. Let me get to Dr. Besser. 

Dr. BESSER. Thank you, Mr. Chairman. I think that you raise a 

critical question and a critical problem. When we look at many of 

the interventions and programs in public health the return on investment is long term. When we are talking about promoting physical activity and appropriate nutrition in children, that will have 

major payoffs to those individuals but also to our economy over the 

lifetime of that individual. 

Mr. DINGELL. Or alcohol or smoking. 

Dr. BESSER. Exactly. Alcohol or smoking. Those behaviors, if presented early, will have lifetime benefits and will have lifetime impacts on our economy. 

Mr. DINGELL. How do we insist CBO assist us in quantifying 

those benefits? 

Dr. BESSER. Well, I think that that is a real challenge. It is very 

promising, some of the data, Trust for America’s Health, and Jeff 

Levi is going to be talking about short-term return on the investment. And that is promising, but I do think that for the broader 

consideration of public health that can’t be the only part of the conversation because even if we were not seeing the return on investment that Trust for America’s Health was seeing, we are seeing a 

very good value on the investment over the lifetime of individuals 

and over the lifetime of the economic return over the lifetime of 

those individuals. So the issue of time frame, cost to whom, who 

is paying the cost and who is the benefit being accrued by are very 

important parts of that discussion and one that we have to find a 

way around if we are going to see a long-term commitment to supporting public health. 

Mr. DINGELL. Thank you, Mr. Chairman. My time has expired. 

Mr. PALLONE. Thank you, Chairman Dingell. Mrs. Blackburn. 

Mrs. BLACKBURN. Thank you, Mr. Chairman, and thank you all 

for your testimony. Listening to you, it seems like we could—and 

listening to the questions, we are coming back to three things, 

which are lack of education, lack of physical activity, and then tobacco as three things that are really detrimental to health and 

good healthy lifestyles. Dr. Besser, you mentioned linkages with 

other resources and other agencies, and I just wanted to ask a couple of quick questions. Number one on the tobacco issue, we know 

that the Sinar amendment, the Sinar program, has been effective 

in helping states reduce their tobacco usage, their underage tobacco 

usage, but we also know that after the master settlement agreement that very little of that money is being used on tobacco. 

I was in the state Senate in Tennessee when that was passed, 

and of course like so many states it went to fund a program, a 

health care delivery program, and the general fund and things of 

that nature that really weren’t dealing with tobacco education. And 

some of us, myself included, who had been active with smoking cessation education, and as chairman of a former lung association, 

were disappointed in that. So would you all support a proposal that 


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would require states to use a certain percentage or an expanded 

percentage of that master settlement money for tobacco education? 

Just a quick yes or no from you all. 

Dr. BESSER. Congresswoman, I have to confess that I am not familiar with the Sinar legislation and so I need some information 

around that. What I can say is that tobacco control is one of those 

areas where we have seen major public health successes both in 

terms of reduction in rates of smoking in adults, children who decide not to start smoking, decrease in second hand smoke, and I 

also know that if we don’t keep up those efforts around tobacco control, we are going to see those benefits go away. It is not something 

where you do it and you are done. 

Mrs. BLACKBURN. Dr. Fielding. 

Dr. FIELDING. I don’t know legally what can be done. It really is 

disappointing that the attorney general settlement did not specify 

that some of that money be used for tobacco control because a lot 

of states have not—tobacco control is an area we know a lot. We 

know a lot what can make a difference, and it is very disappointing 

that in many states unfortunately we are not putting the resources 

in that we need in order to reduce the rate. How that could be 

achieved, I am not sure legally, but it would be very important to 

have money consecrated to that problem because we know how to 

use it well. 

Mrs. BLACKBURN. OK. On the linkages, coming back to that, I 

am one of those that believe that when you took physical education 

classes and consumer science or life skill classes out of the high 

schools that you started seeing lack of education with people, individuals, that did not understand, Dr. Fielding, as you were saying, 

what calories exist in food and what those choices should be. But 

along that line, have either of you worked with the U.S. Department of Agriculture and the Agricultural Extension Service, their 

FSC program or 4H club programs, anything like that on education 

because they have staff and they have materials that are developed 

to address that, either of you? 

Dr. BESSER. I have not personally but let me get back to you 

about any collaboration CDC would have with USDA in that area. 

Mrs. BLACKBURN. OK. That would be great. Dr. Fielding. 

Dr. FIELDING. We have worked with WIC programs which we 

think are moving in the right direction and we have tried to change 

what is served in the schools and that works with USDA but we 

have not had direct contact. 

Mrs. BLACKBURN. Well, and the WIC program for many of us 

that come from state governments when we did welfare reform, 

what we did was to require some of that education, and then in 

Tennessee one of the things we did was to move some of that education back out to our local county extension services because they 

do have the individuals there that not only can provide the education but can mentor, which is a critical component of changing 

the habits and the behavior. And I know when Dr. Satcher does his 

testimony, he is going to speak a little bit to the influence of lifestyle and behavior. Thank you. I yield back. Thank you, Mr. Chairman. 

Mr. PALLONE. Thank you. Mr. Matheson. 


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Mr. MATHESON. Thank you, Mr. Chairman. Dr. Besser, I was 

going to mention to you, have a discussion with you about issues 

about MRSA, if I could. Last year, a study was reported that 

caught a lot of our eyes about the effect that MRSA is having. Specifically, the study estimates that in 2005 more than 94,000 

invasive MRSA infections occurred in the United States and over 

18,000 of these infections resulted in death which was many more 

than had previously been thought. But there are many infections 

and other resistant bugs that aren’t receiving as much attention 

and certainly should be adequately monitored as we discuss prevention and public health. 

You may be familiar with legislation I introduced last year and 

plan to reintroduce that is called the STAR Act. It would establish 

a network of 10 sites across the country which could be part of existing surveillance sites or health departments. These sites would 

provide an early warning system to monitor anti-microbial resistance. I look forward to working with you as we try to develop that 

legislation as a way to strengthen this country’s ability to respond 

to what I see as an emerging public health problem. I wonder if 

you could just discuss with me any gaps you see in our current surveillance capabilities. Specifically, I would ask do we have an early 

warning surveillance system to monitor anti-microbial use and the 

emergence and spread of resistance? 

I would also like to ask you if you think our current systems are 

reactionary or are they geared at preventing outbreaks. And, third, 

I would ask your sense of how we compare with other countries in 

this set of issues. 

Dr. BESSER. Thank you, Mr. Matheson, for these questions about 

a very important public health problem. MRSA is one type of resistant infection and it is one that has gained a lot of national attention. One of my areas of focus early in my career at CDC was 

around appropriate antibiotic use, and I started CDC’s program, 

Get Smart, Know When Antibiotics Work, so that is directed 

around trying to prevent the increasing rise or the academic of antibiotic resistant strains. We are absolutely thrilled that the ERA 

funds that have come down have $50 million in there to look at 

health care acquired infections because when you look at a site 

where resistance is likely to occur and develop health care settings 

are one of those places where you are seeing a lot of bad bacteria 

and a lot of antibiotics. You put those together and you are going 

to promote resistance. 

There are major gaps in our ability to detect infectious diseases 

and detect resistant infections, and those ERA funds are going to 

help with that to some extent. Our ability to look at antibiotic use 

and behaviors around that, we have some surveys in the NCHS, 

National Center for Health Statistics, that allow us to get a window on how antibiotics are being used in clinical practice. As we 

move toward electronic health records, that is going to improve our 

ability to look at practices across providers and for providers to 

look at their own practice and see how are they complying with recommendations, how is their use of antibiotics. 

When we look across different countries, there are some countries that we have higher rates of resistance in and some that we 

have lower rates of resistance, and it is important that we work 


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with other countries to see what strategies and solutions have been 

effective at reducing infections and resistance. We do know how to 

reduce infections in health care settings. We have programs that 

have been very effective that we have developed jointly with the 

Agency for Health Care Research and Quality. These demonstrated 

in southwestern Pennsylvania, implementation of these reduced 

bloodstream infections by 70 percent. And so for many states and 

localities, it is how do we help them go to scale and how do we provide the assistance and resources to make that happen. 

Mr. MATHESON. Well, I appreciate that response, and again I 

look forward to continuing to work on this issue. 

Dr. BESSER. Likewise. 

Mr. MATHESON. I yield back, Mr. Chairman. 

Mr. PALLONE. Thank you, Mr. Matheson. Next is Mr. Burgess. 

Mr. BURGESS. Thank you, Mr. Chairman. I got a number of 

things I want to get through. Of course, Mr. Pitts and Mr. Shimkus 

said before they left that they would yield me their time as well. 

Dr. Besser, let us stay on the subject of infection for just a moment, 

and you reference it in your written testimony but can you talk just 

a little bit about your approach to this or perhaps delineate what 

would be a preferred approach to controlling particularly central 

line infections and do so in a way that so that we don’t inhibit reporting if we come at it. And I worry about this because we do this 

over and over and over again in Congress and CMS. We come at 

things punitively and then we tend to drive reporting underground 

so can you address that? 

Dr. BESSER. Thank you, sir, for that question. It is a challenge. 

There is an inherent difficulty when reporting of an infectious disease could have negative consequences to the individual that is reporting that. The national health care safety network that CDC 

supports and is in place in many states allows for confidential reporting and provides to health care institutions an ability for them 

to look at their own rates of infection and develop strategies to reduce rates of infection. 

Mr. BURGESS. Now under HIPA at CDC can you accept that data 

at CDC if someone wants to compile that data on a state level? Can 

they export it to you? 

Dr. BESSER. CDC is able to receive anonymzed data from many 

sources and when we work with states around this area there are 

provisions that protect those data that come to CDC. What we 

found is that when hospitals start to do the surveillance around 

line infections and implement what have been shown to be effective 

control strategies that they see a dramatic decline in those infections. They are entirely preventable, and that is something that 

where we think there could be major improvements. 

Mr. BURGESS. Sure. That is the epidemiologist mantra. To measure is to control. I guess I am concerned because our tendency is 

to be punitive on this and I know certainly from the physician community we are so goal directed. If you are not going to pay me if 

I diagnose a surgical site infection, I will never diagnose another 

surgical site infection through my professional career because after 

all I want to get paid. So we contend to obscure the data by how 

we focus on things. I want to touch on something else because you 

have got in your testimony about HIV prevention, and nowhere in 


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there do I see—I will just tell you the problem that I have in my 

community in southeast Fort Worth is that we have individuals 

who are arrested for one thing or another, incarcerated and returned to the community and now with an HIV infection and it 

then spreads outward from that exposure. Are we doing anything 

to look at our exposure to our prison population and then their subsequent re-integration into society? 

Dr. BESSER. Mr. Burgess, I will need to get back to you on that 

in terms of specific programs in that setting. I think that when it 

comes to HIV prevention and control as with other infectious diseases understanding where transmission is occurring and ensuring 

that we have programs to address that route of transmission is absolutely essential. Earlier we heard someone mention the 3 percent 

HIV prevalence in African American males in the district. That is 

unacceptable. We need to understand what is driving transmission 

and put in place control efforts so that that will not be the case. 

But let me get back to you in terms of—I know we do a lot of work 

with health care—with infectious disease transmission in prison 

settings but I want to make sure I get back to you with accurate 

information. 

Mr. BURGESS. OK. Very good. And I appreciate that, and of 

course we know that if we are seeing that high a rate in African 

American men it will just be a very short period of time before we 

see a similarly high rate in African American women, and part of 

our job is to prevent that from happening in the first place through 

educational activities. One last thing that I will just mention and 

I have heard access mentioned several points this morning. I have 

an area that I represent. Two or three of my zip codes have some 

of the highest infant mortality rates in the Nation, and it is in 

Tarrant County, which of course has a robust county hospital district, county tax supported facility and literally within the shadow 

of these facilities are some of these neighborhoods where infant 

mortality is so high and the problem therein is utilization and not 

access because access is clearly available but we don’t have clinics 

where the people are, and trying to work through the cumbersome 

bureaucracy that exists in HERSA and HHS has made it all but 

impossible to get a community health center, a federally qualified 

health center, developed in those areas. 

And one of the most meaningful things we can do as we go forward is to try to unravel some of that so that we don’t put these 

barriers up to getting the care were it is actually needed. I hear 

testimony from other members on both sides of the dais where they 

talk about 10, 12, or 14 federally qualified health centers they have 

in their districts. I have zero in my district, and I have got infant 

mortality rates that are third world, and it is unconscionable that 

we will continue this program where—it is not just a racial disparity. It is a geographic disparity that is of startling proportions 

and I really hope that going forward this committee will spend 

some effort in looking at that, and certainly where CDC can give 

us some help, I hope they will do so. So I thank you, Mr. Chairman, and I will yield back. 

Mr. PALLONE. Thank you. Next is Mrs. Capps. 

Mrs. CAPPS. Thank you, Mr. Chairman, and, boy, what an excellent panel. This could go all day. And I have a question for each 


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of you and I have tried to make it narrow but it is impossible. Dr. 

