Health care are much more than the 6 of the people, everyone was important, who would have to buy their insurance and the individual Health Insurance market. We are glad to have this discussion and its a subject on which both republicans and democrats have a lot of interest. To your advice. We are holding a hearing today to look at what can be done to encourage people to make healthier lifestyle choices to help prevent serious illnesses and reduce Health Care Costs. And i will each have an Opening Statement and then we will introduce the witnesses. Testimony,itnesses there will be five minutes of questions from the senators. I want to thank senator murray ar her leadership and being straightforward negotiating partner on our efforts to present to the senate a limited bipartisan bill to stabilize the andrance market during 2018 2019. She and i will go to the Senate Floor Today at 1 00 p. M. And make a brief statement. And put the text of the in the congressional record. The senators can examine it and list a significant number of republican and democratic cosponsors for the legislation host up our hope is that we put a proposal on the table that the senate will consider and the house will consider and the president will consider it. I talked with the president last night and he encouraged the process. He asked me to begin the process. He said he looks forward to considering it and i said if you have suggestions for improving it, thats certainly your prerogative to do and thats what we would expect to happen in the legislative process. Thank senator murray for that and other members of the committee. Years, weast seven have endured this political stalemate over the Affordable Care act with most of the disagreement being over a very small part of Health Insurance market where 6 of americans by their insurance. Beentalemate has really over all of health care. The fact that we have had the stalemate makes us makes this even more refreshing to talk about an area of health care on which most americans, doctors, employers, republicans, democrats agree. That a healthyis lifestyle leads to longer and better lives and reduces the Nations Health care costs. Forrding to the Centers Medicare and medicaid services, Health Care Spending in the United States has grown from consuming 9 of the Gross Domestic Product in 1980 two trillion inr 3. 2 2015 and predicted 20 in 2025. The Cleveland Clinic which is represented by one of our Witnesses Today has said that if you achieve at least four of six normal measures of good health and two behaviors, you will avoid chronic disease about 80 of the time. The six indicators of good health are familiar, Blood Pressure, cholesterol level, blood sugar, body mass index, ability and your to fulfill the physical requirement of your job. The two behaviors are seeing your primary care physician regularly and keeping immunizations up to date. Again, if you hit four of the six indicators and keep up the two behaviors, according to the Cleveland Clinic, you will avoid chronic diseases 80 of the time. Important because we spend more than 84 of our trillionre costs, 2. 6 , treating chronic diseases. Thats something on which almost everyone agrees. Lets add to that another obvious fact about 60 of americans get their Health Insurance on the job. To focus onnt improving the quality of health care in america. Why not connect the consensus about wellness to the insurance policies that 178 million americans get from their job . The formalisely what care act sought to do in 2010. It was one of the only parts of the aca that everybody seems to agree on. Todays hearing is about how successful wellness initiatives have been and what we can do to make it easier to encourage people to lead healthier lives and reduce Health Care Costs. Have developed Wellness Programs to incentivize people to make healthier choices. These programs may reward exercising,ch as eating better, quitting smoking, or offer employees a percentage of their Insurance Premium for doing things like maintaining a healthy weight or keeping their cholesterol levels in check. These programs have the save employers money and improve the health and wellbeing of their employees. Steve byrd, one of our witnesses, is the ceo of safeway. He visited with many of us a few years ago and started a Successful Employee Wellness Program after he left safeway which i hope he will talk about. Thats one part of it and i would also like to hear what communities and the federal government are doing to encourage Healthy Lifestyle choices. I know that Blue Cross Blue Shield of tennessee partnered with privatizations to Fund Community level initiatives across our state. Things like fitness zones in chattanooga. The and rural county to promote rural good habits and an Elementary School program to keep kids moving. An example of encouraging wellness at the federal level is the medicare Diabetes Prevention program,and innovation Intervention Program where medicare recipients diagnosed as to prevent type two diabetes. Medicare spent an estimated 42 billion more in 2016 on people with diabetes than it would have spent if those recipients did not have diabetes. There are other ways to encourage health care behavior but its hard to think of a better way to make a bigger impact on the health of millions of americans than to connect the consensus about wellness to employerbased insurance for 100 78 million people. I look forward to the hearing will stop senator murray think you very much and thank you to all of our colleagues and witnesses for joining us today. Of health care as something you need when you get sick. But we should be thinking a lot more about ways we can help prevent families from getting sick in the first place and ending up in the Doctors Office or the hospital. I am really glad we are having todays hearing on how to better promote health and wellness. The truth is we all have a role to play in supportive family efforts to make healthy choices whether its government or communities or hospitals or schools. And certainly businesses and employers can promote Healthy Behaviors in partnership with their communities. I look forward to a robust discussion today around wellness and Public Health efforts that promote physical activity, improve access to healthy, affordable foods especially for kids, expand on sciencebased ways to reduce tobacco use and a lot more. I would be focused on making sure congress is providing the investments needed to support local, state, and federal efforts to promote Public Health. That includes Grant Programs by the centers for Disease Control as thevention as well prevention of Public Health fund which has made a difference for so many patients and families nationwide. Nations High Health Care costs and the fact that so many of those costs can be attributed to chronic diseases, it is critical we do more to support Public Health efforts focused on Health Education and promotion. I want to be clear on the following while we consider Wellness Programs, we have to do it in a balanced manner and make sure we are protecting workers civil rights and privacy for me and many of my collies, the fact that employer Wellness Programs could impose significant financial penalties on workers who do not wish to Share Health Information is a very serious concern. I want to hear today more about what we need to do to make sure we find the right balance for Wellness Programs that protect workers rights under the american civil disabilities lack three lawsd hipaa, that were written and passed by this committee. I have to be clear, responsibility for make ensure the rights of workers with disabilities and those who do not wish to share Genetic Information are protected and respected in these programs. They will that will rest with the trump eeoc which is one of the reasons why democrats pushed so hard against his recent nominees to the eeoc, nominees who i am concerned who show they are not truly committed to protecting workers from discrimination. This is a balance and we need to work on it and figure it out and i really appreciate all of our witnesses being here to help share your information with us and look forward to the discussion. Mr. Chairman, i have a letter from aarp that it want to submit for the record as follows it will be submitted. Thank you, senator murray. Each witness to please summarize your remarks in about five minutes. That will give us more time to have questions backandforth from senators. ,he first witnesses steve byrd founder and ceo of byrd health. He was ceo of safeway for many years and many of us met him when he roamed the halls during the debate on the Affordable Care act, both the democratic and republican halls with a message about wellness. Second, we will hear from dr. Michael rosen, the chief wellness officer and founding chair of the Wellness Institute , athe Cleveland Clinic program that i just described in my opening remarks. Dr. David asked his executive director of Penn Medicine Center and john morgan professor at the Wharton School at the university of pennsylvania. He is a leading behavioral economist with Much Research on Healthy Lifestyle choices. Is then Jennifer Mathis director of policy and legal advocacy at the judge david elm maslon center for Mental Health law. She supervises the senators policy work and engages in advocacy. Lets start with you, mr. Byrd. Thank you very much. The first thing i would like to say is that i very much appreciate the opportunity to share my experience in the wellness category with the committee here. I really want to applaud