I would say basically impossible to get a c. G. M. Without Health Insurance because most people who are under uninsured cannot afford the cost of a c. G. M. And all the supplies that go with it. So therefore the American Diabetes association is really supporting people having better access to health i shaourpbs. Easier access to Health Insurance insurance. Easier access to Health Insurance so they can afford the medications and instruments and the throlgs technologies that can help them have a bert life with relation to their diabetes. Mr. Beyer thank you, very much. Dr. Herman, im very excited about the effect they are having. But i agree with you that we cant just think about take ago pill to solve this problem. What are you concerned about the downsides, the latest reports of stomach paralysis. How are we balancing the negative side effects on these . Thats a really important question. Its quite clear that the many patients that take them experience some sort of gastrointestinal side effect. Including slowing of the transit of food through the g. I. Tract. And some combination of constipation, dire rea diarrhea. We have put together algorithms to avoid some of those side effects. Most people, if they continue those medications, they tolerate them even with some of the side effects can go away with time. Castro initsal side effects do not seem permanent or persistent. Some people cant tolerate the medications because of the side effects and choose not to continue them. We move to other options. The majority of patients can tolerate the medications and those side effects tend to wane. The other aspect of your question is what are the longterm effects. To date we have not identified any significant longterm adverse events or effects related to it. Lower tkpwhraoeu seema, reduce reducing cardiovascular events. Producing they are saving lives. We have not identified any longterm adverse consequences at this point. Malliotakis ms. Mallioitakis diabetes are some of the main drivers. One third of medicare spend is attributable to diabetes population and as the obesity rate in the u. S. Continues to rise, so will the rate of diabetes. Nearly 300 million diabetes currently accounts for 1 4 of all u. S. Health care spending. The Congressional Budget Office has identified several options to rein in costs. However many of these could be harmful to our seniors. Already suffering from inflation. Promising new drugs and medical devices such as glp1, owe democrat pick ozempic, and glue close upon glucose monitoring. Other innovations are happening in the Health Care Space to treat diabetes, obesity, and other diet related diseases. Again, people can live longer, healthier, and happy lives. One of these innovations is medical nutrition therapy. M. M. T. Is providem. N. T. Is provided by a nutritionist. Who shaozs healthier food who chooses healthier food. In a nationwide study, a Large Health Care providers showed that 130 per member, per month savings or nearly 1600 per year giving members over 65 access to this type of nutrition guidance. Today in medicare only diabetes and renal disease are covered. While obesity, prediabetes, and other chronic illnesses which lead to diabetes related to poor nutrition is not. Yet if we look in the private space and medicaid, we are seeing m. N. T. Coupled with tools to stretch peoples food dollars in ways that allow them to meet their diet, cultural, religious needs saving costs to patients and the system and improving health outcomes. My staff recently met with a company that works with private payors, Medicare Advantage plans and medicaid m. C. O. s. They have data that shows m. N. T. Patients lose an average between 4 to 6. 5 of their wait and continue losing weight after year two due to behavioral changes. Should Congress Press entities like the Congressional Budget Office to review this data to help us understand how we can leverage additional programs as a strategy to provide relief as well as taxpayers continually paying for it. Dr. Ippolito my short answer is i think compared could use any budget help they could get. If you got a proposal that could save money, that seems like something we should look at. Ms. Mallioitakis im joining with congressman garbarino. Dr. Herman, how would these reforms in the snap program affect the rates of obesity among recipients. Do you believe this would play a role in reducing Government Spending on epwaoes eut related chronic conditions . Dr. Herman i am not an economist or epidemiologist. The effect of changing policy on spending is outside my expertise. Lifestyle management is always a part of diabetes and obesity care. And demonstrated benefits. Ms. Mallioitakis at the end of the day the real question is will it help people improve their health . Will it lead to healthier options for americans who are snap recipients so they can meet these choices. To not allow for prepared or hot food is a mistake that probably pushes people into a different direction or some of these preserved foods. Ms. Brownfriday any time anyone has the opportunity for a healthier diet, they would take advantage of it. And what you are proposing starting at younger ages, the younger you start, the yucker you are exposed to healthier foods, the more likely you are to continue that into adulthood and prevention i think is the key. I that i that prevention of obesity is definitely something that can be beneficial. Ms. Mallioitakis thank you, both. Chair schweikert ms. Moore. Ms. Moore thank you so much. I want to thank the panel for being here today. I was caught up on other duties, and i was late. I was listening to a lot of your testimony before i arrived. And i was intrigued, dr. Brownfriday, by some your testimony that talked about diabetes, the