II 

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. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘21st Century Wellness 

5 Trust Act’’. 

6 SEC. 2. FINDINGS AND PURPOSE. 

7 (a) FINDINGS.—Congress finds as follows: 

8 (1) Preventable and chronic diseases are the 

9 epidemic of the 21st century. The number of people 

10 with chronic conditions is rapidly increasing and it 

11 is estimated that, if there is no intervention now, by 


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1 2025 nearly half of the United States population will 

2 suffer from at least 1 chronic disease. About 70 per3 cent of deaths and health costs in the United States 

4 are attributable to chronic diseases (such as cardio5 vascular disease and cancer), some of which may be 

6 preventable. Nearly 90 percent of Medicare bene7 ficiaries have some type of chronic illness. 

8 (2) This affects Americans’ health. The United 

9 States has the highest rate of preventable deaths 

10 among 19 industrialized nations and lags behind 28 

11 other nations in life expectancy. For example, obe12 sity, which is rising rapidly, contributes to a wide 

13 range of problems, from diabetes to stroke to cancer. 

14 The life expectancy for a 20-year old man may be 

15 reduced by 17 percent due to obesity. If trends con16 tinue, children’s life spans may be shorter than 

17 those of their parents for the first time in about a 

18 century. 

19 (3) The wellness gap also affects health care 

20 costs. About 78 percent of all health spending in the 

21 United States is attributable to chronic illness, much 

22 of which is preventable. Chronic diseases cost the 

23 United States an additional $1,000,000,000,000 

24 each year in lost productivity, and are a major con25 tributing factor to the overall poor health that is 


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1 placing the Nation’s economic security and competi2 tiveness in jeopardy. 

3 (4) Unlike some health care challenges, proven 

4 preventive services and programs exist. If effective 

5 risk reduction were implemented and sustained by 

6 2015, the death rate due to cancer could drop by 29 

7 percent. Improved blood sugar control for people 

8 with diabetes could reduce the risk for eye disease, 

9 kidney disease, and nerve disease by 40 percent. 

10 Similarly, blood pressure control could reduce the 

11 risk for heart disease and stroke by 33 to 50 per12 cent. 

13 (5) Yet, only half of recommended clinical pre14 ventive services are provided to adults. About 20 

15 percent of children do not receive all recommended 

16 immunizations, with higher rates in certain areas. 

17 Nearly 70 percent of people with high blood pressure 

18 do not now control it. And racial disparities in use 

19 of prevention exist. 

20 (6) The United States faces low use of preven21 tive services because of the low value placed on pre22 vention, a delivery system bent toward fixing rather 

23 than preventing problems, and financial disincentives 

24 for prevention. Insurers have little incentive to invest 

25 in preventive services today that will benefit other 


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1 insurers tomorrow. This is especially true for those 

2 preventive services that reduce chronic diseases that 

3 develop over a period of several years or decades. 

4 The costs of prevention are incurred immediately 

5 but most of its benefits are realized later, often by 

6 Medicare. 

7 (7) There is a low investment in prevention. 

8 The United States spends only an estimated 1 to 3 

9 percent of national health expenditures on preventive 

10 health care services and health promotion. This has 

11 not increased as much as one might expect since 

12 1929, 1.4 percent, despite the development of expen13 sive screenings, early interventions, and the growth 

14 of the preventable disease burden. 

15 (8) The workforce to deliver prevention is also 

16 insufficient. The supply of providers who are trained 

17 to emphasize prevention is shrinking. Between 1997 

18 and 2005, the number of medical school graduates 

19 entering family practice residencies dropped by 50 

20 percent. There is an acute shortage of community 

21 health workers. Between 25 and 50 percent of the 

22 existing Federal, State, and local public health work23 force is eligible for retirement in the next 5 years. 

24 As of 2008, more than 75 percent of the existing 

25 public health workforce has no formal public health 


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1 or prevention training. There is no national, uniform 

2 credentialing system for public health or prevention 

3 workers that would ensure that these workers are 

4 trained in the basics of preventive care. 