your willingness to work in a bipartisan fashion to improve the health of americans and ultimately legislation thats attached to that. Awill go quickly through little bit of background what have done since i left safeway in the ceo position. It impacted how i think about the subject. Secondly, i want to talk about why we picked wellness as a real important area. Third, i will cover the elements of the Wellness Program that we introduced at safeway. I think its most instructive because we have had a 10 year run so we know what the statistics look like after 10 years. Finally, i want to speak to the results we achieved which i think are extraordinary. I think they are indicative of what others can do and finally, i want to talk about what i think are the five keys to success in a Company Wellness plan. Most people have failed at this and i know that michael and i and maybe others here who testify have succeeded. I think youll find some common success elements. Safeway, while there as the chairman indicated, i got very involved in health that it wascovered a fascinating area of great opportunity to improve the health of americans, an opportunity to improve care without adding to cost and frankly, an opportunity to dramatically lower costs. I committed to spending the next 10 years of my life and i have now spent 4 in this space. Wanted to do was to tell you briefly what my company does. We do three things that are unique. We are able to lower the company andnization cost 40 50 simultaneously lower the expense 6 10 and capable of is significantly improving the care they receive and if they are willing, we can have a dramatic effect on the wellness of their population which has profound expense effen the productivity of that workforce. 2008ked wellness back in because we took note that about 70 of all Health Care Costs are driven by health care behavior. With that as an employer with the right to design a plan however we chose, we could actually affect behaviors in people and people would become healthier. I want to put into context for you because i know you will at some point want to understand how to reduce costs. In the short run, there are other ways to reduce costs more significantly. The first one i would mention would be provider efficiencies and plan discipline and design and wellness. In the first five years, i put wellness in fourth place. In the next 510 years, i would put it probably close to secondplace or third place. There is an opportunity there. We putwellness front, together a program at safeway and we made it a volunteer program which am not sure everybody understood at the time. 85 of our employees opted into this plan and 70 of the spouses opted into this plan. We rewarded people for achieving certain biometric standards with about 600 worth of rewards. People, 78 of the program viewed it as good or excellent. What we measured was Blood Pressure, hba one c, cholesterol, tobacco use and bmi. The results were amazing. I will give you a twoyear look after starting the program. Of the people that failed the Blood Pressure standard, two years later, 73 percent of them passed and they maintain that over the balance of the program. Prediabetics come of those that failed initially, 45 of them past two years later. Cholesterol level, 43 of those past two years later. Fairness,ics comesmokers, 35 n you can beat that test. , 35 d improve the smoking is a bit strong. We took the obesity rate of our population from 28 down. I have the goal that if we were stay, we would be the lowest obesity state in the United States. Senator bennett at that time, colorado held that position. When i left in 2013, we must colorado at 21 . I want to just a shift quickly because it says ive nine seconds left. Why did we succeed . First of all, we rewarded participation. The vast majority of programs are outcome based but they are participation based. We had a put of meaningful amount of money at stake and we had used that starting point at six under dollars. Need to provide support 600. It would allow people to change their behavior, enhancer state of health and we needed to surround it with an ecosystem that constantly convince the employee that we cared about their health. We can talk more about that in and we consciously developed a culture of health and fitness. I did this when i was 57 years of age and i understood that my fitness level down the road would determine my state of health. Once you become immobile, your help begins to decline. We focused on health and fitness. Lastly, it needed leadership. I practice this with clients today and if you dont have ceo leadership, does not work and i would contend that you cannot pick three of the five. You have to do all five. Thank you, mr. Bird. Dr. Roizen, thank you. Chairman alexander and Ranking Member murray and members of the committee, my and is dr. Mike roizen thank you for the opportunity to testify before your committee today. Since 2007, so to chief wellness officer at the Cleveland Clinic. I try to prevent illness and help people live longer and more productive lives. We give people more time keeping people well and enabling them to live their best lives is not just my professional goal, its my passion, my lifes work and the passion of the Cleveland Clinic. Thank you for your leadership in holding this important hearing. An fact, the title of the hearing encapsulates the Cleveland Clinics story. That is how healthy choices can improve Health Outcomes and substantially reduce medical costs. We are hopeful that sharing the results of our efforts over the last nine years can demonstrate that we as a nation can have real impact on the health of our inple while resulting hundreds, literally hundreds of billions of dollars in savings for both the private sector and the federal government. Centrals, the Health Care Debate in washington is about what government should pay in providing Health Insurance. If leaders in washington dont address the skyrocketing cost of health care caused by the influx of chronic disease come a wont matter whether medicare, medicaid, private insurance or individuals pay the bill. Everyone this room has seen the cbo estimates. Unless we do something to bend the cost curve, we will all be bankrupt from this influx of chronic disease that is growing seven times faster than the population. However, something that both the federal government and private insurers could do right now to significantly reduce Health Care Costs across the country, a step that could save our nation hundreds of billions over 10 years and with voluntary participation. Nine years ago, the Cleveland Clinic began an ambitious experiment to improve the health and wellness of its employees and their families. The clinics rewards for healthy choice programs provides employees who volunteer. They get compensation for reaching several outcomes, wellness outcomes and medical outcomes you mentioned each year. The program is born of a few key insights about the cost of chronic disease and the drivers of Health Care Spending. That 84 with the fact of all Health Care Costs are due to chronic disease and 75 of chronic diseases are driven by six measurable factors. Blood pressure, body mass index, fasting blood sugar, your ldl cholesterol, whether you smoke or not, we measure it by urine stress. Nd unmanaged these six predictors of chronic disease are controllable and well in well over 90 of individuals. The Cleveland Clinic rewards are held the programs focus is helping its 100,000 employees independent get and keep these six measurements normal combined with encouraging the two additional behaviors, seeing a primary care provider regularly and keeping immunizations uptodate. The Clinic Program helps employees get these six normals. The way we do it is we paid employees, we incentivize employees and we started very small but ended up a increasing payments by about the same number as mr. Bird who achieved the six normals in the two behaviors. The upshot since the onset of the program, the Cleveland Clinic has saved 254 million in direct medical costs increasing yearly. This year, we will save over 150 million more versus milliman benchmark is more of our employees get and stay healthy. There improved help is reflected in substantial reductions in unscheduled sick leave and the 62 percent of clinic employees who voluntarily participate in the program at seen their Health Care Cost and premiums decrease by 600 for individuals to 2000 annually for families or hitting these targets. Smoking rates of disk have decreased from 50. 42 under 5 where the state of ohio is around 23 . Body mass index of employees for all 100,000 employees taken together is decreasing. 5 per year as opposed to the nations increasing. 