offset of diabetes starting at younger ages. And that not juvenile diabetes by type 2 diabetes. Do you attribute that to the junk foods and stuff thats been talked about . To what do we attribute that . Ms. Brownfriday i want to make a correction. I am not a doctor. I am a registered nurse ms. Moore thats good. Ms. Brownfriday very proud to be one. In terms of types of diabetes starting at younger ages, this is something thats been a concern for the medical community antiAmerican Diabetes association for quite a and the American Diabetes association for quite a while. I agree with dr. Nygren, that the availability of Healthy Foods and having fast foods, not just for for me, who works in the bronx, its access to mcdonalds and other fast food companies. There are higher fats in the foods and younger people are nod at a younger age to healthier foods, then the more likely you are to have those foods when you are older. Ms. Moore its counter intuitive for us to be cutting fruits and vegetables from the w. I. C. Formulary, as an example, and upping things like cheese as part of the formulary for w. I. C. It just doesnt make any sense. If we are trying to curb the cost of diabetes to be cutting fruits and vegetables out of w. I. C. Thats my statement. I wont make you say it. I am intrigued by the disproportionate presence of diabetes in black, native americans, and latino communities. I guess, dr. Herman, there is no genetic proof that these folks are disproportionately susceptible to enduring diabetes. What would you say would who do you explain the disproportionate onset of diabetes in these populations . Dr. Herman thats really an excellent question. And i dont know the answer to that question. I will say there are many investigators out there looking at that question specifically. What we do know is that obesity and diabetes and the populations is an interaction between genetic background and environmental exposure. That includes diet and exercise and all sorts of things. So if there is an increase and prevalence of obesity and diabetes in one population, its some combination of a change in their environment, interacting with their genetics, which is not changed, or decades of producing that outcome. It takes intensive research to identify within specific populations what those specific factors are. But there are many scientists and physicians out there searching for those answers within specific populations points. Ms. Moore thank you so much. Your testimony, i think ms. Brownfriday, made the testimony 85 of people who have diabetes are obese. Are overweight. This is one of the reasons that im so happy that i have reintroduced a bill called the treatment and reduce obesity act. I think it will give us Great Results with regard to stemming one of the causes one of the present features of diabetes. I want to ask the president , the nominee oneida, in my state of wisconsin, has taken on a culturally relevant project to use sort of native foods to stem the tide of diabetes. Can you describe what you all are doing in the Navajo Nation to include culturally relevant foods . Congresswoman, thank you for that question. Very happy to hear that our other tribal communities are doing that. And on behalf of the nation, one of the things we are doing is walking and running. Thats been a part of our culture. At the same time introducing them to foods such as fruits and vegetables that all of our at all of our events, along with almonds and nuts and things like that that help promote a healthy lifestyle. Dr. Nygren one of the things we have always done we take the best practices and try to focus on one of them for the year so that we can implement and educate our people on that. So we really have taken an approach where we invite the people out to the events and they do a walk, run, or educate them on foods. As far as farming, we are really trying to reintroduce farming. Navajo people have been farmers for a very long time. Its just that its a lot easier to drive a couple hundred miles and get a bag of groceries than do the work to produce Healthy Foods. Thats something that we are really working on. Thank you. Ms. Moore my time is waning. I want to get another question in with dr. Brownfriday. I didnt understand why the continuous glucose monitor is not available to more lowincome people. Is that something that is not authorized by medicare . Or what are the dynamics in terms of getting these continuous glucose monitors available to lowincome people . Ms. Brownfriday unfortunately, i am not an expert in medicare. And so what i would have to say is that in general what i have heard from patients is that their insurance will not cover the cost of utilizing the continuous glucose monitor if their blood sugars are not at a certain rate or take ago certain number of injectable medications. Those are the things that are regulating ms. Moore the bureaucracy. Ok. I yield back to you, mr. Chair. Chair schweikert well talk about that because theres been a crash 2349 price in the price of those units and a new product that came on the market within the last six weeks. Dr. Ferguson. Mr. Ferguson thank you, vice chairman. I want to thank you for hosting this. To the witnesses thank you for your time, presence here matters. We learned a lot. Thank you for taking time out of your schedules to help educate us. I want to start my comments by saying that i truly believe that diabetes is probably the cruelest and most underrated disease in america. There are a lot of other things that get a lot of attention, and im glad to see this body is stepping up and focusing on this. Because it is such a long, debilitating process, many times we tend to ignore because we dont see the rapid decline of someone. This is