Transcripts For CSPAN Medical 20240703

Combating diabetes. [inaudible conversations] [inaudible conversations] shall be give this hearing a start . For this joint economic hearing i actually have 2 give senator heinrich and the entire team, democrat and republican staff, has been in discussion for quite a while. As we look at the Health Statistics of the nation, particularly diabetes, its cost to society not just in healthcare costs, but in so many of our brothers and sisters that just have misery. Where this partially came from is 2 or 3 years ago we were doing a weird experiment. Whats the real cause of income inequality in america . And yes, we saw education, we saw other things but the one thing we werent prepared to see was health. The numbers of folks, hate to use the economic term, that had real Health Issues, the number of it was diabetes and so we have spent almost two years digging around in the literature trying to understand whats going on in society, particularly the growth of our population that are suffering but also we are seeing our young people, a chart came out three weeks ago that basically said at the end of this decade almost half of our kids will technically be obese. The cascade effect of potential diabetes with that, maybe there is a moment here, this is not republican or democrat, right or left, it is focusing on whats going on in our society and our moral obligation to find a way to end, and good economics. Our two witnesses and hands it over to the good senator. Doctor herman serves as chief of the section, i always get the word wrong, and roque analogy and metabolic at Baylor College of medicine, practicing doctor, the primary focus is on diabetes treatment and care. An expert in metabolic the research has improved the understanding of diabetes it self as well as made advancements in diabetes treatment. We did our best on this. Doctor benedic ippolitos senior fellow economics and policy studies at the American Enterprise institute. s research focuses on Public Finance and health economics. He has rescued written on competition and pharmaceutical markets and economics of value of medicine innovation. He earned his phd in economics from university of wisconsin madison. I want to start by thanking vice chairman schweikert for his passion in this area and it is something that touches all of us and touches our two states, the Economic Impacts of diabetes on our economy, are really astounding. And another 96 million adults, with an estimated one in 3 americans expected to develop the disease at some point, with so much hot healthcare costs. The high price of medications and treatments in Doctors Office and through employment rates and cost of early retirement. These costs are borne by the patient, by health systems, employers, and entire communities as we hear about today. Thats where we focus on this hearing today, and finding Bipartisan Solutions that ensure we had a healthy population, and all americans have access to quality affordable healthcare no matter their means or where they live geographically. When patients lack access to healthcare, minor challenges can quickly become major challenges with lack of proper diagnosis and treatment and that is true of rural and tribal communities is increasingly prevalent. Too Many Americans living with undiagnosed or untreated diabetes, they cant afford or see a doctor to pay for prescribed medication or travel long distances required to get a provider. And and extreme complications, and ability and Diabetes Prevention and Early Intervention and Health Education are costeffective and lead to Better Health outcomes. Beyond that we must understand address upstream causes of the disease including factors like socioeconomic status and access to quality nutrition. Food insecurity is closely associated with tight 2 diabetes. When families have access to nutrition programs like snap they are able to more consistently access healthy food. Weve seen associated reductions in poverty and health care expenditures. Fortunately, medical science has recent breakthroughs on pharmaceutical Treatment Options for diabetes and im looking forward to hearing more about how recent breakthrough treatments have had positive outcomes for patients and helped change their lives for the better. Unfortunately, many of those Treatment Options remain unaffordable for many patients. The Inflation Reduction Act was an important step in controlling drug costs which it established several cost control measures like limiting insulin copays for medicare beneficiaries, 35 a month and capping annual outofpocket prescript and drug costs at 2000 starting in 2025 the act gives medicare the ability to negotiate the price of high cost Prescription Drugs and forces Drug Companies to pay a penalty when the prices they charge medicare rise faster than inflation. These actions put downward pressure on drug costs while having little impact on innovation. It is clear that the most effective treatments for diabetes require a comprehensive crutch addressing diet, lifestyle, Mental Health and other societal factors alongside medical treatments. Weve had some successes on this front such as with special Diabetes Program for indians which congress established in 1997. This Program Provides funding for Diabetes Prevention and Treatment Services to over 300 Indian Health programs across the United States and provides flex ability to design and implement diabetes interventions that address locally identified priorities. Through this program we see youthbased outreach, planting of community gardens, running and fitness events and Partnership Programs with pharmacies that help patients manage their prescriptions. The special Diabetes Program for indians has been extremely effective. Since it started, the prevalence of diabetes and end stage renal disease and diabetes related i disease among American Indians have all declined. We need to increase the funding for this program to keep up with costs and better serve all tribes. Looking beyond tribal communities we should look to this program as a model for how we can design and implement comprehensive Disease Treatment and management nationwide. I am pleased to join my colleagues from both sides of the aisle to explore these issues and work in this bipartisan hearing and im looking forward to hearing more today on the impacts of diabetes on our communities, the ways we can address upstream causes to the role of health and nutrition programs in prevention, treatment and the role of pharmaceutical interventions. It is my pleasure to introduce our two other distinguished witnesses. The tenth president of the Navajo Nation, and office he assumed in january of this year, he also serves as the navajo area representative to the national Indian Health board. He previously served as the chief commercial officer for the navajo engineering and construction authority, we need more engineers around the here. A quasiindependent tribal enterprise headquartered in new mexico from 201018. He was a National Operations trainer and project manager at a multibilliondollar Construction Companies that build schools, Senior Living homes and Public Safety facilities from nevada to florida. He also served as the first president of the changed labs board of directors, a nonprofit that continues to support navajo and hopi entrepreneurs with basic tribal specific technical assistance. He has a bs in Construction Management and nba from Arizona State university. Youve heard of that, right . And doctor of education in organizational change in leadership from the university of southern california. Janet brown friday is the president of healthcare and education at the American Diabetes association, missus brown friday has been a registered nurse for 40 years and most recently served as Clinical Trial manager at the Albert Einstein college of medicine diabetes Clinical Trial unit. Mrs. Brown friday has previously served on the National Board of the American Diabetes association and she remains a current member of the Nyc Community leadership board. Mrs. Brown friday previously served as a Committee Member for the National Diabetes Education Program and as a special Government Employee and counsel member for the National Institute of diabetes and digestive and Kidney Disease advisory council. Mrs. Brown friday holds mph in community Health Education and ms in Community Health nursing from Hunter College in new york city, new york. We are going to begin with president nygren and then go right to left, left to right down the dice today. Welcome, we look forward to hearing your testimony. Good morning, chairman heinrich, esteemed members of the joint Economic Committee. Im doctor bill migrant, president of the Navajo Nation, i serve the navajo area, representative to the national Indian Health board. I come before you to speak about a matter that not only affects the welfare of our nation but also a significant issue for all Indigenous People across the United States. We are here to discuss the importance of special Diabetes Program for indians. The Navajo Nation provides Governmental Services to over 400,000 members, and on reservation population is 200,000 which accounts for one third of all natives living in Indian Country. Like Many American indian tribes, navajo people experience higher rates of preventable nutrition related diseases such as obesity, diabetes, Heart Disease and cancer, than the general Us Population. These Health Issues are not part of our heritage but the consequences of painful history marked by colonization, forced assimilation, displacement from our tribal homeland and relocated to reservation lands. Historically our communities, farming, herding and hunting, there were nutritious foods, and it was systematically eroded over time, salt have replaced traditional food sources, and lack of transportation, congress established, a clinical response to the escalating diabetes epidemic in Indian Country. This program as mentioned earlier is a budget of 150 million, fund 300 communitybased intervention programs to discuss type 2 diabetes. Despite these efforts diabetes remains a persistent Public Health problem among our people. In 2,011 the Navajo Nation in collaboration with ihs changed their approach. We begin to engage local Community Input to develop and implement interventions that are culturally relevant, and sensitive to our unique circumstances. Recognizing inherent sovereignty we have initiated our own disease prevention activities, data collection, policy develop into an Evaluation Initiative is. In 2014 the Navajo Nation and