Please come to order. We have a vote at 11 45 but that should leave us an opportunity to hear from our witnesses and have good time for questions. I told our witnesses that i was to d lited to be talking about something other than the individual Health Insurance market. And im really quite serious about that because we know that the larger issues in health care are much more than the 6 of the people whom have to buy their Health Insurance in the individual Health Insurance market. So were glad to have this discussion and a subject on which both republicans and democrats have a lot of interest and we look forward to your advice. Today were holding a hearing to look at what can be done to encourage people to make healthier lifestyle choices to help prevent serious illnesses and reduce Health Care Costs. Senator murray and i will each have an Opening Statement and then well introduce the witnesses. After the witnesses team, senators will each have five minutes of questions. Let me say i want to thank senator murray for her leadership and being a straight forward negotiating partner on our efforts to present to the senate a limited bipartisan bill during 2018 and 19. She and i will go to to the senate floor todayali alitt 1 0 make a brief statement and put the text of the legislation in the congressional records. The senders can examine it. Well also list a significant number of republican and Democratic Co sponsors for the legislation. And our hope is that now that weve put a proposal on the table that the senate will consider it and 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. And said he looked forward to considering it. I said if you have suggestions for improving it, thats certainbly your puraugative to do and thats what we would expect in the legislative process. So i thank senator murray and other members of the committee that have been involved in it. Over the last seven years weve endured this political stalemate over the Affordable Care act with much of the disagreement being over very small part of the Health Insurance market where 6 of americans buy their insurance. Our stalemate has really been over all of health care. The fact that weve had that stalemate makes this even more refreshingi to talk about. An area of health care on which doctors, republicans, democrats agree. That consensus is that a Healthy Lifestyle leads to longer and better lives and are edeuces the Nations Health care costs. According to the centers for medicaid and medicare services, Health Care Spending in the United States has grown from consuming 9 of the Gross Domestic Product in 1980 to nearly 18 or 3. 2 trillion in 2015 and predicted 20 in 2025. Cleveland clinic, which is represented by one of our Witnesses Today has said if you achieve at least four of six normal measures of good health and two behaviors youll avoid chronic disease about 80 of the time. The six indicators of good health are familiar, Blood Pressure, cholesterol level, body mass index, smoking status and your ability to fulfill the physical requirements of your job. Two behaviors are seeing your primary care physician regularly and keeping immunizations up to date. If you had had four of the six and keep up the two behaviors, according to the Cleveland Clinic, youll avoid chronic diseases 80 of the time. This is important because we spend more than 84 of our Health Care Costs, our 2. 6 trillion treating chronic diseases. Thats something on which almost everyone agrees. So lets add to that another obvious fact. About 60 of americans get their Health Insurance on the job. So if we really want to focus on improving health care in america, why not connect the consensus of wellness to 178 million americans get from their job. Thats precisely what the Affordable Care act sought to do in 2010. Its one of the only areas everybody seemed to agree on. Todays hearing is how successful wellness initiatives have been. And what we can do to encourage people to live healthier lives and reduce Health Care Costs. Many employers have reduced Wellness Programs. These programs may reward behaviors such as exercising, quitting smoking or offer employee as percentage of their insurance premiums for doing things like maintaining a healthy weight and keeping cholesterol levels in check. These have potential to improve the health and well being of their employees. A ceo of safeway visited with many of us a few years ago and started a Successful Employee Wellness Program after he left safeway. Thats one part of it. Id also like to hear what communities in federal government are doing to encourage had Healthy Lifestyle choices. I know Blue Cross Blue Shield of tennessee partner would organizations to Fund Community level organizations across the state such as fitness zones in chattanooga, promote Healthy Habits and an interactive Elementary School program to keep kids moving. An example of improving wellness is the Diabetes Prevention program, an Intervention Program medicare recipients diagnosed as prediabetic to prevent type 2 diabetes. Medicare spent an estimated 42 billion more on people with diabetes than it would have if they did not have diabetes. There are other ways to encourage healthier behavior but its hard to think of a better way to make a bigger impact than to conelnect the consensus of wellness to the insurance of 178 billion people. Senator murray. Well, thank you very much, chairman alexander, to all of our colleagues and witnesses for joining us today. We often think of health care as something you need when you get sick. But we should be thinking a lot more about ways we can prevent families from getting sick in the first place and ending up in the Doctors Office or the hospital. So im really kblglad were hav todays hearing because the truth is we all have a role to play in supporting efforts to make healthy choices. And certainly businesses employers who can promote Healthy Behaviors in partnership with their communities. So i look forward to a robust discussion around wellness and Public Health efforts that improve access to healthy, affordable food. Reduce tobacco use and a lautd more and i will work on providing the local state efforts and that includes Grant Programs by the is centers for Disease Control that invest in Community Health centers as well as the prevention in Public Health fund that has made such a difference. Given the nations High Health Care costs and that so many can be attributed to chronic diseases, it is critical we do more to support Public Health efforts focussed on Health Education and promotion. We have to do it in a balanced manner and make sure we are protecting workers civil rights and privacy. I know for a lot of my colleagues, the fact employer Wellness Programs could inflict significant penalties on workers who do not wish to Share Health Information is a concern. I want to hear more what we need do to make sure we find this right balance that protects workers rights and hippau and the Genetic Information nondiscrimination act. Three laws that were written and passed by this committee. And i have to be clear responsability for making sure the rights of workers with disabilities and those do not wish to share Genetic Information are protected and respected in these programmed will rest with the trump e, oc. Which is why they push so hard to the eoc nomoinees who dont show theyre committed to protecting those from discrimination. We need to work on it and figure it out. I appreciate all of our witness whose are being here to help share your information with us. And mr. Chairman, i do have a letter from aarp i want to submit for the record. Thanks, senator murray. Wed ask each witness to sums are your remarks in about five minutes. That will give us more time for questions back and forth. First member is founder and ceo of bird health. Many of us met him during the debate of the Affordable Care act, both the democratic and republican halls with a message about wellness. Second well hear from dr. Michael rosen, the chief wellness officer at the Cleveland Clinic, a program i just described in my opening remarks. Executive director of Penn Medicine Center at the Health Care Innovation school of medicine at the Horton School at the university of pennsylvania. Hes 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 azlon senter for Mental Health law and engages in advocacy. Why dont we start with you, mr. Bird. Welcome. Er for. I think the first think id like to say is i very much appreciate the tuntd 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 