Political. As we sometimes feel like were picking up the pieces of problems that are outside of her hands. The people need this assistance but we need to find a Legal Solutions to these complex. Thank you. Thank you for the excellent answer. Thank you all so much for your testimony here today, we are in something that is an annual event, budget, with ten, 20, 30 votes maybe today so we apologize to you, the way in which today is going to be conducted, but it doesnt in any way reduce the thanks we have for you and impressive nature of your testimony to take you so much. This hearing is adjourned. [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy. Visit ncicap. Org] [captions Copyright National cable satellite corp. 2017] on friday, cspan set down with Hillary Clinton to discuss her recent book. She talked about her recent. Speech given by george w. Bush on the current state of american politics. Talked aboutbush the cruelty in american politics. He didnt mention the president by name. Your reaction . I thought it was an important speech. I appreciated president bush delivering it. He covered a lot of ground. He talked about how White Supremacy is an absolute blasphemy to the american creed. He talked about the importance of listening to each other and working with each other. Always agree with president bush, which i think any democrat sitting across from a would say, but i never doubted his patriotism. I never doubted that he worked really hard all day. He went to bed worried. He woke up concerned about what he would do. I was in the oval office with him two days after 9 11 as a senator from new york. I looked into his eyes. I understood a lot of what he was having to face. Out appreciate him coming and making a thoughtful critique of where american politics is right now, because we are on the wrong path. Interviewhe entire with Hillary Clintons a on book tv on cspan2. All five former living president s attended a Hurricane Relief concert at texas a m university. Here is a look at the remarks, starting with a video statement from president trump. What you want to do with your cell phones are now is help your fellow americans by texting and donate 10. Oneamericaappeal. Org. 45th few words from the president of the United States, donald j. Trump. [cheers and applause] my fellow americans, the devastations caused by Hurricane Harvey and maria and nate come along with a terrible wildfires in california have impacted millions of our fellow americans. For thosen, we mourn who died and we pray for those who lost their homes or their livelihood. These aftermath of terrible storms, the American People have done what we do best. We came together. We helped one another. And through it all, we remain resilient. We came together as one as we of texas,the aid florida, puerto rico and the islands. In as we begin to build, some of our finest americans are spearheading the one america appeal. All five former living president s are playing a tremendous role in helping our fellow citizens regarded recover. To jimmy carter, george h. W. Clinton, george w. Bush, and barack obama, milan you and i want to express our deep gratitude for your tremendous assistance. This wonderful effort reminds us that we are truly one nation under god, all unified by our values and our devotion to one another. I also want to thank every person, including everyone here tonight who has contributed to this vital effort. There is a lot of work ahead of us. I want to thank groups like points of light, for making such a big difference in our Disaster Response efforts. Together, we will recover. We will rebuild. And we will come back stronger and better than ever before. Thank you. God bless you. And may god bless the United States of america. [cheering] thank you, president trump. Texas, florida puerto rico phase the aftermath of hurricanes hurricane charley, irma and maria, points of light are embarking on the long road to recovery. Your to chuck more about the foundation and to present awards is president and ceo of points of light, Natalie Portman and chairman neil bush. Much, mr. Leeo outstandingor your patriotism and for being such a great mc tonight. And thank you to all the artists here tonight for volunteering your time and talent. I am proud to chair points of light and proud to support my fathers legacy of service and volunteerism. It is our privilege tonight to assure the moving stories of Everyday Americans who acted on an impulse to help others. In my hometown of houston, a halfmile from my home, entire neighborhoods an entire , wasborhood, like so many flooded. My wife and i went down to help with the cleanup and we were inspired by what we saw, a neighborhood darkened by flood thege was brightened by light of neighbors. We worked sidebyside with , corporations, churches, Service Clubs all across the city. All proactively helping their members, parishioners and employees and many others to clear contaminated flooring, walls and property. Volunteers all united in service. When he came to pulling people out of homes and pulling up damaged floors, no one cared whether you were rich or poor, black, white, brown, christian, jew or atheist, gay or straight. The truth is Service Unites people. [cheering] and people committed to serving others unite around our common humanity. Strength, resiliency and generosity flows from the simple acts of service. The inclination of one american to help another creates kinder and gentler communities, and a nation. Together as a the recent natural disasters have shown us that, yes, neighbors help neighbors, and fellow americans help each other regardless of where they are. Dietz ledeans, sherry a group of volunteers to houston where they conducted search and rescue efforts to save animals trapped in flooded homes. , from his homea in ancient tillie, virginia, organized a group that collected and shipped 120,000 pounds of relief aid with the support of the 103rd teens Air National Guard wing. And and oppose applause. The shirt the stories show interest in common cause making