Transcripts For CSPAN3 Senate HELP Committee Hearing On Healthy Lifestyles 20171030

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 delighted 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, every one of whom is important, who 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 witness testimony, 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 tough negotiating partner on our efforts to present to the senate a limited bipartisan bill to stabilize the Insurance Market during 2018 and 19. She and i will go to to the Senate Floor Today at 1 00 and 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 cosponsors 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 srj your prerogative to do and thats what we would expect to happen 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 most 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 refreshing to talk about. An area of health care on which most americans, doctors, employers, republicans, democrats agree. That consensus is that a Healthy Lifestyle leads to longer and better lives and reduces 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, blood sugar, 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 four of the six indicators 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 about wellness to the insurance policies that 178 million americans get from their job. Thats precisely what the Affordable Care act sought to do in 2010. In fact, it was one of the only parts of the aca that everybody seemed to agree on. Todays hearing is about how successful wellness initiatives have been. And what we can do to encourage people on lead healthier lives and reduce Health Care Costs. Many employers have reduced Wellness Programs. These programs may reward behaviors such as exercising, eating better, quitting smoking or offer employees a percentage of their insurance premiums for doing things like maintaining a healthy weight and keeping cholesterol levels in check. These programs have the potential to save employers money and improve the health and well being of their employees. Steve bird, one of our witnesses, a ceo of safeway visited with many of us a few years ago and started a Successful Employee Wellness Program after he left safeway. Which i hope youll talk about. Thats one part of it. Id also like to hear what communities in federal government are doing to encourage Healthy Lifestyle choices. I know Blue Cross Blue Shield of tennessee partnered with local state and private organizations to Fund Community level organizations across the state such as fitness zones in chattanooga, programs in Rural Counties to 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 for medicare recipients diagnosed as prediabetic to prevent type 2 diabetes. Medicare spent an estimated 42 billion more on people in 2016 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 on the health of millions of americans than to connect the consensus of wellness to the insurance of 178 million people. I look forward to the hearing. 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 glad were having todays hearing on how to better promote health and wellness, 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 promote physical activity, improve access to healthy, affordable food. Especially for our kids. Expand on science based ways to reduce tobacco use and a lot more and i will work on providing the local state efforts and that includes Grant Programs by the centers for Disease Control and prevention 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 the fact that so many of those costs can be attributed to chronic diseases, it is critical we do more to support Public Health efforts focussed on Health Education and promotion. I do want to be clear on the following. While we consider Wellness Programs, we have to do it in a balanced manner and make sure we are protecting workers civil rights and privacy. For me and i know for a lot of my colleagues, the fact employer Wellness Programs could impose significant penalties on workers who do not wish to Share Health Information is a very serious concern. So i want to hear today more about what we need to do to make sure we find this right balance that protects workers rights under the american disabilities act and hipaa and the Genetic Information nondiscrimination act. Three laws that were written and passed by this committee. And i have to be clear responsibility for making sure that the rights of workers with disabilities and those do not wish to share Genetic Information are protected and respected in these programs rest with the trump eeoc which is why they push so hard to the eoc nominees who dont show they were truly committed to protecting those workers from discrimination. This is a balance and 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 look forward to the discussion. Mr. Chairman, i do have a letter from aarp i want to submit for the record. Thank you. It will be submitted. Thanks, saeenator murray. Wed ask each witness to summarize your remarks in about five minutes. That will give us more time for questions back and forth. Fifrlt first member is steve bird. 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 and founding chair of the Wellness Institute at the Cleveland Clinic, a program i just described in my opening remarks. Dr. David ash is 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 jafd judge david lazlon center for Mental Health law and engages in advocacy. Why dont we start with you, mr. Bird. Welcome. Thank you very much. I think the first thing id like to say is i very much appreciate the opportunity with to share my experience in the Wellness Community 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. Because its impacted how i think about the subject. Secondly, i want to talk about why we pick wellness as a real important area. Third, im going to cover the elements of the Wellness Program 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 indicative of what others can do. And finally i want to talk about what i think are the five keys to success in a Company Wellness plan because most people have failed at this and i know michael and i and maybe others here that will testify have succeeded. I think youll find some common success elements. After leaving safeway, while at safeway as the chairman indicated, i got very involved in health care and discovered that it was a fascinating area, a great opportunity improve the health of americans, to improve care without adding to cost and dramatically lower cost. So i committed to spending the next ten years of my life and ive now spent four in this space. What i wanted to do was tell you briefly what my company does. Is we do three things that are unique. We are able to low er our companys organizations cost actually 40 to 50 simultaneously lower the employees expense about 6 to 10 and capable of improving the care they receive and if theyre willing we can have a dramatic effect on the population which has 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. We thought as a selfinsured employer with the right to design a plan however we chose, we could actually effect behaviors and people would become healthier. I know you will at some point want to understand how you can reduce costs. In the short run, there are other ways to reduce cost more significantly. The first one i would mention is provider efficiency, then plan discipline, plan design and then wellness. In the first five years i put wellness in the fourth place. In the next five to ten years i would put it probably close to second place or third place. 