Besser, you discussed examples that make it clear that accurate information about key public health indicators such as infant maternal health is essential to improving the overall health of the public. 

Maybe this is what Chairman Dingell was kind of getting at as 

well. There are currently barriers to surveillance that make it difficult to gather public health data. We have to have the data in 

order to make the case for more access and better ways of implementing public health. Can you describe briefly some of those barriers, what we could do to help accomplish the positive health outcomes that comprehensive surveillance data could give us? 

Dr. BESSER. Thank you very much for that question. There are 

a number of things that I can think about that would improve our 

ability to understand the health status of Americans. Right now 

there is so much discussion around electronic health records and 

what these are going to provide to improve clinical care by providing to that clinician information about screenings that need to 

take place. Well, this also is a potentially very powerful tool for 

population health and insuring that as this moves forward there 

are fields that are in there that represent the important components that we need to look at for public health, and that the clinics 

are not just connecting to each other but they are connecting to 

public health departments. 

That is one thing that would be extremely effective. We at CDC 

have seen over time a decline in support for our National Center 

for Health Statistics. The National Center for Health Statistics is 

critically important to measuring health of people around this 

country. It is important for us in terms of measuring the impact 

of programs that we put in place and ensuring that we are spending our resources appropriately. It is important for identifying disparities and issues that need to be addressed in particular communities. And we have had to make tough choices over time in terms 

of decreasing the frequency of surveys or decreasing the size of a 

population under a survey, and it is very difficult when we are 

doing that to really get a measure of the health status of all Americans. 

Mrs. CAPPS. Even though I know you could talk more about this 

topic, I just want to from that as we look for a comprehensive 

health legislation, we do need to be cognizant that data collection 

is an integral part of doing that. Dr. Fielding, you have done so 

much for the metropolitan Los Angeles area. Thank you. As we 

work to reform the health care system public hospitals and community health centers are essential to ensuring that rising numbers 

of uninsured and underinsured patients can access health care during a recession which we are seeing right before our eyes. In the 

future, safety net health systems must remain intact to provide the 

services that newly insured patients will need to effectively access 

care if we are really going to implement an increased number of 

people getting care. 

We have got to find a place for that to happen, including language translation and social work services. Safety net providers 

will also continue to provide money losing services such as trauma 

and burn care that many other hospitals choose not to offer. So 

what kind of policy questions should we be addressing in our 


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health reform dialogue to insure that the safety net stays viable for 

the future and that kind of topic particularly now if we transition 

into a broader based health delivery system? 

Dr. FIELDING. Thank you very much. You are absolutely right. 

We need to maintain a safety net. These are providers who are 

very sensitive to the population for whom language is not a barrier 

who understand the morays, the culture, the beliefs, and that has 

been lacking is sufficient funding to try and knit all the pieces together so that, for example, community health centers might have 

the same record as the hospital or primary care and secondary care 

might have the same ability and to transport things back and forth 

easily electronically. That is one need. Another need, of course, is 

simply to give people the tools so that they can maintain the infrastructure necessary. 

In some cases, public systems have not done as well in trying to 

maintain themselves just physically as others have. But I also 

think that we have to look over time in the local situation to see 

what impacts a broader mandate will have and in some cases it 

may transform systems. In other cases, it may not change them 

very much. To what degree are there going to be competitive opportunities or not, so I think it is going to be a situation by situation 

issue. I would add one point to answer your last question. We do 

a local health survey. We have the LA health survey, and we do 

over 8,000 people every other year in Los Angeles County of over 

10 million people. And we get a lot of interesting and important information on issues as diverse as breast feeding and what are the 

barriers to that, one of our most important opportunities, or emergency preparedness. What percentage of our population are prepared for emergencies and have a family communication plan, have 

the 10 essential items that they need? 

We have more than our share of natural disasters and we worry, 

of course, about others so I think having local data collection is also 

important to supplement the very important role that NCHS plays. 

And I just want to echo that the National Center for Health Statistics has not had the funding they need, and if we are doing to coalesce our Nation around the 2020 objectives for the Nation, then we 

have to have the data on which to base that, and we have to know 

if we are tracking in the right direction or not and not just nationally but at the local level, so robust funding for that effort is going 

to be essential. 

Mrs. CAPPS. Thank you both. 

Mr. PALLONE. Thank you. Mr. Gingrey. 

Mr. GINGREY. Mr. Chairman, thank you. And I wanted to ask 

both Dr. Besser and Dr. Fielding, all Americans of course should 

have quality health care regardless of income, race or age. Dr. 

Besser, let me start with you. I believe, of course, that any disparity should be a major part of health care reform, and I know 

we have talked about this this morning and several of my colleagues on both sides of the aisle touched on that issue. And, Dr. 

Fielding, I think in your testimony you talked about a lot of things, 

situations, education, but I guess really what I want to find out is 

if either one of you think that there are other reasons for racial disparity in regard to receiving the kind of high quality health care. 


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An example, in the Medicaid program, there might be a tendency, might, I would hope not but I think likely there is for health 

care providers to be a little bit prejudice towards people who come 

in the door who obviously are not taking care of themselves. Maybe 

they are obese, maybe they are unkempt, maybe they are smoking 

cigarettes, whatever. But I really am concerned there could also be 

that same sort of attitude towards different minority groups. And 

so this is a little touchy subject but I think it is hugely important 

that we talk about it, so I would like for you to address that. 

Dr. BESSER. Thank you, Mr. Gingrey. Dr. Fielding, in his discussion earlier was talking on issues around social determinants of 

health, and I do think those are critically important. Where you 

live, whether your parents graduated from school, what type of occupation they may have and what type of occupation you have are 

things that do impact on your health. We know that children who 

live in the inner city have rates of asthma that are far greater than 

individuals who don’t live in an urban environment. We know that 

children who are born to a single parent have a lower likelihood 

of graduating from school, and if you don’t graduate from high 

school then your health future is more bleak. 

And so there are a lot of factors that go into issues of health, 

some having to do with access to care. In the clinic I work in in 

Atlanta, I would say that it is a fraction of the children I see there 

have any health insurance at all. Those who do, the state pays 

Medicaid, and whenever I have one of those children it is like a 

blessing because I know that I can refer them to the dentist down 

the hall to get their teeth taken care of, and I can refer them to 

other services. So I think access to care is part of the issue when 

we look at promoting health, but it is important to look in each 

community to see what are the barriers for the entire population 

to get the health services and the health that they deserve. 

Mr. GINGREY. Dr. Fielding. 

Dr. FIELDING. Yes. I think one of the needs is to develop a work 

force which is reflective of the population and I think there are a 

lot of efforts, and Dr. Satcher has been a real leader and can talk 

about both his leadership training and other efforts. I think that 

is a very important initiative. I think it is also important to realize 

that a lot of the health disparities are really inequities. They arise 

from social and economic disadvantage, and we have some responsibility to try and overcome those. We are not always entirely successful but we need to do that and sometimes it will take some 

extra effort. 

The third point though is that we have a very heterogeneous 

population. In Los Angeles County, for example, there are no minorities because there is no majority currently. Now there will be 

a majority within 10 years and that will be Latino in this largest 

county in the country, so the whole issue of minorities is an interesting one in terms of definition. But I think there is real opportunities, and we have to marry what we do at the individual level 

with what we do at the community level. That is why having core 

public health is so essential to helping to reduce disparities, and 

we need a lot more research on that. 

When we in the community guide look at each of these policies 

and programs we find often times that there isn’t data on which 


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programs have reduced disparities, and we need a very focused research effort to do that, realizing of course that not all disparities 

are ones that come from social or economic disadvantage, sickle cell 

among African Americans, Tay-Sach’s among Jews and northern 

Europe origin, et cetera, et cetera, so there are some differences 

that are not real disparities in the same sense. 

Mr. GINGREY. And thank you, Dr. Fielding, as well. As I read my 

book and material, and I think I noticed the figure of 58,000 or so 

deaths per year in a minority population, all these things considered, which both you and Dr. Besser discussed, over and above that 

there are still this many deaths over what it should be for minority 

groups, and I look forward to the second panel. I will bring up this 

same issue with Dr. Satcher because I think it is very important. 

I would like to know is there any evidence that providers of health 

care whether they are in Los Angeles County or in Atlanta, Georgia that for reasons of maybe unrecognized prejudice within themselves are not ordering the necessary tests or not taking the necessary amount of time with certain populations, and if that is the 

case obviously that is something that we need to stop whether it 

is through educating our young people in medical school or what, 

but I thank you for your response. I know my time has expired. 

And, as I say, I look forward to the next panel as well. I appreciate 

that. I yield back, Mr. Chairman. 

Mr. PALLONE. Thank you, Mr. Gingrey. Mrs. Christensen. 

Mrs. CHRISTENSEN. Thank you, Mr. Chairman. I am tempted to 

answer Dr. Gingrey’s question, but I am going to leave it to Dr. 

Satcher in the interest of time. But I am glad that just about every 

one of the panelists speak to the importance of the social determinants, and I am particularly interested in the health impact assessment, something that I have been advocating for as well. I 

have two questions. I am going to try to get two questions in. Dr. 

Besser, all of us are very pleased with the $1 billion for prevention 

and you have outlined broadly how CDC plans to use that money, 

but in the $650 million for prevention and wellness, how much of 

that is going to be used to target health disparities, maybe expand 

on reach programs, for example, and we also within the three minority caucuses are working on a bill to create health empowerment zones, which would allow health communities to have the resources and develop the plans, address the health disparities, and 

then give them priority for funding from any one of the agencies 

in the federal government to not only address the disease entities 

but also the social determinants. What do you think about that 

program? How are you using the money? 

Dr. BESSER. Thank you, Mrs. Christensen. In terms of the prevention and wellness funds, we are absolutely thrilled to have $650 

million to work on that. Those funds were appropriate to the department, and I chair the group, the subgroup within the department that is looking at how best to utilize those funds. We have 

put together a working group from across the department and it 

has been an incredible process because when we look at the areas 

that CDC has control over, we see what we know, but when we sit 

down in the same room with people from the Agency on Aging, 

folks from SAMSA, folks from HERSA, we get additional ideas, and 

so we are in the process of formulating this signature initiative. 


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Disparities is going to be one of those factors that is looked at here 

because in everything we do in public health, we need to ensure 

that we are addressing disparities. At this point, I can’t tell you 

what the entire program will look like but disparities will be part 

of that. 

Mrs. CHRISTENSEN. Thank you. And I am going to ask the other 

question about the health empowerment zones on the next panel 

as well. So, Dr. Fielding, I am interested to know how the task 

force over 200 proven methods relates to communities of color and 

if they go far enough to help eliminate health disparities. A lot of 

people have made reference to diabetes so let me just focus on that. 

ADA recommends, for example, screening for pre-diabetes if one is 

a racial or ethnic minority or over 45. The task force really as best 

as I understand it doesn’t recommend pre-diabetic screening. And 

in terms of diabetes screening, Medicare covers screening for if one 

has two out of seven risk factors the task force recommends if there 

is hypertension present, but do you think that CMS recommendations or the task force recommendations are adequate to address 

the issues of people of color when, as we have heard, Mexican 

Americans have twice as much—twice as more likely to have diabetes, African Americans and Native Americans as well. 

And you, yourself, have said in your testimony that there is this 

major gap in information on health disparities that needs to be 

closed. What can be done to close that gap and to make sure that 

the solutions that we recommend address all Americans? 

Dr. FIELDING. Well, thank you. A very well crafted and complicated set of questions that I hope I can answer easily, but it is 

not so easy because, first of all, we have to make sure that if we 

screen for something that we have the ability to change the course 

of the disease based on screening. Fortunately, for diabetes the evidence growing for Type II diabetes that we can, that there are programs that can help people, particularly through nutrition and 

physical activity can, in fact, reduce the likelihood that they are 

going to get frank diabetes, so that is very important. 

There are huge differences with Latinos and African Americans 

having much higher rates associated with higher rates of overweight and obesity. There has not been enough research on what 

the differences are, and are there any specific ways that we should 

be treating people based on genetic differences, cultural differences, 

and the like. One of the opportunities, I think, is to take some of 

the money that is being allocated for comparative effectiveness and 

to look at not only comparative effect of different methods but look 

at them with respect to different populations. 

Mrs. CHRISTENSEN. We had a big major battle in trying to make 

that happen, but I think we were successful. 

Mr. PALLONE. Thank you. Mr. Murphy. 

Mr. MURPHY of Connecticut. Thank you, Mr. Chairman. I think 

one of the most exciting things about the more broader comprehensive health care debate that is happening right now is that we are 

focusing not just on the financing piece of the equation but also trying to challenge Congress to step up and look at the way we deliver 

health care. And one of the, I think, emerging consensus points is 

the role of primary care providers in that equation, and our lack 


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of focus on trying to give those primary care doctors the space with 

which to really engage in good preventive medicine. 