a difference in the lives of others. [applause] light are the souls of ame ordinary people who bring care and friendship. Y giving so what all of us can become. We were seeking refuge. We heard it was a shelter. When i walked to the doors, it started powers outcome of the dropped ceilings had fallen. Sewage running in and out of the bathrooms. We have 150 people here. Help to 19, they wanted to. They were not sure. I asked, who is ready to work, and all of them raise their hands. When you are in a position to help others, when they cannot help themselves, it is your duty. It is a we situation. Seeing the storm as it was coming and hurricane andrew, i remember what it was like. I did not want someone else to go through that. Media, puttingl outposts, a group of veterans are looking to help. Who needs help . I was nervous i did not have the means to put up shutters, clear debris, do any of the dirty stuff people shied away from. You just put it out there and ask others around you, how can we do this . That gets you started. Methe story begins with being a wedding planner and having a couple that was getting married on september 3. And a text that i sent to them with a photo of downtown, which was where our location was submerged. From there i asked them if they would like to spend the weekend doing of recovery initiative. They loved that idea, and they thought they would have 100 people at their Wedding Party that would join them. This was a selfless act that ignited an incredible idea. So there is a plunge to find you and there you up with an initiative. That went viral. We found cleared 250 homes and thousands of volunteers to recover. Night, i middle of the thought about, how do we do more . How do we engage more individuals quickly, help those hundreds of thousands of families . We were able to mobilize 700 at the center we were able to do truckloads of milk and water. We were able to organize more people to get the carpets, the sheets. Whatever we can do to show we can help human beings, to show we can improve their quality of life, that is the best thing god has on all of us. This kind of volunteer work is different than traditional volunteer work. We built resources that are really helping people with recovery, with rescue. If it was not for the rescue act , people would have been stranded. It was flooding, rising water. So it was really impactful. Volunteers, being there for somebody in their time of need matters. In the spirit of point of light, you are that for someone else. We just did what we needed to do, because that is what humanity does. To help a follow brother and sister hello brother and sister be one a lot of what we did, i like to believe helped people make it through this time when they were just looking, praying for there to be held. Help. People get overwhelmed thinking they have to do something huge to have an impact. It is really Something Like going to your neighbor and asking if they need help. I am able to help one person, one fellow being, but it is great to see tomorrow, when i need help, i can count on my neighbor, my community, my country. [applause and cheers] jimmy carter it is a great pleasure for me to be here with the other president s to carry out this project. I have just enjoyed seeing what the points of light does for the country. I have seen it for many years. I like to remind people that it is located in georgia. With habitat for 36 years, one week each year. And it is known for volunteer work. We are ahead of any other nation. Last year there were 67 million americans who volunteered to help other people in america. That came to 8 billion hours of work, worth 184 billion, so that is what volunteers did last year. This year they will do more. Five ofabout one out of a total population. We want to see what the other four people do. Build 6000 agreed to houses in a devastated area, and [applause] jimmy carter and to do this, all of us habitat volunteers will raise 100 million. And we have already raised 20 million, so we have got a long way to go. This is a wonderful project, and thatu want to contribute, is fine. If you want to contribute to 1800habitat. Er so lets all Work Together. And make Work Together america still a greater volunteer nation. Thank you very much. [applause and cheers] bill clinton when president george h. W. Bush was trying to persuade the congress to pass the americans with disabilities act, he said, our problems are great, but the heart of america is greater. That is what we are here to celebrate. Us,ere all citizens, even before we were politicians. And after our time was over, we became citizens again. We have been volunteering since before our constitution, when Benjamin Franklin organized the First Volunteer Fire Department in philadelphia. Our neighbors, our friends have gotten an enormous amount of equity from these volunteers, and a lot of money, but make no mistake about it. These were grievous storms back to back. There is still work to be done , and ourand in florida friends in puerto rico and the american Virgin Islands have only begun to dig their way out of what could be still a calamitous disaster. But it can be a new beginning if we just do what we ought to do and prove that the heart of america, without regard for race or religion or political party, is greater than our problem. [applause and cheers] howdy, texas. [applause and cheers] barack obama so all of us on this stage could not be prouder of the response of americans when they see their neighbors, and they see their friends, they see strangers in need, americans step up. [applause and cheers] barack obama and as heartbreaking as the tragedy that took place during texas, in florida, in puerto rico, in the u. S. Virgin islands, have been, what we have also seen is the ,pirit of america at its best when ordinary people step up and do extraordinary things. Is a part of that process. I want to thank president s george w. Bush and most of all in outstanding american, somebody who has always shown grace and character and courage, and served