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 zp and 85 of our employees opted into this plan and 70 of the spouses opted into this plan. We rewarded people for achieving certain biometric standards with about 600 worth of reward and when we polled people, about 78 of the participants viewed the program as very good excellent. We measured was Blood Pressure, cholesterol, tobacco use and the results were amazing. Ill give you a two year look after starting the program. Of the people that failed the Blood Pressure standard two years later 73 of them passed and they maintained that over the balance of the program. Prediabetics, of those that failed initially, 45 of them passed two years later. Cholesterol level, 43 of those passed two years later. 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 of our population from 28 down to 21 . I had a goal to be if we were a state, wed be the lowest obesity state in the United States. Colorado held that position. So when i left in 2013, 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 an outcome 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 viewed that starting point about 600. 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. We con shous developed a culture of health and fitness. I did this when i was about 57 years of age and i understood that my fitness level down the road was going to determine my state of health. Once you become immobile, your health tends to decline. We focused on health and fitness. And lastly it needs leadership and i practice this with clients today and if you dont have ceo leadership, it just doesnt work. I would contend you cant pick three of the five. In my importance, you have to do all five. Thank you, mr. Bird. Dr. Rosen, welcome. 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. In this capacity, 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. That is Health Choices can improve Health Outcomes and substantially reduce costs. We are hopeful in sharing the results over the last nine greers 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 Insurance. But if leaders in washington dont address the skyrocketing cost of health care caused by the influx of chronic disease, it wont matter whether medicare, medicaid pay the it bills. Everyone in this room has seen the cbo estimates. Unless we do something to bend the cost curve, well all be bankrupt from this influx of chronic disease that is growing 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. A step that could save our nation hundreds of billions over ten years and with volunteer participation. Nine years ago the Cleveland Clinic began an ambitious experiment. The clinics reward for healthy choice programs, rewards employees who voluntarily choose to do so, much like mr. Bird, 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 chronic disease and 75 of chronic disease z are driven by 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 disease are controllable in well over 90 of individuals. The Cleveland Clinic rewards for Healthy Program focuses on helping the 100,000 employees and dependents get and keep these six measurements normal, combined with encouraging those two additional behaviors, seeing a primary care provider regularly and keeping immunizations up to date. The Clinic Program helps ploys get these six normals. The way we do it is we pay employees. That is we enincentivize employees. 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. The upshot. Since the onset of the program, the Cleveland Clinic has saved 64 million in direct medical costs. This year we will save over 150 million more versus the bench mark. As more of our employees get and stay healthy. Further their improved health is reflected in unscheduled sick leave and the 62 of clinic employees have seen their Health Care Costs and premiums decrease now by 600 for individuals to 2,000 annually for families. For hitting these targets. Smoking rates have decreases to under 5 while the state of ohios is around 23 . Body mass index of employees for all 100,000 employees together is decreasing. 5 per year as opposed 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 employers. All of whom have seen popular impressive results. For example, a National Construction and supply Company Saving 46 of estimated medical costs as estimated by aetna. We know that other organizations can learn from these examples. In short the Cleveland Clinic rewards for healthy choice programs is doable, supportable and scaleable across the country. The clinic has been working to educate lawmakers on the idea and senators ron wyden and rob portman are collaborating in the Senate Finance committee aimed at reducing the costs of improving health of medicare beneficiaries. But it doesnt have to stop with federal programs. Private sector programs supported by this committee could benefit by the work weve pioneered. This program has at least three critical virtues. Its been tested across different populations and patient groups. Its entirely voluntary and it enables the federal government to achieve substantial cost savings without any of the program added budget cuts and without any initial costs. Bending the cost through volunteer wellness and incentive programs is common sense idea that both democrats and republicans should be able to rally around for both the health of our nations fins and the health of our people and increases the nations competitiveness for jobs. Chairman alexander and distinguished members of the committee, thank you for the opportunity to speak with you today. My name is david ash and im a practicing physician and a professor at the university of pennsylvania. Im here to talk about Workplace Health programs. And their role in the Nations Health. My summary message is this. I believe employer sponsored Wellness Programs have value to contribute. I believe even though the health and financial benefits are often overstated, i believe that even though some of these programs in the ways that i current le designed risk treating some employees 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 we spend about 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. How we eat, whether we exercise, smoke or take our prescribed medications. We can put more and more money into health care, but much of our health is determined in the 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 productive. So more than three quarters of large employers have some sort of workplace Wellness Program targeting risk factors that account for much of chronic illnesses like tobacco use, high Blood Pressure, obesity and the like. Unfortunately its a lot easier to know what conditions to target than it is to know how to do so. Managing these conditions requires substantial behavior change. Our nation has invested considerably in the science of medical treatment as it should, but less in the science of behavior change. Our knowledge of how to break old habits and how to develop healthier ones is rudimentary, but its getting better. Behavior economics is a way were learning. More about changing behavior. Just last week won the nobel prize in economics for saying we the behavior of economicings has been used to help doctors and patients make better decisions and im proud to say that the university of pennsylvania is a world leader in this field. One is called loss e version. It doesnt make economic sense but its how humans tend to think. We found this recently when overweight employees at a large fim to increase their fitness. In one group they were given 1. 