One concept that has been talked a lot about is the medical home 

model which would give primary care doctors a much greater role 

in coordinating care. And it strikes me that to the extent that we 

are going to return to a much more primary care based model it 

is an opportunity for public health as well. And so my question to 

both of you is simply this. What is the space in which a greater 

focus on primary care intersects with public health and what are 

the things that we need to do as a Congress to try to create a 

greater role for primary care physicians to be able to do real coordination with public health systems that surround them? I will ask 

Dr. Besser first and then Dr. Fielding. 

Dr. BESSER. Thank you, Mr. Murphy. I spent 5 years as a pediatric residency director in California and served on a commission 

that was trying to see what we could do to encourage more people 

to go into primary care. Clearly, there are major gaps in the number of primary care physicians in this country and in particular in 

isolated areas that contribute to disparities. I think to make primary care more attractive in addition to the balance on reimbursement being different than what it currently is, we need to have 

community services available that primary care physicians can tie 

into, so that when they see an adult with pre-diabetes they can 

connect to something in the community that will help address that 

issue. 

I visited Vermont a couple weeks ago and was exposed to the 

Vermont blueprint for health, and what they are experimenting 

with is just that, how do they—they have a system where if they 

have a patient who has a medical condition that has partially a 

community solution, they can connect to a team in the community 

to address that. And it is profound what that does in terms of your 

ability as a primary care physician to impact on the health of your 

patients. 

Mr. MURPHY of Connecticut. Dr. Fielding. 

Dr. FIELDING. Yes, I would agree entirely. We need to have ways 

of interfacing between those in primary care and those in public 

health who are doing community services. When I say public 

health, it is not just governmental public health, it is all the voluntary agencies and the other supporting and social agencies that 

are equally important and that aren’t always well coordinated. 

There is a real problem in getting those in training to go into primary care. And I think the reimbursement issue is probably going 

to have to be addressed if we are going to redress some of that balance between those who want to go into specialty care and those 

who want to do primary care. 

But I also feel it is important to point out that even if we have 

good primary care and good linkages unless we are addressing the 

other determinants of health, we are not going to become the 

healthiest Nation. We are going to be still pretty low on that list 

despite spending $1 out of $6 on health care. So the question is, 

and one of the things that would be helpful would be to have the 

physicians who are more understanding and knowledgeable about 

public health, I think the amount of training that a physician has, 

for example, in public health as part of their residency, as part of 


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their medical school, varies tremendously, and in some cases not 

very much, so they don’t have an understanding of how there can 

be a better fit between what goes on in the office and what goes 

on in the community. 

Mr. MURPHY of Connecticut. Thank you for those responses. Dr. 

Fielding, I want to take a right turn and just move to a different 

subject and ask your quick thoughts. About the structure of health 

care delivery through the public sector, in Connecticut we have a 

very disjointed system where we have some municipal offices of 

health, we have some regional offices of health, and in more rural 

areas we have part-time offices of health where there is just a doctor, a physician in the community, who is that local health director. 

And it is of great worry to me that if something big and terrible 

was to happen that we might not have the sort of aligned and consistent infrastructure to respond. I would ask very quickly if that 

is a concern of yours and to Dr. Besser as well. 

Dr. FIELDING. It is a real concern. There is great diversity in the 

capacities. One of the things that I think has to happen is there 

has to be some coalesce. There need to be networks. Whether you 

want to do that structurally or simply through memos of agreement 

and joint training or whatever, but we have too many. In some 

cases we have departments with very, very limited. The accreditation process will help that that will coalesce, will push people to try 

and come together but there needs to be statewide and even regional systems around metropolitan areas where people can respond as one. 

Mr. MURPHY of Connecticut. Thank you very much. I yield back, 

Mr. Chairman. 

Mr. PALLONE. Thank you. Ms. Eshoo. 

Ms. ESHOO. Thank you, Mr. Chairman. I guess the benefit of 

staying for a long time in a hearing is that you get to hear a lot, 

and I appreciate what you have said, both in terms of your testimony, and I respect the work that you do. It seems to me that we 

already know a lot. It doesn’t mean that we shouldn’t continue to 

comply to do the research that is necessary, to drill down, to understand better the composition of a community, what the various factors are that contribute to the bad outcomes that we know that we 

have, and so I support all of that. I am looking forward to a really 

great surgeon general of the United States because I think we need 

someone that is going to really market public health and what we 

can do. 

Now I think that we have a lot of structure. I am not saying that 

we shouldn’t add to it and make sure that we target our investments very well, but we also know what the tremendous contributors are to very poor public health. I mean is there any community 

in the country, rich or poor, black, white, green, purple, yellow that 

benefits from smoking? I mean we just know that it is bad. It is 

worse in some communities because they are targeted. They are 

targeted because they may be uneducated, because they are poorer, 

because they are that much more vulnerable. What community is 

it terrific to be overweight? I mean we know what obesity does. We 

know what it does in children. We know what it does in adults. Everything from heart attacks to juvenile onset of diabetes and on 

and on. I think that the public health system in the country really 


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needs to concentrate or take a fresh look at how you can do better 

marketing. 

Don’t you think it would be powerful to do even ads that show 

maybe a bag of sugar, a 10-pound bag of sugar? I mean where is 

it—children are sweet by nature but they don’t need to consume 40 

to 60 pounds of sugar, refined sugar, a year, in order to be sweeter 

or better or healthier. So I think that there are some things that 

we may be overlooking that are very, very powerful messages, and 

I don’t know, there must be a national association of public health 

directors in the country. Why not look at some of this outreach 

money from the stimulus package that will really target those communities that are being mauled by these terrible things. 

It is more of a statement than a question. I was very taken with 

the public health service did in Japan. They required adults, men 

and women, to come in and have their waist measurements taken, 

and if they were over a certain number of inches for males, over 

a certain number of inches for females, they had to go back in 3 

months to have that taken again. Why? They made a pointed effort 

to bring it to every person that if they are overweight that they are 

subject to that we may not be able to do that in our country that 

way. But the whole issue of food stamps. Why don’t you all come 

out with a great campaign and come here and advocate the hell out 

of the Congress and say let us link obesity and food stamps and 

do something about that together? 

So while my colleagues have come up with a hundred good items 

today, I think that we need to look at just marketing the heck out 

of the country on some of these things that we know are bad, 

awful, that are killers, that are contributors to the heavy, heavy 

costs in our system and to the agony and tragedy that takes place 

in families and also to give kids a chance, give kids a break. So, 

I don’t know, you may not want to respond to that. I got 20 seconds 

left. I think that you have some power that you may be overlooking 

to tell you the truth, and I want you to have the maximum amount 

of dollars to do what needs to be done. I am not going to go into 

that. But do you have anything to say about this? Do you have anything that you can tell us that you are going to be marketing as 

kind of the marketing directors for public health across the country? 

Dr. BESSER. Two comments. Thank you for that statement. One 

is that I think you are on target that for many things we know 

what works, and we need to implement it. And what we are working on with the stimulus dollars is implementing evidence-based 

programs. 

Ms. ESHOO. Yes, I don’t want any wild marketing that can’t keep 

a promise or isn’t based in sound science, but it seems to me we 

got a pile of science about some of these things already. 

Dr. BESSER. The other comment I want to make is that there is 

a $20 million pilot in the Farm Bill to look at what you can do to 

promote healthy food in food stamps. And we have seen improvements in WIC and hopefully there will be evidence that doing that 

with food stamps will also be effective. 

Ms. ESHOO. Well, you know, see, I kind of disagree with that. I 

think that that has got to be the slow man’s approach in order not 

to go anywhere. We know that food stamps purchase junk in plain 


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English and it seems to me that the public health directors in the 

country would be a great antidote to the lobbyists that come here 

and say really this junk is OK, but let us do a study in a slow 

walk. So you can tell where I am headed. I have a legislative impatience, but I think outside of legislation but advocacy in some of 

these areas here that we could really make some headway. Thank 

you, Mr. Chairman. 

Mr. PALLONE. Thank you. Mr. Gonzalez. 

Mr. GONZALEZ. Thank you very much, Mr. Chairman. And to the 

witnesses, thank you for your testimony. We are having hearings, 

multiple hearings, just about every week in preparation for what 

will be landmark legislation, health care reform, so in the context 

of that, first, a general proposition is what is the role of public 

health, but specifically and in the context of what we are contemplating doing here in Congress, which I know that you have been 

following because there is impact to you, but I guess not everyone 

agrees that we should have this reform and surely not everyone— 

we will have witnesses that will follow you that don’t agree even 

about your particular role. There are some that believe that for 

contagious diseases public health has an appropriate role but when 

it comes to treatment and prevention of chronic diseases that public health does not. 

And I believe that one of the witnesses will testify specifically to 

that. I could be incorrect about that, but that is the first question. 

What is the role when it comes to contagious versus chronic? It 

really kind of sets the stage for what is the appropriate role for 

public health. And, secondly, there are those that are saying, well, 

if we do revolutionize the availability of access to health insurance 

with a public option that has tremendous impact, and so I want to 

know what you bring to the table. What does public health bring 

to the table in this greater equation when it comes to expanding 

where we were talking about accessibility, affordability, and quality health care as we attempt to fashion legislation? 

Dr. BESSER. Thank you very much for that question, and I think 

it is a fundamental question that we are dealing with today, and 

that is what is the relative roles between access to care and providing health care services and public health which focuses on prevention and health promotion. I think that if we solely look at access to care, and don’t get me wrong, access to care is critically important, but if we only look at access to care, we are not going to 

see an improvement in the health status of our Nation in the long 

run. We need programs that are looking at what is driving the diabetes epidemic, what is driving the rise in heart disease, what is 

driving these issues. And that is where public health comes in. 

If our entire country has access to care, we still have a critical 

role for public health setting aside the health protection issues of 

emerging infectious diseases and responding to public health emergencies. Public health is responsible for ensuring that the environment we live in is healthy and looking to ensure that there aren’t 

toxins in the environment that are putting people at risk. Public 

health looks at addressing disparities. Even with access to care, 

there will be disparities that need to be addressed by the public 

health community. Public health is critical for occupational safety 


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and health and ensuring that the work environments in our community are safe. 

And we know through so many programs that public health can 

have a dramatic impact by promoting health, by addressing those 

issues of physical exercise, nutrition, and smoking. We keep hearing those three. Those are the big three. There are also additional 

ones, alcohol use, substance abuse, but public health and what public health does within the community setting is fundamental to ensuring that in the long run we are spending less on health care and 

that our population is healthy. 

Mr. GONZALEZ. Thank you. 

Dr. FIELDING. I think Dr. Besser said it extremely well. Our job 

is to provide conditions in which people can be healthy, and we are 

going to get there just by increasing access as important as that 

is. We also need to be clear what we are talking about when we 

talk about public health. I think we have been using it here in different ways. One way is governmental public health, very important. The state and local public health agencies, that is the core infrastructure. But public health also means working with non-profits, working with businesses, working with voluntary organizations 

at the community and state and national level. 

And we need that broader conception of public health to be effective, but we are not going to solve a tobacco problem or unintentional injuries or substance abuse problems just by providing more 

medical care. We have to focus on the prevention side. We have to 

focus on the community support side and that can’t all be done 

through the health care system. We have already medicalized perhaps too much and it is time perhaps to redress that balance. 

Mr. GONZALEZ. Thank you. Mr. Chairman, I have a minute left, 

and I just really want to make a statement in appreciation for 

some of the things that you have said. You have eluded though to 

health information technology or electronic medical records. I can 

think of no greater beneficiary than public health in making sure 

that we have wide acceptance and adoption of HIT. It is called information gathering, analysis and dissemination which is basically 

the essentials in what you all do, so I commend you, thank you for 

your comments, and I hope that you will be pushing hard every initiative that we have regarding the adoption of HIT. I yield back. 

Mr. PALLONE. Thank you. The gentlewoman from Florida, Ms. 

Castor. 

Ms. CASTOR. Thank you very much. Yesterday morning I visited 

a community health center in my district in Tampa and we were 

announcing additional recovery funds, grants, under President 

Obama’s recovery plan. The Tampa Bay area community health 

center has received a little more than $31⁄2 million. The center I 

visited, they are going to hire doctors and physician assistants and 

nurses, and they are very appreciative, and they will be able to see 

more patients. And they took me on a tour afterwards, and I was 

not aware that all of the community health centers in most of the 

urban areas in Florida have already converted to electronic medical 

records. And they raved about it. They said we really are able to 

provide better patient care. 

They also said we are able to cut down on fraud because there 

is a picture of each patient. If they have someone come in and ask 


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for certain pharmaceuticals and the picture doesn’t match that they 

call security. But following up on some of the discussions there are 

requirements in place right now for health centers and other providers to collect data and to transmit it, whether it is a community 

level, a state health level or to the National Center for Health Statistics that you mentioned, are there requirements in place now? 

Dr. BESSER. No. Within particular states and localities, there 

may be individual requirements but at a federal level there is not 

a requirement for reporting of that information. When I was talking earlier about the National Health Safety Network that is looking at infections in health care settings, that is a voluntary system 

of collaboration between states or health care facilities and the 

CDC. I look forward to a day when all of our health care settings 

are connected electronically and that information is flowing to public health at all levels because that can really have a dramatic impact on improving health. 