37 per year. Blood pressure and ldl cholesterol and hemoglobin have them proved substantially resulting in over 11 decrease in the need for illness care since 2009 rather than the expected and projected 20 increase due to our aging population. The Cleveland Clinic model has been replicated with our help by nine other large employers, all of whom have seemed similar impressive results. Is savinge, la farge over 46 of expected medical costs as estimated by aetna. We know other organizations can learn from these examples. In short, the Cleveland Clinic rewards for healthy choice programs is doable, exportable, and scalable across the country. The clinic has been working to educate lawmakers on this idea and senators ron wyden and rob portman are collaborating to work on the senate finest Committee Finance Committee aimed at improving the cost and health of medicare beneficiaries. It does not have to stop with federal programs. Private sector programs supported by this committee could benefit by the work we have pioneered. This program has at least three critical versions it has been tested in multiple sets across multiple population the patient groups, everything from ineers to blue cross bluecollar workers. Its entirely voluntary and it in any evils the federal enables the it federal government to attain substantial cost savings without programmatic budget cuts and any initial cost. Curve throughst voluntary one was an programs is a commonsense idea with democrats and republicans. They should be able to rally round the health of our countrys finances and health of our people and the desert increases our competitiveness for jobs, thank you. Dr. Asch, welcome. Chairman alexander, Ranking Member murray interesting with mentors of the committee, thank you for the opportunity to speak with you today. I am a is david asch and practicing physician and a professor at the university of pennsylvania. Im here to talk about Workplace Health programs and their role in the Nations Health. My summary messages this i believe that employersponsored Wellness Programs have value to contribute. I believe that even though the health and financial benefits of these programs are often overstated, i believe that even though some of these programs in the ways theyre currently designed risk treating some employees unfairly but i am optimistic about these programs Going Forward because we are learning how to design them to be much more effective and much more fair. Americans spend most of their time outside of the Health Care System even those with a chronic illness spend only a few hours per year in front of a doctor. We spend about 5000 waking hours per year doing Everything Else in our lives and its during those 5000 hours when so many of the determinants of her health unfold, how we eat, whether we exercise, smoke, or take our prescribed medications. We can put more and more money into health care but much of our health is determined in the 5000 waking hours outside the reach of doctors and hospitals. Americans spend many of those waking hours at work. Employers have a large financial incentive to advance health not just because of our system of employmentbased Health Insurance but also because healthier workers are more productive. Of large employers of some sort of Wellness Program targeting risk factors you of heard about all ready that account for much of chronic illness. Things like tobacco use, hype bloodpressure come obesity and the like. Unfortunately, its easier to know what conditions to target that is to know how to do so. Managing these conditions requires substantial behavior change. Our nation has invested considerably in the science of medical treatment as it should but less in the science of behavior change. Our knowledge of how to break old habits and develop healthier ones is rudimentary but its getting better. Behavioral economics is one example of how we are learning more about changing behavior. Just wet just last week, Richard Taylor won the nobel prize in economics for recognizing that we also come would also we also come to deterrence against our longterm goals. It is been used to help doctors and patients make better decisions and the university of pennsylvania is a world leader. In this field one such russian one to rationality is loss aversion, where more motivated to avoid a 100 loss than to achieve a 100 game. It does not make economic sense but its how humans tend to think. We found this really when encouraging overweight employees at a large firm to increase their fitness. In one group, employees were given 1. 40 for each day they walked at least 7000 steps. That is a standard economic incentive. For another group, restructured loss, 1. 40 per day or 240 per month. We gave each employee 42 of the beginning of the much and took away loss 1. 40 for every day ty did not walk. An economist would see those two designs as the same. Every day you walk 7000 steps, you are 1. 40 richer but it turned out that those who 1. 40 were no more likely to walk 7000 steps than those who received no incentive at all. Those who had one dollar 40 taken away if they did not walk 7000 steps were 50 more likely to succeed. Mathematically and financially, these do these two approaches are the same but one work and the other didnt. Most Large Companies are using financial incentives to encourage Healthy Behaviors. The vast majority of them do so by adjusting the premiums their employees pay for their Health Insurance. Tohough it may seem obvious charge higher premiums for being a smoker or being overweight there is little evidence that programs designed that way often work. At best, they provide modest financial benefits to employers and unclear Health Benefits to employees. These programs offer promise but they also draw criticism. I remain excited about welldesigned programs that help americans change the behaviors they want to change, help them quit tobacco, help them lose weight, of them better manage their high Blood Pressure. Those changes are much less likely to come from typical premium based financial incentives and much more likely to come from approaches that reflect the underlying psychology of how people make decisions encouraged by frequent engagementotional and contests and acceptance. Those are the ingredients in theirl programs do missing from what most employers normally do. We know much more about how to design financial and other incentives to motivate human behavior, far more now than even tenures ago. Ive not seen than even 10 years ago. There is no reason why this cannot be applied by all employers. Thank you for inviting me to testify and i look forward to your questions. Thank you. Ms. Mathis, welcome. Thank you, chairman alexander, Ranking Member murray, and members of the committee, i appreciate the opportunity to testify about this important issue. My name is Jennifer Mathis and chairman alexander noted my position at the center fermenter health as the center fermenter health but i at the center for Mental Health. I also had a coalition of organizations that Work Together ,o promote doublet policy ensuring selfdetermination, independence, empowerment, integration and inclusion of adults and children with disabilities in all aspects of society. I appreciate the breadth of the topic for this hearing and their many different ways we can promote healthy choices that improve Health Outcomes and reduce costs and many different stakeholders can do so. The primary concern that animates this hearing seems to be the role of employerbased Wellness Programs. But i also think its important to mention the role of state Service Systems, particularly those are people with disabilities and older adults in planning and administering Service Systems in a way that expands opportunities for ,ndependent choice and autonomy enabling people to exert more control and participate actively in the own health care, direct their own lives, and work. We have seen from numerous studies over many years that realigning Service Systems to offer people with disabilities a chance to live, work, and receives set the services in our own community leased to improve Health Outcomes and lowers costs stop im happy to answer questions about that but i will focus the rest of my comments on workplace Wellness Programs. Ccd has supported the development of Wellness Programs as a tool to improve life and Health Outcomes. Those programs can and must operate in a way that respects longstanding and important workplace protections such as those provided by the americans with disabilities act or ada and the Genetic Information or discrimination act, especially workplace privacy protections. People with disabilities need these protections. The implement rate of people with disabilities is much lower than that of any other group tracked by the bureau of labor statistics. They are employed at less than half the rights of people without disabilities. Study after study has examined why the employment rate of people with disabilities is so low. There are attitudinal barriers is one of the chief reasons. Of people with disabilities continue to be pervasive in the workplace. It was precisely for that reason that when Congress Passed the ada, one of our most important civil rights laws for people with disabilities, it created strict protections to enable employees to keep their health and disability related information confidential in the workplace. Employees could be subject to medical exams or injuries only if they were jobrelated or if they were or if there were voluntary inquiries. Provided Genetic Information including spouse Health Information will stop removing or weakening those protections would make many people with disabilities vulnerable in their workplaces and expose them to the risks congressmen to avoid. Last year, the eeoc significant rollback the protections it had enforced for many years to ensure that employees employers could not penalize employees for declining to provide their Health Information as part of a Wellness Program. The agency instead permitted steep financial penalties for employers at you to keep their andth Information Private more steep penalties if their spouses chose to keep their Health Information private making this choice far from a voluntary one for many people. A federal judge is now ruled that the agency violated the law and failed to provide a reason justification for this change in position. The