40 for each day they walked 7,000 steps. Thats a standard economic incentive. 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. For every day you walk 7,000 steps you are 1. 40 richer. It turns out those that received a 1. 40 were no more likely than those who received no incentive at all. But those who had 1. 40 taken away if they didnt walk 7,000 steps 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 using financial insensitives to encourage Healthy Behaviors. The vast majority do so by adjusting the premiums they pay for Health Insurance. Although it may seem obvious that charging higher premiums for being a smoker or being overweight would encourage people to 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. These programs offer promise but they also draw criticism. 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 typical premium based 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 so much more about how to design financial and other incentives to motivate Human Behavior far more now than even 10 years ago. There is no reason why can t cant be. Thank you for inviting me to 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 appreciate the opportunity to testify about this important issue. My name is Jennifer Mathis. Chairman alder noted my position. But im here also as a representative for the consortium for citizens with disabilities, a coalition of over 100 disabled organizations insuring the self determination, independence, inclusion of adults and children with disabilities in all aspect of society. I appreciate the topic for this hearing. Obviously there are many different ways we can promote healthy choices that improve Health Outcomes and reduce costs. The prior marry concern that animates 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 way that expans pands opportunities expands opportunities, 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 9 chaps the chance 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 focus the rest of my comments on workplace Wellness Programs. A tool to improve life and health out comes, but those programs can and must operate in a way that respects longstanding and important workplace protections such as those provided by the americans with disabilities act or ada and the Genetic Information information act, especially workplace privacy protections. People with disabilities need these protections. The employment rate of people with disabilities is much lower than that of any group tracked by the 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 cites attitude barriers. Perceptions that people are incapable continue to be pervasive. Including in our workplaces. It was precisely for that reason when Congress Passed the ada, one of our most important civil rights laws for people with disabilities, it created strict protections to enable employees to keep their health and disability information confidential in the workplace. Employees can be subjected to medical exams or inquiries only if they were job relled or if they were voluntary inquiries part of an Employee Health program. Gina provided similar protections for the Genetic Information. Including their spouses Health 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 the protection it had enforced for many years to ensure that employers could not penalize employees for declining to provide their Health Information. They instead permitted steep financial penalties for those that choose to keep their Health Information private and 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 violated the law and failed to provide a reasoned justification for this change in position. The agency now has an opportunity to revisit the regulations and do the right thing to afford people the rights guaranteed. By the ada and gina. We believe it is not difficult for the eeoc to insure they promote healthy outcomes while respecting important civil rights of people with disabilities. The agent set out a pass clarifying that financial insensitives 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 Wellness Programs highlighted many strategies other than incentives 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 behavioral decision making. I think its really 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. Mr. Ash, ill start with you, with your expertise in this area. Youve indicated behavioral economics is being used to help doctors and patients make better from tobacco litigation to losing weight to managing Blood Pressure. And you indicate the changes are much less likely to come from typical premiumbasised financial incentives and more from the underlying psychology of how people make decisions, encouraged by frequent rewards, emotional engagement contests, 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 questions for you, sir, is what might they learn from behavioral economists . I think ill start by saying theres a misunderstanding often about behavioral economics in health. Many believe youre engaged in behavioral economics for incentives. No, thats just economics. It becomes behavioral economies when you use and understand our psychological foibls and pit falls to super charge the incentives and make their more potent so you dont have to use incentives that are so large. I think there are a variety of approaches that come from behavioral economics that can be applied in the employment setting. I mentioned one which might be a way to structure financial settings in the employment setting in ways to make it more potent and palatabilitable and yes, sir for all employees to participate in programs to improve their health or certain kinds of social norming where its acceptable to show on the leaderboards and contests and engage in the 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 thailer who just won the nobel prize for his work in this area indicated that he as policymakers ought to have on a regular basis not just lawyers and economists at the table as were 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 to figure out how policies would impact individuals health and wellness and a number of other things. Some of the ideas i think we might incorporate in the government context and tell me if any of these sort of pop for you, 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 actually consider, aside from having a congressional budget office, we might have an entity or at least some presence within the cbo 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. One of the lessons that i guess i have repeatedly learned is that seemingly subtle differences in design can make a huge difference in how effective a program can be and how its perceived. We ultimately care about the impact of these programs. So im very much in favor 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. Thank you, senator. Senator murray. Thank you. Doctor, i want to start with you. Weve heard a lot today about workplace Wellness Programs. I think its critically important to think about the investments we make in our community can be a Critical Role to making the healthy choice the easy choice for families in this country. 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. In our country cities and towns were making the town accessible to all users. 