Dr. FIELDING. There is one exception though and that is reportable diseases through the states and to the Centers for Disease 

Control, and one of the real advantages of having electronic systems that work through laboratories is that we get much faster reporting and much more complete reporting because it is one thing 

if you have to ask a busy doctor to fill out this report and send it 

in, and maybe it comes in and maybe it doesn’t and maybe it is 

timely and maybe it isn’t. When you are getting direct feeds from 

the laboratory as we are in Los Angeles County from a lot of the 

large laboratories, we know about identification of problems of reportable diseases much more quickly and are able to get a jump on 

them. And from the standpoint of controlling outbreaks and potential epidemics, that is a crucial advantage. 

Ms. CASTOR. So as we build this infrastructure, there needs to 

be data collection points. What is the logical location? Is it community based, state based? Is it reporting to this National Center for 

Health Statistics? How do we build that infrastructure? What is 

your recommendation? 

Dr. BESSER. There are a number of different models that look at 

this and there are several critical pieces. As Dr. Fielding was saying, being able to transmit laboratory data that way is essential to 

early detection and control of outbreaks. But creating a health information community so that the data can be viewed at different 

levels. It can be viewed within a health system. It can be viewed 

at the local or state public health level. It can be viewed at the federal level. Clearly, there have to be protections within those systems that protect the identity of individuals but having that kind 

of common space for looking at data would have enormous benefits. 

Ms. CASTOR. OK. In my 1 minute that I have left, Dr. Besser, 

you have experienced environmental justice issues. Can you provide your priority recommendations for health care reform and 

public health relating to environmental justice in 1 minute or less? 

Dr. BESSER. Thank you. Clearly, health is not something that 

takes place in a doctor’s office. It takes place in all settings, and 

we have to ensure that our population is living in healthy environments. So looking at schools, work places, where you reside is critically important, and that is an essential protective value of public 

health. Public health is there to look to ensure that our commuVerDate Mar 15 2010 01:39 Mar 02, 2012 Jkt 067821 PO 00000 Frm 00090 Fmt 6633 Sfmt 6633 E:\HR\OC\A821.XXX A821

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nities are safe. From an environmental perspective, we need to 

make sure that we are not being exposed to chemicals and toxins 

that could impact on our health, and the resources need to be there 

for public health at all levels to fulfill that function. 

Ms. CASTOR. Thank you very much. 

Mr. PALLONE. Thank you. Mr. Sarbanes. 

Mr. SARBANES. Thank you, Mr. Chairman. Thanks for your testimony today. I am fighting the same battle you are, Mr. Chairman, 

with my kids and getting them outside, and so I wanted to pick up 

on that theme and develop it a little bit more because there is such 

huge benefits to getting our kids outdoors. I have authored something called the No Child Left Inside Act, which I invite you to 

learn more about. It began with a coalition of 12 organizations in 

Maryland. We now have 1,200 organizations across the country 

that represent 40 million members among them, and this coalition 

is comprised of educators who understand that when you get kids 

outdoors and have a chance to apply what they are learning outside, thy learn better. It consists of environmentalists, of course, 

who want the next generation to have a heightened awareness of 

the environment typically when we are facing issues of climate 

change. 

But it is also comprised of many, many public health advocates 

who recognize that getting kids outdoors and engaging them, not 

just saying go outside, but giving them a reason to be there and 

excited about being outside is fundamental to improving their 

health, health of the next generation. And so I would for starters 

invite you to join the coalition and be a supporter of that. But the 

information that underpins the effort is showing, for example, that 

the average child today spends 4 to 5 hours indoors on television, 

the Internet, the video games, and notwithstanding the arrival of 

Wii and its contribution to physical exercise in a virtual world, 

there are still reasons to get kids outdoors. 

The data also shows that kid spend an average of about 4 minutes a day outdoors in unstructured play and recreation. We have 

predictable consequences for their health, both in terms of attention span and their physical health and so forth. So I am very excited about the potential to link our efforts with No Child Left Inside, which is to try to create a federal source of funding, grant 

funding, to promote environmental education to really integrate it 

in the instructional program across our public school system to get 

kids outdoors to link that effort to the public health effort. 

And what I would love to hear you speak about for just a few 

moments is the extent to which you think environment education 

efforts of that kind can represent kind of a leading edge of public 

health effort with respect to the next generation in particular although I will add that when you talk to these kids who have gotten 

so jazzed and engaged by being outdoors, they are telling you that 

they are going back to their families insisting that their parents 

and their siblings go for hikes on the weekends and get outdoors. 

So they are dragging the rest of their family into the light at a time 

when we need that for so many reasons. 

So I wonder if you have brought this lens in thinking about public health and maybe a revolution of public health, this lens on eduVerDate Mar 15 2010 01:39 Mar 02, 2012 Jkt 067821 PO 00000 Frm 00091 Fmt 6633 Sfmt 6633 E:\HR\OC\A821.XXX A821

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cation and environmental education in particular to the effort. And 

I invite either one to address it. 

Dr. BESSER. Thank you, Mr. Sarbanes. First, I love the title No 

Child Left Inside and look forward to reading more about that particular legislation. I think that this fits in very well with our view 

of how public health can contribute to health and the idea that 

health occurs in all settings. Schools that foster a culture that values the environment, that values getting out into the environment 

will create adults who do the same and that will be a more active 

society and a healthier society. The Academy of Pediatrics has 

standard recommendations on how much time should be allowed in 

front of a television or a computer screen but your point is very 

well taken that there have to be alternatives to that. 

When I talk to a parent about getting their child outside to play 

either on structured play or on team play if those options aren’t 

available there is not a lot of value in my spending that time with 

that parent going through that counseling, so I look forward to 

reading about your legislation. I think the intent of it is right on 

target in terms of promoting health in all areas. 

Mr. SARBANES. We will make sure it is on your desk when you 

get back to your office. Mr. Chairman, I won’t name the particular 

video game that does this, but it is not atypical, and there is one 

game in particular where I think after about an hour of playing on 

it, it invites the child to blink their eyes, close their eyes and open 

them 10 times before they embark on the next level of the game 

and so this is meant to represent the compensation for the fact that 

they are not getting exercise or need a break from that virtual engagement, so we have got a lot—and I just want to say obviously 

the next generation has to be well versed in technology. That is not 

what I am talking about. We are trying to achieve a balance at a 

time when things are way out of whack. I yield back my time. 

Mr. PALLONE. Thank you. You are right. Ms. Baldwin. 

Mrs. BALDWIN. Thank you, Mr. Chairman. As you have heard, 

our committee has had a lot of focus on addressing health care disparities especially based on race and ethnicity, and you have already been questioned a lot about those issues. I believe that there 

are serious health disparities that exist based on sexual orientation 

and gender identity and that belief is based on much input from 

and discussion with leaders of community-based organizations that 

provide direct services to lesbian, gay, bisexual, and transgender 

youth and adults, and also based on some of the few local survey 

tools that actually ask questions. But it is really quite frustrating 

to get a clear understanding of the scope of these disparities because most of the data collection tools at the national level don’t 

ask questions about sexual orientation or gender identity. 

Dr. Besser, you have noted that you have learned about the importance of tracking health data and monitoring changes in health. 

I am wondering if you are aware that the national health interview 

survey, the federal government’s most comprehensive and influential survey, does not include a question on either sexual orientation 

or gender identity. 

Dr. BESSER. That is not something that I was aware of but something that I think I need to learn more about. Clearly, if we are 


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going to address a particular health issue, we need data to be able 

to look at that clearly. 

Mrs. BALDWIN. Would you support adding such a question to that 

survey tool if you find that it indeed doesn’t exist? 

Dr. BESSER. What I would like to do is understand first whether 

it is there and, if not, why it is here, whether there are any legal 

restrictions to collecting any particular data. I think that in order 

to make informed health decisions, we have to know. In addition, 

I think we need to do work on the health care delivery side to improve the core competencies of health care providers to address 

issues of gender and sexual orientation. My experience coming 

through medical school and even as a residency director, it is not 

something where there is a lot of education in how to address those 

issues. 

Mrs. BALDWIN. I think that is a very important companion inquiry. I want to share that it is my understanding that none of the 

surveys that are conducted through the National Center for Health 

Statistics inquire about issues of sexual orientation or gender identity, and it is my understanding that the only mention of such 

issues in the 2020 objectives is that there is a statement basically 

that we need more data on LGBT populations because we cannot 

currently understand the depth of the problem. So I think we have 

a very serious issue that it is really hard to make evidence-based 

recommendations when you are not collecting any evidence. Can 

you tell me in any way right now how does the CDC currently 

track and monitor the health of the LGBT population? 

Dr. BESSER. I can’t answer that question, but I will get back to 

you on that. I think that is an important area for us to be pursuing. 

Mrs. BALDWIN. I have some time left, and I want to ask some 

really broad questions about the public health infrastructure. I 

wonder if you could each give me an assessment of the current 

local, state, and federal public health surveillance system, what 

you think the infrastructure status is right now. As I noted in my 

opening statement, I author a bill with my colleague, Congressman 

Terry, to make some infrastructure investments there. And the second quick comment I would like you to make is whether epidemiology struggles with the same work force shortage issues that we 

are seeing in the medical system generally. 

Dr. BESSER. Addressing your second question first, since it is an 

easy one, there are major gaps in our public health work force and 

a number of organizations have developed estimates of how great 

those gaps are. Of great concern is with the current state of our 

governments at all levels, we are seeing a loss of the work force 

at the state and local level, tens of thousands of state and local 

public health employees who will be let go and so that is a gap. 

Your question about surveillance, I will answer briefly and would 

be happy to follow up in more detail but there is great variability 

in our ability to detect laboratory capacity is extremely variable. 

Some states have wonderful systems. Others are much more rudimentary, and we need a system that protects our entire country. 

Dr. FIELDING. Let me just add a couple of things to that. We also 

have pipeline issues, not just those that are being laid off because 

of the economic climate but in epidemiology, laboratorians and 


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those that can do the analysis work as those techniques become 

more and more sophisticated there is serious gaps in that. With respect to surveillance, I think that we need to be very broad in what 

we look at. Increasingly, we need to look at the environment and 

a lot of aspects of the environment. Some of that is the physical 

environment, some of that is the social environment, and we need 

to have good core indicators to look at those. With respect to the 

LGBT community, we have done some—we have, in fact, in Los 

Angeles asked those questions in our survey and find that there 

are serious gaps in the delivery system, found, for example, that 

the highest rate of tobacco use was among the LGBT community, 

and have, in fact, devoted specific programs to some of the problems that we found. 

Certainly, with respect to HIV, you know, in Los Angeles County 

a very disproportionate burden is on men who have sex with men. 

So I think that information is very important information and we 

can’t develop effective programming without that. 

Mr. PALLONE. Thank you. I think that concludes our questions 

and thanks for bearing with us. I know we have a lot of members 

of the subcommittee now. When they all show up it goes on a for 

a while. But this is very helpful, and I don’t think that we stress 

public health enough but it is also difficult to get a handle on what 

exactly we should do. But I think you gave us some very good ideas 

so thank you very much. 

Dr. FIELDING. Thank you very much. Mr. Chairman, if you can 

indulge me just 30 seconds. I just want to make the point that if 

we do the things that we already know work in terms of things 

from the community guide and the clinical guide, we can save very 

many lives today with what we know, not that we don’t have to 

know more, but we need to make sure we put in place what we 

know. And that has not been fully done and I think we need more 

work to get that out to everybody who can work on it. Secondly, 

I would like to suggest that the Partnership for Prevention, which 

is a good non-profit here has suggested some model legislative language for health reform in the areas of public health and prevention. If you don’t mind, I would submit that for the record so that 

others can—— 

Mr. PALLONE. We would certainly appreciate that. Without objection, so ordered. 

Dr. FIELDING. Thank you so much. 

Mr. PALLONE. And thank you both. 

Dr. BESSER. Thank you, Mr. Chairman. 

Mr. PALLONE. I appreciate it. Let me welcome all of you, and I 

will just basically introduce each of you. From my left certainly no 

stranger to this process is Commissioner Heather Howard, who is 

the Commissioner of the New Jersey Department of Health and 

Senior Services. Thanks for being here today, Heather. And then 

we have Dr. David Satcher, who is the former U.S. Surgeon General, and now Director of the Satcher Health Leadership Institute 

at Morehouse School of Medicine. And then we have Dr. Barbara 

Spivak, who is President of Mount Auburn Cambridge Independent 

Physician’s Association, and Dr. Devon Herrick, who is Senior Fellow at the National Center for Policy Analysis, and, finally, Dr. JefVerDate Mar 15 2010 01:39 Mar 02, 2012 Jkt 067821 PO 00000 Frm 00094 Fmt 6633 Sfmt 6633 E:\HR\OC\A821.XXX A821

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frey Levi, who is Executive Director of the Trust for America’s 

Health. 

