will sell more seles's the people think there are healthy rather than listed as one of a there is a book called eight this not that. and it shows you windigo into what fast food restaurants with the good things are to get there and the bad things are it is surprising what some of the bad things are in those places because you think the chicken in a rap would be less calories than something in a bun. but i'm getting a little far afield as like the new billion dollars so i will relate this is for. >> and how to respond. what senator enzi has done is take out their preparations, and does mention a couple by list some of the others and mentioned a long time ago and repeat them again that is covered that would be covered under our title. on chronic disease prevention

here right now heart disease and stroke right now of the current funding 42 states are currently funded for prevention and control programs were at $50 million a year. we seek to boost that considerably. diabetes, all 50 states are currently funded for dives prevention persisted $2 million. you think of all the money we spend in health care 62 million for prevention of diabetes. arthritis, nutrition -- 13 million, of physical activity, obesity 42 million in 23 states health department's. at cdc is $104 million and all that these days just on tobacco. and smoking. comprehensive school health, cbc

provides $54 million to all the schools in the u.s. oral health for kids and current funding of $12 million a year and i to go through, there's a whole lot of others and give you some idea what of the amount of money that we put into prevention. now the other thing is the community transformation grants. those of go by the wayside also. but the trust for america's health last year issued a finding title prevention for health care american investment yield significant savings and their studies showed that a return of $5 and $0.60 for every $1 investment in community-based prevention and cited in number

of different communities around the u.s. that have done certain things and then they tried how much will the health expenditures were in those communities before and after and that is how they came up with this and the amount of savings that they showed only took into account the clinical safety, it did not show added productivity more people working in not taking absenteeism and things like this here is simply clinical savings from community health programs. all of that would fall by the wayside with the adoption of the eminent. >> mr. chairman. >> yes, we will go back and forth. >> mr. chairman come it strikes me that even though we have all talked about examples even though we have all talked about the samples you mentioned this morning we have talked about safeway and the others. the one thing that all these companies point out to us was one we just offer the program will people did not enroll here

and that it wasn't until we got accretive as a company in some cases actually have given employees cash to enroll in front disease programs or in nutritionist and employees were massed together and some of their works on diabetes maintenance and diabetic mashed together it wasn't until who they really started an intensive education programs on crime disease management that -- and understood what was a need to do an experience after the first 18 months it is where we all want to get two-parent would make this observation this is not about how much money we are willing to spend on prevention and wellness and disease management, this is how well we design the system so that educational process takes place. no and there are two things that are absolutely crucial if we

want prevention, willis and chronic disease management -- to have been successfully and i would say that the third one is probably more important to me standpoint of savings. immediate savings and that is quite disease management is that you have to have education at barrett is impossible to have that level without a medical home. which means that every american has to have access to a medical home and that can be the emirate as a room. two, coverage. without those two things prevention and wellness and disease management are not good to happen and i'll say it third thing we have learned and to lay from the self insured companies enrollment. a buying by the individual employee and the patient and now i think with the fundamental disagreement is that the self insured companies did not turn to ensure it did in turn to the government to create the programs ultimately that were

successful. they did with the marketplace suggested and that was offer this service to your employees. with only 20 percent of your sick and rolled for a company like dell and a highly competitive business there weren't when to stop there so that actually paid employees in the% enrolled in the program and they saved money per enrollee today and i'm sure that the goal is 100 percent. unfortunately we are treating this pot of money and not necessarily creating the pathway to get there and i'm also sure that the money actually is conditional to the success of the program. is the education and is the coverage that is key to it and thirdly the enrollment of the individuals so the bill that we are considering the use of 36 million individuals uncovered. that is the cbo numbers and until we get something that

changes that is what we've got to go by there is senator harkin pointed out very correctly and that low income americans probably need this more than anybody. on and that is on medicaid population, but we are doing nothing as it relates to medicaid. if you look at the senior population or chronic disease management is something that extends life that is beneficial if you look a preventive services we went through this and 98 and when some on both sides went to the table with a list of preventive coverage items we cut that back to five. we covered things in medicare like mammography and psa, diabetes management, chronic heart disease i think was one of them won, colonoscopy -- things that we take for granted in private insurance that they cover a day in and day out of the list was cut off and my only

