to be increased. theirs is going to stay stable. >> who says that? not necessarily. unless you want to say that. >> over time you get a healthier life and that reduces the cost of health care for the entire workforce. >> for the entire workforce. >> mr. chairman? >> we've had a fair amount of testimony. the most conspicuous one, i guess is steve burr with his. maybe we could ask him at safeway, based on their experience, how many employees did they have? a lot. >> a lot, but only about 30,000 are in this program. bv but of the 30,000, or did he find -- did he or other employers find that it was 2% or 20% of their employees who had an illness or some other disability that made it unlikely or impossible for them to benefit from this. if we -- and then maybe there's a different approach we could take toward those people. but, surely if we didn't make it

easier for the safeways of the world to -- as he testified to us, to -- he said -- we said what is the one thing we could do to make it easier for you to encourage wellness and health among his employees. he said take it from 80 to 20. and then if there are 15% who are in effect left behind because of disability or condition, then we should address them in a different way. make sure they aren't being treated unfairly. this seems like such a promising area of agreement. i would hate to restrict it. >> we all agree on that, lamar. it is promising. want to make sure we do it in a way that is fair and doesn't discriminate. i thought kay's point was a good one. if people are doing things to minimize additional costs, that young woman today has got that pump. she uses it. she does all the things she

should be doing. she's still got that problem but she's managing her health care well and that seems the situation where you want to reward a person who is doing that. the fact she's not getting the outcome you'd like, she gets rid of diabetes somehow should not be the ultimate test. >> it wouldn't be. she's probably the perfect example of someone who would benefit from having a higher differential because -- >> i can tell you right now -- >> maintain a healthy lifestyle within her -- >> we're on the same page. i think senator mikulski's question. i thought as we were sitting around talking about this. the safeways, the starbucks, the costcos, the connecticut pitney-bowes. a lot of wonderful examples of very well run corporations that do a lot. obviously, thousands of businesses out there. so and so says i have a wellness program. what is your wellness precinct?

what your doing? i think we want to have some standard other than a declaration as a standard. that's why having a step back before you rush to the 50% and someone just declaring it to be such that you have some ability to make a judgment. and what's a smaller employer as opposed to a -- you have a whole facility. pitney-bowes has facilities on site for its employees. not every employer than do that. but they may have a different idea of a wellness program that will serve their employees in a way that would allow them to encourage that kind of behavior. i think we want to have some taking a step back, other than just branding something being a wellness program. but i'm very encouraged by this program. i think we can really do something worth while in this area. i urge us to spend some time and see if we can't craft something. >> i've been listening. i've spent a lot of time on this issue. and i've asked the department and others for input on this to

try to figure out where to go on this. i happen to be quite enamored of what steve byrd is doing and mr. patelli at pitney-bowes. this looks great. let's just expand it to 50% or 75% or whatever. but then as i began to get more information on it it's not quite as clear cut as it looks. mr. chairman, you raised the point and that is, what's a wellness program? safeway happens to have a darn good one. so does pitney-bowes. but that's a matter of taste. but not all companies do. so we don't have a definition. now one of the things we tried to do in the underlying bill is to give the secretary the power, the authority to start to set up some metrics on this. what would meet the criteria of a good wellness program. and that might be different for

a big company like safeway and maybe a little different for a company that's got 100 or 200 employees. >> if i could just suggest one thing. we have a tendancy to say in the same sentence, prevention, wellness and chronic disease management. and from a policy standpoint we bring that all together. they are three distinct different buckets. prevention is that piece where we're trying to influence somebody up front about making the right healthy choice. >> i'm talking about prevention and wellness. >> and wellness could be taking somebody who is not healthy and encouraging them to change their lifestyle to become healthy. >> losing weight. chronic disease management gets into diabetes maintenance. it gets into heart disease and things that one can do in part in lifestyle change, in part

through regular treatment, scheduled treatment by a physician. i'm not sure that all three of them can be lumped into the same thing. and i think if you look at the savings side, whether it's pitney bowes, safeway, whether it's dell, whether it's sas, whoever it is. there's no question that i think every company is out trying to do prevention and wellness. not every company has figured out how to set the correct incentives in place to do chronic disease management. i just want to draw a distinction between the three boxes. >> the department said that after publication of the department's 2006 wellness program regulations, that's what gave the 20% variance. they said a number of, quote, wellness programs began to proliferate compromised of little more than biometric