And, as I said before to the previous panel, we ask you to basically make a presentation for about 5 minutes and then we will 

have questions from the panel. And I will start with my New Jersey Commissioner Heather Howard. 

STATEMENTS OF HEATHER HOWARD, J.D., COMMISSIONER, 

NEW JERSEY DEPARTMENT OF HEALTH AND SENIOR SERVICES; DAVID SATCHER, M.D., PH.D., FORMER U.S. SURGEON 

GENERAL, DIRECTOR, SATCHER HEALTH LEADERSHIP INSTITUTE, MOREHOUSE SCHOOL OF MEDICINE; BARBARA 

SPIVAK, M.D., PRESIDENT, MOUNT AUBURN CAMBRIDGE 

INDEPENDENT PHYSICIANS ASSOCIATION, INC.; DEVON 

HERRICK, PH.D., SENIOR FELLOW, NATIONAL CENTER FOR 

POLICY ANALYSIS; AND JEFFREY LEVI, PH.D., EXECUTIVE 

DIRECTOR, TRUST FOR AMERICA’S HEALTH 

STATEMENT OF HEATHER HOWARD 

Ms. HOWARD. Good afternoon. Thank you, Chairman Pallone, 

Ranking Member Deal. New Jersey is very, I have said it before 

but it bears repeating, we are very lucky to have your leadership, 

Chairman Pallone. I am pleased to be here today as the Commissioner of the New Jersey Department of Health and Senior Services, and also as a representative of the Association of State and 

Territorial Health Officers. I represent more than 50 public health 

officers today. We know that public health has been the cornerstone for most of the health achievements of the 20th Century. Advances in maternal and child health, sanitation and clean water, 

immunizations, infectious disease control, food safety, declines in 

death from heart disease and stroke and environmental health protection, these were all spearheaded through public health initiatives. 

During the 20th Century, the health and life expectancy of people living in the U.S. improved dramatically. According to the CDC, 

85 percent of that increase, fully 25 of the 30 years gained in life 

expectancy is attributable to public health. So I am optimistic 

today that we are talking about the importance of public health, 

and I am optimistic that significant health reform is going to happen this year and it is long overdue. Part of that health reform 

package together with universal health insurance coverage and 

health systems reforms must be a strengthening of our capacity to 

protect public health, to encourage wellness and to prevent illness. 

Too often when we talk about health policy in the United States, 

we talk primarily about the financing of health care and we don’t 

focus as much on improving health and preventing disease. That 

is why today’s hearing is so important. We know that nearly 80 

percent of our health care dollars are spent on chronic illness, and 

until we do what we need to do to improve the health of all Americans, we will never be able to get those costs under control. We 

need to take a system approach to prevention. Everyone should 

have access to essential preventive services and screenings, and we 

need a public health work force to deliver that basic package. 


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These investments in public health and prevention are essential 

elements in transformation of health reform. 

In fact, a focus on public health is what will make health care 

reform sustainable, both as finances and improving people’s well 

being. As we enhance prevention by preventing and managing 

chronic diseases better and reducing obesity rates, we will reduce 

skyrocketing health costs and achieve significant cost savings over 

the long run. Simply put, public health both improves lives and 

saves money, and health care reform cannot be successful without 

a strong public health foundation. It is clear that President Obama 

and the Congress understand this critical link because of the $1 

billion investment in the Recovery Act and the creation of a prevention and wellness trust. I want to thank the members here for 

that achievement. 

As the President has said, investing in prevention will lower 

health care costs, improve care, and lower the incidents of heart 

disease, cancer, asthma, and diabetes, which are among New Jersey’s leading killers just as they are around the Nation. Public 

health is the responsibility of all levels of government starting at 

local and county level through the state and to the federal government, but the role of a state public health agency is distinct. We 

must work to ensure a clean and healthy environment for the entire community. The state public health system ensures that the 

water along the Jersey shore is safe to swim in and that the beaches are clean, something I know is very important to the chairman. 

The state public health system ensures that the water we drink is 

safe and that our children play in day care centers that are free 

of hazardous contaminants. 

One of the ways that state public health agencies work to reduce 

health disparities is by promoting healthy lifestyles, providing services like services like tobacco quit lines for those who want to kick 

the habit and obesity prevention programs. Recently, I visited several WIC clinics, that is the Women, Infant and Children program, 

as part of a public education campaign to promote healthy mothers 

and healthy babies, and I saw first hand the valuable work that 

peer counselors do to promote breastfeeding and provide new mothers with the support and education they need to successfully breast 

feed their babies. 

In addition, thousands of women at these clinics learn the importance of feeding their family nutritious meals. Just this year, WIC 

will soon be introducing fruits and vegetables as part of the basic 

food package. That is a reform that is long overdue, and I am sorry 

Congresswoman Eshoo is not here. She was talking about the importance of improving what we do with food stamp dollars, but we 

are doing that already with our WIC dollars. This healthy mothers 

equals healthy babies campaign was a key recommendation of a 

prenatal care task force I created to improve access to early prenatal care for women across New Jersey. 

We know that public health has been responsible for a 90 percent 

reduction in infant mortality over the last 100 years but as a public 

health leader, I recognize there is more to be done until all children 

are born with a healthy start in life, and when we know that in 

New Jersey a black infant is more than 3 times as likely to die in 

its first year of life than a white infant, we have more work to be 


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done. In addition to educating the public about public health the 

New Jersey Department of Health is responsible for testing 

chemical and biological agents in its lab and coordinating the 

state’s response to a flu pandemic that would immobilize business, 

cripple the food supply, and sicken millions. 

The state public health agency is also responsible for licensing, 

regulating, and inspecting nursing homes and hospitals, insuring 

access to quality health care for everyone, reducing the incidents 

of adverse medical events and supporting our safety net providers. 

In short, the state public health agency is where the rubber hits 

the road in terms of protecting and promoting the health status of 

New Jersians and all across the country. Let me give you a few key 

examples. Mr. Chairman, I know that food safety is one of your top 

priorities and you have worked with your colleagues to introduce 

a comprehensive bill to reform the FDA. We need to look no further 

than the recent salmonella outbreak to know how important our 

work is in this area. 

When New Jersey was at the center of the anthrax attacks in the 

fall of 2002 the state’s health department lab functioned as New 

Jersey’s only CDC approved facility in the quest to identify anthrax. During this national crisis, the state lab rotated teams of 

trained scientists working 15-hour shifts for 2 months processing 

more than 3,000 specimens and positively identifying 106 samples 

for the presence of anthrax. Since then, New Jersey has developed 

a national reputation as a leader in emergency preparedness. We 

are developing and implementing a statewide response to public 

health emergencies and with critical federal financial support we 

built a health command center, the first and only facility of its kind 

in the Nation which coordinates situational updates, medical assets, and resources to provide a timely and efficient response to an 

emergency. 

Coordination among federal, state, and local agencies is also key 

in addressing environmental conditions that can threaten the public health of our residents. New Jersey is the most densely populated state in the Nation and many of our residents live in an 

urban environment where the potential for exposures to hazardous 

chemicals and contaminants is a very real threat. We have an estimated 20,000 contaminated sites and more superfund sites than 

any state in the Nation. Because of this, the work of the department is so important to coordinate with the federal, county, and 

local partners to protect the public health by preventing potential 

exposures to harmful environmental substances. Just 2 years ago 

after high levels of mercury were discovered in a day care center 

on the site of a former thermometer factory the public health system responded by closing the center. 

Then Governor Corzine quickly enacted legislation requiring the 

department to establish evaluation and assessment procedures for 

the interior buildings used as day care centers—— 

Mr. PALLONE. I am going to have to ask you to summarize a little bit. 

Ms. HOWARD. Wrap it up? 

Mr. PALLONE. Yes. 

Ms. HOWARD. Well, thank you. There are many other examples 

of how we are working together, many other great examples of New 


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Jersey, but in sum, as I said earlier, I am extremely hopeful that 

transformation of health reform will happen this year and that will 

include a strengthening of our capacity to protect the public health, 

to encourage wellness, and prevent illness. I look forward to working with you. 

[The prepared statement of Ms. Howard follows:] 


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Mr. PALLONE. Thanks a lot. Dr. Satcher. 

STATEMENT OF DAVID SATCHER 

Dr. SATCHER. Thank you, Chairman Pallone, Ranking Member 

Deal, and members of the committee for this opportunity. I appreciate the discussion that has taken place this morning around the 

public health approach to health system reform. I want to just say 

a word about my background because I think it may be the basis 

for some of the discussion. I had the opportunity to direct the Centers for Disease Control and Prevention from 1993 to 1998, served 

as Surgeon General from 1998 to 2002. Three of those years, I also 

served as assistant secretary for health which made me responsible 

for leading the development of health to 2010. As Surgeon General, 

I had the opportunity to release the first ever report from a Surgeon General on mental health but also to release the first report 

on sexual health, and finally in 2001 the report on overweight and 

obesity. 

Since leaving government, I have had the opportunity to serve as 

founding chair of Action for Healthy Kids which focuses on programs in the schools to create the kind of environment that help 

children develop habits of healthy living. I have also served on 

WHO’s Commission on Social Determinants of Health, and more 

recently on the Alzheimer’s study group, co-chaired by Speaker 

Newt Gingrich and Senator Bob Kerrey. 

I want to make four quick points. Today, I think based on our 

discussion the health care system is the patient, and the patient 

is clearly sick. You have talked about the problems of runaway 

cost, restricted access, questionable quality of care, and disparities 

in health, not just among racial and ethnic groups but different 

socio-economic groups, rural versus urban, and certainly disparities 

in the way we approach mental health when compared to physical 

health. I think in order to respond to these health systems problems we must revisit the major determinants of health. And again 

I think the four major determinants, access to quality health care, 

which according to our data, accounts for about 10 to 15 percent 

of the variation in health outcome, biological/genetics, which accounts for 15 to 20 percent, environment, both physical and social, 

accounting for 25 to 30 percent, and then human behavior or lifestyle, which accounts for 40 to 50 percent of the variation. 

I point this out because any health system that is going to be effective must respond to all of these determinants, not just access 

to health care. Public health is the only approach that will allow 

us to respond to all of these determinants of health. Only a health 

system that is balanced at the community level that balances 

health promotion, disease prevention, early detection, and universal access to care including mental health parity. Finally, in 

order to implement such a system, I would make points of the following recommendation. 

Clearly, we need the appropriate incentives in place. As you have 

heard, most of the incentives today are for the provision of medical 

care. That is very costly. We pay for procedures. We do not encourage students to go into primary care because primary care does not 

pay the way specialty care does if we are going to encourage people 

to go into primary care. We need to really reimburse appropriately. 


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I heard a recent example which is very interesting, and that is if 

we had a building that we were trying to improve, and it had, say, 

12 to 15 stories, and we focus all of our attention on the 10th floor 

and not on the foundation, then that building would be very weak. 

Primary care, which coordinates public health and medicine, is in 

fact the foundation. A population database is critical and I strongly 

support the electronic health records system. 

After Hurricane Katrina, one of the major problems we had was 

that most of the people who left New Orleans not only didn’t know 

their diagnosis, not only did not know what medications they were 

taking, they didn’t know the diagnosis, so we need an electronic 

health record, but it will also significantly improve data management for improving our system. We need a community-based collaboration for health care, and we need a work force that is balanced, balanced in terms of the different levels of health care and 

not just physicians but nurse practitioners, physician assistants, 

community health workers, a balanced work force. And that work 

force needs to represent a diversity of cultures and language, race 

and ethnicity. So, Mr. Chairman, I strongly recommend that we 

pay much more attention to public health as we move forward in 

this system, that we incentivize prevention and health promotion, 

as many businesses, by the way, are doing right now, and they are 

answering some of those questions about the cost benefits. So I 

again appreciate the opportunity. I look forward to the question 

and answer period. 

[The prepared statement of Dr. Satcher follows:] 


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Mr. PALLONE. Thank you, Dr. Satcher. Dr. Spivak. 

STATEMENT OF BARBARA SPIVAK 

Dr. SPIVAK. Thank you. My name is Barbara Spivak. I am a 

practicing physician in Watertown, Massachusetts, and President 

of the Mount Auburn Cambridge Independent Physician Association, which is a member organization of approximately 500 physicians affiliated with Mount Auburn Hospital and Cambridge 

Health Alliance, the public hospital in Cambridge. I appreciate this 

opportunity to testify about the important role coordinated care 

plans play in helping us both align as incentives and give us the 

resources to create a comprehensive program to deliver higher 

quality care at a reasonable cost. I would like to share with you 

today the—give you some flavor of the infrastructure that we have 

in our organization that provides care coordination, case management, pharmacy management, referral management, utilization 

management, and does quality programs that encourages prevention strategies as well as improvement in chronic disease outcomes. 

Our arrangement with our hospital and Tufts Health Plan 

through the Tufts Medicare Preferred HMO product allows us to 

provide different levels of care for patients depending on their 

health status, their social status, and their frailty. For example, in 

patients who are severely ill who are at home, we have programs 

that send nurse practitioners into the home. When people are in 

rehab facilities, we have nurse practitioners and physicians who go 

in not once a month like in traditional fee for service but go in up 

to four or five times a week to keep them in the facility. 