important. Thank you for being here. I was a practicing dentist for 25 years. I saw the oral effects of this. Week in and week out in my practice. I also saw the systemic effects. My ability to treat patients was greatly restricted. How they responded to care, how they responded to infections. How their body responded to antibiotics played a role in their overall health. I want to if he cuss on focus on something that this committe so questions have already started to go to. Because both your comments about what are you doing in terms of food is really important. I want to start with dr. Herman. If you go back and look at the last, i dont know, 40, 50, 60, 80 years when did we really see the explosion, exponential growth in diabetes within various populations . What sort of the time line and how has that accelerated . Dr. Herman i think the dramatic increase in prevalence began largely in the 1970s, both obesity and parallelled by diabetes. Those dramatically increased at that point. The increase has been pretty consistent since the 1970s. Mr. Ferguson when we look at things that have changed from a policy standpoint, this may be a question for anybody on this panel as well that may have a better history on this than i do. What in the early 70s changed 1970s changed our food supply. What did we begin to prioritize . And what was the what was the biggest part of that . It was calories, right . When we started to value calories over quality nutrition, then we set this thing in motion. When i first started my dental practice in 1992 i could tell the difference in kids that grew up in the country on well water, and kids that grew up in the city limits. They grew up on chlorinated water. Their oral health was dramatically affected because the kids that grew up on well water had just they were ravished by cavities. Income didnt matter. Kids that grew up in city with chlorinated water, without regard to income, they had much Better Oral Health outcomes. As i went through 20 years of practice, coy no longer distinguish between the two of them. And the common link that i saw in this was the food supply and the increase in sugar in our food supply in every form or fine carbohydrates. I think we have to be very focused on our food supply. We can talk about spending more money on snap. Again, i think cutting fruits and vegetables out of nutrition programs is absolutely lunacy. I also think that funding allowing folks to buy high sugar content foods is like saying we are going to pay somebody to keep smoking while they have lung cancer. I dont mean to equate the two. Lets be smart about what we are doing here. President nygren, when you have done the work and you talked about the success that you have had, what other other than money, whats the most important thing you think of do you think we should be doing as a government in terms of nutritional aspect of what your programs are focusing on . Dr. Nygren thank you, congressman, one of the most important things is being able to tailor the nutrition and program to navajo people antidifferent tribes across the country. Which is important that every tribal nation is different. There is different foods and exercises that they use throughout their history. But if we can continue to tailor that. I know over the past 20 years or the past decade when we have actually been able to tailor more geared toward more navajo foods, types of exercises the specifics have gone down because we were able to tailor it to work with the existing dollars we have been getting. Its been very helpful. When we continue to think about the groups specifically to their needs, its easier. I know up on navajo as i mentioned earlier, its very remote and brutal. But there is so much access to processed foods. There is not enough options that people can have more access to. I think education is very critical in that part. Thank you. Mr. Ferguson thank you. I think we we shouldnt try to make this a make false choice here of either addressing the food supply or continuing to innovate. Its going to take both of these in my humble opinion. Ms. Brownfriday, just a comment. Again i practiced in a rural area. My hoefplt was about 64 africanamerican hometown was about 64 africanamerican. I saw this on a very regular basis. You talk about access to health care. Access to Health Insurance. I want us to move i truly believe that americans have access to some type of health care whether its medicaid, whether its private insurance, whether its care on the exchange. I want us to really focus on utilization. I could tell you in my practice, patients had access to care. It was the utilization of the system. And all too often what we saw is that too many of our fellow americans live in poverty. And they live in the crisis of the moment. And the preventive aspect of health care and the early access many times takes a back seat to a plethora of other emergencies going on in somebodys week in a given time. I dont mean to lecture you on this. Please dont take that. But help us talk more about the utilization of the system in addition to making sure that people have access to care. With that, mr. Vice chairman, i yield back. Thank you again for hosting this. Chair schweikert mr. Kelly. Mr. Kelly thank you, mr. Chairman. Thank you for being here today to discuss this critical issue that faces too Many Americans that carry not only physical but also medical effects on families, but also high costs for folks that live with diabetes. And president nygren, great to see you again and being here. Thanks for being an important voice tpopb this issue. I spent a good a time in the Navajo Nation. And i know what the impact of diabetes has on our tribal communities. We have had 22 tribes in the state. And this disease