point there is government has a real bad track record at understanding how to do prevention well as a chronic disease management that if we're going to do that and we're serving going to spend the type of money talking about in this category then must be very prescriptive. of let's make sure it is when to happen, let's not just the of the money out there to create the funding of programs nobody will participate in. i assure you that were ever the funding and up they will come out with their specific guidelines that we can be assured any money was a give manager of so if we are going to err on the side of anything less mention the have making sure that we are reimbursing doctors to do the education to show the importance of like running disease management and participation then it really doesn't matter what if we've got them in rolled the programs are going to take care of themselves

your note the virginia has a very aggressive program for telemedicine as relates to diabetes management. we don't reimburse the federal government for telemedicine, we don't do it in medicare or medicaid even though we have got around the country's these incubators and community health centers that are doing telemedicine for chronic heart disease and now we're remotely they can check some of these low levels and began to adjust their medication so they don't end up in the emergency room in a three day stay to adjust their madison. my point is understand and don't question what is trying to do but i'm not sure that he gets step one. want to begin to get people educated, covered and rolled that we will have a better feel for whether the back end in need sizable amounts of money.

emily will find that the system will, in fact, that these people in a better position house why this and ultimately into the right incentives are there for the individual meeting competitive market where premiums go down because you're healthier that is the incentive and the the individuals in this country make. >> senator sanders will. >> will begin by picking up on a point as an observer raise and i entering 60 million americans have no medical home. and the evidence is quite clear that we are losing thousands of people, i talk to positions in vermont and 20,000 americans die every single year because by the time to get to the doctor there too ill to be treated successfully and one of the things we're doing in this bill and i want to thank the chairman is we're going to expand community health centers to every underserved area so that

every american will have the medical home and put more money into the national health service and do what the primary health-care crisis and to the dentist in need to provide the care needed. but i wanted to touch on another issue. talk about the cost of health care and senator culver is right that we end up spending phar-mor than any other industrialized under sri for health care and often our health care outcomes in terms of life expectancy, infant mortality and disease prevention and preventable deaths are worth the these other countries. senator gore and i will disagree as to why that is all. we're the only country in the industrialized world that emphasizes that where private health-insurance companies dominate our health care coverage and alan argue that there are many hundreds of

billions being wasted in administrative cost and profit sharing high ceo compensation is cetera and we will discuss that later but i wanted to make a point in relevance to the issue of prevention what we don't talk about often enough is that our life expectancy and significantly lower than many other countries. and when you look at life expectancy and from an economic class perspective which you find it if you are pour that is a life sentence. that is a death sentence in america because poor people and working people live significantly lower life expectancy is an upper-middle-class there and that's a fact and that has spread among expectancy between the wealthy and working people growing wider. there was a study that came out and i'm not mistaken and to mention kentucky where there are

a number of counties in america where you may have seen the study or women have seen what a decline in the life expectancy. hysterically life expectancy all over the world is going up and there are a number of counties and think of and in the south and lower income areas where women more than men have seen a decline in their life expectancy primero because of chronic disease and there are some people and i don't know of this is true but i have read in information message just because of obesity and other crime problems the and regeneration for the first time in history will have a lower life expectancy than their parents so i think all of this beast u.s. senator harkin is trying to do. the winning a revolutionary change in the way we do with prevention in this country and it is not going to simply be with employers. some are doing and break john but, on the other hand, there

are some for a dozen different reasons, there are cutting back and eliminating the private health insurance providing to their work and we're seeing more of that. one of the important provisions and was senator harkin is trying to do is dealing with school based health care. sure we want people to get educated on the job appear and i would argue that a better place to get education about disease prevention is in school and i think we should put a great emphasis on school based health care which is what we're doing here and other areas so the bottom line is if we're serious about trying to keep americans healthier in trying to save money and think prevention is the way to go in and think this bill begins of the revolution we need in changing the paradigm puebla. >> senator greg. >> i don't thank you change the

