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[Congressional Bills 110th Congress]
[From the U.S. Government Publishing Office]
[S. 3674 Introduced in Senate (IS)]

110th CONGRESS
  2d Session
                                S. 3674

 To amend the Public Health Service Act to establish a Wellness Trust.

_______________________________________________________________________

                   IN THE SENATE OF THE UNITED STATES

            October 1 (legislative day, September 17), 2008

 Mrs. Clinton introduced the following bill; which was read twice and 
  referred to the Committee on Health, Education, Labor, and Pensions

_______________________________________________________________________

                                 A BILL

 
 To amend the Public Health Service Act to establish a Wellness Trust.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

    This Act may be cited as the ``21st Century Wellness Trust Act''.

SEC. 2. FINDINGS AND PURPOSE.

    (a) Findings.--Congress finds as follows:
            (1) Preventable and chronic diseases are the epidemic of 
        the 21st century. The number of people with chronic conditions 
        is rapidly increasing and it is estimated that, if there is no 
        intervention now, by 2025 nearly half of the United States 
        population will suffer from at least 1 chronic disease. About 
        70 percent of deaths and health costs in the United States are 
        attributable to chronic diseases (such as cardiovascular 
        disease and cancer), some of which may be preventable. Nearly 
        90 percent of Medicare beneficiaries have some type of chronic 
        illness.
            (2) This affects Americans' health. The United States has 
        the highest rate of preventable deaths among 19 industrialized 
        nations and lags behind 28 other nations in life expectancy. 
        For example, obesity, which is rising rapidly, contributes to a 
        wide range of problems, from diabetes to stroke to cancer. The 
        life expectancy for a 20-year old man may be reduced by 17 
        percent due to obesity. If trends continue, children's life 
        spans may be shorter than those of their parents for the first 
        time in about a century.
            (3) The wellness gap also affects health care costs. About 
        78 percent of all health spending in the United States is 
        attributable to chronic illness, much of which is preventable. 
        Chronic diseases cost the United States an additional 
        $1,000,000,000,000 each year in lost productivity, and are a 
        major contributing factor to the overall poor health that is 
        placing the Nation's economic security and competitiveness in 
        jeopardy.
            (4) Unlike some health care challenges, proven preventive 
        services and programs exist. If effective risk reduction were 
        implemented and sustained by 2015, the death rate due to cancer 
        could drop by 29 percent. Improved blood sugar control for 
        people with diabetes could reduce the risk for eye disease, 
        kidney disease, and nerve disease by 40 percent. Similarly, 
        blood pressure control could reduce the risk for heart disease 
        and stroke by 33 to 50 percent.
            (5) Yet, only half of recommended clinical preventive 
        services are provided to adults. About 20 percent of children 
        do not receive all recommended immunizations, with higher rates 
        in certain areas. Nearly 70 percent of people with high blood 
        pressure do not now control it. And racial disparities in use 
        of prevention exist.
            (6) The United States faces low use of preventive services 
        because of the low value placed on prevention, a delivery 
        system bent toward fixing rather than preventing problems, and 
        financial disincentives for prevention. Insurers have little 
        incentive to invest in preventive services today that will 
        benefit other insurers tomorrow. This is especially true for 
        those preventive services that reduce chronic diseases that 
        develop over a period of several years or decades. The costs of 
        prevention are incurred immediately but most of its benefits 
        are realized later, often by Medicare.
            (7) There is a low investment in prevention. The United 
        States spends only an estimated 1 to 3 percent of national 
        health expenditures on preventive health care services and 
        health promotion. This has not increased as much as one might 
        expect since 1929, 1.4 percent, despite the development of 
        expensive screenings, early interventions, and the growth of 
        the preventable disease burden.
            (8) The workforce to deliver prevention is also 
        insufficient. The supply of providers who are trained to 
        emphasize prevention is shrinking. Between 1997 and 2005, the 
        number of medical school graduates entering family practice 
        residencies dropped by 50 percent. There is an acute shortage 
        of community health workers. Between 25 and 50 percent of the 
        existing Federal, State, and local public health workforce is 
        eligible for retirement in the next 5 years. As of 2008, more 
        than 75 percent of the existing public health workforce has no 
        formal public health or prevention training. There is no 
        national, uniform credentialing system for public health or 
        prevention workers that would ensure that these workers are 
        trained in the basics of preventive care.
            (9) A system that promoted full use of high-priority 
        prevention could save lives. A recent comprehensive assessment 
        found that 1,200,000 quality-adjusted life years could be saved 
        by achieving 90 percent use of just the following 3 services:
                    (A) Smoking cessation counseling.
                    (B) Use of aspirin to prevent heart attacks.
                    (C) Screening for colorectal cancer.
            (10) A system that promoted full use of high-priority 
        prevention could reduce costs. For example, complete, routine 
        childhood vaccination could save up to $40,000,000,000 in 
        direct and societal costs over time. Promoting screenings and 
        behavioral modifications in the workplace can lower absenteeism 
        and, in most cases, health costs to firms. Preventive health 
        care services could reduce government spending on health care. 
        If all elderly received a flu vaccine, health costs could be 
        reduced by nearly $1,000,000,000 per year. Over 25 years, 
        Medicare could save an estimated $890,000,000,000 from 
        effective control of hypertension, and $1,000,000,000,000 from 
        returning to levels of obesity observed in the 1980s.
            (11) Investing in community-level interventions that 
        promote and enable proper nutrition, increased access to 
        physical activity, and smoking cessation programs can prevent 
        and mitigate chronic diseases, improve quality of life, 
        increase economic productivity, and reduce healthcare costs.
    (b) Purpose.--The purpose of this Act is to create a 21st century 
prevention system called the Wellness Trust that assures access to 
clinical and community-level prevention services that improve health, 
quality of life, and reduce healthcare costs.