5 (9) A system that promoted full use of high-pri6 ority prevention could save lives. A recent com7 prehensive assessment found that 1,200,000 quality8 adjusted life years could be saved by achieving 90 

9 percent use of just the following 3 services: 

10 (A) Smoking cessation counseling. 

11 (B) Use of aspirin to prevent heart at12 tacks. 

13 (C) Screening for colorectal cancer. 

14 (10) A system that promoted full use of high15 priority prevention could reduce costs. For example, 

16 complete, routine childhood vaccination could save 

17 up to $40,000,000,000 in direct and societal costs 

18 over time. Promoting screenings and behavioral 

19 modifications in the workplace can lower absentee20 ism and, in most cases, health costs to firms. Pre21 ventive health care services could reduce government 

22 spending on health care. If all elderly received a flu 

23 vaccine, health costs could be reduced by nearly 

24 $1,000,000,000 per year. Over 25 years, Medicare 

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1 fective control of hypertension, and 

2 $1,000,000,000,000 from returning to levels of obe3 sity observed in the 1980s. 

4 (11) Investing in community-level interventions 

5 that promote and enable proper nutrition, increased 

6 access to physical activity, and smoking cessation 

7 programs can prevent and mitigate chronic diseases, 

8 improve quality of life, increase economic produc9 tivity, and reduce healthcare costs. 

10 (b) PURPOSE.—The purpose of this Act is to create 

11 a 21st century prevention system called the Wellness 

12 Trust that assures access to clinical and community-level 

13 prevention services that improve health, quality of life, and 

14 reduce healthcare costs. 

15 SEC. 3. WELLNESS TRUST. 

16 Title III of the Public Health Service Act (21 U.S.C. 

17 241 et seq.) is amended by adding at the end the fol18 lowing: 

19 ‘‘PART S—WELLNESS TRUST 

20 ‘‘SEC. 399KK. DEFINITIONS; ESTABLISHMENT OF WELLNESS 

21 TRUST. 

22 ‘‘(a) DEFINITIONS.—In this part: 

23 ‘‘(1) CERTIFIED PREVENTION HEALTH WORK24 ER.—The term ‘certified prevention health worker’ 


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1 means a licensed health professional or other health 

2 worker deemed certified by the Trustees. 

3 ‘‘(2) TRUST.—The term ‘Trust’ means the 

4 Wellness Trust established under subsection (b). 

5 ‘‘(3) TRUSTEES.—The term ‘Trustees’ means 

6 the members of the Trust Fund Board appointed 

7 under section 399LL(b). 

8 ‘‘(b) ESTABLISHMENT OF THE WELLNESS TRUST.— 

9 There is established within the Centers for Disease Con10 trol and Prevention the Wellness Trust. 

11 ‘‘SEC. 399LL. STRUCTURE. 

12 ‘‘(a) TRUST FUND BOARD.—The Trust shall be 

13 headed by the Trust Fund Board. 

14 ‘‘(b) COMPOSITION.—The Trust Fund Board shall be 

15 composed of 7 members appointed by the President by and 

16 with the advice and consent of the Senate. 

17 ‘‘(c) DATE OF APPOINTMENTS.—The initial 7 Trust18 ees shall be appointed not later than December 31, 2009. 

19 ‘‘(d) STAGGERED TERMS.—Of the members first ap20 pointed under subsection (c)— 

21 ‘‘(1) 4 shall be appointed for a period of 4 

22 years; and 

23 ‘‘(2) 3 shall be appointed for a period of 3 

24 years. 


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1 ‘‘(e) VACANCIES.—A vacancy on the Trust Fund 

2 Board— 

3 ‘‘(1) shall not affect the powers of the Trust 

4 Fund Board; and 

5 ‘‘(2) shall be filled in the same manner as the 

6 original appointment was made. 

7 ‘‘(f) MEETINGS.—The Trust Fund Board shall meet 

8 at the call of the Chairperson. 