acted the healthy action act that introduced a 2 tax on unHealthy Foods, this generated 10 million funding vital local Community Wellness projects. This approach provided muchneeded funding and promoted healthier eating habits in our community. However this effort is not enough. The special Diabetes Program for indians is critical in providing quality Diabetes Care and prevention practices resulting in lower incidents of in the stage renal disease and lower prevalence of type 2 diabetes among native americans. All these things save taxpayer dollars and medical costs, 19962013 incident rates of end stage renal disease among native americans and diabetes declined by 54 . This reduction alone is estimated to have a value of 520 million over nine years. These programs have had a tangible impact on our communities, the navajo Wellness Centers have already shown promising results, providing Health Screenings and conducting wellness activities, these centers help detect and manage diabetes and have been successful in promoting Overall Health and wellbeing in our communities. The current funding levels are barely enough to maintain existing initiatives. We need to ensure every navajo individual fighting this disease has access to the resources and care they need. All i ask is the reauthorization of the increase in funding that will enable us to expand our programs, reach more people, ultimately turn the tide in this fight against diabetes. We support legislation passed by committee in each chamber that would renew for two years at the funding level of 170 million a year to serve more native americans effectively, the Diabetes Program for indians is the Gold Standard when it comes to diabetes treatment and considered one of the most effective public Health Programs ever created. We urge you to consider human safety behind the statistics, our elders, our children and families. They all look to you and hope their government will continue to support them in their fight against this devastating disease. You have the power to turn this hope into reality. Thank you for your time, your consideration and your continued support. [speaking in native tongue] thank you. And distinguished members of the joint economic midi, thank you for inviting me to testify on behalf of the American Diabetes association about cost of living with diabetes. We thank you for considering this topic at this critical time. The nations leading voluntary Health Organization fighting the diabetes epidemic and People Living with diabetes thrive. For more than 80 years the ava has been driving discovery and research to treat, manage and prevent diabetes while working relentlessly for a cure or. Today i would like to take this opportunity to describe and offer context for the most significant drivers of Cost Increases for People Living with diabetes and the work ada is doing to make managing diabetes more affordable and prevent adverse outcomes. According to the cdc, more than 37 million americans live with diabetes, one hundred million americans have prediabetes. Diabetes is the most expensive chronic condition in the United States. People with diabetes account for one of every 4 spent on healthcare, one third of medicare drug spending. People of color and other underserved populations, those who lack access to Adequate Health insurance coverage, Healthcare Services and the tools they need to manage their diabetes, a disproportionate share of the cost. That is because 18 of black americans of black americans, 17 of latino americans and 50 of native americans have diabetes compared to 7 of white americans. Because diabetes diagnoses are less likely when people have access to resources, diabetes prevalence is inversely related to household income. Individuals are in less than 30,000 a year are three times more likely to have diabetes than those make more than 80,000. Low income americans in rural and urban areas are likely to develop diabetes, experience complications from poorly managed diabetes and die younger than higher income americans. These cost disparities become even more acute during the recent pandemic and economic impact. Americans with diabetes and other related underlying Health Issues were hospitalized with covid 19 six times as often and died of covid 1912 times as often as those who did not have diabetes. One in 10 coronavirus patients with diabetes died within one week of hospital admission. Americans with diabetes accounted for 40 of covid 19 fatalities nationwide. Despite making up just 10 of the Us Population at the time. Some of the major drivers of the high costs are care for people with diabetes, high risk hospitalizations, having Health Insurance is the strongest single predictor of whether adults with diabetes will receive high quality Healthcare Services. 27 million uninsured americans have a higher likelihood of having undiagnosed diabetes because they are 60 likely less likely to have regular Office Visits with a physician and have one hundred 68 more emergency room visits. Comorbidities, people with undiagnosed diabetes are more likely to develop comorbidities like kelly kidney failure, coronary artery disease, severely limiting their ability to get healthy. Prescription drugs. Americans spend more treating diabetes than any other chronic condition. People with diabetes in the us spent two times more on healthcare than those who do not have diabetes and one in four insulin dependent americans report stashing their supply. The access to diabetes supplies, 10 million americans are treated with insulin and stand to benefit from a continuing insulin pump and yet we know people who lack adequate access to healthcare, providers rely on medicaid for Health Insurance coverage, are least likely to be prescribed diabetes management technology. Lack of access to healthier foods can lead to being overweight and obesity which are proven risk factors driving as many as 53 of new cases of type 2 diabetes each year. We now know that rates of type i and type 2 diabetes have increased and may be linked to covid 19 as has been seen in some studies. I thank you for the opportunity to testify before the joint Economic Committee on the cost of diabetes. We look forward to continuing to work with congress to address health inequities, and help americans with diabetes access tools, medications and services they need to stay safe and healthy. Thank you. Some of that was wonderfully helpful because you he and i did you hear what she said . Doctor. Members of the committee, my name is benedic ippolito, a lot of my work focuses on high healthcare costs broadly speaking. Thank you for having me today. As incidence of diabetes have grown, so have its costs to individuals and as mentioned earlier, they are focusing on the direct health costs, and in the last 5 years or so. Individuals with diabetes pay some portion of that with higher outofpocket spending. And in the commercial markets but also taxpayers in the federal government and when you think about incidence of diabetes and the cost of diabetes, one third of medicare is on diabetics, it is born to the medicare program, and the federal government. Beyond the direct health costs there are indirect costs. The condition affects Labor Market Outcomes by increasing absenteeism, lowering productivity of workers and resulting in lost work years and other outcomes, that adds up to another hundred billion dollars a year in the costs of the disease, so that is really significant even above and beyond the direct health costs. As a result, treatments for diabetes can convey significant value, particularly notable given advancements, please dont ask me to say therefore name. I will highlight a few issues related to those treatments that i think are relevant for folks considering policy in this space. The first is that its not obvious how new therapies are going to affect the overall cost of diabetes. Thats because you have counteracting forces. On the one had new treatments come with their own costs. They have prices. On the other hand they offset some costs. Either they replace existing therapies, lower use of other Healthcare Services or affect Labor Market Outcomes, might increase productivity. How those things balance out is not obvious and in this particular case it is particularly not obvious because this drug market itself is influx. We see new treatments come to market and as that happens, more competition to get on insurance plans, including daily in my written testimony showing the last couple years, some that were at 66,500 net price for the year are now around 4,000, thats a big change over a couple years so thinking how that will evolve across the market in the next 2 or 3 or 5 years is hard to do. That said, its best to consider more than budgetary effects on new therapies, if we are effectively making people healthier we should be able to pay something for that, not indefinite amounts. The second thing is to echo earlier comments that new therapies raise questions about afford ability and access. A simple point, encourage you to consider this question ~ sickly rather than adjusting afford ability for specific drugs or conditions individually and the reason is twofold. The first is the Healthcare System is very complicated as it is. When we have 1off approaches to different diseases and different conditions, makes it all the more complicated to keep track of everything, the second thing is it raises legitimate equity questions, should you preference disease x over diseasey, if so, why and how much . Those are legitimate and challenging questions. Think about approaches like what weve seen with Medicare Part d. There were bipartisan efforts to try to impose an outofpocket limit for folks in that program, that tries to address afford ability, the high end of financial exposure in a broadway that affects everybody regardless of condition. Finally, i focus a lot on drugs in my own work but while new drugs can improve the toolkit to improve Health Conditions there are many nonpharmaceutical interventions that could remain highly costeffective so in the case of diabetes weve heard people talk about it, things like selfmonitoring of blood sugar, Lifestyle Changes are chief among those. To the extent that those interventions provide good value for money we want to make sure not to preference pharmaceuticals to the exclusion of the other interventions. That is hard to nail down a specific policy but on a conceptual approach its important to keep in mind. All told diabetes it is true for people with the disease and people who do not have the disease so thank you for inviting me and i look forward to your questions. Thank you. Thank you for the opportunity to discuss the impact of diabetes and the emerging technologies, therapeutics to address the ongoing epidemics of diabetes and obesity. I chair of avenue the diabetes and battalion Baylor College and medicine. My work as a researchers focus on caring for individuals with diabetes and other endocrine diseases. My scientific laboratories are committed to deciphering mechanisms responsible for these conditions so we can identify ways to treat these diseases. Over the past decade we made significant strides in understanding how these diseases develop in people. Weve made remarkable progress in developing medications and technologies for people. I would like to highlight three areas of progress for you. One, the vital and revolutionary role of related medication to treating diabetes and obesity. 