II 

111TH CONGRESS 

1ST SESSION S. 1181 

To provide for a demonstration project to examine whether community-level 

public health interventions can result in lower rates of chronic disease 

for individuals entering the Medicare program. 

IN THE SENATE OF THE UNITED STATES 

JUNE 4, 2009 

Mr. WYDEN introduced the following bill; which was read twice and referred 

to the Committee on Finance 

A BILL 

To provide for a demonstration project to examine whether 

community-level public health interventions can result 

in lower rates of chronic disease for individuals entering 

the Medicare program. 

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 ‘‘Healthy Living and 

5 Health Aging Demonstration Project Act of 2009’’. 

6 SEC. 2. FINDINGS. 

7 Congress finds the following: 


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1 (1) Chronic diseases are the leading cause of 

2 death and disability in the United States. Seven in 

3 every 10 deaths are attributable to chronic disease, 

4 with more than 1,700,000 Americans dying each 

5 year. Approximately 133,000,000 Americans, rep6 resenting 45 percent of the Nation’s population, 

7 have at least 1 chronic disease. 

8 (2) In 2007, the United States spent over 

9 $2,200,000,000,000 on health care, with 75 cents 

10 out of every dollar spent going towards treatment of 

11 individuals with 1 or more chronic disease. In public 

12 programs, treatment for chronic diseases constitutes 

13 an even higher percentage of total spending, with 83 

14 cents of every dollar spent by Medicaid programs 

15 and more than 95 cents of every dollar spent by the 

16 Medicare program going towards costs related to 

17 chronic disease. 

18 (3) Since 1987, the rate of obesity in the 

19 United States has doubled, accounting for a 20 to 

20 30 percent increase in health care spending. Addi21 tionally, the percentage of young Americans who are 

22 overweight has tripled since 1980. If the prevalence 

23 of obesity was at the same level as it was in 1987, 

24 health care spending would be nearly 10 percent 


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1 lower per person, for a total savings of nearly 

2 $200,000,000,000. 

3 (4) The vast majority of cases of chronic dis4 ease could be better prevented or managed. The 

5 World Health Organization has estimated that if the 

6 major risk factors for chronic diseases were elimi7 nated, at least 80 percent of all cases of heart dis8 ease, stroke, and type 2 diabetes could be prevented, 

9 while also averting more than 40 percent of cancer 

10 cases. 

11 (5) Depressive disorders are also becoming in12 creasingly common, chronic, and costly. In 1990, the 

13 World Health Organization identified major depres14 sion as the fourth leading cause of disease world15 wide, leading to more cases of disability than 

16 ischemic heart disease or cerebrovascular disease. 

17 Research has shown that mental health screenings 

18 following disease diagnosis for diabetic patients can 

19 improve health while remaining cost-effective. 

20 (6) A report by the Trust for America’s Health 

21 found that an annual investment of $10 per person 

22 in proven community-based programs to increase 

23 physical activity, improve nutrition, and prevent to24 bacco use and smoking could, within 5 years, save 

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1 ally, with savings of more than $5,000,000,000 for 

2 Medicare and $1,900,000,000 for Medicaid, as well 

3 as over $9,000,000,000 in savings for private health 

4 insurance payers. 

5 SEC. 3. DEMONSTRATION PROJECT FOR COMMUNITY6 LEVEL PUBLIC HEALTH INTERVENTIONS. 

7 (a) DEFINITIONS.—In this Act: 

8 (1) ADMINISTRATOR.—The term ‘‘Adminis9 trator’’ means the Administrator of the Centers for 

10 Medicare & Medicaid Services. 

11 (2) CHRONIC DISEASE OR CONDITION.—The 

12 term ‘‘chronic disease or condition’’ means diabetes, 

13 hypertension, pulmonary diseases (including asth14 ma), hyperlipidemia, obesity, and any other disease 

15 or condition as determined by the Secretary of 

16 Health and Human Services. 

17 (3) COMMUNITY-BASED PREVENTION AND

18 INTERVENTION STRATEGY.—The term ‘‘community19 based prevention and intervention strategy’’ means 

20 programs and services intended to prevent and re21 duce the incidence of chronic disease, including 

22 walking programs, group exercise classes, anti-smok23 ing programs, healthy eating programs, increased 

24 access to nutritious and organic foods, programs and 

25 services that have been recommended by the Task 


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1 Force on Community Preventive Services, and any 

2 programs or services that have been proposed by an 

3 eligible partnership and certified by the Director of 

4 the Centers for Disease Control and Prevention as 

5 evidence-based. 