that attaches to that. Im going to go quickly through a little bit of background in what ive done since i left safeway in the ceo position. Secondly, i want to talk about why we pick wellness as a real important area. Third, im going to cover the elements that we introduced at safeway. I think its most instructive because weve had a 10year run so we know what the statistics look like after some 10 years and finally im going to speak to the results we achieved, which i think are extraordinary and initdicative 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 michael and i and maybe others here that will testify have succeeded. After leaving safeway, while at safeway as the chairman indicated, i got very involved in health care and discovered that it was a fast needing area, a great opportunity improve the health, improve care without adding to cost and dramatically lower cost. So i have now spent four in my space. What i wanted to do was tell you briefly what we do. Were able to low arcompanys or organizations cost actually 40 to 50 simultaneously lower the employees expense about 6 to 10 and capable of improving the care they receive and we have profound effects on the productivity of that work force. I picked wellness in 2008 because we took note that about 70 of all Health Care Costs are driven by health care behavior. So we thought with the right to design a plan, however we chose, we could actually effect behaviors and people would become hethsier. I know you will at some point want to understand how you can reduce costs. There are other ways to reduce cost more significantly. The first one i would mention is plan discipline, plan design and then wellness. In the next five to 10 years i would put it probably close to second place or third place. Trrs so theres an opportunity there. On the wellness front we put together a program at safeway and we made it a voluntary program, which im not sure everybody understood at the time and 85 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 reward and when we polled people, about 78 viewed the program as very good or excellent and waut we measured was Blood Pressure, cholesterol, tobacco use and the results were amazing. Frrsh of the people that failed, they maintained that over the balance of the program. Prediabetics, of those that failed, 45 passed two years later. Cholesterol level, 43 of those passed two years later. Smokers ive got a number of 35 but in fairness you can beat that test and so while we did improve the smoking, 35 is a bit strong. And then we took the obesity rate down to 21 . If we were a state, wed be it lowest obesity rate. So we matched colorado at 21 . I want to move quickly because it says i have nine seconds left. Why do we succeed . First of all we rewarded a participation. The vast majority of programs say theyre outcome based, theyre not. Theyre participation based. We had to put a meaningful amount of money at stake. We needed to provide support tools that would allow people to actually change their behavior and enhance their state of health. And then we needed to surround it with an ecosystem that constantly convinced the employee that we cared about their health. We could talk more about that in the q and a. I did this when i was about 57 years of age and i understood that my fitness level down the road was going to be stable. And lastly it needs leadership and i practice this with clients today and if you dont have ceo leadership, it just doesnt work. In my experience you have to do all five. Thank you. Chairman alexander, Ranking Member murray, my name is dr. Mike roizen and i thank you for the opportunity to testify today before your committee. Since 2007 i have served as the chief wellness officer at the Cleveland Clinic. I lead the clinics work in preventing illness and helping people live longer, healthier 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. In fact the title of the hearing incapsulates the Cleveland Clinics story. How healthy choices can imp prove Health Outcomes and substantially reduce costs. We hope we 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 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 pay in providing health shurnls. But if they dont address the sky rocketing costs of health care, it wont matter whetheric bills. Unless we do something to bend the cost curve, well all be bankrupt from this influx of chronici disease that is growin five to seven times faster than the population. There is something both the federal government and private insurers could do right now to significantly reduce Health Care Costs across the country. Something that could save. The Cleveland Clinic began an ambitious experiment. The clinics reward for Healthy Choice Programs, rewards employees who voluntarily choose to do so with compensation for reaching several outcomes. Wellness outcomes and medical outcomes that you mentioned each year. The program is born of a few key insights 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 six measurable factors. Your Blood Pressure, body mass index, your fasting hemoglobin, your ldl cholesterol, whether you smoke or not and unmanaged stress. These six predictors of chronic dg zeez are controllable in well over 90 of individuals. The Cleveland Clinic rewards for Healthy Program folkishes on helping the 100,000 employees and dependents get and keep these six measurements normal, seeing a primary care provider regularly and keeping immunizations up to date. The Clinic Program helps emplois get the six normals. The way we do it is we pay employees. That is we incents have employees and we started very small but ended up increasing payments to about the same number as mr. Bird to achieve the six normals and the two behaviors. Since the onset of thegram, the Cleveland Clinic has saved 64 million in direct medical costs. This year well save over 1 had50 million more verses the bench mark. As more of our employees get and stay healthy. Further unscheduled sick leave and the 62 m of clinic employe have seen their Health Care Costs and premiums disd kreez by 600 for individuals to 2,000 annually for families. Smoking rates have decreases to under 5 while the state of ohios is around 23 . Body mass index of emplies for all 100,000 employees together is decreasing. 5 per year as posed to the nations increasing. 37 a year. Blood cholesterol, hemoglobin levels have improved substantially, resulting in over 11 decrease in the need for illness care since 2009, rather than the projected increase due to our aging population. The Cleveland Clinic model has been replicated by nine other empe employers. The construction and supply Company Saving 46 of estimated medical costs and we know other organizations can learn from these examples. In short the Cleveland Clinic rewards for Healthy Choice Program s is doable, supportabl across the country. Senators ron wyden and rob portman are collaborating in the senate fine angs committee aimed at reducing the costs of improving health of medicare beneficiaries. Private sector programs supported by this committee could benefit by the work weve pioneered. This program has at least three clinical virtus. Its been tested across differe different populations and its entirely voluntarily and enables the federal government to achieve substantial cost savings without any of the program added budget cuts and without any initial costs. Its a commonsense idea that both democrats and republicans should be able to rally around for both the health of our nations finances and the hejts of our people and increases the nations competitiveness for jobs. Ash, welcome. Chairman alexander and distinguished members of the committee, thank you for the opportunity to speak with you today. Im a practicing physician and a professor at the university of pennsylvania. Im here to talk about Workplace Health programs. My summary message is this. I believe employer sponsored Wellness Programs have value to contribute. I believe even though the health and financial benefits are often over stated, i believe even though some of the programs risk treating some emplies unfairly but im optimistic about these programs Going Forward because were learning how to design them to be much more effective and much more fair. Americans spend most of their time outside the health care system, even those with a chronic illness spent only a few hours a year in front of a doctor. But 5,000 waking hours a year doing Everything Else in our lives and its during those 5,000 hours when so many of the determinants of our health unfold, whether we eat, exercise, smoke or take our prescribed medications. Much of our health is determined in the 5,000 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 because healthier workers are more effective. So some have a work Wellness Program targeting risk factors that account for much of chronic illnesses like tobacco use, high Blood Pressure, obesity and the like. Unnofrptly its lot easier to know what conditions to target than to know how to do so. Managing these conditions requires substantial behavior change. Our nation has hainvested in the science of treatment but less in the science of behavior change. Our knowledge of how to break old habits and how to develop healthier one sz rudementry but getting better. Behavior economics is a way were learning. The nobel prize in economics for saying we all sucometic to irrational tendencies. Its been used to help doctors and patients make better decisions. Im proud to say the university of pennsylvania is one such proud member. It doesnt make economic sense but its how humans tend to think. We found this recently when encouraging over weight employees to increase their fitness. In one group they were given 1. 