SEC. 3. WELLNESS TRUST.

    Title III of the Public Health Service Act (21 U.S.C. 241 et seq.) 
is amended by adding at the end the following:

                        ``PART S--WELLNESS TRUST

``SEC. 399KK. DEFINITIONS; ESTABLISHMENT OF WELLNESS TRUST.

    ``(a) Definitions.--In this part:
            ``(1) Certified prevention health worker.--The term 
        `certified prevention health worker' means a licensed health 
        professional or other health worker deemed certified by the 
        Trustees.
            ``(2) Trust.--The term `Trust' means the Wellness Trust 
        established under subsection (b).
            ``(3) Trustees.--The term `Trustees' means the members of 
        the Trust Fund Board appointed under section 399LL(b).
    ``(b) Establishment of the Wellness Trust.--There is established 
within the Centers for Disease Control and Prevention the Wellness 
Trust.

``SEC. 399LL. STRUCTURE.

    ``(a) Trust Fund Board.--The Trust shall be headed by the Trust 
Fund Board.
    ``(b) Composition.--The Trust Fund Board shall be composed of 7 
members appointed by the President by and with the advice and consent 
of the Senate.
    ``(c) Date of Appointments.--The initial 7 Trustees shall be 
appointed not later than December 31, 2009.
    ``(d) Staggered Terms.--Of the members first appointed under 
subsection (c)--
            ``(1) 4 shall be appointed for a period of 4 years; and
            ``(2) 3 shall be appointed for a period of 3 years.
    ``(e) Vacancies.--A vacancy on the Trust Fund Board--
            ``(1) shall not affect the powers of the Trust Fund Board; 
        and
            ``(2) shall be filled in the same manner as the original 
        appointment was made.
    ``(f) Meetings.--The Trust Fund Board shall meet at the call of the 
Chairperson.
    ``(g) Quorum; Required Votes.--A majority of Trustees shall 
constitute a quorum for purposes of voting, but a lesser number of 
members may hold hearings. The Chairperson shall require a vote of the 
Trustees on major decisions regarding prevention priorities, resource 
allocation, delivery system structure, and other Trust functions.
    ``(h) Chairperson and Vice Chairperson.--The Trust Fund Board shall 
select a Chairperson and Vice Chairperson from among the Trustees.
    ``(i) Removal.--A Trustee may be removed by the President only for 
cause.
    ``(j) Recommendations.--The Trustees may submit recommendations 
directly to Congress, without opportunity for comment or change by the 
Secretary.
    ``(k) Staff.--The Trustees may employ and fix the compensation of 
personnel as necessary. Not more than 5 percent of the funds 
appropriated in a fiscal year to the Trust Fund established under 
section 399NN may be used to fund the staff, operations, and other 
purposes as the Trustees determine appropriate of the Trust Fund Board, 
subject to the oversight of the Secretary.