america nobly throughout the years, president george h. W. Bush. We are so proud to be with you tonight. [applause and cheers] barack obama he sets an example for all of us, as does first lady barbara bush. [applause and cheers] barack obama and that spirit of volunteerism, that spirit that says we are all in this together , that in dire times and ignores all the differences we had before, that spirit is five pointsby the of light recipients whose stories you just saw on the screen and who are here tonight. So it is my great pleasure to bring these outstanding americans to the stage so that you can acknowledge the extraordinary work they have done, i hope everybody who is watching is inspired by the work they have done. [applause and cheers] in 1989, in 1989, president george h. W. Bush created the daily point of light award to celebrate the power of an individual to make a difference in the lives of others. He was the first president in American History to institute a daily president ial Recognition Program from the white house. The work he began has taken root in americas fabric and has been built upon by every succeeding president. Points of light proudly stewards his legacy by continuing to individuals with daily point of light awards, over 6000 to date. We are grateful to have president carter, president bush 41, president clinton, president bush 43, and president us. A stand with recognize andwe honor the following individual points of light. Zachary bering, for his volunteer leadership at an evacuation shelter. [applause and cheers] Natalye Paquin leah albina for using her Technology Skills to be a virtual volunteer for storm survivors in texas and her home state of florida. Shani for mobilizing 2500 members of the islamic imam fleet and volunteers. For using her professional skills as a wedding planner to organize volunteers to begin rebuilding more than 250 homes, and Derrick Okeefe for organizing volunteers to prepare for and respond to Hurricane Irma and for coordinating the supply ships to puerto rico and after hurricane maria. Congratulations, and thank you for all that you do. [applause and cheers] [applause and cheers] george w. Bush thank you. It is first of all i am thrilled 42,e able to introduce 39, and 44 to one of the finest universities in the United States. [applause and cheers] george w. Bush i too am here to urge you to give to this fine find, and i want to thank all ofnd i want to thank the volunteers. I speak for the folks when i say we admire and love george h. W. Bush. [applause and cheers] cspans washington journal. This morning, Newt Gingrich will discuss the republican Georgetown University professor shon hopwood explained his path from prison to georgetown law. Discusses theeph path the real reason for kneeling during nfl games. Close your eyes for a moment. And stretch. Close your eyes. I see you. Trust me. Empathy. Stretch your imagination. Open your eyes. That is how fast it happens. Q a, theon executive director of paralyzed americans of america talks about his own paralysis and his work to help paralyzed vets. , i am trying to tell them this is the problem. I am trying to tell them you have to empathize. Ideals what will make the provider for veterans. Tonight at 8 00 eastern on cspans q a. Now, a senate panel on how to reduce Health Care Costs. This is one hour and 40 minutes. We know that larger issues in health care are much more important. Glad to have this discussion. It is a subject on which both republicans and democrats have a lot of interest. We look forward to your advice. Today, we are holding a hearing to look at what can be done to encourage people to make healthier lifestyle choices to illnessesnt serious and reduce Health Care Costs. Eachor murray and i will have an Opening Statement and then introduce the witnesses. Before i begin, i want to thank senator murray for her aadership and being straightforward, tough, negotiating partner on our bill toto propose a stabilize the Health Insurance market during 2018 and 2019. She and i will make a brief statement at 1 00 and put the text of the legislation in congressional records so senators can examine it. We will also list a significant ander of Republican Democratic cosponsors for the legislation. Our hope is now that we have put a proposal on the table, the senate will consider it, the house will consider it, and the president will consider it. I talked to the president last night, and he encouraged the process, which he asked me to begin. If you you have have suggestions, that is your prerogative to do, and we will consider it. Years, weast seven have endured this political stalemate over the political care act, with most of the a veryement being over small part of the Health Insurance market, where 6 of americans by their insurance. Our stalemate has really been of health care p of health care. The fact that we have had that stalemate makes this even more refreshing to talk about. An area of health care on which most americans, doctors, employers, democrats agree. That consensus is that a Healthy Lifestyle leads to longer and better lives and reduces the Nations Health care costs. Forrding to the Centers Health care service, medicaid has grown from 9 to nearly 18 of Gross Domestic Product in america. The Cleveland Clinic, represented by one of our witnesses today, has said if you achieve at least four of six normal majors 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. Body mass index. Blood sugar level. Smoking status. Your ability to fill the physical requirements of your jobs. The two brave ears are seeing your primary care physician regularly and keeping immunizations up to date. If you hit four of the six indicators and keep up to behaviors, according to the Cleveland Clinic, you will avoid chronic diseases 80 of the time. This is important, because we spend more than 84 of our Health Care Costs, or 2. 