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 color are taking strides to ensure strong culturally competent programs to promote 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 headline thee, when you get food manufacturers to make food for large distribution to your schools that are 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 inner and outer ring schools around cleveland. And its very hard to get appropriate products for the school lunches, et cetera, and breakfast. And so your state is taking a lead in that and we thank you. Thank you. Ms. Mathis, wanted ask you. As you well know, a Federal District court recently held that the eeo commission failed to support its rules on Wellness Programs. Those rules said that an employees decision not to participate in a Wellness Program was voluntary so long as the employee did not have to pay a penalty greater than 30 of the cost of Health Insurance. In other words, thousands of dollars. That high of a penalty is a problem for those employees and spouses who do not wish to risk disclosure of Genetic Information or the existence 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 Information nondiscrimination act, under hipaa and those as i said are three laws this committee wrote and im proud of. As you may well know 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 at the 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 things 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 analyze what is a voluntary question under gina 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. It used the ordinary meaning of voluntary, that you cant require a person to answer or penalize a person for not answering a question thats consistent with the dictionary definition of voluntary which is not impelled by unconstrained without valuable consideration and having steep financial incentives is 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 incentives but not to incentivize or have significant incentives for people turning over Health Information. That i think would allow Wellness Programs to proceed and develop and use incentives in other ways and use many other strategies to engage people without eroding the civil rights of people with disabilities. Thank you very much. Thank you, senator murray. Senator isaacson. Thank you, senator alexander. Mr. Bird, if i remember correctly, the segue way program had financial incentives, 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 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 hipaa regs. I thought they were well thought out. The adjustments made with the Affordable Care act, i thought those were equally thought out. What i dont want the committee to do is get the impression that its all about incentives. I think incentives are necessary but not sufficient. And going back to something that 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, exercise goals. We gave them the tools to accomplish that and track 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 the 80,000 people at the hhs to do it for free. Unfortunately, that was about 30 days before she left office and she was excited about that. But its not just about incentives. And its important that we employed 10,000 people with disabilities at safeway out of 185,000 people. 2,000 were part of this program. And the hipaa regs, when i say theyre well thought out, they allow for and frankly require if the standard that youve set is judged to be too difficult, that you adopt a different standard and even provide a waiver. In our experience and id be interested in what youve done at the Cleveland Clinic about 3 to 4 would reach for and get either a waiver or alternative standard. So while we wanted you to get below a 30 bmi, if you had a 40 bmi and you made 10 progress. We gave you the reward. At the end of the year we gave you a reimbursement check. We enjoyed writing those checks. If you had comorbidities and your physician said id feel better at going from 45 to 43, we would say fine, and thats the standard. Then we would change that over time and im sure that Cleveland Clinic did something very similar. I appreciate the answer because being one whos had about every bad habit you could possibly to have to be a core contributor to your health at one time or another, i know that what got me into health and Wellness Programs was the desire to change a habit. What kept me in was the reward of that habit changing. You said something important and that is if you give the employee or the individual measurements to show improvement and reinforce that along the way, you can change the program to induce an employee thats not healthy into being more healthy. Those things arent easy. Everybody likes to talk about them and every new years everybody practices them for two days but then they go away. If you get reinforcement in a peer group in a positive way, you can really sustain the practice. If i could just add one more thing, i think that i learned this a long time ago in business and it was helpful i had 1800 stores. Rather than just study and hypothesize things, we just did it on scale and skaecaled it up. For example, if i wanted to increase the sales of some product, id put it in the ad, reduce the price and put it on an end cap. At the end of the day i didnt care which of those three contributed most of that. I did all three of them every time i wanted to increase the sales by 20 fold. So we struck upon something over time that worked and it worked famously. We had no issues with it. If you dont know, the Health Standards 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 then we ultimately began rolling that out to all the divisions. Our initial population was 40,000 members. Thank you, mr. Chairman. Let me just conclude with a compliment, thank you, dr. Rosen, for your reference to what the finance committee was doing. Weve in fact done it. The chronic care bill has passed the senate and is tending now in the Energy Committee and the house. So were close to getting that threeyear effort done and i appreciate your reference to that. May i make a comment . I think a couple things he said deserve reemphasis. One is theres an absolute fire wall between the health plan and the company. They dont know why the premiums are where they are or whats driving or not driving it. Secondly, for every person that interact with their primary care physician in achieving those goals, those six goals plus two behaviors and it is a 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. But it is a culture change. It is multiple programs that work. It is leadership as well. Then we also have a large buddy system that we set up that really does the support system. So there are a lot of things. I didnt get into the nuts and bolts but it is a lot of things that work. Thank you, senator isaacson. Senator franken. Thank you, mr. Chairman, for holding and to the Ranking Member for holding this important hearing. Before the hearing started i spoke to all of you about housing. These Wellness Programs that are employer run are very helpful but what were trying to do is to help people be healthy and lower the cost of their health care in the long run. Mrs. Mathis, you pointed out research that shows a strong connection between a Persons Health and stable housing. Despite the fact that theyre actually very often talked about as completely separate issues. In minnesota, han apin health in the Accountable Care organization in the twin cities saw the lack of stable housing was a major barrier to improving the health of their members