2, the Rapid Advances in medical devices, technologies for diabetes and 3, growing knowledge of the complex nature of diabetes and its complications and what it means for the future of Diabetes Care. Im sure you are aware of the news about a class of medication which mimics a natural hormone which is proven vital in improving control and promoting weight loss. This was developed to reduce blood glucose levels, this is a major goal in the treatment of diabetes. However these medications are are couple effective in helping patients fuel full, reduced caloric intake and lose weight. Moreover, Clinical Trials are showing this reduced the risk of cardiovascular events and death in patients at high risk of type 2 diabetes. With obesity a primary risk factor for diabetes and cardiovascular diseases, the potential of this to reduce meaningful and sustained weight loss may represent a significant advancement in preventative care. In sum, it issued in a new era in management of diabetes and obesity, the latest evidence of a growing understanding of and a and physiology can lead to therapies for pressing Public Health challenges. Next i would like to address how new medical devices and technologies for transforming diabetes management, you are no doubt aware of continuous glucose monitors which replace the painful and inconvenient method of multiple daily finger sticks. Realtime continuous glucose tracking offered by cgms helps to prevent severe hypoglycemic episodes, a source of fear in children with type one diabetes, similarly insulin pumps have revolutionized delivery of insulin providing more clickable approach compared to multiple daily injections. The pump delivers a continuous infusion of rapid acting insulin that can be adjusted with the click of a button to mimic the insulin production of a healthy pancreas. The next steps in Diabetes Technology are artificial pancreas devices, these devices combined with continuous glucose monitors, insulin pumps with advanced control algorithm to automate insulin delivery and reduce the burden of diabetes management. The ongoing integration of these technologies and patient care emphasizes the transformative power of Digital Health in managing chronic disease like diabetes. Finally, i would like to discuss the considerable progress we are making in varieties of diabetes, research is showing the diabetes is a group of disorders with common traits. By analyzing common genetic variation we realize different subtypes of diabetes may be driven by different genetic factors that can lead to different adverse outcomes. In peril, examination of rare genetic variation to identify a point of underlying mechanisms to participate in the developed a more common forms of diabetes. By understanding different genetic contributions to diabetes, a more promising frontier, personalized approaches to treatment. Without a doubt we stand on the cusp of a revolution in diabetes and obesity management. Scientific breakthroughs and technological advancements, so thank you for allowing me to share my perspective with you and i look forward to your questions. Thank you, your questions. I thank vice chairman schweikert for allowing me to go first this morning. I have to hop over to appropriations in a few minutes but i want to start with president nygren. Congress established special Diabetes Program in 1997. In response to the growing prevalence of the disease among American Indian and alaska native populations. It provides funding for Diabetes Prevention and Treatment Services to 300 Indian Health programs across the nation and the strength of it is it provides grantees with a great deal of flexibility and we heard little bit about that on the Navajo Nation today, to design and implement interventions that are culturally confident and directly meet the needs of those individual communities. How have you been able to tailor health prague programs on the nation and you think this kind of approach can be successful on a wider scale in nonnative communities as well . Good morning. Thank you for that question. One of the things i want to mention is i recently lived in crystal, new mexico which is south, north there are a couple hundred walkers so people came out to walk half a mile, 1 mile, two miles are three miles and they were provided with bananas, good foods to eat and education so we have the whole Navajo Department of health goes out there. A very community approach, this is an opportunity for people to come out not only one of the things people take a lot of pride in is the tshirts being provided at those events and a lot of those tshirts encompass culture, health and this is something they like to wear in the community and also brings them a lot of pride. This might be the first tshirt thats brandnew for the year and they look forward to these events. The custom approach to the community is a tickle approach because not every Tribal Community is the same across the country. Theres 574 communities across the country, navajo is one of them. Landwise, population wise we are very unique and if by allowing every individual tribe to have their own unique approach, setting them up for success because there are things in navajo culture that are not the same in hopi or laguna or different tribes across the country so having that taylor approach is a good way to utilize resources and seeing the decrease not only in diabetes on navajo, it is something related to having a tailored approach. Everybody it is easier to walk around with something thats tailored. Thank you to the committee, the programs for allowing us to be successful since 1997. Obviously the funding has been the same since 1997. There are people who need to be hired and it is a very rural, remote, navajo. Thank you so much. Thank you. That is a great point. We have had flat funding for so many years in this program and as a result of inflation we lost a lot of buying power. That is something all of us need to look at. Benedic ippolito, president nygren touched on nutrition but i want to ask you, given that this congress is one where in theory we are going to pass a new farm bill and if we look back in time to when diabetes really took off, in the 1970s, we changed our agricultural policies and focused on commodities over nutrition and we saw these incredible increases from the 1970s to today in the prevalence of diabetes. Do you have thought how to approach the farm bill in light of our challenges with diabetes . I will answer that by focusing on the underlying point that we are accustomed to thinking of new pharmaceuticals as being Cost Effective or not, do they deliver value for the money . When you look at diabetes and other conditions there is ample evidence to suggest there are other things that are costeffective if you look at them through a similar framing. Nutrition, eating habits, Lifestyle Changes, seems like theres strong evidence for that, that fits in the purview of the farm bill, seems like it is something worth considering. Mrs. Brown friday, diabetes should be managed through a combination of prevention and treatment, we heard that here today. For most patients this involves first being able to be diagnosed, then treated with a combination of Lifestyle Changes, related to nutrition, physical exercise alongside advances in medical intervention we have heard about. Many americans simply dont have access to Adequate Healthcare to delay the onset of diabetes and prevent the more extreme complications of the disease. How do issues with accessing healthcare like being uninsured or underinsured, having trouble with medication, create disparities in diabetes outcomes for different populations in the United States . I think being underinsured or uninsured is a problem for the population across the United States, across the board, across cultures. I think when you are under or not insured you do not have access to the Healthcare Providers are less access to Healthcare Providers that can provide the information you need so you can take better care of your self. You go and see a physician or Nurse Practitioner or diabetes educator for 15 or 20 minutes and the rest of the time you have to do it your self. Those visits are extremely important and valuable. If you have access to healthcare, because you are well insured, you have those visits in order to get those jewels that will be able to take better care of your self, to know how to take your medications, not just to take them but how to take them and to have their choices. Underinsured, does correlate also with Food Insecurity. People who are uninsured are in areas or food deserts where healthier foods are not available, supermarkets are not available or not close to them even in urban and rural areas. Thank you. I want to thank you for your testimony today. This is a topic of incredible interest to the vice chairman and myself. I am going to leave it in his capable hands. I want to thank all of you for your input and this has huge budget ramifications but it also has huge ramifications for every individual constituent of hours. I will try to be respectful of everyones schedule because you are here at a screwy time of year. Senator lee, you are up. Thank you, mister chairman, great to have you here. President nygren and i hold the alliance between utah and arizona in check. I was born in arizona and move to utah as an infant, he was born in utah, moved to arizona young in life. It is good to see you, sir. I am grateful, mister chairman administer vice chairman for the fact that you scheduled this hearing. This is an important topic. As of 2018, there were 185,000 People Living with diabetes in the state of utah alone and this is a significant disease. Its a significant disease