agency now has an opportunity to revisit its regulations and do the right thing to afford people the rights guaranteed by the ada and gna. We believe it is not difficult to ensure the Wellness Programs serve to promote the healthy choices and healthy outcomes while respecting important civil rights of people with disabilities. The agency set out a path for doing this and its 2010 regulations implementing gna, clarifying that financial incentives can be used but not for genetics asking information. The same role should apply to questions seeking Health Information of an employee or spouse. The lead study of almost programs conducted for the department of labor highlighted many strategies other than incentives that have made Wellness Programs more effective. The Wellness Programs can be designed without eroding the civil rights of people with disabilities and we will all be better served if that happens, thank you. Thank you, ms. Mathis. We will now have a round of fiveminute questions and we will start with senator young. Thank you, chairman. I am very excited about this hearing because i know a number of our witnesses have discussed behavioralstimonies economics and behavioral decisionmaking. That weits important as policymakers incorporate how people really behave, not according to an economist, per se, or according to other policy experts. It would be based on observed behaviors. Often times, we behave in ways we dont intend to. It leads us to a result we dont want to end up in. Youll start with mr. Asch, have indicated behavioral economics is being used to help doctors and patients make better decisions. Using an opportunity for employers to help americans change their behaviors, too. In ways they want from tobacco mitigation to losing weight, to lowering Blood Pressure and you indicate the changes are much less likely to come from typical premium based financial incentives and much more likely to come from a protein is approaches that of that affect the underlying psychology about how people make decisions. You said in your verbal testimony that you have not seen much of this new knowledge applied effectively by employers. There is no reason why it cannot be. Sir, whatn for you, might employers learn from behavioral economists . Thank you, senator. I will start by saying there is a misunderstanding often about behavioral economics and health. Many people believe you need financial incentives to change behavior. I would say no, this just economics. It becomes behavioral economics when you use an understanding of our little psychological pit falls. Rest of itake the more potent so you dont have to use incentives that are so large. I think there are a variety of other approaches the comfort behavioral economics that can be applied in the employment setting and elsewhere. I mentioned one which is capitalizing on the notion that losses loom large larger than games and might be a new way to structure these in ways in which palatable to advance their health. The delivery of incentives more frequently for example or using contests are certain kinds of social norming where its acceptable to show people on leader boards and get people engaged in fund for their health. All of these are possibilities. Thank you very much. Study theseeed to different phenomena individually i think to have a sense of the that is behavioral economics. We need to increase awareness and the education of Many Employers about some of these ticks we have a message to be part of the answer. Just won ther who nobel prize in this area indicated we, as policymakers, ought to have on a regular bases much as lawyers and economist at the tables where we draft legislation but we ought to have ist. Havioral scient and the u. K. They have the behavioral inside seam and we had a similar team in the United States that did a number of experiments to figure out how policies would impact and a visual health and wellness and a number of other things. Some of the ideas i think we might incorporate in the government context and tell me if these pop for you or you view think they make sense. A need to continue to have unit or units embedded within governments to do a lot of these experiments. We need to have a clearinghouse that employerses might draw on. It does not have to be governmental but it could certainly be. We on capitol hill might actually consider, aside from having a congressional budget office, we might have an entity or at least some presence within the cbo about individuals one understand how people would actually respond given pursuant given proposals. Does that make sense to you . Thank you for your remarks, i think they all make sense to me. While the lessons i guess i had repeatedly learned is that seemingly subtle differences in design can make a huge difference and how effective a program can be and how it is perceived. Favor of auch in greater use of these programs but in addition, greater study of these programs. I think we need an investment in a size that will help all of us it better at delivering these activities, not just in health care but in other parts of society. Im out of time, thank you. Senator murray. Dr. Roizen, we have heard about workplace Wellness Programs but its critically important we think about how the investments we make in our community can also play a Critical Role in making the healthy choice the easy choice for our families in this country. In my home state of washington, we have seen a lot of these critical efforts in our schools, for example. We are investing in physical education and healthy food and beverage preparation. In our cities and towns, we are working to make the environment more accessible to all users, bicycles, pedestrians, people of all ages and abilities. Our Health Care Providers are making it easier to quit smoking and taking steps to that are support breastfeeding. Arecommunities of color taking strides to ensure strong culturally competent programs can promote the health of people in my state. Do you agree in addition to these workplacebased programs, communitybased efforts from health and wellness are also important . The answer is absolutely agree. Schools,tate in your their technique leadership role that the rest of the nation would love to follow and hopefully will be able to. Healthy get kids to be and influence their parents to be healthy, when you get food manufacturers to make foods for large distribution to your schools that are healthy, to really get to change the health of a whole generation. We totally applaud that. We work with that. In fact, i go and we have a network of what we call inner and outer ring schools in and around cleveland. Its her a hard to get appropriate products for the School Lunches and breakfast. Your state is taking a lead and then we thank you. Thank you. Miss mathis, a Federal District court recently held that the eeo commission failed to support its rules on Wellness Programs. Those rules said an employees decision to not persist saavedra in a Wellness Program was voluntary so long as the employee did not have to pay a penalty greater than 30 of the cost of Health Insurance. And other words, thousands of dollars. That type of penalty is a problem for the millions of employees and their spouses who do not wish full disclosure of Genetic Information or release of a disability by participating in Wellness Programs that collect sensitive Health Information. Its a persons right under the ada and under the connecticut information nondiscriminate act. I am proud of these laws. As you may well know, this committee met yesterday and to now lead the eeoc. Among other things, those nominees will now be responsible for rewriting those Wellness Programs. I wanted to ask you, how should setc criteria criteria for when participation in a Wellness Program is not voluntary and what advice would you give those members. I think the most important thing for the eeoc to remember is that their job is to apply the ada and not to rewrite it to try to conform it to another law that also applies of the same not but did not does overturn or modify the ada. There are many circumstances where two laws apply at the same time and one requires additional things beyond what the other requires. Have a lot of experience with applying multiple laws to the same set of circumstances. There or do you have a framework they have used for 16 years they already have a framework they have used for 16 years to analyze with a voluntary question under gna, implementing a parallel provision, allowing requests for employees Genetic Information as part of a voluntary Wellness Program. I would just point out that the gna regulation was done after the Affordable Care act of they considered the two laws and the fact that the formal care act have been passed with his provisions about Wellness Programs and consider those consistent. The framework was logical, used ordinary meaning of voluntary you can require a person to answer or penalize a person for not answering a question thats consistent with the dictionary definition of voluntary. About income held by outside influences. Having steep financial incentives is the dictionary definition of what is not voluntary. Having the sink and a framework in the same path they charted for this 2010 for the 2010 gna regulations to apply to the ada which is how they interpreted the ada before 2016 for many years to allow womans programs to have incentives but just not to incentivize or have significant incentives for people turning over Health Information. Thats not jobrelated. I think that would allow honest programs