6 (4) DIRECTOR.—The term ‘‘Director’’ means 

7 the Director of the Centers for Disease Control and 

8 Prevention. 

9 (5) MEDICARE.—The term ‘‘Medicare’’ means 

10 the program established under title XVIII of the So11 cial Security Act (42 U.S.C. 1395 et seq.). 

12 (6) PRE-MEDICARE ELIGIBLE INDIVIDUAL.— 

13 The term ‘‘pre-Medicare eligible individual’’ means 

14 an individual who has attained age 55, but not age 

15 65. 

16 (7) SECRETARY.—The term ‘‘Secretary’’ means 

17 the Secretary of Health and Human Services. 

18 (8) STATE.—The term ‘‘State’’ means each of 

19 the 50 States, the District of Columbia, the Com20 monwealth of Puerto Rico, the United States Virgin 

21 Islands, Guam, the Commonwealth of the Northern 

22 Mariana Islands, and American Samoa. 

23 (b) ESTABLISHMENT.— 

24 (1) IN GENERAL.—The Secretary, acting 

25 through the Administrator and in consultation with 


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1 the Director, shall establish a demonstration project 

2 under which eligible partnerships, as described in 

3 subsection (d)(1), are awarded grants to examine 

4 whether community-based prevention and interven5 tion strategies, targeted towards pre-Medicare eligi6 ble individuals, result in— 

7 (A) lower rates of chronic diseases and 

8 conditions after such individuals become eligible 

9 for benefits under Medicare; and 

10 (B) lower costs under Medicare. 

11 (2) FEDERAL AGENCY RESPONSIBILITIES.— 

12 (A) CENTERS FOR MEDICARE & MEDICAID

13 SERVICES.—The Administrator shall have pri14 mary responsibility for administering and evalu15 ating the demonstration project established 

16 under this section. 

17 (B) CENTERS FOR DISEASE CONTROL AND

18 PREVENTION.—The Director shall— 

19 (i) certify that community-based pre20 vention and intervention strategies pro21 posed by eligible partnerships are evidence22 based; 

23 (ii) administer and provide grants for 

24 health screenings and risk assessments and 

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1 tion strategies conducted by eligible part2 nerships; and 

3 (iii) provide grants to designated clin4 ical referral sites (as described in sub5 section (d)(1)(B)(ii)(I)) for reimbursement 

6 of administrative costs associated with 

7 their participation in the demonstration 

8 project. 

9 (c) DURATION AND SELECTION OF PARTNER10 SHIPS.— 

11 (1) DURATION.—The demonstration project 

12 shall be conducted for a 5-year period, beginning not 

13 later than 2010. 

14 (2) NUMBER OF PARTNERSHIPS.—The Admin15 istrator, in consultation with the Director, shall se16 lect not more than 6 eligible partnerships. 

17 (3) SELECTION OF PARTNERSHIPS.—Eligible 

18 partnerships shall be selected by the Administrator 

19 in a manner that— 

20 (A) ensures such partnerships represent 

21 racially, ethnically, economically, and geographi22 cally diverse populations, including urban, 

23 rural, and underserved areas; and 


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1 (B) gives priority to such partnerships that 

2 include employers (as described in subsection 

3 (d)(1)(C)). 

4 (d) ELIGIBLE PARTNERSHIPS.— 

5 (1) DESCRIPTION.— 

6 (A) IN GENERAL.—Subject to subpara7 graph (C), for purposes of this section, an eligi8 ble partnership is a partnership that submits an 

9 approved application to participate in the dem10 onstration project under this section and in11 cludes both of the entities described in subpara12 graph (B). 

13 (B) REQUIRED ENTITIES.—An eligible 

14 partnership shall consist of a partnership be15 tween the following: 

16 (i) A State or local public health de17 partment that shall— 

18 (I) serve as the lead organization 

19 for the eligible partnership; 

20 (II) develop appropriate commu21 nity-based prevention and intervention 

22 strategies and present such strategies 

23 to the Director for certification; and 

24 (III) administer certified commu25 nity-based prevention and intervention 


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1 strategies and conduct such strategies 

2 in association with local community 

3 organizations. 