9 ‘‘(g) QUORUM; REQUIRED VOTES.—A majority of 

10 Trustees shall constitute a quorum for purposes of voting, 

11 but a lesser number of members may hold hearings. The 

12 Chairperson shall require a vote of the Trustees on major 

13 decisions regarding prevention priorities, resource alloca14 tion, delivery system structure, and other Trust functions. 

15 ‘‘(h) CHAIRPERSON AND VICE CHAIRPERSON.—The 

16 Trust Fund Board shall select a Chairperson and Vice 

17 Chairperson from among the Trustees. 

18 ‘‘(i) REMOVAL.—A Trustee may be removed by the 

19 President only for cause. 

20 ‘‘(j) RECOMMENDATIONS.—The Trustees may submit 

21 recommendations directly to Congress, without oppor22 tunity for comment or change by the Secretary. 

23 ‘‘(k) STAFF.—The Trustees may employ and fix the 

24 compensation of personnel as necessary. Not more than 

25 5 percent of the funds appropriated in a fiscal year to 


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1 the Trust Fund established under section 399NN may be 

2 used to fund the staff, operations, and other purposes as 

3 the Trustees determine appropriate of the Trust Fund 

4 Board, subject to the oversight of the Secretary. 

5 ‘‘SEC. 399MM. REPORTS; PLAN FOR DELIVERING SYSTEMS. 

6 ‘‘(a) DEVELOPMENT OF KEY REPORTS.—Not later 

7 than 1 year after the appointment of the Trustees under 

8 section 399LL(c), the Trustees shall submit to Congress 

9 and make publicly available the following reports: 

10 ‘‘(1) REPORT ON BROADENING THE PREVEN11 TION WORKFORCE.—A report that develops and de12 scribes a system for certification and recertification 

13 of ‘prevention health workers’ to complement the 

14 health system as in existence at the time of such re15 port. Such system may expand certification efforts 

16 in existence at the time of such report for the public 

17 health workforce and community health workers. 

18 Such report shall also examine the impact of State 

19 licensing requirements and explore and describe op20 tions for health profession training and continuing 

21 education, 1 or more registries of certified preven22 tion health workers, and an employment structure 

23 that encourages flexible deployment but protects pre24 vention health workers’ benefits. 


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1 ‘‘(2) REPORT ON ALIGNING PAYMENTS WITH

2 PREVENTION GOALS.—A report that examines and 

3 describes payment methodologies and presents op4 tions for paying certified prevention health workers 

5 for clinical preventive care that aligns incentives 

6 with goals, as well as payment methodologies for 

7 community organizations involved in the provision of 

8 prevention services. Such report shall address the 

9 shortfalls of the payment systems in existence at the 

10 time of such report that have not proven effective at 

11 encouraging the provision of prevention services. 

12 ‘‘(3) REPORT ON IDENTIFYING EXISTING FUND13 ING FOR PREVENTION.—A report that examines and 

14 describes the amount of money spent on prevention 

15 by public health, public and private health insurers, 

16 and applicable self-insured health plans (as defined 

17 in section 399OO) during the most recent year for 

18 which such data is available. 

19 ‘‘(b) PLAN FOR DELIVERY SYSTEMS.—Not later than 

20 1 year after the appointment of the Trustees under section 

21 399LL(c), the Trustees shall establish a plan for deliv22 ering and financing prevention priorities and implement 

23 pilot programs. Such plan shall include— 

24 ‘‘(1) identifying effective delivery systems based 

25 on evidence and expert judgment to determine how 


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1 best to deliver priority clinical and community-based 

2 prevention activities; 

3 ‘‘(2) assessing the current capacity of effective 

4 delivery systems and actions necessary to ensure 

5 adequate infrastructure and capacity to deliver pri6 ority clinical and community-based prevention activi7 ties as determined by the Trust; and 

8 ‘‘(3) identifying cost-saving clinical and commu9 nity-based interventions to implement before Decem10 ber 31, 2011, which shall include evidence-based 

11 interventions in obesity, diabetes, heart disease, or 

12 cancer. 

13 ‘‘SEC. 399NN. INFRASTRUCTURE AND PRIORITIES. 