Our lowest level of care was where a case manager may just call 

the patient on a monthly basis, make sure they are taking their 

medicines properly and help them arrange rides for their doctor’s 

appointments. In some cases, nurse practitioners actually go with 

patients to physician’s appointments because the patients themselves may not be able to hear everything that the physician says 

and organize all the med changes that happen. We use case managers who follow patients through the continuum of care so that 

when a patient is in the hospital in a rehab and then goes home 

that case manager knows their family and social situation and can 

help set them up with the most appropriate services to keep them 

at the lowest level of care possible. 

We have a pharmacist who works with us full time who works 

with patients who are on eight or more medicines to simplify their 

regime, encourage the use of generics, and when patients with 

chronic diseases are out of control in terms of cholesterol management, for example, or diabetic control, they work with specialists 

to make recommendations to the primary care doctor for better 

medical management. We have utilization management programs 

that do not deny care but work with physicians to make sure that 

they are ordering the right test for the right patient for the right 

disease or referring to the right doctor the first time. This avoids 

both duplication of testing and unnecessary testing. 

We work with a health plan in doing disease management programs in CHF and COPD, and the help plan provides us with a 

care alert program that takes claims data and runs it against 1,500 

rules based on evidence-based medicine that provides us with gaps 


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in care that our physicians can then address. Our hospital works 

aggressively on decreasing med errors, improving quality so that 

we have not had a ventilation assisted pneumonia in over a year. 

Many of these programs are not funded in traditional fee for service medicine. Traditional fee for service medicine leaves the doctor 

alone in the room with the patient and when the patient walks out, 

they are on their own. 

In our system, we have multiple levels of support for the physician, the patient, and their families. We use education as a prime 

method of improving care. We just try to help physicians do a better job. We help to keep patients at the lowest level of care possible, mainly trying to keep them at home when we can. Traditional medicine really does not allow for the infrastructure that we 

have had to do that, and I would encourage the committee as they 

look forward to funding plans that continue to allow us to have the 

networks and the support and the infrastructure. I also would like 

in my testimony, I made reference to some quality data because I 

think it is important for people to see that we actually do what we 

say we do. 

So if you look at our mammogram rates, they are 14-percent 

higher than in fee for service medicine. Diabetic eye exams are 21- 

percent higher. Colon cancer screening rates are 18-percent higher. 

Diabetic patients go to the hospital 35-percent less often. Our readmission rates are 58-percent fee for service Medicare, and our ER 

utilization is over 20-percent lower. Our diabetic patients have 

heart disease that is 23-percent lower than Medicare patients and 

have strokes that are 46-percent less often. So I think the statistics 

show that what we are doing actually works. Part of what this does 

is it really aligns the incentives so that the health plans, the hospitals, and the physicians all work together in a collaborative way 

to do the right thing. 

[The prepared statement of Dr. Spivak follows:] 


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Mr. PALLONE. Thank you, Dr. Spivak. Dr. Herrick. 

STATEMENT OF DEVON HERRICK 

Mr. HERRICK. Mr. Chairman and members of the committee, I 

am Devon Herrick, a Senior Fellow at the National Center for Policy Analysis, a nonprofit, nonpartisan research institute. We strive 

to solve problems by relying on the strength of the competitive entrepreneurial private sector. I welcome the opportunity to share my 

views, and I look forward to your questions. Community-based public health has a very important role in our society in our health 

care system, and it has achieved some very significant results over 

the past century. I mean, for example, like I mentioned before, vaccination, safe foods, fluoridation. The London cholera epidemics in 

the late 1800’s are a classic example of a public health initiative 

that was very successful as are controlling contagious diseases. 

Yet, over the past few decades public health has struggled to 

tackle many of the problems through community-based initiatives 

that don’t particularly lend themselves to community-based solutions. Most Americans who suffer from chronic ailments don’t really consider their problems to be public health problems. Rather, 

people who suffer from diabetes, from asthma, from hypertension, 

to them their problems are very real and very personal. That is to 

improve public health. We also need to free the doctors and free the 

patients to find innovative solutions that meet their individual 

needs. America is unlikely to mitigate the increasing problem of 

chronic diseases unless patients themselves become more involved, 

and moreover patients are not likely to become more involved unless they have a financial incentive for doing so and control more 

of their own health care dollars. 

For example, approximately 125 million Americans have a chronic ailment and many of these are not receiving the appropriate care 

from their physicians. One reason for this poor compliance is because the physicians often lack the integrated systems to care for 

their patients but a bigger reason is they often lack the financial 

incentives to provide appropriate care. For example, consider diabetes. Nearly 24 million Americans have diabetes, about a third of 

which don’t even know they have it. This constitutes around 8 percent of the population arising to nearly one in four seniors the leading cause of death. We spend several billion dollars a year for diabetes complications that could have been averted through appropriate care. 

But, yet, numerous studies have shown that considerable benefit 

from self management training for Type II diabetes, patients can 

be trained to inject insulin, monitor and maintain a log of blood 

glucose levels, and use the results to appropriately adjust dietary 

intake, activity levels, and medical doses. I recently came across a 

firm that helps patients manage diabetes remotely using tele-medicine. For example, an enrollee is given a wireless blood glucose 

monitor. They are instructed to test their blood glucose or blood 

sugar at selected times a day. They can send the results wirelessly 

to their physician’s office. If they fail to test on schedule, they are 

given an e-mail or a phone call to prompt them to repeat the test 

or take the test. A particularly high reading might prompt a phone 


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call from a diabetes nurse inspecting them, inquiring what have I 

just eaten, and don’t do it again. 

This all becomes part of their electronic medical record, the result of which can be used and shared with their health coach to 

help them maintain better compliance. A great example of what is 

often times considered a community-based approach was the 

Ashville project in North Carolina, which helped enrollees and selfinsured health plans better control their diabetes, but yet on closer 

inspection what it really was, was individual pharmacists being 

compensated and being paid to help individual patients manage 

their diabetes. Another area I want to talk about is asthma self 

management. Nearly 20 million Americans suffer from asthma, 

around 2.5 million school kids miss around 15 million school days 

per year because of asthma. 

A Dutch study comparing self management to usual care found 

that those that were trying to monitor their own conditions received a savings of about 28 percent in their second year compared 

to additional physician care alone. They can also use software 

packages just to track and monitor their conditions and their readings. These become part of their electronic medical records, the 

data which can be shared with their physicians. A recent study of 

asthma patients trained to perform in-home asthma self-monitoring found that their readings were consistent to establish guidelines. Another study of bleeding and clotting disorders by the VA 

and the home self-monitoring of clotting of those taking Warfarin 

therapy was superior to standard monitoring alone. Tele-medicine 

holds significant promise to allow patients with chronic ailments 

who are motivated to better manage their conditions and interact 

with physicians in ways not possible just a few years ago. I think 

this is critical to better self-management of chronic conditions. 

In conclusion, community-based health care has a place in our 

health care system. However, disease is very personal. The solution 

to the public health problems associated with increasing chronic 

disease is to allow patients to control more of their own health care 

dollars and to allow patients and providers to benefit from new arrangements that produce higher quality and lower cost. For example, government insurers, Medicare and Medicaid should also allow 

doctors and hospitals to repackage and re-price their services under 

government health care payment systems allowing them to gain financially from providing better care. The most important lesson is 

entrepreneurs can solve many of the problems that plague our 

health care system. Public policy should encourage these efforts, 

not discourage these efforts. Thank you. 

[The prepared statement of Mr. Herrick follows:] 


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Mr. PALLONE. Thank you, Dr. Herrick. Dr. Levi. 

STATEMENT OF JEFFREY LEVI 

Mr. LEVI. Thank you, Mr. Chairman. Good afternoon. My name 

is Jeffrey Levi and I am the Executive Director of Trust for America’s Health, a nonpartisan, nonprofit organization dedicated to 

saving lives by protecting the health of every community, and 

working to make disease prevention a national priority. I would 

like to thank the members of the subcommittee for the opportunity 

to testify on the role of prevention and public health as a component of the health reform debate. This afternoon I would like to 

make 2 major points. First, the critical importance of public health 

programs, in particular, population and community-based prevention in improving the health of Americans and making a reformed 

health care system more effective. 

Second, the need to create a reliable, stable funding stream for 

public health programs and services as part of health reform. Otherwise, the potential benefits of public health to the health care 

system will be lost. My written testimony also addresses the need 

to build the evidenced-based prevention programs and invest in 

public health systems and services research, to improve the quality 

of public health that is delivered in the U.S. Much of what is said 

there has been covered in Dr. Fielding’s testimony. Health care in 

the United States has become an expensive burden on our economy. High rates of chronic disease are among the biggest drivers 

of the American health care costs. What this means in real terms 

is that Americans are not as healthy as they could be or should be 

and that is translating into huge growth in our health care costs. 

The country will never be able to contain health care costs until 

we do a better job of preventing people from getting sick in the first 

place. That is where public health comes in. The Nation’s public 

health system is responsible for keeping Americans healthy and 

safe by preventing disease and promoting healthy lifestyles including those that prevent or mitigate chronic disease, diseases that 

are driving up health care costs. The goal is to prevent disease, 

prevent people from having to enter the clinic and need disease 

management, which is really what Dr. Herrick was talking about. 

He was talking about disease management rather than primary 

prevention. Yet, there are proven community-based programs that 

actually prevent disease that promote healthy environments and 

behavior making it easier for people to make healthy choices. 

Shifting community norms about tobacco use, the social marketing campaigns, changing the physical and social environment in 

which people live by making communities more walkable through 

better street lighting and sidewalks, creating group walking or exercise programs to encourage physical activity or improving access 

to healthy foods are all examples of community interventions that 

work to prevent or mitigate chronic diseases; and we know that investing in prevention, especially community-based programs, can 

have a big payoff. A study, Trust for America’s Health, issued last 

summer found that an investment of $10 per person per year in 

improving community-based programs to increase physical activity, 

improve nutrition and prevent smoking and other tobacco use, with 


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that the country could save more than $16 billion annually within 

5 years. This is a return of investment of $5.60 for every dollar spent, 

based on an economic model developed by Urban Institute and an 

extensive review of evidence-based studies by the New York Academy of Medicine. Out of that $16 billion in savings Medicare could 

save more than $5 billion, Medicaid $1.9 billion, and private payers 

could save more than $9 billion. That is the good news. We have 

proven community-based public health interventions work; but to 

fully realize this potential return on investment and keeping Americans healthy requires a larger and sustained investment in public 

health. The bad news is right now the public health system is 

structurally weak in nearly every area and that is the system 

which ranges from federal agencies such as the CDC from whom 

you heard earlier to the nearly 3,000 state and local public health 

agencies to countless non-governmental organizations. 

That system does not have enough resources to adequately carry 

out core disease prevention functions. In collaboration with the 

New York Academy of Medicine, Trust for America’s Health convened a panel of experts to analyze how much is currently spent 

on public health in the United States and how much more would 

be needed to support core public health services at a sufficient 

level. The panel’s professional judgment was that there is currently 

a shortfall of $20 billion per year in spending on public health. 

Therefore, we believe that a reformed health care financing system 

must include stable and dedicated funding for core public health 

functions and community-based prevention. We recommend the establishment of a public health and wellness trust fund through a 

mandatory appropriation or set aside of a portion of new revenues 

generated from the financing of health reform. Resources from the 

trust fund would be allocated to specific public health programs or 

activities as directed by the relevant appropriations committees 

those public health functions and services that surround, support, 

and strengthen the health. 

The trust fund would fund core governmental public health functions. It would also fund population level non-clinical prevention 

and wellness programs which can be delivered both through governmental and non-governmental agencies. It would support clinical preventive services such as screening and immunizations that 

are not covered by third party payers, and it would also support 

work force training and development, as well as public health research. The trust fund could help make up for the country’s current 

$20 billion annual shortfall in public health spending. Based on the 

current distribution of responsibility along with federal, state, and 

local governments, $10 to $12 billion of that amount should be a 

federal responsibility. In short, Trust for America’s Health believes 

that prevention and public health must be at the center of any effort to reform our health system. Public health programs are a critical and underfunded component of the Nation’s health system. We 

encourage Congress to establish a public health and wellness trust 

fund to make our country healthier, our health system more cost 

effective and our economy more competitive. Thank you, Mr. Chairman. 

[The prepared statement of Mr. Levi follows:] 


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Mr. PALLONE. Thank you, Dr. Levi. Those bells mean that we 

have votes. We have three, 15 minutes, a 5 and a 5, so figure I 

guess about a half an hour. So what we are going to do is have 

questions when we come back in about a half hour or so. I hope 

no one has to leave. OK. So the committee stands in recess. 

[Recess.] 