4 (ii) A medical facility as deemed ap5 propriate by the Administrator, including 

6 health centers (as described under section 

7 330 of the Public Health Service Act (42 

8 U.S.C. 254b)) and rural health clinics (as 

9 described in section 1861(aa)(2) of the So10 cial Security Act (42 U.S.C. 

11 1395x(aa)(2))), that shall— 

12 (I) serve as the designated clin13 ical referral site for medical services, 

14 as described in subsection 

15 (e)(4)(B)(i); 

16 (II) provide assistance to the des17 ignated public health department with 

18 organization and administration of in19 dividual health screenings and risk as20 sessments, as described in subsection 

21 (e)(3); 

22 (III) collect payment for medical 

23 treatment and services that have been 

24 provided to individuals under the dem25 onstration project in a manner that is 


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1 consistent with State law and applica2 ble clinic policy; and 

3 (IV) provide mental health serv4 ices or obtain an agreement with a 

5 designated mental health provider for 

6 referral and provision of such services. 

7 (C) OPTIONAL ENTITIES.—An eligible 

8 partnership may include other organizations as 

9 practicable and necessary to assist in commu10 nity outreach activities and to engage health 

11 care providers, insurers, employers, and other 

12 community stakeholders in meeting the goals of 

13 the demonstration project. 

14 (2) APPLICATIONS.—An eligible partnership 

15 that desires to participate in the demonstration 

16 project shall submit to the Administrator an applica17 tion at such time, in such manner, and containing 

18 such information as the Administrator may require. 

19 (e) USE OF FUNDS.— 

20 (1) IN GENERAL.—An eligible partnership shall 

21 use funds received under this section to conduct 

22 community-based prevention and intervention strate23 gies and health screenings and risk assessments for 

24 pre-Medicare eligible individuals from a diverse se25 lection of ethnic backgrounds and income levels. 


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1 (2) COMMUNITY-BASED PREVENTION AND

2 INTERVENTION STRATEGY.—An eligible partnership, 

3 acting through the State or local health department, 

4 shall promote healthy lifestyle choices among pre5 Medicare eligible individuals by implementing and 

6 conducting a certified community-based prevention 

7 and intervention strategy that shall be made avail8 able to all such individuals. 

9 (3) INDIVIDUAL HEALTH SCREENINGS AND

10 RISK ASSESSMENTS.—An eligible partnership, acting 

11 through the State or local public health department 

12 (or an appropriately designated facility), shall agree 

13 to provide the following: 

14 (A) SCREENINGS FOR CHRONIC DISEASES

15 AND CONDITIONS.—Individual health screenings 

16 for chronic diseases or conditions, which shall 

17 include appropriate tests for— 

18 (i) diabetes; 

19 (ii) high blood pressure; 

20 (iii) high cholesterol; 

21 (iv) body mass index; 

22 (v) physical inactivity; 

23 (vi) poor nutrition; 

24 (vii) tobacco use; and 


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1 (viii) any other chronic disease or con2 dition as determined by the Director. 

3 (B) MENTAL HEALTH SCREENINGS.—A 

4 mental health screening and, if appropriate, re5 ferral for additional mental health services, for 

6 any individual who has been screened and diag7 nosed with a chronic disease or condition. 

8 (4) CLINICAL TREATMENT FOR CHRONIC DIS9 EASES.—The eligible partnership shall agree to pro10 vide the following: 

11 (A) TREATMENT AND PREVENTION REFER12 RALS FOR INSURED INDIVIDUALS.—To refer an 

13 individual determined to be covered under a 

14 health insurance program who has been 

15 screened and diagnosed with a chronic disease 

16 or chronic disease risk factors (including high 

17 blood pressure, high cholesterol, obesity, or to18 bacco use)— 

19 (i) to a provider under such program 

20 for further medical or mental health treat21 ment; and 

22 (ii) for enrollment in an appropriate 

23 community-based prevention and interven24 tion strategy program. 


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1 (B) TREATMENT AND PREVENTION REFER2 RALS FOR UNINSURED INDIVIDUALS.—To refer 

3 an individual determined to be without coverage 

4 under a health insurance program who has been 

5 screened and diagnosed with a chronic disease 

6 or chronic disease risk factors (including high 

7 blood pressure, high cholesterol, obesity, or to8 bacco use) to the designated clinical referral 

9 site— 

10 (i) for determination of eligibility for 

11 public health programs, or appropriate 

12 treatment (including mental health serv13 ices) pursuant to the facility’s existing au14 thority and funding and in accordance with 

15 applicable fees and payment collection as 

16 described in subsection (d)(1)(B)(ii)(III); 

17 and 

18 (ii) for enrollment in an appropriate 

19 community-based prevention and interven20 tion strategy program. 