that presents all kinds of challenges, it manifests itself 24 hours a day. It never sleeps. In the case of type i diabetics there is no reasonable prospect of living without it. No reasonable prospect with technology in existence today of becoming no longer insulindependent. It is with you for the rest of your life and so as a result of that, this causes all kinds of headaches, financially, emotionally, in every aspect of your life at every moment of your day, it can step in and cause problems. This hearing focuses on one disease. My comments are relevant to multiple conditions. I believe the federal government has itself been one of the main driving obstacles to increase innovation, we know increased innovation brings about higher quality, better prospects for treatment of the disease and ultimately brings down the cost, it produces cost savings with additional competition. Sometimes when confronted with issues such as drug shortages and high costs, the government seeks impulsively to intervene through increased spending and more regulation. This strategy ignores the fact that shortages and high prices are often the result of excessive and unwise Government Action in the first place. It shows up all the time in the case of overregulation, difficult to get approval, sometimes needlessly so. There are fewer and fewer competitors. Its a natural barrier to entry. Sometimes it comes about in the form of price controls, take the Inflation Reduction Act for example which seeks to impose price controls on certain pharmaceuticals. The Congressional Budget Office, the nonpartisan entity that we hire to perform analyses like this predicted that this would result in 15 fewer new drugs being launched over the next 30 years. Experts are increasingly warning that this policy will exacerbate shortages. Instead of increasing spending and imposing mandates and engaging in more aggressive regulatory actions. In many instances Congress Needs to buckle down and focus on addressing the excessive Government Intervention problem, dealing with the regulatory stranglehold that exists. I would like to talk about two pieces of legislation that i have introduced to address those regulations the prevent these Innovative New treatments from coming forward and lower cost drugs from coming to market. Recently i introduced s 2305, bio similar red tape a limitation act, this is a bipartisan bill i filed alongside my colleagues, senator braun and vance. The bill would align line the uss bio Similar Program along with the rest of the developed world by getting rid of the arbitrary, unwise and unnecessary distinction between approved bio similars and interchangeable bio similars. Bio similars is a word we use that is essentially the functional equivalent of generics for complex biological drugs. The us is the only country that has these two tiers of approval, approval and interchangeability. Congress created the interchange. Designation and im concerned there might be a risk of switching from one biologic to its bio similar and they might not function the same way. And might cause problems what those concerns have not been borne out empirically. The science doesnt back them up. What we gain from the distinction is next to nothing and what we lose is significant. A lot of voices in the Scientific Community argue the initial approval of a bio similar is sufficient to establish the bio similar is interchangeable with its referenced product. Moreover the interchangeability designation confused states, patients, doctors and those who work with them by signaling bio similars are significantly different from their reference product. This makes it less likely that they will be available for use or be used as substitutes and the availability and use of substitutes brings down costs and so interchangeability does raise cost because bio similars would otherwise provide muchneeded competition for biologics. Biologic drugs make up 46 of us Prescription Drug spending, despite making up less than one half of one of all prescriptions, 1. 4 . When you talk about the high cost of drugs we are often really talking about biologics even though they are a tiny share of the overall picture. The bill would increase bio similar competition by declaring that all bio similars upon initial approval shall be deemed interchangeable. The fdas subject Matter Experts that communicate to my office, that the bill would align, the bio Similar Program of current Scientific Understanding and improved bio similar approval, Bipartisan Legislation will help usher in greater bio similar competition thus reducing prices and benefit all patients including and especially those with type i diabetes who are for the rest of their lives dependent on insulin. Another way to support type one diabetes is by exporting ways the current regulations simply dont make sense for innovative treatments. Treatments of this sort that could actually bring about functional your for the disease or something approaching that. When we just throw money at Government Program sometimes we incentivize the status quo, lock in existing technology, to use an analogy, if we had done that in music listening devices we might still be stuck in the 8 track tape world, something most people in this room probably dont even remember. We dont want to do that with healthcare especially in an area like the treatment of type i diabetes where technological advances are so important i was joined by senators bud and blackburn in introducing the increased support for lifesaving and a and treatment act. They are these micro organs inside the pancreas that produce insulin. Patients with type i diabetes dont have a normally functioning pancreatic pilot cells. We are not sure why, but they stop working, theres an autoimmune condition that attacks the healthy pancreatic islets, killed the more causes them to be nonfunctional, so they routinely require these insulin injections. These Treatment Options are important but they can become burdensome and expensive and cause the patient constantly to have to chase between highs and lows which is its own form of hell. Thankfully we do have other options and possibilities, scientists have found ways to take pancreatic islet cells from deceased donors and transplant them into the bodies of patients with type one diabetes. Some patients who receive these procedures have been able to go years without any insulin injections or any type of continuous Glucose Monitoring but regulations have squashed the procedure, made it almost impossible. Rather than regulating organs, hhs and fda have regulated islets as drugs since 1993 despite the fact that other countries appropriately regulate islets as organs and not as drugs. We have to take care of this. We have to fix this problem and i have serious concerns about the fdas recent action, the fda approved drug for this treatment but rather than going the route proposed by the islet act, im out of time, wish i could have more time to do this but i do want to know eventually from the fda, how do you decide to approve the products biological licensing application is a drug especially since one of their previous reports of the agency couldnt assure the products attributes correlate with clinical outcomes and how will this decision impact access to islet transplantation, would such procedures be more affordable and accessible if they were regulated as organs . The answer is almost certainly yes. The fda has a lot to answer for this and encompass other areas, they are needlessly making this disease more expensive, more deadly, more longlasting simply because of their own regulatory malfeasance, thank you. Thank you for convening this, greatly appreciate it, thank you for being here. I thought i knew about diabetes, ive learned so much this one. I want to one add one factoid from our last Economic Committee meeting when Mick Mulvaney who used to chair the office of budget management, talking about how much of the medicare budget spent on dialysis, the number he came up with was 30 one . One . 250 billion a year of taxpayer money spent on dialysis. Senator lee talked about not incentivizing the status quo, appropriate comment, the agriculture, 5year farm bill right now. The farm bill in trenches food policy in a way that subsidizes commodity crops, our current rather than working on ensuring what is produced, we are denying the nutritious greens we need to do. We are good at making corn cheap and sugar cheap and that gives us a Food Industry specializing in making highly processed foods but the education intervention that will keep us from continuing to provide type 2 diabetes. We need to be concerned about unintentionally structuring a farm system at the federal level that supports the kind of obesity. If you look at the rest of the farm bill you have snap and with, supplement alliteration Systems Program that produces severe Food Insecurity between 12, and 19 . It is Food Insecurity and inadequate nutrition missus brown friday pointed out, the lower the income the more likely you are to get diabetes, the hiring, the better the food, the less likely. We are struggling with a budget where they are talking about funding for 2024 for the snap program at a level of 2,007, rolling it back decades. Same with the wic program, cut by 8 million which which is 5 million women and children losing food and vegetable vouchers. We need to look hard at the farm bill in the light of the diabetes challenge we are facing now. Miss brown friday talk about food deserts. Thank you. When it comes to food deserts, how big a challenge is it for you with the navajos who live on the reservation and off . In terms of the ability to get the healthy food . Thank you. Congressman. When it comes to food and having grown up myself, the nearest grocery was 75 miles, so in order to get to a walmart you had to go 75 miles where i grew up from and most of the time the nearest grocery store, the local trading post, the local gas station, all this, a speedway or st. Clair or whatever the gas station is, most of the time, candy, food, chips, things that are normally for people headed to a certain direction. I know one of the things, that is why we imposed a tax on junk food to encourage Grocery Stores and gas stations to at least carry some fresh fruit, fresh vegetables and things like that but when you are in remote locations like navajo, it is difficult to get access to quality foods. That is the landscape of the Navajo Nation, you can go one hour, two hours and the only thing you will find is gas stations. The location of more stores that offer farm goods would be