14 ‘‘(a) DESIGNATING NATIONAL PREVENTION PRIOR15 ITIES.—The Trustees shall issue a ranked list of des16 ignated ‘prevention priorities’. The inclusion of an activity 

17 on such list shall be based on the potential of such activity 

18 to improve health and the cost effectiveness of such activ19 ity. Such list shall— 

20 ‘‘(1) include clinical preventive services and 

21 community-based interventions; and 

22 ‘‘(2) be used by the Trustees to— 

23 ‘‘(A) determine what prevention services 

24 shall be paid for through the Trust Fund under 

25 section 399OO; 


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1 ‘‘(B) allocate resources within the Trust; 

2 ‘‘(C) educate the public on critical preven3 tion priorities; and 

4 ‘‘(D) emphasize coverage and use within 

5 existing authorities. 

6 ‘‘(b) CREATION AND SUPPORT OF INFRASTRUC7 TURE.—The Trustees shall establish and otherwise sup8 port and sustain the infrastructure for an effective 

9 wellness system, including the following components: 

10 ‘‘(1) CENTRAL SOURCE OF PREVENTION INFOR11 MATION.—A centralized, national, easily accessible 

12 information clearinghouse on prevention priorities. 

13 Such information clearinghouse shall be made avail14 able in multiple media and updated regularly and 

15 shall connect individuals, health care providers, and 

16 others to national and local resources. 

17 ‘‘(2) DEVELOPING, IMPLEMENTING, AND MAIN18 TAINING THE ELECTRONIC PREVENTION RECORD.— 

19 If no nationwide interoperable electronic medical 

20 record system exists, a privacy-protected electronic 

21 prevention record or registry to— 

22 ‘‘(A) track provision of prevention over the 

23 course of individuals’ lifetimes; 

24 ‘‘(B) facilitate reimbursement of certified 

25 prevention health workers; and 


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1 ‘‘(C) assist in evaluations of the efficacy of 

2 the policies of the Wellness Trust. 

3 ‘‘(3) TRAINING AND CREDENTIALING PREVEN4 TION HEALTH WORKERS.—Training for prevention 

5 health workers through agencies such as the Health 

6 Resources and Services Administration and the Cen7 ters for Disease Control and Prevention. The Trust8 ees shall— 

9 ‘‘(A) provide funding to such agencies 

10 through the Trust Fund under section 399OO; 

11 ‘‘(B) establish a central registry of cer12 tified prevention health workers; and 

13 ‘‘(C) encourage such workers to access ad14 ditional training. 

15 ‘‘SEC. 399OO. FUNDING FOR WELLNESS TRUST. 

16 ‘‘(a) INITIAL FUNDING.—There is authorized to be 

17 appropriated and there is appropriated to the Trust Fund 

18 Board such sums as may be necessary to carry out sec19 tions 399MM and 399NN and other activities necessary 

20 for the implementation of this part. 

21 ‘‘(b) ESTABLISHMENT OF WELLNESS TRUST

22 FUND.—Not later than January 1, 2011, there shall be 

23 established in the Treasury of the United States a trust 

24 fund to be known as the ‘Wellness Trust Fund’ (referred 

25 to in this section as the ‘Trust Fund’), consisting of such 


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1 amounts as are appropriated or credited to the Fund as 

2 provided under this section. 

3 ‘‘(c) APPROPRIATIONS TO THE FUND.— 

4 ‘‘(1) FISCAL YEAR 2011.—There is hereby ap5 propriated to the Trust Fund for fiscal year 2011 an 

6 amount equal to the amount spent by all Federal 

7 health programs to pay for prevention services (as 

8 defined by the U.S. Preventive Services Task Force) 

9 in the most recent year for which complete data is 

10 available, as estimated by the Trustees. 

11 ‘‘(2) FISCAL YEAR 2012.—There is hereby ap12 propriated to the Trust Fund for fiscal year 2012 

13 the amount appropriated to the Trust Fund for the 

14 previous fiscal year, increased by the annual percent15 age increase in the medical care component of the 

16 consumer price index (United States city average) 

17 for the 12-month period ending with April of the 

18 preceding fiscal year. 