21 (C) HEALTHY INDIVIDUALS.—To provide 

22 an individual who is not diagnosed with a 

23 chronic disease and does not exhibit any chronic 

24 disease risk factors with appropriate informa25 tion on healthy lifestyle choices and available 


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1 community-based prevention and intervention 

2 strategy programs. 

3 (5) RULE OF CONSTRUCTION.—Nothing in this 

4 section shall be construed as entitling an individual 

5 who participates in the demonstration project to 

6 benefits under Medicare. 

7 (f) MONITORING.—The Secretary shall develop and 

8 administer a program to evaluate the effectiveness of the 

9 demonstration project by collecting the following: 

10 (1) HEALTH RISK ASSESSMENT RESULTS.— 

11 Each eligible partnership shall maintain records of 

12 medical information and results obtained during 

13 each individual’s health screening and risk assess14 ment to establish baseline data for continued moni15 toring and assessment of such individuals. 

16 (2) MEDICARE EXAMINATION RESULTS.—The 

17 Secretary shall collect medical information obtained 

18 during the initial preventive physical examination 

19 under Medicare (as defined in section 1861(ww) of 

20 the Social Security Act (42 U.S.C. 1395x(ww))) for 

21 those individuals who received health screenings and 

22 risk assessments through the demonstration project. 

23 (g) EVALUATION.— 

24 (1) INDEPENDENT RESEARCH.—The Secretary, 

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1 trator, shall enter into a contract with an inde2 pendent entity or organization that has dem3 onstrated— 

4 (A) prior experience in population-based 

5 assessment of public health interventions de6 signed to prevent or treat chronic diseases and 

7 conditions; and 

8 (B) knowledge and prior study of the gen9 eral health and lifestyle behaviors of pre-Medi10 care eligible individuals. 

11 (2) EVALUATION DESIGNS.—The entity or orga12 nization selected by the Secretary under paragraph 

13 (1) shall, using the information and data collected 

14 pursuant to subsection (f), conduct an assessment of 

15 the demonstration project through— 

16 (A) a population-based design that com17 pares those populations targeted under the 

18 demonstration project with a matched control 

19 group; and 

20 (B) a pre-post design that measures 

21 changes in health indicators (including im22 proved diet or increased physical activity) and 

23 health outcomes in the targeted populations for 

24 those individuals who participated in individual 

25 health risk assessments and, prior to completion 


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1 of the demonstration project, became eligible 

2 for benefits under Medicare. 

3 (h) REPORTING.— 

4 (1) PROGRESS REPORT.—Not later than 3 

5 years after implementation of the demonstration 

6 project, the Secretary shall prepare and submit a re7 port on the status of the project to Congress, includ8 ing— 

9 (A) the progress and results of any activi10 ties conducted under the demonstration project; 

11 and 

12 (B) identification of health indicators 

13 (such as improved diet or increased physical ac14 tivity) that have been determined to be associ15 ated with controlling or reducing the level of 

16 chronic disease for pre-Medicare eligible individ17 uals. 

18 (2) FINAL REPORT.—Not later than 18 months 

19 after completion of the demonstration project, the 

20 Secretary shall prepare and submit a final report 

21 and evaluation of the project to Congress, includ22 ing— 

23 (A) the results of the assessment con24 ducted under subsection (g)(2); 


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1 (B) a description of community-based pre2 vention and intervention strategies that have 

3 been determined to be effective in controlling or 

4 reducing the level of chronic disease for pre5 Medicare eligible individuals; 

6 (C) calculation of potential savings under 

7 Medicare based upon a comparison of chronic 

8 disease rates between the populations targeted 

9 under the demonstration project and the 

10 matched control group; and 

11 (D) recommendations for such legislation 

12 and administrative action as the Secretary de13 termines appropriate. 

14 (i) AUTHORIZATION OF APPROPRIATIONS.—For the 

15 purpose of carrying out the demonstration project estab16 lished under this section, there is authorized to be appro17 priated $200,000,000 for the period of fiscal years 2010 

18 through 2016. 

Æ 


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