screenings to obtain reduced premeiums. these have the potential to discriminate based on health status. so, again, if we're going to have these variations, they should be based upon a prevention and wellness program, not just upon what your biometric screening is at one point in time. they use the example of a cholesterol wellness program that conducts pyometric screenings and rewards participants if they have a cholesterol leading rnd 200. frank is lucky. he's got good genes, despite the fact he's a couch potato, eats a lot of fast food. reminds me of some people. but he passes it with flying colors. his cholesterol is low. however, sally is not so lucky. she's genetically predisposed to high cholesterol. she's a marathon runner. follows a low fat diet. takes the daily staten drug but

her cholesterol is 230. it might be 300 without what she's doing but it's 230. so she flunks the biometric screenings. so that's why we need to have some idea of what is a wellness program beyond just biometric screenings. and again, what is the empirical evidence that raising it to 50% will incentivize additional healthy lifestyles. so far we've seen no evidence that the thousand of dollars already offered are not enough to maximize participation rates already. so some people saying that some advocates appear to be more interested in tlefrg direct cost of coverage to high risk individuals without risk spreading costs across the broader population. that's what you talked to about earlier. and that is as i've said before. one person's incentive should not be another person's

punishment. if you've got a pool and you are putting all the premeiums for these healthy people and stuff like that and sally here can't quite make the grade, do their premiums go up because you've got an insurer. if premiums go down, they've got to keep this all in balance. so they raise the premiums. so i think that's why we've got to be very careful on this on how we structure it. how do we define the parameters of a wellness program. if, in fact, it's constructed on a definite wellness prevention program that has good markers along the way, that doesn't discriminate and if it can be shown that it's not punishing someone who has a genetic problem or someone who is disable disabled, if it doesn't punish them, i can care less. i would be all for raising it to 50%. so i think we've got to be careful in the language.

i think that's why our staffs have worked together with senator gregg. i have modified the -- i have an amendment that i will offer that modifies the underlying amendment. what it does is it returns to present law. it returns it to the present 20%. leave it where it is. but then working with senator greg's staff, we've agreed that our staff's -- any other interested offices, we'll see if we can't come to some type of agreement on these issues and the others that we have identified in section "b" of my amendment. if that's possible, we can incorporate that agreement in title 1 of the bill, which is the coverage section, by the way, of the bill. and where it really belongs. and, if not, then we'll have to offer maybe competing amendments at that time when we get the title one. i hate to put another burden on you, jeff. but this really is in the coverage -- kind of the coverage

area. so is that okay? >> that's fine. if i can just briefly respond to your point. we have to get to the minutia of managing the wellness program. i think that would be -- that's not necessary. basically what drives this is the market. i mean, the whole purpose of having the wellness differential is to drive down the costs of the premiums to everybody in the business that's participating in the program. that's why safeway does this, not because i'm sure there's altruism there but primarily it's because they've been able to freeze over their entire company the increase of the cost of health insurance because been successful in their wellness differential. and that's the incentivizer here. we could never come up with all the lists of the myriad of list of things you might want to do to make people participate? a lifestyle that was better for

them. and it might actually vary state to state. the northeast you might have a different wellness program than you'd have in arizona simply because of the physical ability to use the outdoors. so, i mean, i don't think we want to get into minutia here. we want to set it up to create the incentive for wellness to be a large part of employers' ability to say to people. if you get the prescreening, if you join a gym, if you get your -- if you do -- if you stop smoking, you're going to benefit. and that's going to benefit the price of the insurance for the entire company n that's what's going to drive the decision on the program. they're not going to put in place wellness programs and give them no return in the reduction of insurance premiums. i guess we'll get to talk about this again. >> i want to instruct the staffs here to really work at this because this is one where i really do believe we ought to bridge these -- this discussion

and debate. this will be a very important contribution to this bill. and i am going to ask if tom, you and your staff will take a lead on this thing on our side and judd, i presume you and your side really pull together and coming up with a good compromise on this that will achieve the results and care for the things tom has identified with and yet we heard -- i was stunned by the number on obesity, where you can deal with it, for every 1 pound lost in weight, according to steve burr there was a $50 a year saving in premium costs. that's a remarkable statistic. correct me if i'm wrong. as i recall in the hearing the other day where he testified he mentioned that specific savings in premium cost by that relatively small amount of weight loss where the person obviously could. so it's a very valuable contribution. it goes right to the heart of what i mentioned about the