to proceed and develop and use incentives in other ways and use many of the strategies to engage people without you wrote in the civil rights of the people with disabilities. Thank you very much. Thank you, senator murray, senator isaacs . Byrd, i you, mr. Remember that the segway program have financial incentives, is that right . [indiscernible] the segway program had financial incentives . Correct. What to do find your work to reduceess programs more people to participate . We had extruder participation , even greater than some of the numbers you had, michael. We were 85 voluntary from employees and 70 with spouses. Im a big fan of that 1996 hepa regulations because i thought there were thought out and the adjustments made with the if or look air act. I thought those were equally well thought out. Why dont want the committee to do is get the impression that its all about incentives. I think incentives are necessary but by themselves not sufficient. Going back to something that was said earlier, the secret sauce was creating small support groups. We have thousands of groups that , settogether on their own goals and objectives and time , set goals and objectives and time frames, maybe exercise goals are weightloss goals and we gave them a tools to a compass that, the tools track one another. It really was a driving force along with ceo leadership. As being anvernment enabler in this process oils of think theres an opportunity for government to lead. I think others have been down here over the years. Lead with hisy to i would like see the federal government a. Programs like this for their own employees. I actually offered it to do this for secretary sibelius in the this and the eddie thousand people at Blue Cross Blue Shield, to do it for free but that was dirty says that was 30 days before she left office and she was excited about that but its not just about incentives. Employedrtant that we 10,000 people with disabilities at safeway out of 185,000 people. To says in of them were part of this program 2000 of them were part of this program. They allow for and frankly require if the standard you have set is judged to be too difficult that you adopt a different standard. And even provide a waiver. In our experience and i would be interested in what you have done the Cleveland Clinic, about 3 4 would reach for and get either a waiver word alternative standard. Thee he wanted you to get lowest bmi, if you had a 45 and you made 10 progress, we give you the reward. We enjoyed writing those reimbursement checks. It was about encouraging wellness. If you had comorbidities in your physician set i feel better said i feel better going from 45 to 43, that would be fine and we would stain and we would change the standard. I appreciate the answer because being someone who has had all the bad habits, i know what got me into Health Programs and Wellness Programs was the desire to change a habit. Book kept me in them was the result was the reward. Use a something thats important and that is you give the employee or individual the measurements to show improvement. And reinforce that along the way. You can change what a program is doing to an employee that is more healthy. Habits, your eating exercising regularly, none of those things are easy. Andke to talk about them everyone practices them every new years but then they go away. In au get reinforcement peer group, in a positive way, you can really sustain the practice. Guest if i can add one more thing, i learned this a long time ago in business and its helpful, i had 1800 stores. Rather than just study and hypothesize, we just did it ons galen and skilled it up. Toexample, if i wanted increase the sales of some product, it would put in the ad that i would reduce the price. I did not care which of those three contributed most to that end it all three of them every time i wanted to increase the sales by 20 . Something over time that worked in a work famously. It and ifissues with you dont know, the Health Statistics do not go to the hr department. They dont know what some of these with somebodys bmi is. They know there is a controversial a contribution of a premier effect of the dont know what some of his past and failed. We did not have any issues in the company. We ultimately began rolling it out to all the divisions. Our initial population was 40,000 members. Translator thank you and let me conclude with a complement. Thank you dr. Roizenm. We have a Chronic Care Working Group bill. Senate is nowthe pending in the Energy Committee so we are close in a threeyear effort. I think a couple of things she said deserve reemphasis. Why is there an as lou firewall between the health plan and the company. They dont know why the premiums are where they are debtor was driving on a driving it. Secondly, for everyone person who interacts with her primary care physician in achieving those goals, the six goals plus the variables, the primary care physician and they sit a goal of progress is that relationship and that progress that determines their incentives. It is a culture change. It is multiple programs that work. It is leadership as well. And we also have a large buddy system we set up that really does the support system. There are a lot of things i didnt get into but is a lot of things that work. Senator franken. Thank you, mr. Chairman for into the Ranking Members for holding this board and hearing. Before the hearing started, i spoke to all of you about housing. Know, one of these runrams that the employer are very helpful, but what we are trying to do is help people be healthy and lower the cost of their health care in the long run. You pointed out research that shows a strong connection between a Persons Health and stable housing. Despite the fact that they are actually very often talked about as completely separate issues. Hennepin health, an Accountable Care organization in the twin cities, saw the lack of stable housing was a major barrier to improving the health of their members, so they decided a Development Program that paired Health Care Housing and social services. Just one year after participants in the program were placed in the housing, they saw innificant reductions significant hospitalizations and Psychiatric Care and imprisonment or going to jail. The number one cure for homelessness is, it turns out to be a home. If you can wrap around supportive services, it yields amazing things. I brought this up to all of you. Mr. Mathis and all of you that you speak to how focus on housing, particularly when it is paired with social supports, could lower Health Care Costs and improve Health Outcomes. I think that is absolutely right. I think the recognition that has become increasingly more ago,lent 20 or 25 years Mental Health directors would have said we are not in the business of housing. We do Mental Health. That has changed dramatically. Now, most will tell you we think housing is a critical part of what we do. Housing support, subsidies, assistance, all of that. All of these things, housing, stability, work are all social determinants of health. They havent a normas impact on Peoples Health they have an enormous impact on Peoples Health. Studies of people who are homeless versus people who are in support of housing, kind of similar twin studies of people in those two situations where it costs us as much money to keep people homeless as it does to have them stably housed. I want to hear from the others as well because you all seem to respond when i brought this up. Thanks for the question and comment. I fully agree. There is certainly a movement and a Knowledge Base called Housing First that would it is the fundamental importance of housing for those without it. I would probably embed your question in a much larger set of issues that reflect the importance of the social determinants of health. If you are a hospital or Health System and you face patients were chronically ill and have been admitted to the hospital for multiple times for congestive Heart Failure or lung disease or some chronic illness, almost always the major determinant in addition to their serious illness that brings them back to the hospital is some for of social circumstance. Somsometimes it is inadequate housing. Sometimes it is inadequate support. Those considerations were at least from a financial perspective less relevant. Now, hospitals and Health Systems are much more aware of their responsibility to be part of the solution to the social factors that affect health, including housing, and some of the most progressive Health Systems are targeting housing directly along with other social determinants. Those social determinants were always there. Now we need to think about financial incentives at the organizational level that will allow the resources we have in our society to address them. I want to give the other two witnesses a chance to answer senator frankens question, but i want to stay close to the time because we have votes at 11 45. Someone would say senator franken, you are a genius for bringing this up because it is one of the social determinants is thank you. [laughter] the social determinants are really important. It is hard to not have stress if you dont have a home. It is very hard to get adequate sleep without housing. Those are really key points in getting well and staying well and lowering the cost of medical care. First of all, i wanted you to know that if he has not said you were a genius, i was ready to a in on that. And i was ready to do that as well. [laughter] my wife and i have been involved for several years in a philanthropic