``SEC. 399MM. REPORTS; PLAN FOR DELIVERING SYSTEMS.

    ``(a) Development of Key Reports.--Not later than 1 year after the 
appointment of the Trustees under section 399LL(c), the Trustees shall 
submit to Congress and make publicly available the following reports:
            ``(1) Report on broadening the prevention workforce.--A 
        report that develops and describes a system for certification 
        and recertification of `prevention health workers' to 
        complement the health system as in existence at the time of 
        such report. Such system may expand certification efforts in 
        existence at the time of such report for the public health 
        workforce and community health workers. Such report shall also 
        examine the impact of State licensing requirements and explore 
        and describe options for health profession training and 
        continuing education, 1 or more registries of certified 
        prevention health workers, and an employment structure that 
        encourages flexible deployment but protects prevention health 
        workers' benefits.
            ``(2) Report on aligning payments with prevention goals.--A 
        report that examines and describes payment methodologies and 
        presents options for paying certified prevention health workers 
        for clinical preventive care that aligns incentives with goals, 
        as well as payment methodologies for community organizations 
        involved in the provision of prevention services. Such report 
        shall address the shortfalls of the payment systems in 
        existence at the time of such report that have not proven 
        effective at encouraging the provision of prevention services.
            ``(3) Report on identifying existing funding for 
        prevention.--A report that examines and describes the amount of 
        money spent on prevention by public health, public and private 
        health insurers, and applicable self-insured health plans (as 
        defined in section 399OO) during the most recent year for which 
        such data is available.
    ``(b) Plan for Delivery Systems.--Not later than 1 year after the 
appointment of the Trustees under section 399LL(c), the Trustees shall 
establish a plan for delivering and financing prevention priorities and 
implement pilot programs. Such plan shall include--
            ``(1) identifying effective delivery systems based on 
        evidence and expert judgment to determine how best to deliver 
        priority clinical and community-based prevention activities;
            ``(2) assessing the current capacity of effective delivery 
        systems and actions necessary to ensure adequate infrastructure 
        and capacity to deliver priority clinical and community-based 
        prevention activities as determined by the Trust; and
            ``(3) identifying cost-saving clinical and community-based 
        interventions to implement before December 31, 2011, which 
        shall include evidence-based interventions in obesity, 
        diabetes, heart disease, or cancer.

``SEC. 399NN. INFRASTRUCTURE AND PRIORITIES.

    ``(a) Designating National Prevention Priorities.--The Trustees 
shall issue a ranked list of designated `prevention priorities'. The 
inclusion of an activity on such list shall be based on the potential 
of such activity to improve health and the cost effectiveness of such 
activity. Such list shall--
            ``(1) include clinical preventive services and community-
        based interventions; and
            ``(2) be used by the Trustees to--
                    ``(A) determine what prevention services shall be 
                paid for through the Trust Fund under section 399OO;
                    ``(B) allocate resources within the Trust;
                    ``(C) educate the public on critical prevention 
                priorities; and
                    ``(D) emphasize coverage and use within existing 
                authorities.
    ``(b) Creation and Support of Infrastructure.--The Trustees shall 
establish and otherwise support and sustain the infrastructure for an 
effective wellness system, including the following components:
            ``(1) Central source of prevention information.--A 
        centralized, national, easily accessible information 
        clearinghouse on prevention priorities. Such information 
        clearinghouse shall be made available in multiple media and 
        updated regularly and shall connect individuals, health care 
        providers, and others to national and local resources.
            ``(2) Developing, implementing, and maintaining the 
        electronic prevention record.--If no nationwide interoperable 
        electronic medical record system exists, a privacy-protected 
        electronic prevention record or registry to--
                    ``(A) track provision of prevention over the course 
                of individuals' lifetimes;
                    ``(B) facilitate reimbursement of certified 
                prevention health workers; and
                    ``(C) assist in evaluations of the efficacy of the 
                policies of the Wellness Trust.
            ``(3) Training and credentialing prevention health 
        workers.--Training for prevention health workers through 
        agencies such as the Health Resources and Services 
        Administration and the Centers for Disease Control and 
        Prevention. The Trustees shall--
                    ``(A) provide funding to such agencies through the 
                Trust Fund under section 399OO;
                    ``(B) establish a central registry of certified 
                prevention health workers; and
                    ``(C) encourage such workers to access additional 
                training.