6 trillion, treating chronic diseases. That is something on which almost everyone agrees. Lets out to that another obvious fact. About 60 of americans get their Health Insurance on the job. So we really want to focus on improving the quality of health care in america, so why not connect the consensus about wellness to the insurance policies that americans get from their job . That is precisely what the Affordable Care act sought to do. It is one of the only part of the aca everyone seemed to agree on. Todays hearing is about how successful wellness initiatives have been an how we can make it easier to encourage people to live healthier lives. Many employers have developed. Rograms to incentivize people these may reward behavior such as exercising, eating better, including smoking, or offer employees a percentage of their insurance premiums for doing things like maintaining a healthy weight or keeping cholesterol levels in check. Steve byrd, one of our witnesses, is ceo of safeway. A Successful Employee Wellness Program after he left safeway, which i hope you will talk about the that is one part of it. I would also like to hear what communities and federal government is doing to encourage Healthy Lifestyle choices. I know Blue Cross Blue Shield of tennessee partnered with organizations to Fund Community wellness initiatives across our state, such as fitness zones in chattanooga. An example of encouraging wellness at the federal level is the medicare Diabetes Intervention Program for patients that most as prediabetic. There is hard to think of a millionsy to impact men to connect the incentive for wellness to employerbased wellness. Senator murray. All ofrray thank you to our colleagues and witnesses for joining us today. We often think of health care are something you need when you get sick. But we should be thinking more about ways we can help prevent families from getting sick and the first place and ending up in the Doctors Office or in the hospital. So i am glad we are having todays hearing to better promote health and wellness. Inall have a role to play supporting familys efforts to make healthy choices, and certainly business employers who behaviors. Healthy i look forward to a robust discussion that promote physical activity, improve access to healthy, for the foods, expand on sciencebased ways to reduce tobacco use and more. I will be focused on making sure congress is providing the investments needed to support local and state and federal efforts to promote health, including Grant Programs by the centers for Disease Control and prevention that invest in immunity centers, as well as the Prevention Health fund, which a difference. Given our high healthcare costs, and given that so made those costs can be attributed to chronic diseases, it is critical we do more. While we be clear consider Wellness Programs, we have to do it and a balanced manner and make sure we are protecting workers civil rights and privacy. The fact that employer wellness impose significant financial penalties on workers who do not wish to share protected Health Information is a serious concern. So i want to hear more about what we can do to make sure we find this right now, Wellness Programs that protect workers rights under the americans with disabilities act, and responsibility for making sure that the rights of workers with disabilities and those who do not wish to share Genetic Information are protected and respected will rest with the trump eeoc, which is one of the reasons democrats pushed so hard against recent nominees, who i am concerned show they are not truly committed to protecting those workers from discrimination. Appreciate all of our witnesses who are being here to help share your information with us and look forward to the discussion. And mr. Chairman, i have a letter from aarp that it want to submit for the record as well. Sen. Alexander thank you. It will be submitted. Thank you, senator murray. We would ask each witness to please summarize your remarks in about five minutes. That will give us more time to have questions backandforth from senators. The first witness is steve byrd, steve burd, founder and ceo of burd 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 roizen, the chief wellness officer and founding chair of the Wellness Institute at the Cleveland Clinic, a program that i just described in my opening remarks. Dr. David asch is 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. And then, Jennifer Mathis is director of policy and legal advocacy at the judge david elm Bazelon Center for Mental Health law. She supervises the senators policy work and engages in advocacy. We will start with you, mr. Burd. Mr. Burd 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. I will go quickly through a little bit of background what have done since i left safeway in the ceo position. Because it has 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. And, i think, 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. Because 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. After leading safeway, while at safeway, as the chairman indicated, i got very involved in health care and discovered that it was a fascinating area. A great opportunity to improve the health of americans, a great opportunity to improve care without adding costs, and, frankly an opportunity to , dramatically lower costs. So i committed to spending the next 10 years of my life and i have now spent 4 in this space. What i 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 Organization cost 40 to 50 . Simultaneously lower the employee expense 6 to 10 . 