so they decided to develop a program that paired health care, housing and social services. Just one year after participates were placed in supportive housing, han apin health saw significant reductions in hospitalizations and Psychiatric Care and imprisonment or going to jail. The number one cure for homelessness turns out to be a home. If you can wrap around supportive services, it fields amazing services. I brought this up to all of you. Mrs. Mathis and all of you, could you speak to how a focus on housing, particularly when its paired with social supports can lower Health Care Costs and improve Health Outcomes. I think thats absolutely right. Thats i think a recognition that has become increasingly prevalent in state health Service Systems 20, 25 years ago, 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 authorities would tell you we do housing. Housing is a critical part of what we do. Housing support, housing subsidies, housing assistance, housing local assistance, all of that because all of these things, housing stability, work are all the social determine ant ents of health have 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 of people who are homeless versus people who are in supportive housing, kind of similar twin studies of people in those two situations where it costs us as much money to keep people homeless as it does to have them stably housed with services. I want to hear from the others as well because you all seemed to have responded when i brought this up. Senator franken, thanks for the question and comment. I agree theres a movement and base that recognizes the fundamental importance of housing for those without it. I would probably embed your question in a much larger set of issues that reflect the importance of the social determinants of health. If youre a provider or hospital or Health System and face patients who are chronically ill and readmitted multiple times for congestive lung failure oregon some color some chronic illness, everything that brings them back to the hospital is some form of social circumstance. Sometimes its housing. Sometimes its other social support. At the time when hospitals were incentivized only to deliver health care, those considerations were at least from a financial perspective less relevant. Now theyre much more aware of their responsibility to be part of the solution to the social affec factors that affect health, along with other social determinant determinants. They were always there and now we need to think about the financial incentives at the organizational level that would allow the resources that we have in our society to address them. I want to give the other two witnesses a chance to answer senator frankens question but i want to stay pretty close to the time because we have votes at 11 45. Some would say, senator franken, youre a genius for bringing this up because it is really one of the social determinants thank you, thank you. But the social determinants are really important. Its very 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 in lowering the cost of medical care. First of all, i want you to know that 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. My wife and i have been involved for several years in a philanthropic effort to provide housing to the homeless. And im also involved in another philanthropic effort with a good friend where we take people who have been homeless and have the capability to learn a skill, theyre taught the skill and then we find them a job and they can succeed at that. So i think having a home is really important and that social environment that surrounds it is also something that we create. 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 both dr. Ash and ms. Mathis. I wanted to say first, dr. Ash, were grateful youre here and grateful for the work you do at penn. I guess youve done work with both the school of medicine and at warton but 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 wasnt here for senator murrays questions but i believe she asked a question about penalties and incentives. Am i right about that . I just want to make sure. And 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 the many hours, i guess 5,000 hours of waking activity when were not interacting with the health care system. Senator murray indicated that some wellness plans use both penalties and rewards that can be as high as thousands of dollars a year. Weve heard that dr. Roizens program uses a 30 penalty, the let me that the eeoc set when it issued the rule last year. So 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 would consider to be the mistaken impression that the way to make incentives effective is to make them larger and larger. And that naturally leads to very large incentives putting large amounts of money at risk whether theyre in the form of rewards or penalties. Weve heard of course that penalties are more offputting than rewards and actually sort of jack up the concerns about the lack of voluntariness. But i think its a potentially a mistake to think that way. I actually think that is old, outdated thinking that the only way to increase the potato tentsy of an insin tif is to increase the size of it. The way we design the incentives has much more of an impact. If you can imagine a 500 incentive bundled into someones paycheck. If theyre paid once a week, thats 10 a week. It looks much smaller then. Its put alongside other sorts of elements in the paycheck. It may not even be seen, its directly deposited. You can imagine handing someone two 100 bills and have it be much more potent. I think another mistake is setting explicit targets for goals. If you believe that your employee should be at a bmi of 25 which is the upper limit of normal and you set that as the goal, thats a good way to make people whose bmi is 26 lose a few pounds. If your bmi is 40, thats a demoralizing goal. What we care about is improvement. And pay for improvement programs are going to be far more effective for the people who we find we need to help the most. So i think both Design Elements with the structure of incentives and Design Elements with the target for incentives can be improved by most employers and i am optimistic that they can do that. Thank you. I have more to pursue there but i want to move to a separate line of questioning. Ms. Mathis, ill start with you and invite others to answer as well. The written testimony you have regarding balancing the personal rights of individuals, especially those with disabilities, while also pursuing the goal or encouraging wellness, your references to the privacy protections in the americans with disabilities act and other statues are critically appreciated i think at this time. We know that october is National Disability employment awareness month. And as youve pointed out in your testimony, the employment rate for those with disabilities is very low in comparison to the general population. Those with disabilities have the lowest rate of employment of any sector of our population. Im concerned that 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. And i should just clarify that i think our primary concern about the large financial incentives is around those privacy protections. Folks have talked about the incentives for outcomes and as mr. Bird mentioned there are builtin safeguards in the Affordable Care act that i think do address that concern that 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 sort of implement that. I dont think that certainly