``SEC. 399OO. FUNDING FOR WELLNESS TRUST.

    ``(a) Initial Funding.--There is authorized to be appropriated and 
there is appropriated to the Trust Fund Board such sums as may be 
necessary to carry out sections 399MM and 399NN and other activities 
necessary for the implementation of this part.
    ``(b) Establishment of Wellness Trust Fund.--Not later than January 
1, 2011, there shall be established in the Treasury of the United 
States a trust fund to be known as the `Wellness Trust Fund' (referred 
to in this section as the `Trust Fund'), consisting of such amounts as 
are appropriated or credited to the Fund as provided under this 
section.
    ``(c) Appropriations to the Fund.--
            ``(1) Fiscal year 2011.--There is hereby appropriated to 
        the Trust Fund for fiscal year 2011 an amount equal to the 
        amount spent by all Federal health programs to pay for 
        prevention services (as defined by the U.S. Preventive Services 
        Task Force) in the most recent year for which complete data is 
        available, as estimated by the Trustees.
            ``(2) Fiscal year 2012.--There is hereby appropriated to 
        the Trust Fund for fiscal year 2012 the amount appropriated to 
        the Trust Fund for the previous fiscal year, increased by the 
        annual percentage increase in the medical care component of the 
        consumer price index (United States city average) for the 12-
        month period ending with April of the preceding fiscal year.
            ``(3) Fiscal year 2013 and subsequent years.--There is 
        hereby appropriated to the Trust Fund for fiscal year 2013 and 
        each subsequent fiscal year an amount equal to the sum of--
                    ``(A) the amount appropriated to the Trust Fund for 
                the previous fiscal year, increased by the annual 
                percentage increase in the medical care component of 
                the consumer price index (United States city average) 
                for the 12-month period ending with April of the 
                preceding fiscal year.
                    ``(B) the amount collected by the Secretary from 
                health insurance issuers and applicable self-insured 
                health plans under subsection (d) for the fiscal year; 
                and
                    ``(C) the amount associated with prevention 
                priorities for State and local spending, under-use, and 
                the uninsured for the fiscal year, as estimated by the 
                Trustees (which shall not exceed the amount equal to 10 
                percent of the amount otherwise appropriated to the 
                Trust Fund for the fiscal year).
            ``(4) Availability.--Amounts appropriated pursuant to this 
        subsection shall remain available until expended.
    ``(d) Assessment of Health Insurance Issuers and Applicable Self-
Insured Health Plans.--
            ``(1) In general.--Beginning in fiscal year 2013 and on an 
        annual basis thereafter, the Secretary shall, subject to 
        paragraph (2), assess and collect a fee from each health 
        insurance issuer and each applicable self-insured health plan 
        in an amount equal to the estimated amount spent by such health 
        insurance issuer and self-insured health plan, respectively, 
        for prevention services (as defined by the U.S. Preventive 
        Services Task Force).
            ``(2) Collection amount adjustment beginning in fiscal year 
        2013.--The amount determined under paragraph (1) shall, on an 
        annual basis, be increased by the annual percentage increase in 
        the medical care component of the consumer price index (United 
        States city average) for the 12-month period ending with April 
        of the preceding fiscal year.
    ``(e) Definitions.--In this section:
            ``(1) Applicable self-insured health plan.--The term 
        `applicable self-insured health plan' means any plan for 
        providing accident or health coverage if--
                    ``(A) any portion of such coverage is provided 
                other than through an insurance policy; and
                    ``(B) such plan is established or maintained--
                            ``(i) by 1 or more employers for the 
                        benefit of their employees or former employees;
                            ``(ii) by 1 or more employee organizations 
                        for the benefit of their members or former 
                        members;
                            ``(iii) jointly by 1 or more employers and 
                        1 or more employee organizations for the 
                        benefit of employees or former employees;
                            ``(iv) by a voluntary employees' 
                        beneficiary association described in section 
                        501(c)(9) of the Internal Revenue Code of 1986;
                            ``(v) by any organization described in 
                        section 501(c)(6) of such Code; or
                            ``(vi) in the case of a plan not described 
                        in the preceding clauses, by a multiple 
                        employer welfare arrangement (as defined in 
                        section 3(40) of the Employee Retirement Income 
                        Security Act of 1974), a rural electric 
                        cooperative (as defined in section 3(40)(B)(iv) 
                        of such Act), or a rural telephone cooperative 
                        association (as defined in section 3(40)(B)(v) 
                        of such Act).
            ``(2) Health insurance issuer.--The term `health insurance 
        issuer' means an insurance company, insurance service, or 
        insurance organization (including a health maintenance 
        organization, as defined in paragraph (3)) which is licensed to 
        engage in the business of insurance in a State and which is 
        subject to State law which regulates insurance (within the 
        meaning of section 514(b)(2) of the Employee Retirement Income 
        Security Act of 1974).
            ``(3) Health maintenance organization.--The term `health 
        maintenance organization' means--
                    ``(A) a federally qualified health maintenance 
                organization (as defined in section 1301(a));
                    ``(B) an organization recognized under State law as 
                a health maintenance organization; or
                    ``(C) a similar organization regulated under State 
                law for solvency in the same manner and to the same 
                extent as such a health maintenance organization.