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 effects on the productivity of that workforce. I picked wellness back in 2008, because we took note that about 70 of all Health Care Costs are driven by health care behavior. Because we thought 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, plan design, and wellness. In the first five years, i put wellness in fourth place. In the next five to 10 years, i would put it probably close to secondplace or thirdplace. So there is an opportunity there. On the wellness front, we put together a program at safeway, and we made it a voluntary program, which i 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. And when we polled people annually, about 70 of the dissidents view the program as either good or excellent. What we measured was Blood Pressure, hba one c, cholesterol, tobacco use and bmi. As i said, 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 of them passed, and they maintain that over the balance of the program. Prediabetics, of those that failed initially, 45 of them passed two years later. Cholesterol level, 43 of those passed two years later. For smokers, i have a number at 35 . But in fairness, you can beat that test. So while we did improve the smoking, 35 is a bit strong. Then, we took the obesity rate 28 ur population down from to 21 . I have the goal that if we were state, 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 matched colorado at 21 . I want to just shift quickly, because it says i have nine seconds left. Why did we succeed . First of all, we rewarded participation. The vast majority of programs say they are outcome based and they are not. They are participation based. We had to put a meaningful amount of money at stake. We put the starting point at 600. We had to allow people to actually change their behavior, enhance their state of health. And we needed to surround it with an ecosystem that constantly convinced the employee that we cared about their health. We can talk more about that in the q a. 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 Health Begins to decline. So we focused on health and fitness. Lastly, it needed leadership. I practice this with clients today. And if you dont have ceo leadership, it just does not work. And i would contend that you cannot pick three of the five. In my experience, you have to do all five. Sen. Alexander thank you, mr. Burd. Dr. Roizen, thank you. Dr. Roizen chairman alexander and Ranking Member murray and members of the committee, my name is dr. Mike roizen, and i thank you for the opportunity to testify before your committee today. Since 2007, i have served as chief wellness officer at the Cleveland Clinic. I work 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 impacts on the health of our people while resulting in hundreds, literally hundreds of billions of dollars in savings for both the private sector and the federal government. For years, the Central Health care debate in washington has been about what role government should play in providing Health Insurance. But if leaders in washington dont address the skyrocketing cost of health care caused by the influx of chronic disease, it wont matter whether medicare, medicaid, private insurance or individuals pay the bill. Everyone in this room have 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 five to seven times faster than the population. There is, 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 Program provides employees who voluntarily chose mr. O so, such like with burd, to 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 about the causes of chronic disease and the drivers of health care spending. It starts with the fact that 84 of all Health Care Costs are due to chronic disease, and 75 of chronic diseases are driven by six measurable factors. Your Blood Pressure, body mass fasting blood sugar, hemoglobin a1c, your ldl cholesterol, whether you smoke or not, we measure it by urine levels, and unmanaged stress. These six predictors of chronic disease are controllable 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 by increasing payments by about the same number as mr. Burd, who achieved the six normals and 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 the milliman benchmark as more of our employees get and stay healthy. Further, there improved health is reflected in substantial reductions in unscheduled sick leave and the 62 of clinic employees who voluntarily participate in the program have seen their Health Care Costs and premiums decrease by 600 for individuals to 2000 annually for families. For hitting these targets, smoking rates have decreased 15. 4 to under 5 where the , state of ohio is around 23 . Body mass index of employees for all 100,000 employees taken together is decreasing 0. 5 per year as opposed to the nations increasing 0. 37 per year. Blood pressure and ldl cholesterol and hemoglobin a1c levels 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. For example, la farge is saving over 46 of expected medical costs, as estimated by aetna. And we know other organizations can learn from these examples. In short, the Cleveland Clinic rewards for Healthy Choice Program 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 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 virtues it has been tested in multiple settings across different populations in different groups. Everything from engineers to blue cross bluecollar workers. Its entirely voluntary, and it enables the federal government to achieve substantial cost savings without programmatic budget cuts and any initial cost. Bending the cost curve through voluntary Health Programs is a commonsense idea that democrats and republicans should we able to rally around. Thank you. Der dr. Asch, welcome. Dr. Asch chairman alexander, Ranking Member murray, and distinguished members of the committee, thank you for the opportunity to speak with you today. My name is david asch, and i am a 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. But we spend about 5000 waking hours a year doing Everything Else in our lives. And its during those 5000 hours when so many of the determinants of our 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. And 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. Now, more than 3 4 of large employers of some sort of Wellness Program targeting risk factors you of heard about already that account for much of chronic illness. Things like tobacco use, high bloodpressure, 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 last week, richard thaylor won the nobel prize in economics allrecognizing that we succumb 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. One such irrationality is loss version, where we are 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, we structured it as a loss, 1. 