has dire consequences. And there are a lot of individuals that are suffering from this. And many are members of your tribe and the other tribes. And i know you worked very hard to imprets upon the federal government impress upon the federal government the importance of the special Diabetes Program for indians. Could you talk a little bit more in depth about that, the impact it has had on the Navajo Nation. Tell us why its so important that congress reauthorize this program before it expires at the end of september. And what are the consequences if we do not reauthorize it . Dr. Nygren thank you, senator kelly. I appreciate, always happy when you spend time in our community and all the communities across the state of arizona. One of the effects that i have had is read the statistics here for the first time diabetes prevalence in american native alaskan native adults has decreased and done so consistently in four years, dropping 15 . From 2013 to 2017. I think just a decrease in diabetes was great through the program. Also diabetes related mortality has decrease interested about 37 during those times. These are so stats. The key thing is there its decreasing. Whatever the percentage is is that this program is working. And we are really trying to its very unique. There are over 300 communities that have served across the country. I know i think about a dozen thats tailored to the Navajo Nation. Overall i think its critical because we are trying to make sure that we can continue to have Healthy People in our communities so that they can thrive. For it to be renewed, which is coming up very soon, and i think both the senate and the house has approved it for 170 million through their committees. Thats 20 million more than the 150 we were initially getting. That 150 has been consistent for 20 years. This 20 million is a good amount of increase to really help us get some of the some of those programs out there implemented right away. Its critical in terms of not every Indian Country is the same. But a tailored approach and partnership we have been able to develop through this program has really helped us. I always see pictures of our elders. They were slim. They why fast. They looked very healthy a lot of the times. When you look through history, as the president i have access to historical photos and things like that that i look at thats within our community. They were farmers, ranchers, they were gardeners. You just look at how healthy some of these people looked through history. And then you look at the people now its very sad to see that we have come from very selfdetermined, selfresilient people to people just really trying to fight for their lives on a daily basis. I think that this program is critical. And i definitely would continue to urge both the house and senate to approve this. Thank you. Senator kelly what would happen if we dont reauthorize it . Dr. Nygren all of Indian Country would lose staff. They would lose the program. The people. Senator kelly what the consequences of that would be . I think we no what the consequences are. Dr. Nygren you would lose a lot more people to diabetes. Senator kelly people would die. And probably in significant numbers. Dr. Nygren significant numbers. And you would also a lot of people would lose hope and faith and it was just be very think it would break a lot of hearts. Not only are you looking at communities that already in dire poverty levels, you would put them in even tougher situations. Senator kelly for seniors, now capped at 35 a month. Some other individuals the pharmaceutical companies have provided insulin at 35 a month. That could still be a very very hard to afford. For members of the Navajo Nation, one of the poorest areas of the country. That is true for the other tribal communities in the state of arizona and across the nation. Its critical that we reauthorize this program in september. Thank you. Chair schweikert thank you, mr thank you, mr. Chairman. This has been a fascinating discussion, and i think they important that we hold this hearing. Obviously the chairman has said previously this is a driver of our Health Care Costs that will impact our future expenditures, our future debt. Its also, as hes fully aware, affects so many other areas. It affects the ability for individuals to lift themselves out of poverty by taking a great job. It affects that workforce Participation Rate that is so critical for us to grow an economy. And it affects the everyday ability of individuals to live their lives to the fullest. Mr. Smucker i think there are a lot of things we can do for our smits stitz, but if for our constituents, if somehow diabetes could be solved, it would have a dramatic impact. Than anything else we could possibly do. By the way, the same thing could be said for heart disease, for cancer, and for alzheimers. All of these are drivers of all these conditions, including our expenditures, including impact on peoples lives. Its been a great discussion. I agree with so much of what has been said here. I agree with senator lee that we should create a system that promote additional private investment, private innovation to help to develop new solutions for treatment. But i also agree with others who talked about the Government Role in this. I have always supported investment in n. I. H. Funding. Which is very, very important to drive to drive the Underlying Research and development that leads to some of those innovations. And then like it or not, i think government has for a long time been engaged through the choices that incentives maybe is a better way to put it. The incentives we have had in the system regarding nutrition, regarding the food that people eat. We have done food pyramids. Recommendation. School