``SEC. 399PP. INSURING PREVENTION PRIORITIES.

    ``(a) Wellness Trust as Primary Payer for Prevention Services.--The 
Trust shall enter into contracts with certified prevention health 
workers to reimburse such workers for the prevention services 
designated by the Trustees under section 399NN(b) as prevention 
priorities.
    ``(b) Priorities.--The Trustees shall develop annual and 5-year 
targets for prevention priorities, budgets to achieve these targets, 
and a list of what shall be included for funding. Such targets shall 
include a set-aside for community-based services.
    ``(c) Eligible Individuals.--Pursuant to the contracts described 
under subsection (a), the Trust shall reimburse certified prevention 
health workers for the prevention services described under such 
subsection provided to all individuals who are United States citizens 
or legal immigrants, without regard to the insurance status of such 
individuals.
    ``(d) Development, Refinement, and Change of Payment Systems.--The 
Trustees shall determine payment methodologies for prevention 
priorities. Such payment methodologies shall correspond to the 
following tiers of activity:
            ``(1) Competitive contracting authority.--The Trustees 
        shall have a competitive contracting authority for the national 
        delivery system activities.
            ``(2) Direct payment systems.--The Trustees shall develop 
        different payment methodologies for the various designated 
        prevention services. These payment systems shall take into 
        account existing rates, rates for similar services, and whether 
        geographic adjustment is needed. Such systems shall link the 
        priority of the service with payments.
            ``(3) Use of state and local grant systems.--The Trustees 
        shall utilize existing grant programs where feasible to 
        distribute funds from the Trust Fund for prevention priorities.
            ``(4) Reports from federal programs.--Programs that receive 
        funding for prevention priorities through the Trust Fund shall 
        report annually to Congress on the extent to which this funding 
        displaces existing spending on prevention priorities.
    ``(e) Partnership With Medicare and Other Insurers.--The Trustees 
shall determine the most efficient way to transfer funds from the Trust 
Fund to certified prevention health workers. In making such 
determination, the Trustees shall carry out the following:
            ``(1) Coordination with medicare.--The Trustees shall 
        examine the use of Medicare systems for direct payments to 
        certified prevention health workers. Any additional 
        administrative cost associated with the use of the payment 
        systems, including those of a broader set of providers, shall 
        come from the Trust Fund.
            ``(2) Contract with other insurers.--To the extent that 
        Medicare program, private insurers, or States prove that such 
        program, insurer, or State has the capacity to deliver 
        prevention priorities in a cost effective manner, the Trustees 
        may contract with such entity for delivery of prevention 
        services covered under this Trust Fund.''.
                                 <all>
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