19 ‘‘(3) FISCAL YEAR 2013 AND SUBSEQUENT

20 YEARS.—There is hereby appropriated to the Trust 

21 Fund for fiscal year 2013 and each subsequent fiscal 

22 year an amount equal to the sum of— 

23 ‘‘(A) the amount appropriated to the Trust 

24 Fund for the previous fiscal year, increased by 

25 the annual percentage increase in the medical 


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1 care component of the consumer price index 

2 (United States city average) for the 12-month 

3 period ending with April of the preceding fiscal 

4 year. 

5 ‘‘(B) the amount collected by the Secretary 

6 from health insurance issuers and applicable 

7 self-insured health plans under subsection (d) 

8 for the fiscal year; and 

9 ‘‘(C) the amount associated with preven10 tion priorities for State and local spending, 

11 under-use, and the uninsured for the fiscal 

12 year, as estimated by the Trustees (which shall 

13 not exceed the amount equal to 10 percent of 

14 the amount otherwise appropriated to the Trust 

15 Fund for the fiscal year). 

16 ‘‘(4) AVAILABILITY.—Amounts appropriated 

17 pursuant to this subsection shall remain available 

18 until expended. 

19 ‘‘(d) ASSESSMENT OF HEALTH INSURANCE ISSUERS

20 AND APPLICABLE SELF-INSURED HEALTH PLANS.— 

21 ‘‘(1) IN GENERAL.—Beginning in fiscal year 

22 2013 and on an annual basis thereafter, the Sec23 retary shall, subject to paragraph (2), assess and 

24 collect a fee from each health insurance issuer and 

25 each applicable self-insured health plan in an 


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1 amount equal to the estimated amount spent by 

2 such health insurance issuer and self-insured health 

3 plan, respectively, for prevention services (as defined 

4 by the U.S. Preventive Services Task Force). 

5 ‘‘(2) COLLECTION AMOUNT ADJUSTMENT BE6 GINNING IN FISCAL YEAR 2013.—The amount deter7 mined under paragraph (1) shall, on an annual 

8 basis, be increased by the annual percentage in9 crease in the medical care component of the con10 sumer price index (United States city average) for 

11 the 12-month period ending with April of the pre12 ceding fiscal year. 

13 ‘‘(e) DEFINITIONS.—In this section: 

14 ‘‘(1) APPLICABLE SELF-INSURED HEALTH

15 PLAN.—The term ‘applicable self-insured health 

16 plan’ means any plan for providing accident or 

17 health coverage if— 

18 ‘‘(A) any portion of such coverage is pro19 vided other than through an insurance policy; 

20 and 

21 ‘‘(B) such plan is established or main22 tained— 

23 ‘‘(i) by 1 or more employers for the 

24 benefit of their employees or former em25 ployees; 


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1 ‘‘(ii) by 1 or more employee organiza2 tions for the benefit of their members or 

3 former members; 

4 ‘‘(iii) jointly by 1 or more employers 

5 and 1 or more employee organizations for 

6 the benefit of employees or former employ7 ees; 

8 ‘‘(iv) by a voluntary employees’ bene9 ficiary association described in section 

10 501(c)(9) of the Internal Revenue Code of 

11 1986; 

12 ‘‘(v) by any organization described in 

13 section 501(c)(6) of such Code; or 

14 ‘‘(vi) in the case of a plan not de15 scribed in the preceding clauses, by a mul16 tiple employer welfare arrangement (as de17 fined in section 3(40) of the Employee Re18 tirement Income Security Act of 1974), a 

19 rural electric cooperative (as defined in 

20 section 3(40)(B)(iv) of such Act), or a 

21 rural telephone cooperative association (as 

22 defined in section 3(40)(B)(v) of such 

23 Act). 

24 ‘‘(2) HEALTH INSURANCE ISSUER.—The term 

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1 pany, insurance service, or insurance organization 

2 (including a health maintenance organization, as de3 fined in paragraph (3)) which is licensed to engage 