lunches, recommendations there. And then we have done the snap program, the farm bill. All of these help to lead to decisions that folks are making about their own lifestyle, about their own nutrition exercise, and so on. So we are in this like it or not. We ought to be looking not only to the opportunities for additional new treatments that we could help to ensure that the right conditions are there for those to develop them. We ought to be incentivizing the right human behaviors to prevent the disease to the extent that we can. That individuals can prevent in the first place. I guess the first question i have, dr. Herman, i would like to get your thoughts. We talked about the link between obesity and diabetes. We talked about the link from the early 1970s of kphodization of food. What we have promoted. How much of diabetes is related to these lifestyle choices that individuals make . Just imagine for a minute that people are eating healthy. They are exercising. Doing the things we know are good lifestyle choices. How much of diabetes would we do away with if that were the case . Dr. Herman thank you for the question. Its an excellent question. It was quite clear that a significant proportion of type 2 diabetes is the direct result of obesity. And its also clear that some lifestyle choices play into the development of obesity and diabetes and that path. Its hard to quantify how much of the lifestyle, which components of the lifestyle or other environmental factors are the specific factors that have led to this epidemic. So there is a lot of controversy around what are the specific nutritional components or combination of nutrients or in what fashion are they presented that leads to obesity, per se, and diabetes. Its clear that that is a major component. Its hard to nail down an amount. Mr. Smucker anybody else want to take a stab at that . President nygren, you talked about programs and exercise. Anybody else want to take a stab how much we could resolve if people were making the right choices and had access to the right nutrition . Dr. Nygren as president of the one Navajo Nation i noticed, thank you, congressman, when people get out there i think they are really enjoying these walks and their runs and opportunities to educate themselves on Healthy Foods, healthy diets, healthy lifestyles. I have seen a lot of people change turn around. They tell me, president , this is what i looked like a couple years ago. Now i have been attending these events being hosted and sponsored by this program we are trying to get reauthorized. To me it helps. It helps doctor matically. I dont know the percentage or dramatically. I dont know the percentage or number. I think overall mental health, depression, diabetes i think it really just helps the person overall if they could eat healthier and participate in exercise. In my community its really been working. Mr. Smucker i dont know go ahead. Ms. Brownfriday i think you said a very key thing. I think the availability of the Healthy Foods is really a very big key access. You said lets imagine everybody is eating healthy, thats not the case. Everyone does not have the Healthful Foods or they cannot afford the Healthful Foods out there. And i think that thats the key that we have to think about. I think that definitely as president nygren was saying, when people are introduced to things and they are interduesed to healthier introduced to healthier lifestyles, they want to take advantage of t im not saying its 100 , but that for the most part. Those who i have worked with, who i introduced healthier lifestyles through lifestyle change programs have embraced it. And have made significant changes. Again its access. Mr. Smucker i couldnt agree more with that. We dont maybe know the exact amount, but dramatic impact we all would agree with that. I think this is a wonderful discussion to have in regards to how we can ensure that new treatments are being developed. I think we need to spend a lot of time figuring out how Government Programs today are incentivizing bad nutritional choices. Talking about the snap program. Im talking about the farm bill. We subsidize a lot of Agricultural Development as well. A lot of farming. We ought to be thinking about how we can ensure that we are educating. We are encouraging people to make the right choices. And access is so critical. And i completely agree these are discussion that is we really should be having to help to enscheyer that people have abg to help to ensure people have access to the choices and what they should be. Thank you for holding this hearing. Chair schweikert thank you, mr. To my good friend, peter. Senator welch thank you, its very good to be with my colleagues from the house. The two issues that we have been talking about, everyone seems to be focusing on, are nutrition and exercises. If you get diabetes, you get into the incredible medical challenges that folks face. I am interested in what are the policies. Its tough to get good food. Dr. Ferguson left, he was talking about how being poor is a hard job. Its a fulltime occupation. Just to try to figure out how to get from here to there. You might have to take three buses. You are supposed to get in your car and go. You have to try to figure out where you can get something thats affordable for you. Which isnt necessarily the most nutrition nutritious. Im interested in hearing from each of you what are the two things that could be done to try to help folks who are really lowincome and struggling with a lot of the everyday challenges. Trying to make things work. What would the two policies help both with nutrition and make an exercise available. Dr. Herman. Dr. Herman in terms of exercise, i mean the things we do with every patient we see is start with simple