prevention side of this equation and this bill. if we can really achieve some meaningful results of that lifestyle change is what we're talking about, then, obviously, we'll have accomplished a great deal. >> mr. chairman, i appreciate that. we will work on that. let's all keep in mind that on the finance side, we have a provision in the finance bill that would provide up to $200 a year tax credits per employee for wellness and prevention programs. that's incentives. again, reducing premiums that could be an incentive. but i have a small company in des moines, iowa, employs about 200-plus people. the owner of it didn't start reducing premiums. he found that didn't work that well. he wasn't getting that much reduction. but what he did is he just built a gym on to his workplace. and he hired a full-time

trainer/nutritionist. he went to iowa state. i don't know why i wanted to add that. but then, he said to his employees, okay, this is all voluntary. i want to get you all into a smoking cessation program. and i may be a little off here. i can't remember it. but like if you sign up with our

less absenteeism. he runs two shifts a day, two eight-hour shifts. it used to be that, boy, when the first shift finished for the last half hour you didn't get any work. people rushing for the doors. now he said people hang around. they take care of their equipment. they are more condeucive to working longer. a lot of times their families will come over and use the gym so they stay there and work a little bit longer. so he just found his productivity shot through the roof on this kind of a thing. so when you talk about incentives, premium reductions, yes. might be a part of it, but there are a lot of other incentives out there. and finance committee, hopefully

will have that -- well, i'm sure they're going to have their provision in there. so there are other incentives besides preme amy reductions. >> can we vote on harkin 4? >> a voice vote. >> all nose in favor of harkin number 4, say aye. >> aye. >> those opposed say no. >> the ayes appear to have it. >> i have an additional amendment i want to offer. >> all right. then we'll go back. >> i didn't actually offer an amendment. i was -- >> that's true. >> go ahead with senator binghaman. >> i have one i hope doesn't take very long. this is amendment number one. it provides for modernization of our national disease surveillance system. amendment was developed in close collaboration with the council of state and territorial epidemiologists. it's been endorsed as standalone

legislation by a lot of different health ground, incl e including the american public health association, american society of microbiology, infectious diseases society of america, the center for infectious disease research and policy. the national public health information coalition and the society for health care epidemiology of america. at the current time, many parts of the local, state, federal disease surveillance system are fragmented, are based on paperwork. they have not been the beneficiaries of new technology that could improve the completeness and the timeliness of reporting. the amendment establishes national standard and authorizes existing grant programs to ensure that all state and local health departments and public health laboratories can readily receive, monitor and report infectious diseases and other urgent conditions of public

health importance. the amendment will help ensure that everyone at state, local and federal level is communicating and equipped to rapidly detect and diagnose and respond in the event of a public health emergency such as the swine flu pandemic, which is currently ongoing. my amendment will return lost funding for surveillance and response activities for deadly viruses such as west nile, antivirus, monkey pox, sars and other. the funding will permit state localities to participate in a national disease system for identifying food-born outbreaks such as e. coli and salmonella. this does not establish new programs. i want to just emphasize that for all my colleagues. instead it updates existing

authorizations and does so in ways that i think make a lot of sense. it is authorizing language, and i hope my colleagues will agree that this is a proper -- a proper amendment to a proper set of provisions to include in this health reform bill. >> very comprehensive. very thoughtful amendment. any conversation about this? >> i'm just glad he added the part that this isn't anything new. it sounds like something new, but it sounds like duplication. we've already got the information on swine flu. i mean, i've been seeing numbers on that. we've been following it. so i appreciate your comment on that. so what it is is just an increase in the amount of funding that goes to that. >> it increases the authorization level for three existing programs that are intended to modernize the system. >> any further debate or discussion on the bingaman amendment? if not, all those in favor say

aye. >> aye. >> those opposed nay. the ayes appear to have it and the bingaman amendment is agreed to. congratulations. senator gregg. >> one of the biggest issues in the area of chronic diseases that's going to drive health care costs in the future is alzheimer's. there will be 70 million people retired by 2019. we know that people past the age of 85, the percentage of folks who get alzheimer's is extraordinarily high. i've heard numbers as high as 60% to 70%. alzheimer's is also incredibly expensive disease from the standpoint of the cost to the system because it leads to institutionalization. and institutionalization is of course, the most expensive way to deal with any situation. so basically, what i've proposed is amendment 21. we set up a tax credit for people who care at home for

immediate family members and actually for nonfamily members in certain situations who have alzheimer's. so that we can create an atmosphere out there where there is an incentive to take care of a parent who has alzheimer's or at home rather than institutionalize the person. there's obviously no way to score this as to whether or not it saves money. it's clearly going to score losing money. but you've got to figure when we double the retirement population and, therefore, double the number of people going to into the alzheimer's extended care facilities, that there has to be significant savings to the extent that we can motivate people to keep their parents or keep their relatives at home to care for them. >> well, thank you judd.