great. On navajo, we are trying to encourage more of our people to be farmers, to utilize the water, go back to jude traditional practices because overall when it comes to being able to farm and sell foods and groceries, that is a way, as president , im trying to encourage our people to do that but regular Grocery Stores are hard to find. Miss brown friday, so much debate has been about Health Insurance and access to Health Insurance. Can you talk from your perspective why Health Insurance is critical for people with diabetes especially we talked about cgms, continuous glucose monitors, how do you get a cgm without Health Insurance . Thank you so much. I would say it is basically impossible to get a cgm without Health Insurance because most people who are uninsured do not, cannot afford the cost of a cgm. And all the supplies that go with it. So therefore the American Diabetes association is supporting people having better access to Health Insurance, easier access to Health Insurance, so they can afford the medications and instruments and technology that can help them have a better life with relation to their diabetes. Thank you very much. Doctor herman. Im excited about the impact they are having, but i agree with you that we cant just think about taking a pill. Are you concerned about the downside of the latest reports of stomach paralysis . How are we balancing the negative side effects . That is a really important question and it is quite clear many patients the take them experience castro intentional gastrointestinal side effect about the transit of food to the g. I. Tract and a combination of constipation, diarrhea, abdominal distention. We put together an algorithm to try to avoid some of those side effects. Most people if they continue those maddock medications, tolerate them with some of the side effects that could go away with time. Those side effects do not seem to be permanent or persistent. Some cant tolerate the medications because of these side effects and choose not to continue them and we move to other options. The majority of patients tolerate these medications. The other aspect of your question, what are the longterm adverse effects . To date weve not identified significant longterm adverse effects related to that. They are clearly in large clinical studies reducing the use of insulin, reducing cardiovascular events and mortality. They are saving lives. Weve not identified consequences at this point. Nearly 300 billion diabetes currently accounts for onefourth of all u. S. Healthcare spending. The Congressional Budget Office has identified options to reagan because. Many of these could be harmful to our seniors. Already suffered from inflation to promising new drugs and medical devices such as glp1, pacific, and continuous Glucose Monitoring service should play a role in reducing the risks diabetics face and lower cost of both individual finances and the federal government. However, other innovations are happening in the healthcare space to treat diabetes, obesity and other diet related diseases so give people can live longer, healthier and happy lives one of these innovations is medical nutrition therapy, provided by the nutritionist with the goal of assisting a patient to foods, manage behavioral changes. In a nationwide representative study a Large Health Care provider showed 130 per member, per month savings orderly 1600 per year from giving members over 65 access to this type of nutrition guidance. But today in medicare only diabetes and renal disease are covered while obesity prediabetes and other chronic illnesses which lead to diabetes related to poor nutrition is not. Yet if you look at the private payer space and medicaid we are seeing mnt coupled with the tools to stretch food dollars in ways that allow them to meet their diet cultural religious needs saving cost to patients and say the cost of the system and improving Health Outcomes here my staff recently met with a company that works with private payers Medicare Advantage plans and medicaid mcos to deliver tele Nutrition Services to patients and they have data that shows mnt patients lose an average between four to 6. 5 of their weight to continue losing weight after your two due to behavioral changes. Should congress pressed entities like the Congressional Budget Office to review this data to help us understand how we can leverage nutritional programs as a strategy to provide relief to those at risk of diabetes as well to taxpayers continually paying for it . Short answer is medicare could use any budget help they can get so if youve got a proposal that could save money event certainly seems like something we should look at. Anyone else want to chime in before i moved to my next point . During my time at congress ive been advocating and pushing to require at least in part or incentivized s. N. A. P. Recipients to purchase Healthy Foods. I enjoyed congressman garbarino in new york to end banner purchasing prepared hot foods with s. N. A. P. Which would be a big step. Dr. Herman, how with these reforms of the s. N. A. P. Program affect the rates of obesity and diabetes on the recipient and do you believe this will play a role in reducing Government Spending on obesity related chronic conditions . Excellent question. I have to say im not an economist or an epidemiologist so the impact of changing policy on spending a foot outside of my expertise but i would say that lifestyle management is always a part of diabetes and obesity care and is demonstrating medicine spirit i guess at the end of the day the real question is will it help people improve their health . Will it lead to healthier options for americans who are s. N. A. P. Recipients so they can make these choices . To not allow for repairs or hot food is a mistake that probably pushes people into a different direction or some of these preserved foods and stuff like that to anybody else like to respond . Yes. I would say that anytime anyone has opportunity to have a healthier diet i think it would be able to take advantage of it. And i think with the programs you were proposing that even start at younger age, the younger you start, the younger you are exposed to healthier foods the more likely you are to continue that into adulthood and prevention i think is really the key. I think that prevention of obesity is definitely something that can be beneficial. Thank you both. Thank you. Is more desperate ms. Moore. Thank thank you so much o thank the panel for being here today. I was caught up on the other dude so i was late but i was listening to a lot of your testimony before i arrived and i was intrigued, dr. Brown friday, by some of your testimony that talked about diabetes, the onset of diabetes starting at younger ages, and not juvenile diabetes but type two diabetes. And do you attribute that to the junk foods and stuff that mr. Nygren, for example, is talked about . To what to we attribute that . First i want to make a correction to im not a doctor spirit will case the other registered nurse by profession. Thats good. Very proud to be one appeared so in terms of type two diabetes starting at younger ages this is something that is been a concern for the medical community and the American Diabetes association for quite a while. I definitely agree with mr. Nygren that the availability of Healthy Foods and having it closed availability, fast foods, not just for dr. Nygren, and for me who works in the bronx its access to mcdonalds and other Fast Food Companies where it says hire fat in the foods and younger people are not like if it once youre interested at a younger age to healthier foods, the more likely you are to have those foods with your old spirit so its sort of counterintuitive for us to be cutting fruits and vegetables from the wic formulary as an example and upping things like cheese as part of the formulary for which peer it just doesnt make any sense if we are trying to curb the cost of diabetes to be cutting fruits and vegetables out of which. Thats my statement. I wont make you say it. I am intrigued by the disproportionate presence of diabetes in black, native americans and latino communities. I guess dr. Herman theres no sort of genetic proof that these folks are disproportionately susceptible to enduring diabetes. What would you say, how do you explain the disproportionate onset of diabetes in these populations . Thats really an excellent question, and i dont know the answer to that question. I will say there are many investigators out there looking at the question specifically. What we do know is that, is that obesity and diabetes and all populations, is an interaction between genetic background and environmental exposure. And that includes diet and exercise and all sorts of things. And so if there is an increase in prevalence of obesity diabetes and one population into some combination of a change in their environment, interacting with their genetics which has not changed over decades thats producing that outcome. And takes intensive research to identify within specific populations with the specific factors are but there are many scientists and physicians out there searching for the interest within specific populations at this point. Thank you so much. Your testimony, i think ms. Brownfriday made the testimony that 85 of people who have diabetes are obese, overweight this is one of the reasons im so happy that i have reintroduced a bill called the treatment reduce obesity act. I think it will give us some Great Results with regard to standing one of the causes, one of the present features of diabetes. I want to ask president nygren, the nations in my state of wisconsin have taken on a culturally relevant project to use sort of data foods to stem the tide of diabetes. Can you describe what you all are doing in the Navajo Nation to include culturally relevant foods . Congresswoman, thank you for that question. Very happy to hear that our other tribal communities are doing that, and on behalf of the Navajo Nation one of the things were doing is walking and running thats been very part of our culture, and at the same time introducing them to foods such as fruits and vegetables at all of our events along with like almonds and thats the things like that that really help and promote a Healthy Lifestyle pick one of the things weve always done is we take the ihs best practices try to focus on one of them for the year so we can do that and educate our people of that period so we really had taken an approach we invite the people out to the events and then they do a walk, around or we educate them on foods. But as far as farming we