40 for each day they walked 1,000 steps. For another group we structured it as a loss. So in that group we gave each employee 42 at the beginning of the month and took away 1. 40 for every day they didnt walk 7,000 steps. An economist would see those two designs as the same. But it turned out those who received a 1. 40 were no more likely than those who received no incentive at all. But those who had 1. 40 taken away were 50 more likely to succeed. Mathematically and financially these approaches are the same but one worked and the other didnt. Most Large Companies are encouraging Healthy Behaviors the vast majority do so by adjusting the premiums they pay for Health Insurance. Although it may seem obvious that it would encourage people to modify their habits, there is little evidence that programs designed that way work. At best they provide modest financial benefits to employers and unclear Health Benefits to employees. I remain nevertheless excited about well designed programs that help americans change the behaviors they want to change. Help them quit tobacco, help them lose weight, help them better manage their high Blood Pressure. Those changes are much less likely to come from financial incentives and much more from the underlying psychology of how people make decisions encouraged by frequent rewards, emotional engagement, contests and social acceptance. Those are the ingredients of successful programs and theyre missing from most of what employers currently do. We know much more about how to design financial and other incentives far more now than even 10 years ago. There is no reason why can t cant be. Thank you for inviting me testify. I look forward to your questions. Thank you, dr. Ash. Ms. Mathis, welcome. Thank you. Chairman alexander, Ranking Member murray and members of the committee i welcome the opportunity to talk about this important issue. My name is Jennifer Mathis. The senter for Mental Health law but im here also as a representative for the consortium for citizens with disnlts, a coalition of over 100 na disability organizations, insuring the self determination, np independence, inclusion of adults and children with disabilities in all aspect of society. Obviously there are many different ways we can promote healthy choices that improver Health Outcomes and reduce costs. The primary concern that an mates this hearing seems to be the role of employerbased Wellness Programs. But i think its important to mention the role of state Service Systems, particularly those with disabilities and older adults and planning and administering Service Systems in the way that expands systems, enabling people to exert more control and participate actively, direct their own lives and work. We have seen from numerous studies over many years that realigning Service Systems to offer people from disabilities to live, work and receive services leads to improve Health Outcomes and lowers costs. So im happy to answer any questions about that. But i will folk this is rest of my comments on Workplace Wellness pro. Grams. 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 act, especially workplace privacy protections. People with disabilities need these protections. The employment rate is much lower than that of any other group track fwhied bureau of labor statistics. Theyre employed at less than half the rates of those without disabilities. Study after study that has studied why its so low sites attitude barriers. Perceptions that people are incapable continue to be pervasive. It was precisely for that reason that when congress passed, the ada for people with disabilities, it created strict protections to enable employees to keep their health and disability information confidential in the workplace. They can be subjected only if they were job related or voluntary inquiries part of an Employee Health program. Gina provided similar protections for the Genetic Information. Removing or weakening those protections would make many people with disabilities vulnerable in their workplaces and expose them to the risk that congress meant to avoid. Last year the eeoc significantly rolled back protection it had enforced to insure employers could not penlize employees for declining to provide their Health Information. They instead permitted steep financial penalties for those that choose to keep their Health Information prive squt more steep penalties if they spouse chose to keep the information private. Making this choice far from a voluntary one for many people. A federal judge now ruled they failed to provide a reasoned ju justification. The agency now has an opportunity to revisit the regulations and do the right thing to afford people the rights garnuaranteed. We believe it is not difficult for the eeoc to insure they promote healthy outcomes while protecting civil rights of those with disabilities. Clarifying that financial incentives can be used but not for questions asking for Genetic Information. The same rules should apply for questions seeking Health Information of an employee and a spouse. The lead study on we Wellness Programs highlighted many strategies that have made Wellness Programs more effective. They can be designed without eroding the rights of those with disabilities and we will all be better served if that happens. Thank you. Thank you, ms. Mathis. Well now have a round of five minute questions. Well start with senator young. Thank you, chairman. Im very excited about this hearing because i know a number of our witnesses have discussed in their testimonies behavioral economics and decision making. I think its important that we as policy makers incorporate how people really behave, not according to an economist per se or according to other policy experts but based on observed behaviors. Often times we behave in ways we dont intend to. It leads us to results we dont want to end up in. Build ash, ill start with your expertise in this area. Youve nuindicated behavioral economics used to help doctors and patients make better decisions and you see way for employers to change. From tobacco litigation to losing weight and Blood Pressure and you indicate the changes are much less likely to kr come from typical premiumbasised financial incentives and more from the underlying psychology of how people make decisions, encouraged by frequent rewards, social acceptance and so forth. And you said in your verbal testimony you havent seen much of this new knowledge applied effectively by employers but theres no reason it cannot be. So my questioness f esfor you s what might they learn from behavioral economists . I think ill start by saying theres a misunderstanding often about behave ill economics in health. Many believe youre engaged in behavioral economics for incentives. No, 24589s its economics. So that you dont have to use incentives that are so large. I thinking there are a variety of approaches that come from behavioral economics that can be applied in the employment setting. I mentioned one that losses loom larger than gains might be a new way to structure financial settings in ways that make it more palatable and easier for all employees to participate in programs to improver their health or certain kinds of social norming where its acceptable to show on leaderboards and contests and engage