we havent heard that thats a major concern. I think that was addressed. Our concern is really much more around the privacy issues and it is true that i think in many cases the information will not go directly to an employer. Sometimes it will if the employer does directly run a Wellness Program. Obviously its not that hard to figure out who has what Health Condition thats identified in aggregate data. Frankly, i think for many people with disabilities just having to turn over your sensitive private Health Information, whoever its going to go to, is 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 and i think its very understandable why people we need to try to stay within the time, maam. Thats all i have to say. Thanks very much. Ill do some followup in writing. Thank you, senator casey. Senator cassidy. Dr. Ash, im an internist as you, and although this is a health committee, nonetheless i feel as if that which were doing in the employer based setting has a fairly mature science. When i think of my patients that i used to care for, the medicaid patient or uninsured, its a bigger problem if you will, some of these wellness issues. You probably have a practice thats somewhat similar to mine. How can we translate some of this we have been discussing for the workplace into the medicaid populati population, which statistically has a higher incidence of chronic disease, morbidity, et cetera than the workplace . Thanks for the question, senator cassidy. I think in most cases these activities can translate. I do think that employers have a special role and a special trust connection with employees that may be not as high as the trust relationship people have with their doctor and their hospital but might be potentially higher than people have with their insurance carrier and that 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 structure allows them to give you 30 minutes to go walk around the track if they have built one there. Medicaid patients taking Public Transportation to their clinic appointment are cigarette smoking and theres nothing you can do to incentivize them against smoking, im not seeing that its easily translated and im willing to open this up to anybody because to me it seems almost an apple and an orange. We have run some programs that were employer based that were designed to reduce the burden of tobacco in employees. We did two studies, one at General Electric and one at cbs, published in the new england journal of medicine and adopted by those two companies. Theres no reason why programs like that could not be introduced into the medicaid population. Theyre incentive based. They were successful. We can think of translating some of the science and learning that weve developed from the employer setting let me stop you because youre familiar with the structure of medicaid which if its managed care they contract with a provider to provide a service at a certain rate and if it is fee for service, youre paying the bills as they come in but typically the patient is not directly impacted by this. The indiana experiment may be a little different in which they prefunded Health Savings accounts. You can build a reward for that. So are you thinking when you say build an incentive and again i hope this to anyone, how would you do that for the medicaid as commonly structured under the aca or any other program . Im not sure i would know how to do it as its commonly structured but it doesnt mean that it couldnt be rethought and state medicaid agencies might think about behaviors or the like that would enable them to engage in those kinds of activities in order to achieve their mission. Im not sure that they can do exactly what i just described under the rules as they are now, but under changed rules, they might be able to. So the state could apply for a waiver asking for the flexibility to incentivize this sort of behavior trying to translate that which you successfully shown works for an employer but to do it for the medicaid population . Yes, i totally agree with that. Would you elaborate or just accept just agree . I dont want to take too much time but basically it is how do you get both programs that work, leadership and incentives into the Medicaid Program and obviously indiana and even ohio are doing major efforts to do that and seem to be succeeding. So the prefunded Health Savings accounts of the indiana experiment really seemed to be quite novel but quite effective. Folks who put in a little bit of money got a lot more in their hsa and seemed to modify their behavior. Is that what youre thinking about . There are other ways of doing that as well but that works. What about things such as obesi obesi obesity . One of the things is again a Culture Program and multiple programs so one program doesnt work for everyone. We have in fact ten 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 curves may work for a group and our own e Coaching Program works for a group but when you get ten programs together you can find programs that people can adopt and in groups if you will participate and succeed. This might be a program by the managed care program to lower their overall cost burden . Exactly. Thank you. I yield back. Thank you, chairman. Id like to start by thanking you and the Ranking Member for your work, your bipartisan effort to fix the system that we have. On behalf of the people in colorado who have been waiting forever it seems for a bipartisan effort here i want to express their gratitude for the work that youve done and i 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 youve 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 cost of health care in this country. So i thank you for that as well and whatever any of us can do to help your efforts, i hope youll let us know. Dr. Roizen, could you describe briefly the bill that you mentioned in your testimony that 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 employers, offer programs, offer incentives to get to there, work with the primary care physician to set the trajectory to improve and to get to the goals, and if you did that, if the Cleveland Clinic number and participation number goes to medicare and medicare is 0. 6 of medicare if chief even four of the six behaviors and standards, if we did much more of that and got the 62 participation and 44 or so percent success at getting to goal, the government would save over 500 billion, maybe 1. 2 trillion. One of the things weve learned is putting stress management in first, even for the medicare population, is really important at getting change. We think this is an enormous opportunity and senators port ma man and widen are working on this. The reason were here in this committee is not about medicare and medicaid but the 178 million americans who are privately insured through their employer who could also benefit from the kind of incentive structures that you and mr. Bird put into place. And other parts of the program. Its not just incentive. Its some leadership, some cultural change. It is programs that help them. It literally changes the way they relate to their primary care physician. So the the way you could there have to be some insurance rule changes that this committee could work on to be able to allow the small non selfinsured cooperation to do this in a way that allows the employee to take the benefit as they go from one company to another, that allows the company to benefit after theyve gotten the person healthier, so there needs to be some rule changes but those are minor and there wouldnt be a dollar spent, not a federal dollar needs to be spent in advance or, in fact, if there isnt an ask for money from the federal government at all its just a rule change. Mr. Bird, 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 just cant resist because of what your job used to be. The question that 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. 