effort to provide housing to the homeless, and i am also involved in another philanthropic effort with a good friend where we take people who had been homeless and the capabilities to learn a skill, and they are taught this skill, and we find them a job, and they can succeed at that. I think having a home is really important. That social environment that surrounds it is also something we create. Thank you. Thank you, mr. Chairman. Thank you very much, senator franken. We will go to senator casey. Senator casey thanks, mr. Chairman. I want to thank the panel for being here for your testimony. These important issues. I will direct most of my question time to dr. Asch and ms. Mathis. We are grateful you are here and for the work you do at penn. You have done work but at wharton and the school of medicine, by also want to thank you for the work you have done at the v. A. Medical center in philadelphia as well. Critically important work. I was not here for some of the large questions, but i believe a question was asked about the penalties and incentives. Am i write about that . Am i r ight about that . Want to make sure. My followup to that line of questioning would be with regard to your doctor asch that indicates the penalty incentives may not have had the effect on individual behaviors. Both you and another doctor have thecated the importance of many hours, i guess 5000 hours, of waking activity when we are not interacting with the Health Care System. Senator murray indicated that someone is plans with both penalties and rewards that can be as high as thousands of dollars a year. A program uses a 30 penalty. Eeoc set with the the rule last year. Based upon your research and other behavioral economic research, is it necessary to use such large penalties and rewards . If not, what would you recommend such rewards or penalties to be . Thank you for your question, senator casey. You have identified some Critical Issues at the interface of effectiveness and voluntariness right there. A lot of employers are under what i would consider the mistaken impression that the way to make incentives effective is to make them larger and larger, and that naturally leads to very large incentives putting large amounts of money at risk. And we have heard that penalties are more offputting than reports and actually jacked up the concerns of lack of voluntariness. It is a potential mistake to think that way. I think that is old outdated thinking that the only way to increase the potency of an and consen incentive is to increasee size of an incentive. The way we design incentives probably has much more of an impact than the amount. A 500 imagine incentives that might be put into semis paycheck. If they are paid once a week, that is 10 a week. It looks much smaller then. It is put alongside many other elements and may not be directly seen. Imagine handing somebody two bills. 100 a mistake made is sending explicit targets for goals. If you believe your employers should be at a bmi of 25, which is the upper limit of normal and you said that as the goal, that is a good way to make people is 26 to is 26 bmi lose pounds. It demoralizes those at 20. It is far more effective for the people who we fund the mentally need to help the most. The Design Elements with targets for incentives can be improved by most of lawyers and i am optimistic they can do that. Thank you. I have more to pursue there, by want to but i want to move to another line of questioning. Testimony you have regarding balancing the personal rights of individuals, especially those with disabilities, while also pursuing the goal or encouraging wellness, your references to the privacy protections and the americans with disabilities act and other statutes are critically appreciated i think at this time. We know that october is National Disability employment awareness month. As you pointed out in your testimony, the employment rate for those with disabilities is very low in comparison to the general population. Those with disabilities have the lowest rate of employment of any sector of our population. I am concerned that aggressive Wellness Programs could not only does committee against a person with a disability, but also create a Workplace Climate that does not value people with disabilities. Would you like to comment on that further . Sure. I should just clarify that i think our primary concern about the large financial incentives is around the privacy protections. The incentives for outcomes and as mr. Mnuchin, there are builtin safeguards in the Affordable Care act that do address the concern that if you cannot meet a particular Health Outcome because of a disability, you are supposed to get a reasonable alternative standard and there are regulations that implement that. I dont think that, assuming we have not heard that i was a major concern, i think that was addressed. Our concern is much more around the privacy issues. There are inat many cases the information will not go directly to an employer. Sometimes it will if the employer does directly run Wellness Programs with small employers. Obviously, it is not that hard to figure out who has what that theydition identified in aggregate data, and frankly, for many people with disabilities, just having to turn over your sensitive private Health Information, whoever it is going to go to, is concerning and not the way to build an environment of trust and a productive working environment. People with disabilities have in many cases had many negative experiences in their lives stemming from the disclosure of those disabilities. I think it is very understandable why we need to try to stay within the time. That is all i have to say. Thank you very much. I will followup in writing. Thank you, senator casey. Senator cassidy. Cassidy although this is a health care committee, nonetheless i feel as if that which we are doing in the employerbased setting has a fairly mature science, but i think of my patients who are used to care for any louisiana it ac hospital system, bigger problem some of these wellness issues. Youou are in philadelphia, probably have a practice mine. At similar to how can we translate some of this which we have been discussing for the workplace into the medicaid population, which statistically has a higher level of morbidity, chronic disease than the workplace . Thanks for the question. I think in most places, these activities can translate. I think that employers have a special role and a special trust connection with employees that may not be as high as the trust relationship people have with their doctor or hospital, but might be a potentially higher than people have with their insurance carrier. That trust is an important determinant. Let me stop you for a second because i think of my medicaid patients. There is a structure associated with an employee relationship, and that allows you to give them 30 minutes to walk around a track if they have built when there. Medicaid patients taking Public Transportation to their clinic are cigarette smoking and nothing you can do on their medicaid to incentivize them to stop smoking. I guess i am not seeing that as easily translated. By the way, i am willing to open this up to anybody. Because to me, it seems almost an apple and an orange. We have run some programs that were employerbased that were designed to reduce the burden of tobacco on employees wh. We did two studies. Both were highly successful interventions. They reflect a largely positive financial incentives to workers to help them reduce the burden of tobacco. There is no reason why programs like that cannot be introduced into the medicaid population. They are incentivebased. They were successful. We can think of translating some of the science and learnings we have developed from the employer setting. Let me stop you because again you will be familiar with the structure of medicaid, which is managed care. They contract with a provider to provide service at a certain rate, and if it is a feeforservice, you are paying the bills as they come in, but typically the patient is not directly impacted by this. They prefunded Health Savings accounts, you can build a report for that. Are you thinking when you say building an incentive, how would you do that for the medicaid as commonly structured under the aca or any other program . Not sure i would know how to do it as it is commonly structured but it does not mean it could not be rethought. They might think about waivers or the likes that might enable them to engage in those kinds of activities in order to achieve their mission. I am not sure they can do exactly what i just described under the rules as they are now, but under changed rules, they might be able to. The state can apply for a waiver asking for the possibility to incentivize this sort of behavior trying to translate that which you successfully show works for the employer but to do for the medicaid population . Yes. I totally agree with that. Would you elaborate or just agree . I dont want to take too much had you getsically, both programs that work, leadership, and incentives into the medicaid program, and obviously indiana and even ohio are doing major efforts to do that and seem to be succeeding. So the prefunded Health Savings account in the nas permit seems to be quite novel but also quite effective. Folks who put in a little bit of money put a lot got a lot more money. Is that what you are thinking of, along those lines . Along those lines, and there are other ways of doing that as well. But that works. What about obesity . Cigarette smoking seems almost