are trying to reintroduce farley because navajo people had been farmers for a involved time. Its just a lot easier to drive a couple hundred miles and get a bag of groceries that you actually do the work and to produce Healthy Foods thats something were really working on, congresswoman. My time is waiting for someone to get another question in with dr. Brownfriday. Didnt understand why the continuous glucose monitor is not available to a low income people is that softly that is not authorized by medicare, or what are the dynamics in terms of getting these continuous glucose monitors available to low income people . Unfortunately, i am not an expert in medicare and so what i would have to say is that in general what i have heard from patients is that their insurance will not cover the costs of utilizing the continuous glucose monitor if their blood sugars are not at a certain rate or if theyre not taking a certain number of injectable medications. And so, therefore, those are the things that are regulating the bureaucracy is stopping us from saving money. I will yield back to you, mr. Chairman. Were going to talk about that because theres been a crash in the price of the units and some new products have just come to the market within the last six weeks. Dr. Ferguson spirit thank you vice chairman to i want to thank you and thank you all for hosting this into the witnesses thank you for your time, your presence here matters and wevee learned a lot so thank you for taking time out of your schedules to help educate us. I want to start my comments by saying that i truly believe that diabetes is probably the coolest and most underrated disease in america there are a lot of other things that get a lot of attention and glad to see that this body is stepping up and focusing on this. Because it is such a long debilitating process many times we tend to ignore because we dont see the rapid decline of someone. So this is important so thank you for being here. I was a practicing dentist for 25 years i saw the oral effects of this week in and week out in my practice but it also saw the systemic effects and viability to treat patients was, if they had diabetes, was greatly restricted, how they responded to care, how to respond to infections, how other bodies respond to antibiotics all played a role in the Overall Health. I want to focus on something that this committee, some of the questions have already started to go to because president nygren your comments about what youre doing in terms of food is really important. But i want to start with dr. Herman. If you go back and look at the last, i dont know, 40, 50, 60, 80 years, when did we really see the explosion of the exponential growth and diabetes within varioUs Populations . Whats sort of the timeline and how is that accelerated . I think a dramatic increase in prevalence began largely in the 70s, both obesity and paralleled my diabetes, those both dramatically increased at that point. I think the increase has been pretty consistent since the 70s. When we look at things that are changed from a policy standpoint, and this may be a question for anybody on this panel as well that may have a better history on this that i do. What in the early 70s changed our food supply . What did we begin to prioritize . And what was the biggest part of that . It was calories, right . So when we started to value calories over quality nutrition, that we set this thing in motion. When i first started my dental practice in 1992, i could tell the difference in kids that grew up in the country on well water and kids that grew up in the city limits that grew up on fluoridated water because their oral health was dramatically affected because the kids that grew up on well water had just come with they were ravished by cavities of your income didnt matter, okay . Kids that grew up in the city on fluoridated water again because without regard income they have much Better Health outcomes. As i went through 20 years of practice i could no longer distinguish between the two of them. The commonly that i saw in this was the food supply in the increase in sugar in our food supply in every form of refined carbohydrates. I think weve got to date, i think we got to be very focused on our food supply. We can talk about spending the money on s. N. A. P. Listen, i get i think cutting fruits and vegetables out of nutrition programs is absolutely lunacy. But i also think that funding, allowing folks to buy high sugar content foods is light say were going to pay somebody to keep smoking while they get lung cancer care i dont mean to equate the two of us be smart about what we are doing here. President nygren, wherein the all done the work and you talked about the success that you had, that when you all desperate other than money whats most important thing you think of, do you think we should be doing as a government in terms of nutritional aspect of what your program, your programs are focusing on . Thank you, congressman. One of the most important things as you mentioned is being able to tailor the nutrition and the programs to navajo people and the different types across the country which is important because every tribal tres different there there is different foods and exercises and ceremonies that they used throughout their history but if we can continue to tailor that because under over the past 20 years or the past decade when weve been able to tailor it more towards a more moree navajo foods come forth navajo type exercises, the actual specifics have gone down because we were able to tailor it to work with the existing dollars that we have been getting and its been very helpful so i think that when we continue to think about the groups specifically to the needs then its a lot easier. Because i applaud navajo as i mentioned earlier its very remote and rural but theres so much access to processed foods that theres not enough options that people can have more access to. I think education is very critical in that part so thank you expert look, we shouldnt try to make this a one, make a false choice year of either addressing the food supply or continue to innovate. Its going to take both of these things in my humble opinion. Ms. Brownfriday, just a comment, and again i practice in the rural area. My hometown was about 64 africanamerican. It was and again i saw this on a very regular basis. Talk about access to health care and access to Health Insurance. I want us to move because i truly believe that americans have access to some type of health care whether its medicaid, whether its private insurance, whether its care on the exchange. I want us to really focus on the utilization, because i can tell you in my practice, patient had access to care here it was the utilization of the system. And all too often, and be candid with you, what we saw is too many of our fellow americans live in poverty and they live in the crisis of the moment, and the preventive axis of health care in the early access many times takes a backseat to a plethora of other emergencies that are going on in somebodys week of any given time. Ms. Brownfriday, i dont mean to lecture you on this, please note, please dont take that help us talk more about the utilization of the system in addition to making sure that people have access to care. And with that, mr. Vice chairman ideal doctor paige again for hosting this. Senator kelly. Thank you, mr. Chairman. I thank you all for being here today to discuss this critical issue that faces too Many Americans. That kerry not only physical but also medical effects or families but also high costs for folks that live with diabetes. And president nygren, great to see you here. Good to see you again. And thanks for being such an important voice on this issue. I spent a good amount of time on the Navajo Nation and under all the index and diabetes has on our tribal communities. Weve got 22 tribes in the state, and this disease has dire consequences. There are a lot of individuals that are suffering from this, and many are members of your tribe and the other tribes. And i know endo youve wd to impress upon the federal government the importance of the special Diabetes Program for indians. Could you talk a little bit more indepth about that, the impact it is set on the Navajo Nation and tell us why its so important that congress reauthorize this program before it expires at the end of september and what are the consequences if we do not reauthorize it . Thank you. That you senator kelly. Always happy when you spent some time out in our communities and other communities across the state of arizona. What are the effects it has had is just, recent statistics here, for the first time diabetes prevalence in American Indian has decreased and a stencil consistently for four years dropping 15. 4 from 2013, from 2013 to 2017. Just a decrease in diabetes prevalence was great through the sdp i program also diabetes related mortality has decreased from about 37 during those times per again these are some of the stats pick the key thing is is decreasing. Whatever the percentage is that this program is working and were really trying, its very unique theres over 300 communities that it is serving across the country but i know theres about a dozen that is tailored to the Navajo Nation but overall i think its critical because were trying to make sure we can continue to have Healthy People in our communities so they can thrive at for it to be renewed which is coming up very soon and i think both houses, both the senate and the house has uprooted from 170 million through their committees here and really thats 20 million more than the 150 we were initially getting and that 150 has been consistent for 20 years so this 20 million as a good amount of increase to really help us get some of those programs out there implemented right away because its critical in terms of not every Indian Country is the same, but the tailored approach of the partnership we have been able to develop through this program has really helped us. I only see pictures of our elders. They were slimmer, faster, they look very healthy a lot of the time. So when you look through history, as the president i have access to historical photos of things like that that i look at is within our communities were farmers, ranchers, they were gardeners, and you just look at how healthy some of these people looked through history and then you look at the people now, its very sad to see that we have come from very selfdetermined, self resilient people to people that are just really trying to fight for the lights on a daily basis. So again i think