in fun. So thank you very much. And you really need to study these different phenomena individually i think to have a sense of the growing body of work that is behavioral economics, right . So we need to increase awareness and i guess the education of Many Employers about some of these ticks we have and that seems to be part of the answer and in fact richard, who won the nobel prize in this area said we as policy makers ought to have, not just lawyers and economists at the table drafting legislation but we ought to have a Behavioral Scientist as well. In the uk they have the Behavioral Insights team, the Previous Administration had a similar team that did a number of experiments i to figure out how policies would impact individua individuals health and wellness and a number of other things. Some of the ideas i think we might incorporate in the context. Tell me if you think they make sense. We need to continue to have unit or units embedded within government that do a lot of these experiments. We need have a Clearing House a best practices that others, employers included might draw on. This doesnt have to be governmental but it could certainly be. We on capitol hill might consider, aside from a congressional budget office, we might have an entity or at least a presence within of individuals who understand how people would actually respond to given proposals. Do any or all of those make sense to you . Thank you for your remarks. And i think they all make sense. Seemingly subtle differences in design can make a huge difference in how effective a program acan be and how its perceived. So im very much in faver of greater use of these programs. I think we need an investment in the science that will help all of us get better at delivering all of these activities, not just in health care but other parts of society. Make as lot of senses. Im out of time. Thank you. Senator murray. Thank you. I want to start with you. Wreer weve heard a lot about workplace Wellness Programs. I its critical to think about the investments we make in our community can be a Critical Role to making the healthy choice the right choice. In my home state of washington weve seen a lot of these critical efforts in our schools for example. Were investing in physical education and healthy food and beverage preparation. Bicycles, pedestrians. Our Health Care Providers are making it easier to quit smoking and taking steps to better support Breast Feeding for example and our communities of cu color are taking strides to insure programs to improve the health of people in my state. I wanted to ask do you agree in addition to the workplace based programs, Community Based efforts from what health and wellness are also important . The answer is absolutely agree. And your state and your schools are taking a leadership role that the rest of the nation would love to follow and hopefully will be able to. What i mean by that is when you get kids to be healthy and in fact influence their parents to be health had, when you get foo manufacturers to make food for large distribution to your schools that there healthy, you get to change the health of a whole generation. So we totally applaud that. We work with that. In fact i go and we have a network of what we call innerand outer ring schools around cleveland. And its very hard to get appropriate products for the school lunches, etc. And breakfast. And so your state is taking a lead in that and we thank you. Thank you. Ms. Mathis, i waumwanted ask yo. The eeo commission recently reported it failed to meet its roles. It says an employees decision not to participate 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 high of a penalty is a problem for those employees and spouses who do not wish to risk the exposure of a disability by participating in Wellness Programs that do collect of course sensitive Health Information. Its a persons right under the ada, under genetic nondiscrimination act, hippa and those are three laws this committee wrote and im proud of. This committee met yesterday and cleared for the full senate the Trumps Administration nominees to now lead the eeoc and among other things, those will now be responsible for rewriting those wellness rules. So 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 . I think the most important thing for the eeoc to remember is that their job is to apply the ada and not to rewrite it. To try to conform it to another law that also applies that same time but do not overturn or modify the ada. There are many circumstances where two laws apply at the same time and one requires additional thing s beyond what the other requires. We have a lot of experience with applying multiple laws to the same set of circumstances. They already have a framework they had used for 16 years under the ada and they used the same framework to frame what is a voluntary question in their 2010 regulations. Allowing requests for employees Genetic Information as part of a voluntary Wellness Program and i would point out that regulation was done after the Affordable Care act and they considered the two laws and the fact the Affordable Care act had been passed with its provisions about Wellness Programs and considered those consistent. That framework was logical. Used the ordinary meaning that you cant require a person to answer or penlize a person for thought answering a question consistent with the dictionary definition of involuntary. Which is not impelled by unconstrained without valuable consideration and its actually the dictionary definition of what is not voluntary. So having the same path that they charted for the 2010 regulations to apply also to the ada which is how they interpreted the ada before 2016 for many, many years to allow Wellness Programs to have inceptives but just not incentivize or have significant incentives for people earn itting over health care information. Thats not job related and that i think would allow Wellness Programs to proceed and develop and use incentives in many other ways and use strategies to engage people without eroding the civil rights of people with disabilities. Thank you very much. Senator isaacson. Thank you, senator alexander. Mr. Bird i remember correctly the sachway program had financial incentives is, is that right . Could you repeat the question. The Safeway Program had financial programs for the employees participating in the Wellness Program . Correct. What have you found are the best financial incentives to induce more people to participate . I think we had had had an extraordinary participation, even than some of the numbers that you had. We were 85 voluntary for employees, 70 for spouses. Im a big fan of both the 96 hippa regs. I thought they were well thought out. And the adjustments what i dont want the committee to do is get the impression that its all about incentives. Incentives are, i think necessary but by them svls notficient. And going back to something david you 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, objectives and time frames. It may have been weight loss goals, exsers goals. We gave them the tools to attract one another and it really was a driving force in this along with ceo leadership. So i look at government as being an enabler in this process but i think theres an opportunity for government to lead. And i think others have been down here over the years. One opportunity to lead is i would love to see the federal government adopt programs like this for their own employees. I actually offered to do this for secretary sabilias and the people at ahs to do it for free. That was 30 days before she left office. But its not just about incentives. And its important that we employed 10,000 people with disabilities at safeway out of 1 185,000 people. 