less tractable than obesity. One of the things is again a Culture Program and multiple programs. One program does not support everyone. We have 10 Weight Management programs at the cleveland connect. City to purchas62 a participane choice to participate. In our own Coaching Program works for a group, but when you get 10 programs together, you can find programs that people can adopt in buddy systems and in groups if you will participate and succeed. This might be employed by the Medicaid Managed Care program. Exactly. To lower their overall cost burden. Exactly. Thank you. Senator bennett. Senator bennett thank you, mr. Chairman. I like to start by thanking you and the Ranking Member for your work on your bipartisan efforts to fix the Health Care System we have. On behalf of the people of been waiting have forever for a bipartisan effort here, i want to express their gratitude to you for the work thatave done and my hope the senate and the house and the president will Work Together to deal with the issue that confronts us right now with respect to the csrs. As you pointed out, mr. Chairman, this is a cherished 6 of the people that are insured, but it is only 6 . This hearing is really about what we need to be doctor, which is supervising cost of health care in this country, so i think you for that as well and whatever any of us can do to help your efforts, i hope you let us know. Can you describe briefly the bill that you mentioned in your testimony that senator portman is working on in the finance committee . It basically allows medicare samecentivize and do the type of thing that we do for our employees, offer programs, offer incentives to get there, werent with a primary care physician to send the trajectory to improve and to get to the goals, and if you did that, if the Cleveland Clinic dollar number and participation number goes to medicare and medicare is 0. 6 of medicare achieve even 4 of the six behaviors and standards, if we did much more of that and got 62 participation and 44 or so success at getting the goal, the government would save over 500 billion, maybe 1. 2 trillion. One of the things we have learned is putting stress management in first even for the medicare population is really important and getting change, and so we think this is an enormous opportunity. The senators are working on this. The reason we are here today in this committee is not about medicare and medicaid, but the 178 million americans are privately insured through their employer who can also benefit from the kind of incentive structures that you and mr. Byrd have placed. And other parts of the program. It is not just incentives. It is leadership, cultural change, programs that help them. It literally changes the way they relate to their primary thereician, so the have to be some insurance rule changes that this committee can work on to be able to allow the small nonselfinsured corporation to do this in a way that allows the employee to take the benefit as they go from one company to another, that allows the company to benefit after they have gotten a person healthier, so they need to be some rule changes, but those are minor, and it would not be a dollar spent, not a federal dollar needs to be spent in isnte or in fact, there an ask for money from the government at all. It is just a rule change. Mr. Berg, it is nice to see you again, and i want to thank you for your leadership over many years in this area. We got a little bit offbase, but i cannot resist because of what your job used to be. The question i have for you is what you learned about what we are eating in this country in that job, and how that is connected to health and how it is changing if it is changing . Increasingly, the population is becoming more health conscious. I employ a number of millennials these days, and they are particularly careful about their nutrition. When you run a Supermarket Chain and you have 45,000 stock, you have all kinds of products in there. I am a big believer in free choice, but only if you also suffer the consequences of that , and so i think all of us should be able to enjoy a french fry now and then, but i think those of us that are really into nutrition and fitness understand that if we another halfave hour to spend on the treadmill or walk after dinner. One of the things i wanted to mention about improving health, particularly working on bmi, i find that the safeway numbers are extraordinary. The reason we started at 28 bmi is because of all the people on their feet all day. We are not doing that here. We could have had a standup meeting and gotten healthier, but the point is when people just diet, and i think everybody here would agree, it does not work, and the reason it does not work, if i lose 20 pounds and all i did was diet, for every pound i lost, i lost a quarter pound of muscle. Muscle is more efficient at burning calories. And you finish that diet you go back to your old eating habits or maybe even refined eating habits, you cannot eat as much in terms of calories because your burn rate has slowed down. When i talk about an ecosystem that is safely created, we stressed the importance of cardiovascular workouts. We stress strength training. 60 haveat the age of the burn rate of somebody in their late 20s if you do resistance training, and i contend it is the secret to weight maintenance. I would be shocked to not go through resistance training. I do. Thank you. Our next wellness hearing will be a standup hearing. [laughter] very good. Even if we just stand up once during the hearing, it helps. That. I will be sick that day. Senator warren. Senator warren thank you, mr. Chairman. I want to see if i can ask more questions along this line. We honor that the Affordable Care act allows employers to offer financial incentives to their employees in order to encourage participation in these programs, but one thing the aca does not do is eliminate the protections already in federal they cannotoyers so disseminate against their employees on the basis of Genetic Information, health status, or disability. These protections were put in place by two very important pieces of legislation, the americans with disabilities act and the Genetic Information nondiscrimination act. A bipartisan bill. Senator ted kennedy worked with a number of folks on this committee. Last year, senator enzi and i wrote and passed new legislation strengthening genome protections so personally identifiable Genetic Information collected through federal research can never be made public. In short, our nations nondiscrimination laws say that employers can collect sensitive medical information from their employees only of providing that information is voluntary, meaning the employee can decide to say no, so i just want to , whatby asking ms. Mathis types of personal Health Information do employers typically ask for as part of Wellness Programs . So i have seen these Health Risk Assessments ask about all matters of health and medical information on a variety of levels of detail. To give you some examples, specific cancer diagnoses such as breast cancer, cervical cancer, prostate cancer, bmi, whether youre being treated for depression or bipolar disorder, specifics about your depression such as how many times you felt oppressed in the last week, whether you have crying spells in the last week, how often you like people dislike you, how often you feel happy, whether you have been diagnosed with heart disease, stroke, high Blood Pressure, high cholesterol, angina, bronchitis, hepatitis b, obesity, blood sugar, diabetes, sexuallytransmitted diseases to name a few, whether you are pregnant, trying to be pregnant, how old you were when you first became pregnant, and those are some of the medical things they asked about. Lots of other questions about also to life habits. Senator warren this is Sensitive Information voluntary to hand over. Thats right. Senator warren let me ask that. Mr. Burd, you set up a Wellness Program that you called completely voluntary at the same time that families were charged 1500 more in Health Care Premiums if they did not participate in the program. In fact, i think you said that you felt the penalty was not high enough and you lobbied hard to get that. Today you own a business that designs these kind of penalties for other companies. When it costs is, an employee 1500 or maybe more a year to get health care because they dont want to have to share this kind of confidential medical information with their boss or because they cannot pass biometric tests, i dont understand how that connects them with the rules on discrimination. It sounds a lot like discrimination. We have been tested on that numerous times, and we were never accused of discrimination during the 10 year life of the program. What you are referring to about my desire to raise those limitations that were in hip a, it originally allowed a 20 premium differential based on behavior. If you look at Something Like smoking, the impact smoking would have, smoking alone would cost 3000 more. I did not say in my direct testimony, but i will see you now that in our experience, about two thirds on average of that comes immediately back to the employee as a reward for making those standards. It is not like they were charged 1500. The 1500 one, that would be if there was a spouse and an employee. Byas questioned by the eeoc, the labor department, and that the end of a 45 minute interview, i was told that i had properly followed the letter and spirit of the law. We had not been accused of discrimination during that time period, and the person that