paradigm by throwing money and giving money to some cabinet secretary. that doesn't change it, in fact, it aggravates the paradigm because we have proven the bureaucracy in washington does a good a good job of managing the medicare system for the medicaid system. waste fraud and abuse and incentives for people to live healthy lifestyles and that the medicare system has mess of this events were held late lifestyles so setting up a billion dollar a year annual fund noir without any oversight basically ends up being secretary/ms. nilsson's this emmy this bill and the cbo's for this bill as costing $2.3 trillion when fully implemented over 10 years and not pay ford and the bill is anibal to score the most expensive part which is going to

be the employer mandate and a public plan. so this bill is headed to a 3 trillion to $4 trillion pricetag front page and added to the event and there is no reason to aggravate that with another $80 billion basically walking around here and it just doesn't make any sense. if you want to create incentives in the public sector to changing the medicare rolls for people to pursue a healthy livestock i have a number of amendments to accomplish that and to simply throw a bunch of money on the table is the old way of solving the problems and not the way we should proceed with his we have to start banning year the cost curve. we're going to spend a billion dollars in the context of three to $9 or it is an unwanted. we could start here and try to bend in the cost curve.

i don't understand a new claim mad this bill will is going to reduce the amount year cost of health care when you got this core versus an expose the about your cost of health care and don't even have the full bill score. and don't understand how to climb this bill is conducive giving to improve the health care delivery when you have 47 million uninsured people when this bill is finished spending $2.3 trillion we don't have a plus is still have 30 million uninsured so philosophy seems to be disconnected from the goals which are to cover everybody in america, and everybody insurance in debt that costs of health insurance in the eye years and certainly this amendment is a time to get us back on track toward having affordable event here. >> senator white house.

>> just two points. with respect to spending will we have very significant market failure with an eye on prevention sign of health care in this country would hear it if you are an entity that is insured and you want to put the other and prevention per m you have to take all the trouble and all the rest into the recruiting and you don't get the savings. if the savings will approve 15 years later wandering that person is not likely to be insured and 15 years later. and they may very well be on medicare.

i think it is very important that we admit the reality that if we're born to solve that conundrum there has to be some spending on this and with respect to why it doesn't show up the savings we have a them publicly saying two things -- one, is one today executive administration to make this work and because we can't calculate for that it is not mechanical and can you do a number because it is given to take some experimentation and innovation and things we should have competences in, that is a great honor to been a real country, we can calculate to that but he has sent that is rational to expect

some of it in savings. we just can't calculate it in so i think it is very misleading to suggest that because of cbo's limitations their inability to put the savings side of the ledger and cannot put the cost side that this will save money. that says more about cbo than the reality of prevention and even cdl admits that. they say there really is substantial savings that can be achieved through health-care reform that is hard for them to quantify because we've done to win this fight and can't just lay out a hand in have to happen automatically but it is a fi we have to the airport and we never started will never get those savings on i respectfully take a different view than my colleague him and senator mccain. >> thank you mr. chairman and again i want to apply their patience and your courtesy that you have continued to extend to us recalcitrance on this side. >> i won't put that to a vote

but i appreciate it. >> i do thank you, you have been more than generous with your time and allowing us to express our views but i would also like this to ask the chairman first of law and tristan from media reports that you submitted to cbo cost request estimate of three options for employer mandates. will you share those options with this side? >> absolutely. >> you have submitted for cbo estimate? wamp we would be pleased to see that. as to in regards to address in this some time ago. when i been the committee transformation branson line think that the object is. excellent, but are we looking at spending a billion dollars to create the infrastructure to support i still living and

access to nutritious foods in a safe and are meant? what does the means? assessing and implementing were assigned to wallace and program incentives, working to highlight all the options at restaurants and other food menus. this is astonishing lack of specificity and it seems to me from my experience around here when a billion dollars is turn it into specific programs this just creates a plethora of the pork-barrel in your mind projects. it seems to me that we are turning over a very large amount of money to the federal bureaucracy and to the appropriations committee to earmarked a lot of this money to specific programs. i would be glad to hear the chairman's response to that.