this program is critical and i definitely would continue to urge both the house and senate to approve this so thank you. What would happen if we didnt reauthorize it . For the navajo, all of Indian Country would lose about, they would lose staff. They would lose a program. They would lose the people. Whats the consequences of that would be here i think we do with the consequences are. I think you would lose a lot more people to diabetes. People would die pure and probably insignificant numbers. Significant a scheduled also of other people would lose hope and faith and it would just be very i think it would just make a lot of hearts because not only are you looking at communities that are already in dire poverty levels that you would put them in even tougher situations. Folks, some cant even come for seniors insulin is now capped at 35 a month and for some other individuals the pharmaceutical companies have provided insulin at 35 a month but that could still be very hard to afford for members of the Navajo Nation which is one of the poorest berries of the country. That is true for the other tribal communities in the state of arizona and across the nation. Its critical that we reauthorize this program in september. Thank you. Thank you, mr. Chairman. This has been a fascinating discussion. I think its very important that we hold this hearing. Obviously as the chairman has said previously, this is a drive of our Health Care Costs that will impact our future, expenditures are future debt but its also as he is fully aware, it affects so the other areas appear it affects the ability for individuals to lift themselves out of poverty by taking a great job. The workforce Participation Rate that is so critical for us to grow an economy and it affects the everyday ability of individuals to live their lives to the fullest. And i think theres a lot of things we could do for our constituents but it somehow diabetes could be solved it would have a dramatic impact, perhaps more impact our constituents and anything else we could possibly do. By the way, the same thing could be said for Heart Disease, for cancer and for alzheimers. All of these are drivers of all these conditions including our expenditures, including impact on peoples lives. Its been a great discussion i agree with so much with what has been said here i agree with senator lee that we should create a system that promotes additional private investment, private innovation to help, to help to develop new solutions for treatment. But i also agree with others who have talked about the Government Role in this. I have always supported investment in nih funding, which is very, very important to drive, to drive the Underlying Research and development that leads to some of those innovations. An event like it or not i think the government has for a long time been engaged through the choices, the incentives may be is a better way to put it, the incentives that weve had in the system regarding nutrition, regarding the food that people eat we have been food pyramids with recommendations. Weve done school lunches, recommendations are there, and then weve done we d, the farm bill. All of these help to lead to decisions that folks are making about their own lifestyle, about their own nutrition, exercise and so on. So we are in this like it or not. So we ought to be looking not only at the opportunities for additional new treatments that we could help to ensure that the right conditions are there for those to develop but we ought to be incentivizing the right human behaviors to prevent the disease to the extent that we can help that individuals can prevent into first place for the first question i have, doctor herbert, id like to get your thoughts. We talked about the lake between obesity and diabetes but we talked about the link from the early 70s of that icon that what we have promoted. How much of diabetes is related to these lifestyle choices that individuals make . If you had come just imagine for a minute that people are eating healthy, exercising, doing the things that we know are good lifestyle choices how much of diabetes would we do away with if that were the case . Thank you for the question. Actually an excellent question. It is quite clear that a significant proportion of type two diabetes is the direct result of obesity. And its also clear that some lifestyle choices put into the development of obesity and diabetes in that path. Its hard to quantify how much of the lifestyle, which composed of livestock or other environmental factors are specific factors that have led to this epidemic. And so theres convinced a lot of controversy around what are the specific nutritional component or combination of nutrients, in what fashion are they presented that leads to obesity per se and diabetes yet its clear that is a major component spur its hard to nail down at about does anybody else want to take a stab at that . I know president nygren when you talked about the importance of program that encourage exercise your does anybody else want to take a stab at how much we could resolve if people were making the right choices and that access to the right nutrition . Again, as president one of the things, at the Navajo Nation, ive noticed, thank you, actually, with people get out there they are really enjoying these walks in the resident opportunity to educate themselves on Healthy Foods, healthy diets, Healthy Lifestyles. Ive seen a lot of people change, turned around and they tell the the president , thit i looked like a couple years ago, and now ive been attending these events that are big hosted and sponsored by this program and will try to get reauthorized, and really to me it helps, it helps dramatically that i dont know the percentage or the numbers but i think that its better, it would definitely decrease and i think overall Mental Health, depression, diabetes i think it really just helps a person overall if they can eat healthier and participate in exercise. In my community its been working. I dont know, go ahead. I think that you set a very key thing you. I think the availability of Healthy Foods is really a very big key access. You said lets imagine everybody is eating healthy but thats not the case. Everyone doesnt have Healthy Foods available to them, or they cannot afford the Healthy Foods that are out there. I think thats one of, thats the key way to think about that i think definitely as president nygren was saying, which people are introduced to things and introduce to healthier lifestyles and healthier ways to really do want to take advantage of it or im not saying its 100 obviously but i think that is for the most part and those who have worked with those that introduce healthier lifestyles to lifestyle change programs have embraced it and it made significant changes. But again its accessed. If i could follow up i couldnt agree more with that by the way. We dont maybe do the exact amount but dramatic impact we i think all would agree with that. I think this is a wonderful discussion to have in regards to how we can ensure that new treatments have been developed but i think windows to spend a lot of time figuring out how Government Programs today are incentivizings bad nutritional choices. Im talking about the s. N. A. P. Program. On talking about the farm bill. We subsidize a lot of Agricultural Development as well, a lot of farming and we ought to be thinking about how we can ensure that we are educated, we are encouraging people to make the right choices and that access is a critical. And i completely agree, these are discussions we really should be having to help to ensure that people have access to be able to make the right choices and know what those choices should be correct thank you so much for holding this hearing its been a great discussion. To my good friend peter. Thank you. Its very good to be with my colleagues from the house. The two issues that weve been talking about, everyone seems to be focusing on arbitration and exercise, right . If you get diabetes you get into the incredible medical challenges that folks face. I am interested in what are the policies but its tough to get good food. Dr. Ferguson left and he was talking about how being poor is a hard job. Its a fulltime occupation just to try to figure out how to get from here to there. You might have to take three buses. As opposed to just get in your car and go. You have to try to figure out where you can get something that is affordable for you which is is it best to start the most nutritious. I just interested in maybe hearing from each of you what i like the two things that could be done to try to help folks who are really low income and struggling with a lot of the everyday challenges, trying to make things work . What could be to policies that can help both with nutrition and making exercise available . Dr. Herman, start with you. So in terms of exercise, the things we do with every patient we see is start with simple things, which is suggest try to get 10,000 steps a day. These are things that, that cut across social economic , that are shown to be beneficial and it speed is 10,000 steps. Yes. How are you doing today . I probably about a quarter of the way there today paired. The rest of the folks in the pan are better experts to always one thing that is important for all of these policies which is the function to insurance he always have to be very careful that we dont allow Interest Companies to use policies that really are sort of nominally designed to be helping people to be healthy but is it really just risk selected for try to track Healthy People of your insurance but so whatever the specific policy i would like that is one consideration to keep in mind. Ms. Brownfriday, you do underground with lots of folks spread i do deal with a lot of folks and i think access as ive been mentioning multiple times to board nutrition, nutritious foods, more vegetables in both rural and urban areas, as well as safe areas for people to exercise. Thats also, building infrastructure, having a park or assisting people who might want to go to a gym to pay for that so that they get accident in the safe environment. The thing that i found about exercise, the more easy it is to do, integrate into what have you taken your day is different n my day. How do you find a way within your day . And anybody stay for them to get the exercise and if they have to go to a gym thats a project. Well like it it doesnt have to be going to a gym. Having a safe place in your neighborhood that i do have these conversations with some patients appear you have a safe place to walk. Or