2,000 were part of this program. And the regs, when i say theyre well thought out, they allow for and frankly require if the standard you set is judged to be too difficult that you adopt a different standard and even provide a waiver. In our experience id be interested in what youve done at the Cleveland Clinic, about 3 to 4 would reach for and get either a waiver or an alternative standard. So, while we wanted to get below a 30 bmi, if you had a 45 bmi and made 10 progress at the end of the year when we measured we gave you a reimbursement check. We enjoyed giving those checks. If you had comorbidities and if you said id feel better going from 45 to 43 we would say, fine, thats the standard. Then we would change that over time. Im sure Cleveland Clinic did something very similar. I appreciate the answer. Being one who has had about every bad habit you could possibly have to be a poor contributor to your health at one time or another what got me into health and Wellness Programs was desire to change a habit and what kept me in them was the reward of that habit changing. You said something very important. If you give the employee or individual the measurements to improvement. And reinforce that along the way you can change to endeuce a more healthy employee induce an unhealthy employee to be more healthy. Change your eating habits, stop smoking and exercise regularly. After new years they practice them a few times, and then they go away because theyre hard to do. If you get enforcement in a peer group in a positive way you can sustain the practice. If i could add one more thing. I learned a long time ago in business, i had 1800 stores, rather than just study and hi pohi hypothesize things we scaled it. I would put in an ad and reduce the price and put it on an end cap. At the end of the day, i didnt care which of those three increased it, i wanted to increase the sales 20 fold. We struck on something that worked and it worked famously. We had no issues with it. If you dont know, the Health Statistics dont go to the hr department. They dont know what somebodys bmi is. They know theres a contribution to premium effect but they really dont know what somebody passed and what somebody failed. We didnt have any issues in the company and we ultimately began rolling that out to all the divisions. Our initial population was 40,000 members. Thank you, mr. Chairman. Let me conclude with a complement. Thank you, dr. Roczen to the reference what they have done. The Chronic Health care bill has passed the Senate Finance committee and senate and pending in the Energy Committee in the house. Were close to getting that three year effort done and i appreciate your reference to that. May i make another comment. A couple things he said deserve reemphasis. There is an absolute firewall between the health plan and the company. They dont know why the premiums are where they are or whats driving it or not driving it. Secondly, for every person that interacts with their primary care physician in achieving those six goals plus two behaviors, it is the primary care physician and they set a goal and set a progress and it is that relationship and that progress that determines their incentive. It is a culture change. It is multiple programs that work and 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 a lot of things that work. Thank you. Senator franken. Thank you, for holding and for the Ranking Member for holding this important hearing. Before the hearing started i spoke to all of you about housing. These Wellness Programs that the employer run are very helpful but what were trying to do is to help people be healthy and lower the cost of their healthcare in the long run. Police mathis, you point out research that shows a strong connection between a Persons Health and stable housing. Despite the fact that the theyre actually very often talked about as completely separate issues. In minnesota, hanipen, a 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 to develop a program that paired healthcare, housing and social services. Just one year after participants in the program were placed in supportive housing, henipen health saw significant reductions in participant hospitalizations and Psychiatric Care and imprisonment, going to jail. You know, the number one cure for homelessness is it turns out to be a home and then if you can wraparound supportive services, it yields amazing savings. I brought this up to all of you, so mr. Mathis and all of you, could you speak to how a focus on housing, particularly when its paired with social supports can lower healthcare costs and improve Health Outcomes. I think thats absolutely right. I think a recognition that has become increasingly prevalent in state Mental HealthService Systems maybe 20, 25 years ago, state Mental Health directors would have said we dont do housing, were not in the business of housing, we do Mental Health. That has changed dramatically. Most statement authorities would tell you we do housing. Housing is a critical part of what we do, housing supports, housing subsidies, housing assistance, housing locate assistance, all of that because housing stability work or all the social determinants of health have been shown to have an enormous impact on peoples health. There have been many studies done, i think some of the interesting ones have been studies have people who are homeless versus people in support of housing, twin studies of people in those two situations, where it costs us as much money to keep people homeless as it does to have them stainly housed with services. I want to hear from the others as well because you all seem to respond when i brought this up. Senator franken, thanks for the question and comment. I fully agree, there is certainly a movement and Knowledge Base called Housing First that recognizes the central 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 health. When you face patients chronically ill readmitted to your hospital multiple times for congestive Heart Disease or chronic ailment almost always the serious illness that brings them back to the hospital is a social circumstance, sometimes housing or social support. At the time when hospitals were incentivized only to deliver healthcare those considerations were les relevant from a financial perspective. Now theyre 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 as long as other social determine nantz. Those social determinants were always there and now we have to think of 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 say pretty close to the time because we have votes at 11 45. Some would say, senator franken, youre a genius for bringing it up. The social determinenous is i was afraid you might say that. The social determinants are really important. Its really hard to not have stress if you dont have a home. Its very hard to get adequate sleep without housing. Those are really key points in getting well and staying well and lowering the costs of medical care. First of all, i wanted you to know if he hadnt said you were a genius, i was ready to weigh in on that. And i was ready to do it as well. [ laughter ] my wife and i have been involved for several years in a fi philanthropic effort to provide housing to the homeless and another philanthropic effort with a good friend where we take people who had been homeless and had the capability to learn a skill, theyre taught the 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 that would create it. Thank you. Thank you, mr. Chairman. Thank you very much, senator franken. Well go to senator casey. Thanks, mr. Chairman. I want to thank the panel for being here and for your testimony on these important issues. Ill direct, i think, most of my question time to dr. A and miss mathis. I want to say first, dr. Ash, were grateful for the work you do here and at penn and at wharton. I also want to thank you for the work youve done at the v. A. Medical center in philadelphia as well. Critically important work. I know i wasnt here for senator murrays questions but i believe she asked a question about the penalties and incentives. Am i right about that. I just want to make sure. I guess my followup to that line of questioning would be with regard to you, dr. Ash, that your Research Indicates the penalty incentives may not have had the effect on individual behaviors. Both you and dr. Roizen have both indicated the importance of many hours, 5,000 hours of waking activity when were not interacting with the Healthcare System and penalties and rewards can be as high as thousands of dollars a year. We heard dr. Roizens program uses a 30 penalty, the limit the eeoc has set when it issued the rule last year. My question is basically this. Based upon your research and other behavioral economic research, is it necessary to use such large penalties or rewards, and if not, what would you recommend such rewards or penalties to be . Thank you for your question, senator casey. I think youve identified some Critical Issues at the interface of effectiveness and voluntariness right there. I think a lot of employers are under what i consider the mistaken impression the way to make incentives is to make them larger and larger and that puts large amounts of money at risk whether in the form of rewards or penalties. We heard penalties