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 keeping, 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 halfhour to spend on the treadmill or walk after dinner. One of the things that i wanted to mention about improving health, particularly when you work on bmi, i find that the safeway number is extraordinary. The reason we started at 28 bmi is because the people are on their feet all day. Were not doing that here. We could have had a standup meeting and gotten healthier, but the point is when people just diet and i think everybody here would agree, it doesnt work. The reason it doesnt work, if i lose 20 pounds and all i did was diet, for every pound i lost, a lost a quarter pound of mussel and muscle is more efficient at burning calories, so when you go back to your old habits, you cant eat as much in terms of calories because your burn rate has slowed down. When i talk about an ecosystem that we created, we stress the importance of cardiovascular workouts. We stress strength training. At the age of 60 you can have the burn rate of somebody in their late 20s if you do resistance training. I contend its the secret to weight machines. I would be shocked if you dont do resistance training. I do. Okay. Thank you. Thank you, mr. Burd. Our next wellness hearing will be a standup hearing. Well see what happens. Very good. Even if we just stand up once during the hearing it helps. Im going to be sick that day. Senator warren. Thank you, mr. Chairman. I want to see if i can just ask some more questions along this line. We all know that the Affordable Care act allows employers to offer financial incentives that their employees in order to encourage participation in these programs, but one thing the aca doesnt do is eliminate the protections already in federal law for employers so they cannot discriminate against their employ employees on the basis of Genetic Information, Health Status or disability. These protection sz were put in place by two very important pieces of legislation, the americans with disabilities act and the Genetic Information nondiscrimination act or gina. This is a bipartisan bill. Senator ted kennedy worked with a number of folks on this committee. Last year senator enzy and i wrote and passed new legislation strengthening gina protections so that personally identifiable Genetic Information collected through federal research can never be made public. In short, our nations nondiscrimination laws say that employers can collect sensitive medical information from their employees only if providing that information is voluntary, meaning the employee can decide to say no. I just want to start by asking ms. Mathis, what types of personal Health Information do employers typically ask for as part of Wellness Programs . Ive seen these Health Risk Assessments ask about all manner of health and medical information on a variety of levels of detail. Give you some examples. Specific cancer diagnoses such as breast cancer, cervical cancer, prostate cancer, weight, bmi, whether youre treated for depression or bipolar disorder, specifics about your depression such as how many times you felt depressed in the last week, whether youve had crying spells in the last week, how often you felt like people disliked you, how often you feel happy, whether youve been diagnosed with heart disease, stroke, high Blood Pressure, high cholesterol, angina, bronchitis, obesity, high blood sugar, 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, and those are some of the medical things that they ask about, lots of other questions about all sorts of other life habits. So this is some really Sensitive Information and its supposed to be voluntary to hand it over. Thats right. So let me ask about that. Mr. Burd, when you were the ceo at safeway, you set up a Wellness Program that you called completely voluntary. At the same time that families were charged 1500 more in Health Care Premiums if they 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 Health Care 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. Weve been tested on that numerous times and were never accused of discrimination during the tenyear life of the program. What youre referring to about my desire to raise those limitations that were in hipaa, hipaa originally in 96 allowed a 20 differential based on behavior. If you look at Something Like smoking, the impact that smoking would have Toby Cosgrove would say smoking alone would cost 3,000 more. I didnt say in my direct testimony but ill say now in our experience about twothirds on average twothirds of that comes immediately back to the employees as a reward for making those standards. So its not like they were charged 1500. The 1500 one, that would be if there was a spouse and employee. So we think that we i was questioned about the eeoc. I was questioned by the labor department. At the end of a 45minute interview i was told that i had properly followed the letter and spirit of the law. We had not been accused of discrimination during that time period, and the person that was interviewing me actually wrote the hipaa regs in 1996 or had a role in that and said that if i ever opened up a washington d. C. Office theyd love to work for me. Im glad thats the case and im now over time so i want to be respectful of the time here, but i have to say, when you charge differentially 1500 or sometimes more and that can happen because people dont want to reveal very sensitive personal medical information, thats a penalty. Paying a penalty may be legally all right although as i understand it the courts have said that 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 and i want to raise the issue that i think the question about what constitutes voluntary on this kind of Sensitive Information is one that weve got to keep on the table and maybe do some pushing in the other direction as well. I apologize for going over. May i make a quick comment . This information is not revealed with the company. Its revealed with the health plan. Theres an absolute fire wall between the health plan and the company, and in fact, we fire people who break that health plan because we have a tracking system. Every other health plan i know has a tracking system. If you break that fire wall, you get fired. Dr. Roizen, all i want to say is, what the law says is that the revealing information has to be voluntary. It is. But its with the health plan. It will cost you 1500 if you dont reveal very sensitive medical information. I think stretches the bounds of what constitutes voluntary. Thank you, mr. Chairman. 