can you just walk up and down the stairs me personally i get up at 5 30 a. M. I cant talk to everyone. Thank you. With the gentleman yield . Sure. What about these medications and behavior modifications, medications like ozempic i think is a name of one of them. What about that as an intervention . Dr. Herman, anybody . Sure. So it is clear that medications like ozempic in that class of medication, they are very effective in helping people suppress their appetite and reduce their caloric intake and lose weight. And they have not been approached as kind of, you know, what with their impact be if used widely as a preventative measure but i think its probably a matter of time before, its a matter of time before folks like yourself begin to think about utilizing interventions like that in that way from a Public Policy perspective. I yield back to the gentlema gentleman. President nygren . Thank you, congressman. One of the things i think about is trying to start early for our young kids because on navajo a lot of reservation theres not a lot of parks come not a lot of playgrounds and not a lot of places to play basketball or any sports activities. One way for us to do is probably to create those parts and facilities for kids while they were younger they can learn how to exercise, that as adults to have these facilities open to them because they are on, at t of reservations a lot of these things are funded by the government closed off, only open from eight to five and in the air close at the afterschool and people who have Left High School dont have access to go and exercise. Thank you very much but i yield back. I do think it got around to saying congratulations. Were going to try to do i know a house coded insult when i hear its. [laughter] yeah, i was heading in that direction. All right. I saved myself for last because for some my colleagues here, this is a fixation for me. And from the start on the economics. Ive heard a number of you say 25 or i can actually show you really well peerreviewed numbers is 33 33 of all hh care spending of 33 of medicare spending is functionally related to diabetes period i hope everyone will get a chance to read the republican joint economic report chapter three. We went to a place very uncomfortable for some but we looked at diabetes and obesity in society, and its both cost, its more cost, its potential effect on clothing. Care a lot about this so let me instead of proving what an idiot i am i just talking, we over and over and over and over have this discussion, changes in the farm bill, access to the technology, the new over the skin blood glucose. Underwood got released a couple days ago, just a wristband that works number three, the adoption of some other gop wines for those who particularly in the morbid categories or those who have type two diabetes, particularly now that when they have the oral single shot which assassinated which may be making it through fda. And never formulated by the end of the decade for our brothers and assisters that succeeded in getting the weight down but ive seen some data for the sata 30 of that population which have type two diabetes the body will not produce by itself appear theres some of the new stem cell, duchess cadaver bleaching model but actually some of the ones that are in type without look like they have high efficacy. May be this path over the ten years of a radical change in diabetes in our society, and our math is that five or 6 trillion spent in the ten years. Its real money and it may be one half we have for our brothers and assisters on the left and those of us on the right might agree on something. Lets go down tell me where im right. No, who were on wrong. Unwilling to take the meetings. I think youre right. [inaudible] so i need ill just say this from the perspective of a physician has been treating these condition for a couple of decades, the last decade has been a revelation with the new technology in these new medications. We have things to offer patients for the first time that are incredibly effective for conditions that were previously very difficult to treat. The options seem to be improving. And so im very optimistic about the possibilities over the next ten years and applying these medications and technologies more widely. Ill highlight perhaps the piece of optimism on the cost side we often see Transformational Development in the pharmaceutical market or devices that are widely e dont have that here. We have classes with lots of different products coming to market that have different benefits and costs of course but thats beneficial in the short term because major competition to get full delays come price competition that you dont always get debbie on that you as the patient, you have four options to choose from but you can choose whats best for you but also i will highlight ten year budget windows i understand focus for you guys but when you think about the cost of drugs and technologies you have to think longer term. You got huge savings when things come off of patents which happens there are some gops almost at the end of the cycle. Right that fsr tapley is not just that those prices go down, it puts more pressure remaining on Brand Products to compete with those offBrand Products to signal a focal point of the cost side and immediately quite as devastating as some other projections are. Ms. Brownfriday. From my perspective i would say that im very thankful and hopeful that all the innovations do come to pass and that is available to everybody. I want to say also that in terms of cost, insulin was always extremely expensive pier and it became expensive due to whatever the situation came ashley. Look, weve had a fixation on the coop thats about 70 miles from here, not too far from where you are, that actually is also producing even lower than the subsidized price but the revolution is here. I do have additives concern though that it be available for all populations. I agree with you. If indeed it is. And Navajo Nation, you know, ive been blessed as a young man i spent lots of time in the community, and most of who have never been there dont understand. There is rural and then theres the Navajo Nation. And you actually have a really tricky job because lets be honest, living there is different than some of the chapter houses at the border. But ive been incredibly helpful with your leadership. What can we do, if my fantasy is a change of the farm bill, access to the blood glucose type of management so you can see your macro to sort of understand your diet and maybe living on fried bread, even though it is delicious, difficult, forgiving for the cultural reference, what else can they do other than just funding and of the program . Is that revolution something we can actually deliver to the navajo people . One of the things, im glad that you brought that up, because even like with broadband, trying to bring it up to that level, starlight, noble waiting another 25 years from wire to go to that chapter after put up the damn satellite picked sorry. If we go down that route, some form of some of the latest technology thats coming out, it would be great to implement it within the program so it is being staged instead of later down the road i think having that better coordination accessibly get out to the main facilities out there, i think that would be a key thing is communicating with the federal partners in the nation and be able to have our people have access to the latest and greatest. A derivative everywhere mr. Beyer had asked a question to unblessed represent salt river maricopa it ended my whole life next to that community. Its an economically Stable Community being that close, its an urban tried, and yet i see some data this is it may be the second highest per capita diabetic population in the world. Their sister tried may be number one. So sometimes its more complex than just saying its poverty. It turns out time, as some have said, sometimes its our need for convenience and those things, and thats why for those of you who actually also have the microphone and the credibility for what you all do, help those of us who care passionately to tell the story maybe it is time for revolution and what we do in the farm bill picked may be just going to say five commodity crops with north american musical 3300 types of grain. Functionality so you dont have to process the process to make profit or number to the new technology. Im dying for the apple watch that will actually have glucose and which im telling desperate it might be two generations away so i just might my samsung. Im glad someone got that joke. But the gop wives, every day and reading one. Prices are crashing really here and there may be some that are out of exploration entered maybe the crazy thing is we buy the last 18 months and use that for medicare, medicaid any Dell Services p. A. Populations because the savings is remarkable. I mean, sometimes those of us who are on the right sound cruel because were talking about the dollars and cents that dont talk about the reality of peoples lives and their ability to participate in society and income inequality that Health Differential causes. But the four of you actually on the cusp of the thing that may be the one point we can come if we could build a unified theater here that could have an amazing effect on u. S. Sovereign debt and economic growth, but it cant do what a lot of here do which is we talk about the one thing we know of eating onion rings are fried bread have you ever had navajo taco . I will explain later. In the last part here i need to give myself, this is a danger of being unscripted, i owe a thank you to the democrat staff and the republican staff thank you for actually communicating with each other on this. This is one where the solution is great economics and wonderful morality. Help us tell the story. The last bit i will give you is if any of you have things you want us to read, we are not walking away from this. This is almost the only path that to dramatically change the direction of the society right now. Send it to us and will continue to evangelize it here and there for all of you, you have i think it is another, how count hy days to be able to send additional for the record . Three. Three days . The house we do a lot more pic if you have other documents that you would like us to put into the public record, please send it our way. Please do it within three days but it is dependent on the fourth day i will still put it into and with that, we call the hearing adjourned. Thank you for participating. [inaudible conversations] [inaudible conversations]