40 per day or 42 per month. For that group, we gave each employee 42 of the beginning of the month and took away 1. 40 for every day they 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 received 1. 40 were no more likely to walk 7000 steps than those who received no incentive at all. But those who had those who had 1. 40 taken away if they did not walk 7000 steps were 50 more likely to succeed. Mathematically and financially, these two approaches are the same, but one worked 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. Although it may seem obvious to charge higher premiums for being a smoker or being overweight would encourage people to modify their habits 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, tthey also draw criticism. 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 help help them weight, 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 rewards, emotional engagement, and contests and acceptance. Those are the ingredients of successful programs and are 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 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. Sen. Alexander ms. Mathis, welcome. Ms. Mathis thank you, chairman alexander, Ranking Member committee, i appreciate the 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 lon centert the baze for Mental Health law, but i am also the head of a coalition of organizations that Work Together to promote 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 independent 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 receive services in our own community leads to improve Health Outcomes and lowers costs. 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. Attitudinal barriers is one of the chief reasons. Perception 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 subjected to medical exams or inquiries only if they were jobrelated or if if they were voluntary inquiries. Gna provided similar protections for Genetic Information including spouse Health Information. 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 significantly rolled back the protections it had enforced for many years to ensure that 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 employees who keep their Health Information private and 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 has 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 in its 2010 regulations implementing gna, verifying that financial incentives can be used but not for questions asking for Genetic Information. The same rule should apply to questions seeking Health Information of an employee or a spouse. The lead study on Wellness Programs conducted for the department of labor highlighted many strategies other than incentives that have made Wellness Programs more effective. But 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. R thank you, ms. We will now have a five minute questions. 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 in their testimonies behavioral economics and behavioral decisionmaking. Is important that we, 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. I will start with mr. Asch, you 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. From tobacco toigation to losing weight managing 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 approaches 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. My question for you, sir, what might employers learn from behavioral economists . Thank you, senator. I will start by saying there is often a misunderstanding 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 to make incentives 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 gains mightr than be a new way to structure these in ways in which to be more 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. You really need to study these different phenomena individually i think to have a sense of the growing body 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. Hey Richard Thaler who just won the nobel prize in this area a 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 a behavioral scientist. 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. We need to continue to have a unit or units embedded within governments to do a lot of these experiments. We need to have a clearinghouse of best practices that employers 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 who would 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. I am very much in favor of a 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. Our communities of color are 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. Your state and or schools are taking a leadership role that the rest of the nation would love to follow and hopefully will be able to. When you get kids to be healthy 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 it is very 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. In 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. Under hipa. Those are three laws that this committee wrote, and i am proud of these laws. As you may well know, this committee met yesterday and cleared nominees 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 the eeoc criteria set criteria for when participation in a Wellness Program is not voluntary and what advice would you give those five members to the eeoc . I think the most important thing for the eeoc to remember is to remember that their job is to apply the ada and not to rewrite it to try to conform it to another law that also applies at the same time but does not 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. We have a lot of experience with applying multiple laws to the same set of circumstances. You have a framework that they have already 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 Affordable Care act, and they considered the two laws in 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. Its not about income held by outside