are more off putting than rewards and actually jack up the concerns about the lack of voluntariness. I think its a potentially a mistake to think that way. I actually think that is old outdated thinking, the only way to increase the potency of an incentive is increase the size of an incentive. Instead, we know from years of research in behavioral economics the way we design incentives probably has much more impact than the amount of an incentive. Imagine a 500 incentive that might be bundled into someones paycheck. If theyre paid once a week, 10 a week, it looks much smaller then, put alongside all sorts of other elements in the paycheck, may not even be seen, directly deposited. You can imagine handing someone two crisp 100 bills much smaller incentive and much more potent emotionally. Another mistake employees make often they dont need to make setting explicit targets for goals. If you believe your employee should be a bmi of 25 upper end of normal and set that as a feel that will make those with 26, lose a few pounds. If your bmi is 40, thats demoralizing. What we care for is improvement and pay for improvement programs are far more effective for the people we fundamentally need to help the most. I think both Design Elements with the structure of incentives and Design Elements with the targets for incentives can be improved by most employers and im optimistic they can do that. Thank you. I have more to pursue there. Want to move to a separate line of questioning. Miss manthis, i will start with you. The written question you have regarding balancing personal rights of individuals, especially those with disabilities while also pursuing the goal and encouraging wellness, your references to the privacy protections in the americans with disabilities act, and other statutes are critically appreciated, i think, at this time. We know october is National Disability employment awareness month. As youve pointed out in your testimony the employment rate for those with disabilities is very low in comparison with the general population. Those with disabilities have the lowest rate of employment of any sector of our population. Im concerned aggressive Wellness Programs could not only discriminate against a person with a disability but also create a Workplace Climate that doesnt value people with disabilities. Would you like to comment on that further . Sure. I should clarify our primary concern about the large financial incentives is around those privacy protections. Folks have talked about incentives for outcomes. As mr. Burd mentioned there are safeguards in the Affordable Care act that do address that concern, if you cant meet a particular Health Outcome because of a disability you are supposed to get a reasonable alternative standard and there are regulations that implement that. I dont think that certainly we havent heard there are a lot of thats a major concern anymore. I think that was addressed. Our concern is much more around the privacy issues. It is true in many cases the information will not go directly to an employer, sometimes it will if the employer does directly run a Wellness Program with smaller employees. Not that hard to figure out who has what Health Condition identified in aggregate data and frankly for many people with disabilities, just having to turn over your sensitive private Health Information whoever it will go to concerning is not the way to build an environment of trust and a productive working environment. People with disabilities have in many cases had many negative experiences in their lives stemming from the disclosure of those disabilities. I think its very understandable why people you need to try to stay within the time. Thats all i have to say. Thanks very much. I will do some followups in writing. Thank you, senator casey. Dr. Asch, im a Healthcare Provider such as you. I feel that which were doing in the employerbased setting, i think of my patients i used to care for in the hospital system, its a bigger problem, if you will, some wellness issues. If youre in philadelphia you probably have a practice that was somewhat similar to mine. How can we translate this into the medicaid population and workplace with a higher chronic disease morbidity an the workplace . Thanks for the question, senator cassidy. I think in some places these can translate. I think employers have a special role and special trust connection with employees that may be not as high as the trust relationship people have with their doctor and hospital but might be potentially higher than people have with their insurance carrier and trust is an important determinant. Let me stop you for a second. I think of my medicaid patient, theres a structure associated with an employer relationship and that allows you to give them 30 minutes off to walk around the track if they have built one there. Medicaid patients taking Public Transportation to their clinic appointment or cigarette smoking and nothing you can do under medicaid to incentivize them to stop smoking, i guess im not seeing its as easily translated. By the way, im willing to open this up to anybody, to me it seems almost an apple and an orange. We have run some programs employerbased designed to reduce the burden of tobacco on employees and we did two, both highly successful interventions later adopted by those two companies and reflected largely positive financial incentives to workers to help them reduce the burden of tobacco. No reason why programs like that couldnt be introduced to the medicaid population. We can translate some science and learnings from the employer settings. Let me stop you. You would be familiar with the structure of medicaid, managed care, contract with a provider to provide a service at a certain rate. If it is fee for service youre just paying the bills as they come in. Typically the patient is not directly impacted by this. The indiana experience may be a little different they prefunded Health Savings accounts, you can bill a reward for that. I open this to anyone, when you say incentive, how would you do that for medicaid as commonly structured for the aca or any other program. Im not sure i know how to do it as commonly structured. It doesnt mean it couldnt be rethought or state medicaid agencies would think of waivers to allow them to engage in those kinds of activities in order to achieve their mission. Im not sure they can do them under the rules as they are now. Under changed rules they might be able to. The state could apply for a waiver asking for flexibility to incentivize this sort of behavior to incentivize that shown to work for an employer and works with a medicaid population. I totally agree with that. Would you elaborate but just to agree . I dont want to take too much time, basically how do you get both programs that work and leadership incentives into the Medicaid Program and obviously indiana and ohio are doing major efforts to do that and seem to be succeeding. The prefunded Health Savings accounts of the indiana experiment seem to be quite novel and effective. Folks who put in a little bit of money got more in the hsa and seemed to modify behavior. Is that what youre thinking along those lines . I was thinking along those lines and others ways of doing that and that works. What about obesity. Cigarette smoking seems almost les tractable than obesity more intractable it seems. One is a Culture Program and multiple programs so one program doesnt work for everyone. We have in fact 10 Weight Management programs at the Cleveland Clinic that are 62 of participants have the choice of participating in and Weight Watchers may work for a group and kerr may work for a group and when you get 10 programs together you can find programs that people can adopt and in buddy systems and in groups, if you will, participate and succeed. This might be a program employed by the Medicaid Managed Care program. Exactly. To lower the overall cost burden. Exactly. Thank you. I yield back. Thank you, senator cassidy. Senator, bennett. Thank you, mr. Chairman. Id like to start by thanking you and the Ranking Member for your work on your bipartisan effort to fix the Healthcare System that we have, on behalf of the people of colorado who have been waiting forever it seems for a bipartisan effort here. I want to express their gratitude to you for the work that youve 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 its only 6 of the people that are insured. This hearing really is about what we need to get after, which is the rising costs of healthcare in this country. I thank you for that as well and whatever any of us can do to help your efforts i hope you will let us know. Dr. Roizen, could you describe briefly the bill you mentioned in your testimony senator portman and senator wyden are working on in the finance committee . It basically allows medicare to incentivize and to do the same type of thing that we do for our employees, offer programs, offer incentives to get to there, work with the primary care physician to set the trajectory to improve and get to the goals. If you did that, if the Cleveland Clinic dower number and participation number goes to medicare and if 6 of medicare achieve four of the six behaviors and standards, if we did much more than that and got the 62 participation and 44 success getting to goal the government would save over 5 50 billion, maybe 1. 