>> any other members wish to be heard in? i think senator harkin went through and explain that, while the numbers are talking millions of dollars would right now is about a $2.3 trillion cost per year for health care, exceeds anything anywhere else run the world and we're all familiar with the numbers vary 46 to 50 million without insurance although i have broken down into prostitutes that 46 million in remember any in north may have been one year but it holds up every. maybe even more so given the economy we're in an somewhere around 90 million any 12 months are without health care for a time. not necessarily the whole year but some point we talked about those who may be conniff without

health care throughout the entire year one point or another that many of our fellow citizens are without health care coverage. we have this morning with women we talked to suffering from lyme disease and when, 17 years before they adequately diagnosed your where she was accused of being a hypochondriac which is not uncommon with lyme disease. another young woman was diagnosed with type one diabetes at 15, not overweight, never smoked salmon never did anything wrong in some of life's all. as we know it is a growing problem and she now finds herself in a situation where she is pale or 400,000 month into a health-care plan, million 400,000 a week so she is spending about $120 a week on health care costs alone and that is going to expire fairly soon. in just two examples of what goes on. what we're doing here and green with which you said yesterday

and i strongly agree that clearly one of the major provisions of our average if we're going to bend these curves is got to get people to change livestock. if people continue lives down here this isn't going to work despite all of the effort is making in other places and we don't change that this is not want to work so bottom of incentivizing whatever else we can do now we did try to model and a way that we can help achieve those results. i think there is this is where i would disagree with richard and i think i suspect we're questioning on this i think there is a value in creating the structures we will where we are achieving those. it wasn't just a question of incentivizing by providing vacation time are lower-cost and that actually build facilities in that place some in addition

to a lifestyle change they invested the money in a wellness center where so they could take did manage of the incentives on site. not everyone can do that but i think tom harkin is suggesting with his proposal over 10 years which is a fraction of health-care cost is to build into the system here and obviously for lack of a better and incentivizing employee but where rican is a look across the range of ages use can they think about this as well in terms of how women make a difference so when we talk about people getting out into what they're doing in terms of visible exercise that is a mandate requires investment in this area with an anyone suggest going to work perfectly in will be out

government functions. we know there are dangers associated with this but deeply concerned that if we didn't make these investments were wounded or incentivizing people's personal behavior and responsibilities we're going to come up short of that going and actually changing lifestyles and getting people to reduce the cost. our system is entirely dependent upon people showing up in a doctor's office or hospital to get well. that is entire system here and we're fundamentally trying to alter that and incentivize the system this is you don't show up at the doctor's office. it is safe fundamental alteration of how we have been conducting health care and to achieve that goal of 90 make that shift, how do we move this 300 million people in our country and the coming generations and a chronic

illnesses. with and we do what we can to move that shift to the juan assigned. it is a herculean investment and anybody tells you it is fine to produce the results doesn't know they're talking about. it is hard to do this but absence of trying to do but i guarantee without it will fail. when so i'll be the first to admit i don't of this is going to work or not. and what we don't now have incentivize individual the now predict what the outcome here and which represent and i see no indication that the costs will decline or that the numbers of uninsured are going to go away as we wish them to appear in this is a bad we are taking a chance and all of us need to admit that but doing nothing

about this absolutely guarantees an outcome. >> no one advocates. we do advocate not pursuing a plan that according to cbo will leave two-thirds of the american people uninsured and cost a trillion dollars and that is the plan before us and that is a new reason why it seems to be keeping adding on a billion dollars for treating the infrastructure to support active living in access to nutritious food in a safe environment. that is a very nice motherhood kind of thing. how does that translate into an efficient expenditure of the taxpayer dollar? what we're looking at according to cbo is expenditure and in this plan over a trillion dollars is still living two-thirds of the american people without health insurance. maybe we ought to look at what private companies and corporations are