was interviewing me actually wrote the hipa in 1986 or had a role in that and said if i open a washington, d. C. , office, they said they would work. With me with me. When you charge differentially 1500 or more, that can happen because people do not want to reveal very sensitive personal medical information. That is a penalty. Paying a penalty may be legally although as i understand it, the courts have now said that the eeoc will have to go back to the drawing board on the latest iteration of what the rules are, but we have not repealed our laws on discrimination, and i just want to raise the issue that i think the question about what constitutes voluntary on this kind of Sensitive Information is one that we also have to keep on the table and maybe do some pushing and the other direction as well. I apologize for going over. May i make a quick comment . This information is not revealed with the company. There is an absolute firewall between the health plan and the company. In fact, we fire people who break that health plan because we have a tracking system. Every other health plan i know has a tracking system. If you break a firewall, you get fired. All i want to say is what the law says is that revealing information has to be voluntary. It is. Voluntary with the health plan. 1500 if you do not reveal very sensitive medical information i think stretches the bounds of what constitutes voluntary. Thank you. Thank you, senator warren. Let me pursue that a little bit because my interest in this hearing while there are several possibilities is to take this remarkable consensus we have at the Cleveland Clinic but certainly not the only one. The mayo clinic the same and others say it. There are few things we can do that dramatically affect lifestyle, that dramatically affect chronic disease. And disease is 84 of our Health Care Costs. We are talking about hundreds of billions of dollars to make a difference. Then you go to the obvious point. It is not only long as you are looking at when you look at employer plans, but insurance is clearly an obvious opportunity to take wellness and use employer insurance as a of helping 178 million americans have an opportunity to be healthier and save a lot of money for the country at the same time. How big of a problem is it . Hasnt been for you and your employer plans has it been for you at europe lawyer plans to deal with what senator warren talked about and others have is that a major impediment or can you deal with those and treat employees fairly . We deal with it. We have a thousand roughly exceptions requested by physicians who say this person, no matter what we do with them, cannot get to that normal. Those are accepted. They get a different plan. In fact, in some of the extreme examples, somebody comes down to the amount of water they drink a day to hit the health plan target and get the premium reduction. To get a premium reduction, say,ave the opportunity to i need a different standard. Or i need an exception. That is exactly right. You have to have two therefore provide a fair process to meet that objective. Ms. Mathis, does that work . I think i heard you say it probably did. Right. That is not the primary concern we have. The primary concern is the incentive for disclosing information. What would your comment be on t kind of impediment actually, you talked some about it, but the reward or penalty for healthier lifestyle, has that been a problem . I would say it has not been a problem. Consider the fact that 85 of the people did opt in. One of the reasons why we had such a high Participation Rate is i put enormous effort into communicating why this was a good idea. I reported my public earnings quarterly at the town hall meeting and at a broadcast, and i reported on the health of the organization. People would catch me individually and asked me some questions about it. When they really understood it, they quickly opted into the program. To michaels point, there is a firewall there. When you have a premium differential, you really are just risk adjusting the premium for individuals but giving them an opportunity to change the risk profile. We do that in life insurance, and we do that in automobile insurance. And behavior really matters. I think what i like the committee to really focus on is two practitioners here, maybe three, there are very few people, less than 1 of the companies in this nation have turned back obesity that have approved improved the results of Blood Pressure and cholesterol and smoking. These programs, and michael and i have not had a chance to put them out in all their glory, they work. And nothing else has. 21 obesity rate versus the nation now close to 40 . We are close to the time. We will be voting in a few minutes. I assume based on your behavioral research, dr. Asch, that if we wanted to incentivize the u. S. Senators to pass an appropriation bill on time that you would subtract from our salary. [laughter] but you deserve a raise. [laughter] thank you for that. [laughter] i will take it under advisement. Senator murray, do you have additional questions . I think senator franken had an additional question. I will just say i know we are getting close to vote and we need to go, this has been a really good hearing. I think it is critically important. This has been a really important hearing and i appreciate it. Thank you, senato. Senator franken. Is very refreshing to talk about keeping people healthy and having a Health Care Discussion that is not all about structures of insurance. It has something to do with that. I want to talk about the national Diabetes Prevention program, which has been very successful. Before that, i just want to return one thing on the housing thing, which is on the opioid crisis. From, ivisit yesterday think it was yesterday, from boys four, which is a band of jibway in minnesota. In minnesota, we just had an explosion in opioid use, especially in Indian Country. In Indian Country, housing is an enormous issue. Opioid as this it is being declared a crisis and emergency, i would really like to see a Pilot Program where people come back for treatment, especially in indian gontry, have a place to i was in rochester, minnesota, a couple breaks ago. We did an opioid roundtable. And a woman whose daughter died, she had gotten treatment, got with, but she went back her old crowd. And she is gone. Believe, to give people the opportunity to go to sober living facilities that are good sober living facilities. There is probably a distinction to be made here. But i would love to be able to minnesota. Gram in nationally as is bad as it can be in minnesota in Indian Country because there is housing shortages there where people coming back from rehab can go into a sober living setting, so they have secure housing. They have people that are in their same boat and in recovery, so instead of a peer group, which is ap peer group that has a high drug use, they are having a peer group of people in their own fellowship. That is something i want to bring up. Yes . Just to elaborate on what i said earlier, that is exactly what we do in this philanthropic effort. In other words, they have to be s sober before they come i. They have to be tested. Got to get tested. They have to be reinforced. The program works. It is a way to expand that. It has great value. On the national Diabetes Prevention program, this is something a senator and i put in the aca. Senator grassley and senator collins have been very helpful in getting cms to do this, the medicare. What we learned is this is a 16 week program where, and it was piloted at the ymca in st. Paul nih and cdc,lis by but what it turned out, it is 16 weeks of nutritional training and exercise. After five years, this is people who have high levels of sugar in and theyod, glucose, were 50 less likely after five years 58 less likely after five years to be diabetic, 70 less likely if they were over 60, which is why cms is now in the process of implement in this medicare whoe in wants to get the Diabetes Prevention program will be able to take this 16 week program and have it paid for by medicare. Can anyone speak to why this has been successful . We have about 20 seconds. You get behavior change, which is consistent. It is a group. You get buddy support. You get everything that i will this program should be. And you are targeting one of the specific high cost things. So it is a great program. I agree. I think Diabetes Prevention program is a great example of the importance of behavior change. The fact that this can be done without medication, without financial incentives speaks to a strong program. It has outcomes that you mentioned that are incredible, and they are persistent. This i think is an incredible optimistic light at the end of the tunnel. Thank you. Thank you. Thanks to the witnesses for coming. I had we would senator murray. It has been a terrific hearing. We have heard a lot. We will remain open for 10 days. Members may submit information within that time if they would like. The Health Committee will meet again at 10 00 a. M. On thursday, october 26, for a hearing entitled exploring free speech on college campuses. Thank you for being here today. The committee will stand adjourned. Their everyday number of said Health Hearing committee wa meetings of Affordable Health care and the Affordable Health care act. We have done a number of them and you can find them on cspan. Org. The committee breaking here, they are done for the day. They finish up work today on the 2018 budget resolution. You can follow that debate over on cspan2. The house ng