4 in the business of insurance in a State and which is 

5 subject to State law which regulates insurance (with6 in the meaning of section 514(b)(2) of the Employee 

7 Retirement Income Security Act of 1974). 

8 ‘‘(3) HEALTH MAINTENANCE ORGANIZATION.— 

9 The term ‘health maintenance organization’ 

10 means— 

11 ‘‘(A) a federally qualified health mainte12 nance organization (as defined in section 

13 1301(a)); 

14 ‘‘(B) an organization recognized under 

15 State law as a health maintenance organization; 

16 or 

17 ‘‘(C) a similar organization regulated 

18 under State law for solvency in the same man19 ner and to the same extent as such a health 

20 maintenance organization. 

21 ‘‘SEC. 399PP. INSURING PREVENTION PRIORITIES. 

22 ‘‘(a) WELLNESS TRUST AS PRIMARY PAYER FOR

23 PREVENTION SERVICES.—The Trust shall enter into con24 tracts with certified prevention health workers to reim25 burse such workers for the prevention services designated 


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1 by the Trustees under section 399NN(b) as prevention 

2 priorities. 

3 ‘‘(b) PRIORITIES.—The Trustees shall develop annual 

4 and 5-year targets for prevention priorities, budgets to 

5 achieve these targets, and a list of what shall be included 

6 for funding. Such targets shall include a set-aside for com7 munity-based services. 

8 ‘‘(c) ELIGIBLE INDIVIDUALS.—Pursuant to the con9 tracts described under subsection (a), the Trust shall re10 imburse certified prevention health workers for the preven11 tion services described under such subsection provided to 

12 all individuals who are United States citizens or legal im13 migrants, without regard to the insurance status of such 

14 individuals. 

15 ‘‘(d) DEVELOPMENT, REFINEMENT, AND CHANGE OF

16 PAYMENT SYSTEMS.—The Trustees shall determine pay17 ment methodologies for prevention priorities. Such pay18 ment methodologies shall correspond to the following tiers 

19 of activity: 

20 ‘‘(1) COMPETITIVE CONTRACTING AUTHOR21 ITY.—The Trustees shall have a competitive con22 tracting authority for the national delivery system 

23 activities. 

24 ‘‘(2) DIRECT PAYMENT SYSTEMS.—The Trust25 ees shall develop different payment methodologies 


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1 for the various designated prevention services. These 

2 payment systems shall take into account existing 

3 rates, rates for similar services, and whether geo4 graphic adjustment is needed. Such systems shall 

5 link the priority of the service with payments. 

6 ‘‘(3) USE OF STATE AND LOCAL GRANT SYS7 TEMS.—The Trustees shall utilize existing grant 

8 programs where feasible to distribute funds from the 

9 Trust Fund for prevention priorities. 

10 ‘‘(4) REPORTS FROM FEDERAL PROGRAMS.— 

11 Programs that receive funding for prevention prior12 ities through the Trust Fund shall report annually 

13 to Congress on the extent to which this funding dis14 places existing spending on prevention priorities. 

15 ‘‘(e) PARTNERSHIP WITH MEDICARE AND OTHER IN16 SURERS.—The Trustees shall determine the most efficient 

17 way to transfer funds from the Trust Fund to certified 

18 prevention health workers. In making such determination, 

19 the Trustees shall carry out the following: 

20 ‘‘(1) COORDINATION WITH MEDICARE.—The 

21 Trustees shall examine the use of Medicare systems 

22 for direct payments to certified prevention health 

23 workers. Any additional administrative cost associ24 ated with the use of the payment systems, including 


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1 those of a broader set of providers, shall come from 

2 the Trust Fund. 

3 ‘‘(2) CONTRACT WITH OTHER INSURERS.—To 

4 the extent that Medicare program, private insurers, 

5 or States prove that such program, insurer, or State 

6 has the capacity to deliver prevention priorities in a 

7 cost effective manner, the Trustees may contract 

8 with such entity for delivery of prevention services 

9 covered under this Trust Fund.’’. 

Æ 


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