2 trillion. Putting medicare in for the population is really important at getting change. So we think this was an enormous opportunity and senators portman and widener are working on this. The 178 million americans privately insured through their employer could also benefit from the kind of senate structures you and mr. Burd put in place. Not just parts of the program. It is not just cultural change, programs that help them and literally changes the way they relate to their primary care physician. There have to be some insurance rule changes that this committee could work on to allow the nonsmall selfinsured corporation to do this in a way that allows the employee to take the benefit as they go from one company to another and allows the company to benefit after theyve gotten the person healthier. There need to be some rule changes. Those are minor. There wouldnt be a federal dollar spent in advance or in fact there isnt an ask for money from the federal government at all, just a rule change. Mr. Burd, its nice to see you again. I want to thank you for your leadership over many years in this area. This is going to sound a little bit off base but i cant resist because of what your job used to be. The question i had for you is what you learned about what were eating in this country in that job and how that is connected to health and how its changing, if its changing. Well, i think increasingly the population is becoming more health conscious. I employ a number of millennials these days and theyre 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. Im a big believer in free choice, but only if you also suffer the consequences of that free choice. 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, weve got another, you know, half hour to spend on the treadmill or walk after dinner. One of the things i wanted to mention about improving health particularly when you work on bmi, i find the safe way numbers extraordinary. The reason we started at 28 bmi, all the people are on their feet all day. Were not doing that here. We could have had a standup meeting and gotten healthier. The point is when people just diet and everybody here would agree, it doesnt work. The reason it doesnt work. If i lose 20 pounds and automatic 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 go back to your old eating habits or refined eating habits you cant eat as much in temrms of calories because your burn rate has slowed down. We stress the importance of cardio vascular workouts and strength training. You can at the age of 60 have the burn rate of somebody in their late 20s if you do resistance training. I contend its the secret of weight maintenance. I would be shocked if you dont do resistance training. I do. Thank you, mr. Burd. Our next wellness hearing will be a standup hearing. Well see what happens. [ laughter ] very good. Even if we stand up once during a hearing that helps. I will be sick that day. Senator warren. Thank you, mr. Chairman. I want too see if i can ask some more questions along this line. We all know the Affordable Care act allows employers to offer financial incentives to employees to encourage participation in these programs. One thing the aca doesnt do is eliminate the protections already in federal law for employers so that they cannot discriminate 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, americans with disabilities act and Genetic Information or nondiscrimination act, gena. This is a nonbipartisan bill and senator kennedy worked on this and last year, i worked on this with others tore personal Genetic Information collected by federal research can never be made public. In short, our nations nondiscrimination laws say that employees can collect sensitive medical information from their employees only if providing that information is voluntary. Meaning the employee can decide to say no. So i just want to start by asking, miss mathis, what types of personal Health Information do employers typically ask for as part of Wellness Programs. Ive seen these Health Risk Assessments ask about all manner of health and medical information on a variety of levels of detail and give you some examples, specific cancer diagnosis such as breast cancer, cervical cancer, prostate cancer, weight, height, bmi, whether youre being treated for depression or bipolar disorder, specifics about your depression such as how many times you felt depressed in the last week, whether you had crying spells, how many times you felt people disliked you, diagnosed with Heart Disease, high cholesterol, angina, bronchitis, copd, diabetes or sexually transmitted diseases, to name a few, whether youre pregnant, trying to become pregnant, how old you were when you first became pregnant. Those are some of the medical things they ask about all sorts of other life habits. So this is really Sensitive Information and its supposed to be voluntary to hand it over. Thats right. Let me ask about that. Mr. Burd, when you were the ceo at safe way you set up a Wellness Program you called completely voluntary at the same time families were charged 1500 more in healthcare premiums if they didnt participate in the program. In fact, i think you said that you thought the penalty wasnt high enough, and you lobbied hard to get the limits relaxed. The quote is legislation needs to raise the federal legal limits on the size of these penalties. I know that today you run a business that designs these kinds of penalties for other companies. So my question is, when it costs an employee 1500 or maybe more a year to get healthcare coverage because they dont want to have to share this kind of confidential medical information with their boss or because they cant pass a biometric test, i dont understand how that connects then with the rules on discrimination. It sounds a lot like discrimination. Well, weve been tested on that numerous times and were never accused of discrimination during the 10 year life of the program. What youre referring to about my desire to raise those limitations that were in hippa. Hippa originally in 96 allowed a 20 premium differential based on behavior. If you look at Something Like smoking, the impact smoking would have, cosgrove used to say smoking alone would cost about 3,000 more. I didnt say in my direct testimony but ill say now in our experience about twothirds of that comes immediately back to the employees as a reward for making those standards. Its not like they were charged 1500. The 1500 one, that would be if there was a spouse and employee. We think we i was questioned by eeoc, i was questioned by the labor department. At the end of a 45 minute interview i was told i had properly followed the letter and spirit of the law. We had not been accused of discrimination during that time period. The person interviewing me actually wrote the hip pa regs in 1996, had a role in that and said if i ever opened up a washington, d. C. Office theyd want to come to work for me. Im glad thats the case and im now over time. I want to be respectful of the time. I want to say when you charge differentially 1500 or sometimes more that can happen because people dont want to reveal sensitive medical information, thats a penalty. Paying a penalty may be legally all right, although, as i understand it, the courts have now said the eeoc is going to 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. I just want to raise the issue i think the question about what constituents voluntary on this kind of Sensitive Information is one to keep on the table and maybe push in the other direction as well. May i make a quick comment. This information is not revealed with the company. The health plan. Is there an absolute firewall with