things, which suggests trying to get 10,000 steps a day. These are things that cut across socioeconomic status. That are shown to be beneficial. And senator welch 10,000 steps. How we doing today on that . Dr. Herman im probably about a quarter of the way there today. Senator welch dr. Ippolito. Dr. Ippolito ill raise one thing that is important. If it functions through insurance we have to be very careful we dont allow Insurance Companies to use policies that are nominally designed to be helping people be healthier, but really just risk select. They try to track Healthy People on to your insurance. Of what the policy i flag that as one. Senator welch ms. Brownfriday. You deal on the ground with lots of folks. Ms. Brownfriday i do. And i think access, as i have been mentioning multiple times to more nutritious foods. More vegetables. In both rural and urban areas. As well as safe areas for people to exercise. Thats also building infrastructure. So they can exercise in safe environment. Senator welch the thing i find about exercise, the more easy it is to do, integrated into whatever your day s your day is different than my day. How do you find a way within your day. Anybodys day, for them to get the exercise. To got to the gym, thats a project. Ms. Brownfriday it doesnt have to be going to a gym. Having a safe place in your neighborhood. I do have these conversation was some of my patients. Do you have a safe place to walk. Or can you just walk up and down your stairs. Talk about me personally, i get up at 5 30 in the morning. Would the gentleman yield. Ms. Moore what about these medications and behavior modifications, medications to ozempic, what about that as an intervention . Dr. Herman, anybody . Sure, so it is clear that medications like ozempic and that class of medication they are very effective in helping people suppress their appetite and reduce their caloric in take and reduce weight. They have not been approached ae if used widely as a preventive measure. Dr. Herman its probably matter of time before folks, like yourself, think about utilizing interventions like that in way from a Public Policy perspective. Ms. Moore i yield back to the gentleman. Senator welch president nygren. Dr. Nygren thank you, congressman. One of the things i think about is try to start early for our young kids. On navajo a lot of reservations there is not a lot of parks. Not a lot of playgrounds. And not a lot of places to play basketball or any sports activities. I think one way for us to do it is probably to create those parks and facilities so kids while they are younger can learn how to exercise. As adults to have these facilities opened to them. A lot of reservations, a lot of these things are funded by the tkpwofpt, but they are closed off they are only opened from 8 00 to 5 00, then they are closed. And after school, people that have left high school, dont have access to go and exercise. Senator welch thank you very much, i yield back. Chair schweikert i dont think i said congratulations. Senator welch i know a house code when i hear it. Chair schweikert i saved myself for last because for some of my colleagues here, this is a fixation for me. For me it starts on the economics. I have had a number of you say 25 , i can actually show you really well pier reviewed numbers Peer Reviewed numbers. 33 of medicare spending is related to diabetes. I hope everyone will get a chance to read the republican joint economic report, chapter 3. We went to places, very uncomfortable for some, we looked at diabetes and obesity in society and cost, low cost, potential effects on quality. Let me prove what an idiot i am by just talking. We over and over and over and over have this discussion. Changes in the farm bill. Access to the technology, the new blood glue close. A new one got release glucose, a new one just got released. The adoption of gop1s, those in the morbid category, or type 2 diabetes. Now we have the single shot, which is fascinating. And number four, maybe by the end of the decade for our brothers and sisters who get their weight down. Im seeing data about 30 of that population which had type 2 diabetes, their bother will not produce insulin again. So new steps not just the cadaver bleaching muscles that some of the ones in type one that look like they have already have high efficacy. There may be this path over the 10 years of a radical change in diabetes in our society. And our math thats five or six trillion dollars are spent in the 10 years. Its real money. It might be the one path we have where our brothers and sisters on the left and those of us on the right might agree on something. Tell me where im right. Tell me where im wrong. Im willing to take the beating. Dr. Herman i think youre right. Ill say this from the perspective of a physician who has been treating these conditions for a couple of decades. The last decade has been a revelation with the new technology and these new medications. We have things to offer patients for the first time that are incredibly effective for conditions that were previously very difficult to treat. And the options seem to be improving. So im very optimistic about the possibility over the next 10 years and applying these medications technologies more widely. Dr. Ippolito ill highlight perhaps we often see the transformational developments in the pharmaceutical market or devices that are one shot. We dont have that here. We have classes with lots of different products coming to market that have different benefits and costs. But thats beneficial in the shortterm because it means you have a competition with the formularies, price competition in the shortterm you dont always get. Beyond that you as a patient have four options to choose from. Can you choose