influences. Having steep financial incentives is the dictionary definition of what is not voluntary. So, having the same kind of framework, the same path that they charted for the 2010 regulations, to apply all of those to the ada which is how they interpreted the ada before 2016 for many years to allow Wellness Programs to have incentives but just not to incentivize or have significant incentives for people turning. Ver Health Information that would allow Wellness Programs to proceed and develop. To use many other strategies and rodingage people without e the civil rights of people with disabilities. Thank you, senator murray. Senator isakson . If i remember, the program for employees participating in the Wellness Program . Correct. From yourve you found work with companies willing to put in the Wellness Programs you have suggested . Voluntary for withyees and about 70 spouses. What i do not want the committee to do is think it is all about incentives. I think they are necessary not by themselves selfsufficient. Going back to something that was said earlier, the secret sauce at safeway was creating small support groups. We had thousands of groups that came together on their own, set goals and objectives and time frames, maybe exercise goals are exercise goals or weight loss them take thesaw tools we gave them to work towards those goals. It really was a driving force along with ceo leadership. I look at government as being an enabler in this process, but i also think theres an opportunity for government to lead. One opportunity to lead would be officesore government adopt programs like this for their own employees. I actually offered it to do this for the secretary. 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. Its important that we employed 10,000 people with disabilities at safeway out of 185,000 people. 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. While he wanted you to get the 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 and your physicians said, i feel better going from 45 to 43, that would be fine and we would change the standard. I appreciate the answer because being someone who has to beery opportunity involved in good Health Programs, i know what got me into Health Programs and Wellness Programs was the desire to change a habit. What kept me in them 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. Changing your eating habits, exercising regularly, quitting smoking, none of those things arent easy. I like to talk about them, and everyone practices them every new years but then they go away. If you get reinforcement in a peer group, in a positive way, you can really sustain the practice. 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 a certain level we did it on a certain level first and then scaled it up. For example, if i wanted to 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. All three of them every time i wanted to increase the sales by 20 . We struck upon something over time that worked in a work famously. We had no issues with it and if you dont know, the Health Statistics do not go to the hr department. They do not know what somebodys bmi is. They know there is a contribution of a premier effect about howont know many of it passed 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. It has passed the senate is now pending in the Energy Committee so we are close in a threeyear effort. I think a couple of things she said deserve reemphasis. She said there is an absolute firewall between the health plan and the company. They dont know why the premiums are where they are, what is 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 set a goal of , and that determines their incentives. It is a culture change. It is multiple programs that work. It is leadership as well. 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 the nuts and bolts, but there are a lot of things that work. Senator franken. Thank you, mr. Chairman for holding and the Ranking Member for holding this important hearing. Before the hearing started, i spoke to all of you about housing. What we are trying to do is help people be healthy and to lower the cost of their health care in the long run. Mathis, you pointed out research that shows a connection between Peoples Health and stable housing. Despite the fact that they are actually very often talked about as completely separate issues. In minnesota, 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 supportive housing, they saw significant reductions in participant 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. You, cans and all of 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 prevalent 20 or 25 years ago, 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, locating assistance, all of these things. Housing, stability, work are all social determinants of health. They have an enormous impact on Peoples Health. There have been many studies done. Some of the interesting ones have been on people are homeless versus people who are in support ive housing. A twin study of people in those two situations where a cost just 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 that recognizes 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 who are 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. Sometimes it is inadequate housing. Sometimes it is another form of 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. And 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. Some would say, senator franken, you are a genius for because thes up, social determinants can be important in [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. Weigh 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. Ash,ted to say first, dr. We are grateful you are here and for the work you do at penn. At whartonne work butthe school of medicine, i 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 right about that . My followup to that line of questioning would be with regard that your. Ash, Research Indicates the penalty incentives may not have had the effect on individual behaviors. Both you