Mr. PALLONE. The subcommittee will reconvene if the panel 

could take their seats. I realize I think I said half an hour but it 

was more like an hour unfortunately. So we will start with questions, and I will begin and yield to myself 5 minutes. Basically, on 

the disparities issue, I guess I would ask Dr. Satcher and Commissioner Howard this questions. I don’t know if you were here when 

the first panel was here, but I basically said that a lot of these decisions that lead to healthy lifestyles are very personal and so you 

wonder to what extent public health agencies can really influence 

them, but I know that they can because I think the anti-smoking 

efforts on the part of public agencies were very successful, and I 

used my kids as an example. 

But when we hear about disparities, you know, I go back to the 

same thing again. To what extent are some of these disparities 

things that we can change, and of course I think, Dr. Satcher, of 

the fact that often times in the inner city, you know, you don’t have 

as many parks or open spaces so it is more difficult for people 

maybe to get exercise. I don’t know if that is necessarily true but 

sometimes it is true. And other members have made the argument 

that sometimes in certain urban areas you don’t even have a supermarket where you can get fresh foods or vegetables. 

But I could just as well make that argument, I use the example 

of some of the American Indians. I am very familiar, for example, 

with some of the Pema tribes in Arizona, and they have some of 

the highest incidents of diabetes, you know, that comes from a lot 

of it from obesity, and yet they have plenty of open space although 

they do have a problem in that their traditional diet ranching, 

farming, has sort of disappeared in the last few years. So I mean 

do you think that there are things that we can do that make a difference in terms of these disparities, you know, like creating more 

open space or providing more fresh vehicles or whatever you think 

is the case? 

Dr. SATCHER. Well, I think it is a very important question, and 

the answer is, yes, I do. Beginning with our children, I think again 

it gets back to providing incentives and some of those incentives 

are being with parents out walking and enjoying, you know, that 

association. But I really think there are a lot of ways that we can 

incentivize our children to engage in health efforts. Now one of the 

reason I spent so much time with the schools since I left office with 

the Action for Healthy Kids program that is now in all 50 states 

and the District of Columbia is that schools are the great equalizers. 

Some of the kids come from homes with single parents and the 

parent may only have time to get up and get the kids off to school 

and try to be there when they get back, but the children spend over 

1,000 hours in school every year. We pay for that, and we ought 

to be committed to an environment that helps habituate children 

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unhealthy lifestyles and that is foods that are high in fat, foods 

that are high in salt, foods that are high in sugar are really addicting and children become habituated so the time that they spend in 

school and the resources that we use at school ought to be devoted 

to helping to habituate children to healthy lifestyles. We can do 

that. We provide the resources. 

And I think what Congress did in 2004 with the WIC reauthorization basically requiring every school district that received funds 

for free meals to have in place a wellness policy within 2 years has 

worked well. According to our studies, over 90 percent of the school 

districts have those. Now the problem is how do we get them to implement them? 

Mr. PALLONE. But, you know, and I want to move on to ask Commissioner Howard a question, you know there is a proliferation 

now in a lot of urban areas and all over like charter schools and 

smaller public schools. A lot of times they don’t have the buildings 

or the playgrounds and to some extent as we have emphasized, you 

know, studies and I think of the charter schools, a lot of them 

started for high tech or math or science or whatever, and then they 

don’t necessarily have the facilities, you know, or the playgrounds 

or whatever. But, anyway, I have to ask Commissioner Howard 

this question. 

Ms. HOWARD. Just on that point. 

Mr. PALLONE. Yes, sure. 

Ms. HOWARD. I think that is a great point for you to raise because even when we control for health insurance, we see troubling 

disparities based on race, so we know that just universal access to 

health insurance is not the only answer to get—— 

Mr. PALLONE. That is what I was going to ask you actually, so 

why don’t you just get into it. 

Ms. HOWARD. Well, I think it is clear, and I think that is where 

public health plays a role where we can focus on evidence-based 

community interventions. And I will just give you one example. In 

your own district, I visited the FUEC in Long Branch and they are 

doing an interesting project with pregnant women called the health 

start model. 

Mr. PALLONE. The health center, yes. 

Ms. HOWARD. The FUEC that is run by the VNA there. Every 

pregnant woman who comes in is assigned a nutritionist and a social worker. So I toured, and I said this is better care than I got 

when I was pregnant. It was amazing the follow-ups she got, so she 

got nutritional counseling throughout her pregnancy and so her 

risks were detected early. Then she got the social supports that she 

needed, and those are the kind of programs that we know are evidence-based that we know work to reduce infant mortality, so I 

think public health really does play a critical role in reducing disparities since we can’t there just on expanding coverage. 

Mr. PALLONE. I am going to try to get in my second question to 

you which was I think the notion that if we do health care reform 

and somehow we manage to cover everyone that a lot of these public health concerns are going to go away but I don’t think that is 

true, and I wanted you to comment on that. What happens in this 

post-Nirvana environment when we pass comprehensive health insurance and everyone has health insurance, are you still going to 


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have a major public health role here and how do we build that into 

it? 

Ms. HOWARD. I think that is a great question to discuss today. 

I think absolutely public health has a role for two reasons. One, I 

think public health is critical to the sustainability of the health reform that you all will enact. Public health, as we have talked about 

today, and you heard from your first panel of the critical role we 

can play in managing chronic diseases and containing cost will be 

critical to making health reform work, so I think it is part of health 

reform. I think we also can’t ignore the fact that health reform will 

probably leave some people behind. We have seen in Massachusetts, for example, that none everyone has been covered. 

And actually we have seen, I was looking this up last night, that 

federally qualified health centers, the community clinics, have seen 

an increase in the number of visits since they have had their universal health care. So safety net providers like federally qualified 

health clinics will still play a role because they know how to reach 

perhaps hard to reach populations in culturally competent ways. 

They are critical to reducing disparities. So, one, it is critical to the 

sustainability from a financial perspective, but also we know that 

coverage is not the only answer to improving the health of Americans, and so public health will still be vital whether it is dealing 

with making sure that kids go to a day care center that has clean 

air, whether it is making sure that we don’t have food safety problems. All those things we are still getting in public health. 

Mr. PALLONE. OK. Thank you. Mr. Deal. 

Mr. DEAL. Thank you. Dr. Spivak, I was intrigued by your testimony as to what your group is doing. It is apparently very impressive results that you are achieving. And I notice that you mentioned the Tufts Health Plan Medicare Preferred. I assume that is 

a Medicare Advantage program, is that correct? 

Dr. SPIVAK. That is correct. It is a Medicare Advantage HMO 

product, so it is different than the Medicare Advantage fee for service products in that the patients choose a primary care physician 

and choose a network, so it allows us to get information about 

them because we know who their primary care doctor is and who 

is responsible for their care, so it give us access to claims data 

about their pharmacy utilization, what prescriptions they are really 

filling, and gives us easier access to if they go out of our network 

getting information about their care as well. 

Mr. DEAL. Obviously, you are aware that much of the movement 

about Medicare Advantage is to do away with those kind of programs. If Medicare Advantage is basically abolished then your network that you have established would virtually disappear because—and you wouldn’t have the flexibility that you have described in the way you outreach now, is that right? 

Dr. SPIVAK. That is correct. And it is one of the problems that 

we see if Medicare Advantage goes away that the fee for service 

medicine just doesn’t allow us to give the infrastructure and the 

support that we need to do this kind of care. The medical home 

concept that people are talking about goes a little bit towards it but 

it really doesn’t go far enough in the current models to provide the 

extensive programs that we have today. 


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Mr. DEAL. Dr. Herrick, following on that same line of questioning 

from your printed testimony excerpts you say government insurers 

should also allow doctors and hospitals to repackage and re-price 

their services under government health care payment systems allowing them to gain financially providing better care. You go on to 

say entrepreneurs can solve many of the health care problems that 

critics condemn. One of the concerns I have is that if we move into 

a system that is as rigid as our current systems are in basically 

a fee for service format, I think we bill rigidity into the system and 

we don’t allow any room for entrepreneur or even for those providers who want to do things in a little different way. Is that the 

point you were trying to make? 

Mr. HERRICK. Well, the point I was trying to make is under the 

current system it is a very rigid system. Basically Medicare and 

Medicaid tend to pay by task. We are not paid for results, we are 

not paid for outcomes. In a sense, if you have pay for performance 

often times it is the payers of health care trying to tell the purveyors of health care, the providers of health care, how to practice 

medicine. It is the doctors and hospitals that know the most about 

how to practice medicine. Let them propose novel solutions. Let 

them experiment. And if they can find a way that has higher quality and lower cost let them suggest ways of getting paid. 

For example, I gave some anecdotes about how the chronic disease management firms talk to you on the phone. They might email you to tell you, you forgot to take a certain blood glucose test, 

but Medicare will not pay for those, will not reimburse for that 

type of advice, neither will Medicare, but yet these are very innovative type of arrangements. Tele-medicine is a very efficient way to 

prod people into compliance. We need to have ways of reimbursing 

physicians for doing those very novel ideas. 

Mr. DEAL. Dr. Satcher, once again, I compliment you for all the 

good work you are doing and for things that you are continuing to 

promote. The Alzheimer’s research is particularly important. But I 

think as we look at children, which has I think been one of your 

focuses as well in your testimony here today as Georgia has its 

peach care component of our S–Chip program isn’t it important 

that we give some flexibility to the way that program works so 

that, for example, there can be coordination between community 

health centers that may be providing part of the care between primary physicians that may become a medical home and then the 

traditional providers of health care. I have a sense that we don’t 

have that kind of coordination of care that is allowed under our 

current silos in which we deliver health care. Do you agree or disagree? 

Dr. SATCHER. Oh, I agree. This was about Alzheimer’s. One of 

our major recommendations, in fact, a second recommendation is 

for enhancing community collaborative care using electronic health 

records but tying people together all the way from family members 

who take care of relatives when they are ill with Alzheimer’s, tying 

them together with physicians and other health care providers so 

the community collaborative system of care is one that I think is 

very important at every level. 


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Mr. DEAL. I have to keep shielding my eyes to see the clock up 

there. I think I am over and exhausted my time. Thank you all for 

being here. 

Mr. PALLONE. Mrs. Christensen. 

Mrs. CHRISTENSEN. Thank you, Mr. Chairman. And I want to 

thank the panelists for their patience. I know you have had a long 

week. Dr. Howard, you say in your testimony that we need a public 

health work force to deliver the basic package. Would you elaborate 

on the components and the characteristics that you see being needed in that work force? 

Ms. HOWARD. Thank you. That is a great question. I think one 

thing we haven’t talked about today is the nursing public health 

work force. We haven’t talked enough about nurses, and nurses are 

a critical component of our public health system, and we are facing 

a very dire shortage of nurses in New Jersey but nationally. So 

that is just one example of where we are facing a shortage. We are 

also facing in New Jersey, and I know this is true nationally and 

in our urban areas, a shortage of other practitioners as well. And 

access to dental care is restricted, so we have a number of practice 

areas where there is a real shortage. I am pleased that in the recovery act there was funding for development of the work force, 

and I think that will go a long way. 

But I encourage you all as you think about reforms to think 

about that, and I think one of the lessons learned from Massachusetts was that even having universal health insurance was not 

good enough. People can’t see a provider. And then from my own 

perspective also states are unfortunately having to make lots of 

cuts in programs, and we are cutting staff in vital programs because of the economy, so it is hitting us on all fronts. 

Mrs. CHRISTENSEN. Thank you. Dr. Satcher, references have been 

made to 2010 and I guess it is now 2020 goals. I think we started 

at 2000 goals, then to 2010, and now to 2020. Why do you think 

we have not been doing better achieving our 2010 goals, and if you 

could also in your answer comment on the importance of diversity 

in the work force? 

Dr. SATCHER. Healthy People started, as you know, in 1980 with 

Healthy People 90, and then we had Healthy People 2000, so you 

are right. It has been around. And we have had goals for each decade, and the idea is that we maintain those goals until we achieve 

them. I think there are several issues related to the achievement 

of 2010 goals, and one, of course, is we did not anticipate that we 

would have 8 million more people uninsured than we had in the 

year 2000. We also, as you know, have not put in place the kind 

of system we have been discussing here this morning that are 

going to really be critical for the elimination of disparities in 

health, and they have got to be programs that target all of the determinants of health, which is why I took time to mention those determinants again. 

So I think a real commitment to eliminating disparities in health 

is a commitment to a public health approach to health care delivery in this country. I also think that the whole issue of cultural diversity is critical. The Institute of Medicine in its 2003 report 

following our having set the goal of eliminating disparities pointed 

out that the absence of cultural diversity in health care was a very 


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dangerous situation. They gave examples from several areas including mental health. When the people providing the care don’t 

understand the language or the culture of the people they are taking care of, and I know that Congressman Gingrey mentioned that 

this morning. 

But it was very clear from that report that it did, in fact, damage 

health care when the providers didn’t understand the culture, not 

just the language, but the culture of the patients they were taking 

care of, so I have seen some good examples of programs now where 

they try to integrate the community into the system of care. We 

don’t have enough African American physicians or Hispanic physicians or Native American physicians to do that or nurses. That is 

what I was getting to that we have to look beyond just the physicians if we are going to have that kind of diversity. And we can 

make progress down the line with community health workers, 

nurses, and others, and that is what some programs are now doing, 

programs that take care of southeast Asians, Native Americans, African Americans. 