whats best for you. Also highlight can your budget window, i understand the focus for you guys, when you think about the cost of drugs and technologies, i think you have to think longer term. You had huge savings when things come off patents, which happens in the case chair schweikert there are some that are ending their cycle. Dr. Ippolito right. As that starts happening. Its not that those price goes down, it puts pressure on the remaining on Brand Products to compete with those. Ill signal a hopeful appoint on the cost side i dont think it will be quite as devastating as some other projections are. Ms. Brownfriday also my perspective i would say im very thankful and hopeful that all the innovations do come to pass and that its available to everybody. And i want to say also in terms of costs, insulin wasnt always extremely expensive. And it became expensive due to whatever the situation chair schweikert we have had a fixation on the coop about 70 miles from here. Not too far from where you are. That actually is also producing even lower than the subsidized price. But the revolution is here. I do have an intense concern that it be available for all populations. Ms. Brownfriday i agree with you. If indeed it is. Chair schweikert Navajo Nation, i have been blessed as a young man i spent lots of time in the community. Most folks who have never been there dont understand. There is rural and then theres the Navajo Nation. And you actually have a really tricky job because lets be honest, it looks a lot different than some of the chapter houses near the border. Im incredibly hopeful with your leadership. What can we do if my fantasy is change the farm bill access to the blood glucose management so you can see it to understand your diet, maybe living on fried he pwr bread, even though its delicious, its difficult. What else can i do other than just funding another program . Is that revolution something we can actually deliver to the navajo people . Dr. Nygren one of the things im glad you brought that up. Even with broadband, im trying to bring it up to that level. Startling. Chair schweikert no more waiting for 25 years to go out to that chapter house. Put up the damn satellite. Dr. Nygren if we go down that route. Some form of the latest technology thats coming out, it would be great to implement it within the programs so that its being staged instead of later down the road. I think having that better coordination so we can get it out to those main facilities out there. That would be a key thing. Communicating with federal partners. And the nation. And being able to have our people have access to the latest and greatest. Chair schweikert some people say this is a tker riff derivative where mr. Beyer asked the question. Im blessed to represent maricopa. I lived my whole life next to that community. And fort mcdowell. Its an economically stable community. Being that close. Its an urban tribe. Yet i have seen data that said maybe the second highest per capita diabetic population in the world. Their sister tribe may be number one. Sometimes its more complex than just saying its poverty. It turns out time as some said. Sometimes our need for Vice President pence and those things. And thats why sometimes sometimes our need for those things help. Those who care passionately tell the story maybe it is time for a revolution and what we do in the farm bill. Maybe just growing the same commodity crops. Where north america used to grow 3,000 types of grain. Optionality so you dont have to process to make the profit. The new technology. Im dying for the apple watch that actually have blood glucose in it that might be two generations away so i might buy a samsung. Last one got that joke. G. O. P. 1, every day im reading an art erikle somebody coming out with a new an article somebody coming out with a new product. There may be some out of the patent expiration. Maybe the crazy thing is we buy the damn patent. And use that for medicare, medicaid, Indian Health services, v. A. Populations because the savings is remarkable. Sometimes those of us who are on the right sound cruel because we are talking about the dollars and sense. Dont talk about the morality of peoples lives and ability to participate in society and the income and equality. The four of you actually on the cusp of the thing that may be the one point we can if we can build a unified theory here that could have amazing impact on u. S. Sovereign debt and economic growth. But it cant be what a lot of us here do which is we talk about the one thing we know of eating onion rings. Have you ever had a taco . Ill explain later. The last part here i need to give myself, this is the danger of being unscripted, i owe thank you to the democrat staff and the republican staff. Thank you for actually communicating with each other on this. This is one where the Solutions Great economics, and wonderful morality help us tell the story. The last i will give you is if any of you have things you want us to read. We are not walking away from this. This is the only path i have to dramatically change the direction of this society right now. Send it to us. Well continue to evangelize it. Then for all of you, you have i think it is another how many days additional for the record . Three days. In the house we do a lot more. If you have other documents you would like us to put into the public record, please send it our way. Please do it within three days. If you send it on the fourth day ill still put it in. With that we call this hearing adjourned. Thank you for participating. [captions Copyright National cable satellite corp. 2023] [captioning performed by the national captioning institute, which is responsible for its caption content and accuracy visit ncicap. Org]