the health plan and company. We track that system. If you break that firewall, you get fired. Dr. Roizen, what i want to say is what the law says is the revealing information has to be voluntary. It is voluntary with the health plan. And it will cost you 1500 if you dont reveal very sensitive medical information i think stretches the bounds of what constituents 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 that the Cleveland Clinic is certainly not the only one to suggest it, the mayo clinic, lots of people say it, there are relatively few things we can do that dramatically affect about lifestyle, that dramatically affect chronic disease and chronic disease is 84 of our healthcare costs and were talking about hundreds of billions of dollars to make a difference. Then you go to the obvious point and mr. Burd has pointed out, its not only wellness youre looking at looking at an employer plan, 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. So how, mr. Burd and dr. Roizen, how big a problem is it, has it been for you, in your employer plans, to successfully deal with the concerns miss mathis talked about and senator warren talked about . Is that a major impediment or do you think you can 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, cant get to that normal. Those are accepted and they get a different plan. In fact, in some of the extreme examples someone counts the amount of water they drink, bottles or grasses of water they drink a day to hit the healthcare 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. Thats exactly right. And you have to have a they therefore try to provide a fair process to meet that objective. Miss mathis, does that work . Thats not the primary concern we have. The primary concern is the incentive for disclosure of information. Right. Mr. Burd, what would your comment be on what kind of impediment are actually, you talked some about it, the reward or penalty for healthier lifestyle, that been a problem for you . I would say it has not been a problem. Just consider the fact that 85 of the people did opt in. One of the reasons why i think 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 publicly at a town hall meeting and public broadcast and reported on the health of the organization. People would catch me individually and ask me questions about it. When they really understood it they quickly opted into the program. To michaels point, theres a firewall there. When you have a premium differential, you are really just risk adjusting the premium for individuals but giving them an opportunity to change their risk profile. We do that in life insurance, we do that in automobile insurance. And behavior really matters. I think what id like the committee to really focus on is that weve got, you know, two practitioners here, maybe three, there are very few people, i would say les than 1 of the companies in this nation that have turned back obesity that have improved the results on 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 a nation now close to 40. Thank you, mr. Burd. Were close to the time were going to be voting in a few minutes. Dr. Ashe, i would assume, based on your behavioral research, if we wanted to incentivize United States senators to pass an appropriation bill on time, that you would subtract from our salary instead of giving us a bonus . Maybe so but i think you all deserve a raise. Well, thank you for that. Ill take it under advisement. Senator murray, do you have additional questions . I dont. I know senator franken had an additional question. Ill just say, i know were getting close to votes and we need to go. This has been a really good hearing. We have a lot of work making sure we do this right. Its critically important balancing workers civil rights and privacy. This has been a really important hearing and i appreciate everybody being here. Thank you. Senator franken. Thank you both for this hearing. Its very refreshing, to be talking about keeping people healthy and having a healthcare discussion that isnt all about structures of insurance, although this has something to do with that. I do 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 ford, a band 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 being declared a crisis, emergency, i would really like to see, like a Pilot Program where people come back for treatment, especially in Indian Country, have a place to go after they this is not 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 and 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. Theres probably a distinction to be made here. But i would love i would love to be able to pilot a program in minnesota, i would love to do it in minnesota where we actually, this is the national as bad as it can be in minnesota in Indian Country because theres housing shortages there where people coming back from rehab can go into a sober living setting so they have secure housing an that they have people that are in their same boat and in recovery and so instead of a peer group, which is the other a peer group that there has a high drug use, theyre having a peer group of people in their own fellowship. Thats something i want to bring up for yes. Senator, just to elaborate on what i said earlier, thats exactly what we do in this philanthropic effort. In other wordsy they have to be sober before they come in. They get tested in that safe environment. Got to be tested. Get constantly reinforced. The program works. If theres a way to expand that i think it has great value. On the national Diabetes Prevention program this is something senator luger and i put in the aca, senator grassley and senator collins have been very helpful in getting cms to do, the medicare. We learned this was a 16 week program piloted at the ymca at st. Paul and indianapolis by nih and cdc. This is why it was me and senator luger who put it in. It turned out its 16 weeks of both nutritional training and exercise. After five years, this is people who have high levels of sugar in their blood, glucose. And they were 58 les likely, after 5 years, to become diabetic, 70 less likely if they were over 60 why cms is in the process of implementing this so 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 why this has been successful. We have about 20 seconds. You get behavior change, consistent, buddy, its group, so you get buddy support, you get everything a Wellness Program should be and youre targeting one of the specific high cost things, huh mo go ben a1 c or diabetes, a great program. I agree. The Diabetes Program is a great example of behavior change and the fact this can be done without financial incentives speaks to a Strong Program and outcomes incredible and they are persistent. This is an incredibly optimistic light at the end of the tunnel. Thank you. Thanks, senator franken and to the witnesses who have come. I agree with senator murray. The Health Committee will meet again at 10 00 a. M. Thursday, october 26th for a hearing entitled exploring free speech on college campuses. Thank you for being here today, the committee will stand adjourned. On news makers this weekend we take a look at counterterrorism efforts with Nicholas Rasmussen who heads the counterterrorism center. It was formed in 2004 and tasked with analyzing intelligence that pertains to counterterrorism threats. Watch it at 10 00 a. M. And 6 00 p. M. Eastern sunday on cspan. Close your eyes for a moment. Stretch close your eyes, i see you. [ laughter ] trust me, empathy. I want you to stretch your imagine nation. [ loud noise ]. Open your eyes. Thats how fast it happens, in a blink, no warning. Sunday night, on q a, executive director of paralyzed veterans of america retired u. S. Marine Corps Officer gillums jr. Im trying to tell them from a patients perspective, policy perspective, advocates perspective you have to empathize and why it makes the v. A. The ideal provider for combat veterans who sacrificed. On cspans q a. The Supreme Court began its new term this month with a group of questions of employers who contract to prevent employees in class action lawsuits. The court will decide if such contracts violate the Labor Relations act that give workers the ability to organize for the purpose of collective bargaining or other mutual aid and protection. This oral argument is just over an hour. We will hear argument first this term in case 16285, Epic Systems Corporation versus lewis and the consolidated cases. Mr. Clement. Mr. Chief justice and may it please the court, respondents claim for