Mrs. CHRISTENSEN. Dr. Levi, I was going to ask you how much 

the public health trust fund—what was your estimate, but you 

gave me that. We also have been talking about a health disparity 

elimination trust fund or a health equity trust fund, so I was really 

interested in that. I wonder if you would want to comment on community health centers and their role. One easy area to get funding 

for in the Congress has always been community health centers, but 

I find that we only think about the community health centers and 

not all of the things that community health centers need. Do you 

understand my question? Can you speak to that? 

Mr. LEVI. I think I do, and I think it is partly again to be thinking about what needs to surround the primary care system in order 

for it to be effective. And the kinds of community prevention programs that we were talking about really the things that can make 

a difference to—a community health center doctor can write a prescription, so to speak, for a person to go out and get more exercise. 

Mrs. CHRISTENSEN. If you have the staff. 

Mr. LEVI. Assuming you have the staff. Making certain assumptions. If you have the staff and someone needs—the prescription is 

get more exercise and eat healthier, but you live in a community 

where it is not safe to walk, where there aren’t sidewalks, there 

aren’t opportunities to exercise, and where healthy food isn’t accessible, then you are not going to have a successful intervention 

there. So for the community health center to be effective the people 

who are served by that health center need to live in a healthier 

community, and that has to be built into what we think about in 

health reform, and find a way to bring these together. 

The return on investment that I spoke about in my testimony 

was thinking about doing these interventions truly on a population 

level, the entire country. Is we target it to high risk communities 

where there is a high prevalence of these conditions the return on 

investment would be even greater. And we are talking about flexibility in the Medicaid program and the Medicare program. Some 

flexibility, we would love to see as an opportunity for Medicare and 

Medicaid dollars to do work in a community. So we know people 

who are on Medicare and obese have much higher costs than peoVerDate Mar 15 2010 01:39 Mar 02, 2012 Jkt 067821 PO 00000 Frm 00160 Fmt 6633 Sfmt 6633 E:\HR\OC\A821.XXX A821

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ple who are not. So let us target people 55 to 64 in their communities with proven evidence based interventions, spend some Medicare dollars up front to get them healthier as they are entering the 

Medicare program. 

As I was going around the country talking about this report, I 

met with some Medicaid plans, some Medicaid managed-care plans, 

and they were frustrated that they didn’t have the flexibility, for 

example, to go into their catchment area and give everyone a pedometer. They were absolutely convinced that if they did that, they 

would save money but that was not an allowable cost because they 

would also be reaching non-Medicaid beneficiaries which only emphasizes the point that we have to surround whatever is this reformed health care system with true community level interventions. 

Mrs. CHRISTENSEN. Mr. Chairman, I plan to introduce a health 

empowerment zone bill that I hope will do that, and we invite you 

to look at it when we do. 

Mr. LEVI. Great. Thank you. 

Mr. PALLONE. Thank you. Mr. Gingrey. 

Mr. GINGREY. Mr. Chairman, I want to remind that I waived my 

opening statement so hopefully I will have time to ask two questions. Dr. Spivak, I think Ranking Member Deal may have addressed this a little bit a moment ago in regard to this independent 

physician association that you run in Massachusetts and the success rate that you think it has. It is a Medicare Advantage plan 

as I understand your testimony, is that correct? 

Dr. SPIVAK. We also do the similar management for commercial 

products with Tufts Health Plan, Blue Cross and Harford Pilgrim, 

so we have about 50,000 commercial lives as well. 

Mr. GINGREY. Right, but this plan that you have with Tufts Medical Center is a Medicare Advantage, and as you described it, and 

that was always—has always been my understanding of what a 

Medicare Plus Choice and not Medicare Advantage Plan does in 

contrast to the Medicare fee for service where it is just kind of episodic care, in fact, until we made some recent changes in the law 

even a routine physical examination was not covered and now it is 

only covered at the entry into Medicare exam, and yet what the 

Administration is proposing in the 2010 budget is to really cut significantly the funding to Medicare Advantage, I would say almost 

to the bone, and take some of that money at least to create this 

escrow account to help pay for health care reform which would 

then go toward creating more payment to primary care physicians 

to man a medical home, to incentivize them by additional payments 

for wellness. 

It seems like it is the very same thing that Medicare Advantage 

was designed to do, and I realize that maybe we are paying a little 

bit too much, 115 percent or whatever it is, and maybe some cuts 

could and should be made, but it is like just scoring in esthetic way 

and saying, well, this compared to Medicare fee for service is too 

expensive, but if you look at it over a 10 or 20 or a lifetime period 

of those Medicare patients who receive their care through that type 

with an emphasis on prevention and wellness, at the end of the day 

if you score esthetically or dynamic then the savings, I think, 


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would be there. If you would quickly comment on that for us, then 

I will go to Dr. Satcher. 

Dr. SPIVAK. I think that one of the things that was not talked 

about today is that the public health crisis that we face is also the 

aging population, and as our population ages they are going to 

need more and more help with their health care. I think that the 

Medicare Advantage programs allow physicians to work with 

health plans and with hospitals in a way that forms a network that 

will give much more support to the elderly than any type of traditional fee for service medicine can, and in the long run will keep 

costs down. I think we have looked at alternative methods of paying doctors. Paper performance does not seem to—it may improve 

quality a little bit but it doesn’t seem to cut costs down. 

All of the programs in public health that we have talked about 

are critical but at the end of the day when patients are sick, they 

need a model of health care that will support them. I really believe 

groups like mine provide the model. 

Mr. GINGREY. Reclaiming my time, I believe that too, and I hope 

we are not about to throw the baby out with the bath water, as 

they expression goes. I really feel that if we had continued in a cost 

effective way to let Medicare Advantage provide care for right now 

10 million Medicare recipients have chosen that over fee for service, and then to incentivize people through the tax code maybe or 

through ha reduction in Medicare Part B premium, if they executed 

a living will advance directive that is actually on line as we get this 

fully integrated electronic medical system to cut down on those 

costs and let them say what they want at the end of life. But thank 

you so much for that. 

Dr. Satcher, I want to thank you again for your service to our 

country and the time you have spent in government and outside 

government and what you are doing now at Morehouse School of 

Medicine. It is great to see you again. You stated in your testimony 

that half of health outcomes come as the result of human behavior 

and that we must provide incentives and rewards for healthy lifestyles. I agree completely. Do you think that businesses that have 

implemented programs that let us say reward smoking cessation, 

a healthy diet, regular exercise are an effective way to better the 

public health and what kind of benefits come from these types of 

programs and cost savings associated with this type of program. I 

would imagine it is pretty significant. 

Dr. SATCHER. Yes, I do think that businesses that invest in, for 

example, work site wellness programs, we have been working with 

the Technology Association of Georgia, and we have been looking 

at data from many of those businesses. And it is clear that they 

can show that for every dollar invested in wellness, in some cases 

they save $4, in mental health I think it is a little bit more than 

that. They save by investing. Now they save it by preventing illness in the population that they would have to pay for but they 

also save it by preventing absenteeism from work and they save it 

by enhanced productivity. 

I would be happy to submit to you data from several of those 

companies as opposed to naming them because I am on the board 

of one of those companies, so it wouldn’t be fair. But clearly there 

is data showing that investment in work site wellness programs 


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saves money in terms of how much we pay for care and how much 

we pay for absenteeism and lost productivity when people become 

sick. 

Mr. PALLONE. I am going to try to wrap up because—— 

Mr. GINGREY. Dr. Satcher, thank you, Dr. Spivak, thank you, and 

thank you, Mr. Chairman, for your indulgence. I yield back. 

Mr. PALLONE. And we are going to end with Mr. Engel because 

otherwise you would have to wait another half hour or an hour for 

us to come back again because there are more votes. Mr. Engel. 

Mr. ENGEL. Thank you, Mr. Chairman. I am going to try to give 

the abbreviated version of questions. Let me ask Dr. Levi about 

HIV prevalence in the United States. We found out last year it was 

higher than we had thought much to our dismay and that the global HIV prevention working group which is comprised of 50 leading 

public health experts and others released a study last summer 

called behavioral change in HIV prevention, and in the study essentially what they came to conclusion is they said prevention efforts to be successful will be unsustainable unless there is a comprehensive evidence-based approach employed that targets behavior social norms and other underlying drivers in the HIV AIDS epidemic. 

So, Dr. Levi, could you please discuss the contributions the guide 

to community preventive services has made with regards to reviewing HIV behavioral and social interventions at the community level 

and where is our research lacking and how much do you believe 

that increased funding would enable the guide to better assist HIV 

prevention efforts? 

Mr. LEVI. Overall, the guide has been chronically underfunded 

and so it is unfair to judge the guide on what it has covered and 

not covered. But one of the things I think we need to be careful 

about is that there are actually within CDC several efforts, for example, in addition to the community guide in identifying successful 

interventions. And within the HIV AIDS division of the CDC, they 

have developed a compendium of what they consider to be approved 

community-based interventions and successful prevention program 

from which grantees can choose as they decide to spend federal dollars, so there are multiple ways of approaching it. 

I think the real challenge that we have around HIV prevention 

in this country, and this is something I have been working on since 

the beginning of the epidemic, is that we haven’t fully committed 

the resources to the kinds of community change that is necessary 

to implement the policies that we know work so we have had restrictions, frankly, on use of needle exchange, use of federal funds 

for needle exchange programs. That is an evidence-based approach 

and countries that adopted it early on in the epidemic, they have 

not had the same kind of epidemic as they did, you know, among 

injection drug users, not just for HIV but also for transmission of 

hepatitis which has resulted in tremendous cost savings in those 

countries. 

We have not had that benefit of that because we failed to adopt 

evidence-based practices. In terms of community change, I think it 

really does again come back to community level interventions that 

reach the multiple communities that are affected by the epidemic. 

It is not a one size fits all effort. It is not just going to be promoting 


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use of commons or promoting safe sex or promoting abstinence. It 

is going to be what works in a particular community and what 

brings people together to feel empowered to adopt the norm 

changes that need to happen. That is much more complex than the 

programs we have been willing to talk about until now, but that 

is what it is going to take in the same way, as we have been talking about earlier, there isn’t a one size fits all for obesity. There 

isn’t a one size fits all for physical activity. There isn’t going to be 

one size fits all for HIV. And I don’t think that we have been willing to invest in those affected communities enough to empower 

them and give them the resources. 

Mr. ENGEL. Let me ask you one final question on another topic. 

Health insurance pays for many clinical preventive services like 

immunizations and screening tests such as mammograms but important community level prevention services such as fluoridation of 

water or lead abatement in buildings are not reimbursed by health 

insurance, so it means that federal, state, and local agencies that 

provide these services rely on our annual appropriations process to 

fund these important activities. I would like you to explain what 

kind of challenges that poses and in your testimony you mentioned 

there was a need for reliable funding source for public health activities. What would that funding stream look like? 

Mr. LEVI. Well, you are absolutely right. The dependence on the 

fluctuations in the annual appropriations cycle has meant, and 

Commissioner Howard could probably speak to this better, meant 

that there isn’t a reliable source of revenue and therefore not a predictable source of funding and it is very hard to plan to build programs and to build capacity, and so what we have been seeing, we 

have seen it in many areas, we have seen it in chronic diseases. 

We have seen it most evidently, I think, on the preparedness side 

where there is an initial major investment state staff up using 

those dollars and then the dollars start withering away literally, I 

mean 25 percent cut since the peak. 

And so it is hard to keep staff. It is hard to retain staff. And, 

in fact, you know, at a time when we are seeing whole generation 

of public health workers retiring and we need to fill back fill, we 

don’t have the resources and the stability of resources to make sure 

that we have a new work force coming in and that this is a viable 

occupation for people to enter. To resolve that, we think there 

ought to be the equivalent of a trust fund. If we are going to guarantee funding for health care, we should also be guaranteeing funding for public health. So there is a reliable mechanism that states 

can depend on, the CDC can depend on, and we can make the investments that over time will indeed pay off. 

Mr. PALLONE. We are going to have to—I think we only got a 

couple minutes. 

Mr. ENGEL. OK. I was going to ask the commissioner if she 

agreed. 

Ms. HOWARD. I do. 

Mr. ENGEL. Thank you. 

Mr. PALLONE. Thank you, Eliot. I hate to rush, but I don’t want 

you to have to wait another hour for us to come back because we 

have another series of votes. So thank you very much. This has 

been very helpful. We want to stress the public component of this 


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health care reform. You may get additional questions in writing 

within the next 10 days from some of us to respond to, and hopefully you will respond to them. But, again, thank you for all your 

input and what you do. And without further adieu, the subcommittee hearing is adjourned. 

[Whereupon, at 2:35 p.m., the subcommittee was adjourned.] 

[Material submitted for inclusion in the record follows:] 


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