and dr. Rauzen have indicated the importance of the many hours, i guess 5000 hours, of waking activity when we are not interacting with the Health Care System. Senator murray indicated that some plans could have penalties and rewards as high as thousands of dollars a year. We have heard a program uses a 30 penalty. The limit that the eeoc set with the rule last year. My question is this 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. We have heard that penalties are more offputting than reports and then rewards 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 of an incentive is to increase the size of an incentive. The way we design incentives probably has much more of an impact than the amount. You can imagine a 500 incentive that might be bundled into someones paycheck. Once a week, that is 10 a week. If it is put many other elements and may not be directly seen. Imagine handing somebody two crisp 100 bills. That is a smaller incentive, but it has a much more potent effect. 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 whose bmi is 26 to lose pounds. Demoralizes those at maybe 30 or 40. It is far more effective for the people who we fund the mentally need to help the most. You have to Design Elements with the 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 but i want to move to another line of questioning. The written 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 discriminate against someone 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 protections. Outcome was very they do address the concern. But if you cannot meet a particular health come because of a disability, there are regulations that implement that. We have not heard that that is a major concern. Our concerns are much more around the privacy issues. Cases,rue that in many the information will not go directly to an employer. Sometimes, it will if the employer does directly run a Wellness Program. With small employers, it is not that hard to figure out who has what health condition. Frankly, i think 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 in many cases have had many negative experiences in their lives thanks to the disclosure of their disabilities. I will do some followups in writing. Cassidy . Cassidy i feel as if when i think of my parents, its a bigger problem. If you are in philadelphia probably have a practice similar to mine. 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 appointment 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. 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 time, but basically, had you get 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. 62 a participants have the 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 colorado, who have been waiting forever for a bipartisan effort here, i want to express their gratitude to you for the work you have done and my hope that 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 to incentivize and do the same 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. Will 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 care physician, so the there 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 advance or in fact, there isnt 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 . I think 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 free choice, 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 indulge, we have another half 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. When you finish that diet and 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. A when i talk about an ecosystem that is safely created, we stressed the importance of cardiovascular workouts. We stress strength training. You can at the age of 60 have 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 law for employers so they cannot 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 start by asking ms. Mathis, what 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. I know that today you own a business that designs these kind of penalties for other companies. So my question is, when it costs an employee 1500 or maybe more a year to get Health Care Coverage 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 hipa, 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. I was questioned by the eeoc, by 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. 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 all right, 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 method 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 do you how big of a problem is it . Hasnt been for you and your employer plans has it been for you to deal with what senator warren talked about and others have asked about, 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, you have the opportunity to say, i need a different standard. Or i need an exception. That is exactly right. You have to have 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 what 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 that we have 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] maybe so, 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. 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. I had a visit yesterday from, i 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. As we go into this opioid as 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 Country, have a place to go after they 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 sober, but she went back with her old crowd. And she is gone. We just need, i 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 pilot a program in minnesota. Actually, this is nationally as 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 sober before they come in. 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 and indianapolis by nih and cdc, 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 their blood, glucose, and they 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 so that anyone in medicare who 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
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