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, and the Cleveland Clinic is certainly not the only one to suggest it. The mayo clinic says the same, lots of people say it. Relatively few things that we could do that dramatically effect about lifestyle, that dramatically affect chronic disease and chronic disease is 84 of our Health Care Costs and wrs ta 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 when youre looking at an employer plan but insurance is clearly 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 mr. Burd and dr. Roizen, how big a problem is it, has it been for you in your employer plans to successfully deal with concerns that ms. Mathis has talked about and senator warren talked about and that others have asked 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 1,000 roughly exceptions requested by physicians who say this person no matter what we do with them cant get to that normal. Those are excepted and they get a different plan. In fact, in some of the extreme examples, someone counts the amount of water they drink, bottles or glasses of water they drink a day to hit the health plant target and get a premium reduction. So you have the opportunity to say i need a different standard or i need an exception . Thats exactly right. And that you have to have you therefore try to provide a fair process to meet that objective. Ms. Mathis, does that work . I think i heard you say it probably did. Right. Thats not the primary concern that we have. The primary concern is the incentives for disclosure of information. Right. And mr. Burd, what would your comment be . What kind of impediment actually, youve talked some about it but the reward or penalty for healthier lifest e lifestyle, that been a problem . I would say it has not been a problem and 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 witness stawas a good idea. I reported my public earnings quarterly in a town hall meeting and in a broadcast, and i reported on the health of the organization. People would catch me individually and ask me some questions about it and when they really understood it they quickly opted into the program. To michaels point, theres a fire wall there. When you have a premium differential, you really just risk adjusting the premium for individuals but then 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 kmi committee to really focus on is that weve got two practitioners here, maybe three, and there are very few people, less than 1 of the companies in this nation that have turned back obesity, that have improved results on Blood Pressure and cholesterol and smoking. So these programs and michael and i have not had a chance to put them out in all their glory. They work and nothing else has. 21 obesity rate versus the nation now close to 40. Thank you, mr. Burd. Were close to to be voting in few minutes. Dr. Ash, i would assume based on your Behavioral Research that 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. Well take it under advisement. Senator murray, do you have additional questions . I dont. I know that senator franken i think had an additional question. Ill say i know we need to go. This has been a really good hearing and we have a lot of work making sure we do this right. I think its critically important and of course balancing workers civil rights and privacy but this has been a really important hearing and i appreciate everybody being here. Thank you. Senator franken. Thank you again both for this hearing. Its very refreshing to be talking about keeping people healthy and having a Health Care 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. I just want to return one thing on the housing thing which is on the opioid crises. I had a visit yesterday from i think it was yesterday from boyce ford which is a band of ogibwe in minnesota. In minnesota weve had an explosion in opioid use by especially in Indian Country. In Indian Country, housing is an enormous issue. As we go into this opioid its being declared a crises and emergency, i would really like to see like a Pilot Program where people come back for treatme 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 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 and that they have people that are in their same boat and in recovery. So instead of a peer group which is the other a peer group that has a high drug use, theyre having a peer group of people in their own fellowship. Thats just 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 words, they have to be sober before they come in. They get tested while theyre in that safe environment. They get constantly reinforced. So 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 the senator and i put in the aca. Senator grassley and senator collins have been very helpful in getting cms to do medicare. What we learned is this is a 16week program that was piloted at the ymca in st. Paul and in indianapolis by nih and cdc. This is why it was me and senator luger who put it in. It turned out, 16 weeks of both nutritional training and exercise and after five years this is people who have high levels of sugar in their blood, glucose, and they were 58 less likely after five years to become diabetic, 70 less likely if they were over 60 which is why cms is now in the process of implementing this so that anyone in medicare who wants to get the Diabetes Prevention program will be able to take this 16week program and have it paid for by medicare. Can anyone speak to why this has been successful . Weve got about 20 seconds. You get behavior change which is consistent. You also get buddy its a group so you get buddy support. You get everything that a Wellness Program should be and youre targeting one of the specific high cost things, hemoglobin a1c or diabetes. Its a great program. The fact that this can be done without medication, without financial incentives speaks to a Strong Program and it has outcomes incentives sfoes a Strong Program. It has outcomes you mentioned that are incredible and they are persistent. This is incredibly optimistic looift light at the end of the tunnel. Thank you. Thanks to the witnesses for coming. I agree its been a terrific hearing. Weve learned a lot. The hearing record will remain open ten days. Members may submit Additional Information before that time if they like. Meet again thursday october 26th for a hearing entitled exploring free speech on college campuses. Thank you for being here today. The committee will strapped adjourned. Tomorrow morning cspan, brock long testifies about the federal response to hurricanes. Live 10 00 a. M. Eastern cspan. Also watch online cspan. Org or using cspan radio app. Live on cspan3 tomorrow afternoon exccutives from google, facebook, twitter testifying on russias use of social media and its influence in the 2016 elections before Senate Judiciary subcommittee at 2 30 eastern. Watch live online or listen live with the radio app. During thursdayed washington journal, were live in austin, texas, as part of the cspan bus 50 capitals tour. Former senator wendy davis will be our guest on the bus at 9 30 eastern. Next, a hearing on Campaign Finance regulation of political advertising on social media. Well hear about russias purchase of political ads on facebook for 2016 president ial election. Texas congressman will herd chairs this nearly twohour meeting. Subcommittee on Information Technology will come to order. Without objection the chair is authorized to declare a recess at any time. Good afternoon. Todays hearing is part of a series of hearings the i. T. Subcommittee has held to analyze existing laws and regulations that may have become obsolete updating technological advances. Weve held hearings on health i. T. , drones, autonomous vehicles, internet of things and many other issues. Today we turn attention to laws and regulations governoring political advertisement hearing. Civil Campaign Finance laws, Disclosure Requirements from Public Information for campaign candidates, parties or Political Action committees related to federal offices. In additionhe