let me ask others to comment on this. obviously, i called herb kohl yesterday to get his advice on a judiciary committee matter. i have no -- i have no substantive argument with it. i think your on the right track. but this one we are directly writing the tax provision, is -- i presume you can offer this as well. >> it would just be counseling the finance committee. think of it is counseling the finance committee. >> i don't know if max is going to warmly receive that from the health committee counseling. secondly, one thing we've done, and again, this is a hard point. but it's one that we tried. and i speak on behalf of senator kennedy in this case who, i think, 20 or 30 years ago as a result of what he went through with teddy and the cancer bill. here's a cancer bill they wanted to add to this bill. he has restrained himself from

adding it here because he knew if he did he'd be hard pressed to then say to others who had other areas of chronic illness or disease to put into this bill and it might then start a grocery list of issues. not all of which can have tremendous merit, as this one does. i think judd gregg is absolutely correct about this. this is going to be a skyrocketing cost, in particularly the aging population. we've got to deal with it. but i know several other members. in fact, in my own state from the other side of the body have come to me and asked if i'd be willing to add some specific disease or illness to this bill. i've respectfully had to say, no, i couldn't do that because i felt it would start an endless request, in which case, if we started saying dwros some and no to others we'd end up playing a game here that -- not a game. these are all serious issues. but i think the idea is to try and leave out of this particular bill those very legitimate issues that involve specific illnesses and areas of

legitimate interest and concern. and so aside from the jurisdictional question, which we've -- it's been pointed out, we're stepping all over each other's jurisdiction in these bills. that's an argument. but the more compelling one that i'd make to my colleagues on this matter is that i can't very well sit in the chair of the chairman who restrained from putting his cancer bill into this bill for the very reason and turn around and start accepting ones that have great legitimacy but i think would then open up the possibility of every one of my colleagues here wanting to recommend additional areas of coverage. i say that respectfully, judd. i think your on the money with this thing. but i don't know how you break around that. >> i appreciate both your points. on the first point, i would be willing to change this in the sense of the senate so that we're not clearly engaging ourselves in there. on your second point, in most instances, i would say that your course of action is correct.

but we know there are two diseases that we know are driving -- really driving health care costs. one is obesity. and the other is going to be alzheimer's. we know that. this bill is about health care costs in the future. and if you -- you know, all the other diseases can make a unique case. yes, they drive -- a lot of them can. but nothing -- but they all pale compared to obesity and alzheimer's. cancer is such a diffuse disease. it's not a -- it's not a single homogenous disease event. so i just think in this area, long-term potential for cost is so dramatic that a statement that we're willing to try to push on a policy which will reduce the institutionalization is important.

rchlt >> i'm not going to debate you on your point you make. i think it's a legitimate one. in the sense of the senate, has some appeal. i have a feeling somebody else is going to approach me in five minutes and ask for something else to be included as well. because it doesn't require anything but highlighting it. i just -- i say respectfully, i kind of -- i'll do whatever you want to do, but it's one of those matters. >> if the chairman doesn't want to entertain this, i can appreciate that, and i'm not here to embarrass anybody. so let's just say that it didn't pass. >> mr. chairman? >> yes. >> you predicted that somebody was going to jump up in about 15 seconds. and i'm inclined to do so, but i'm not going to. i have taken a very particular interest in what is happening with als in this country and

particularly lou gehrig's disease and the incidents that we're seeing amongst our veterans. veteran has a 60% higher likelihood of contracting als than a nonveteran. our gulf war vets, they say between 20% and 30% of them -- >> do we know why? >> no, and we're trying to figure out and trying to understand it. but to reduce costs, keep people in their homes, i do think it's worthy of conversation. i'm not suggesting that we do go down the laundry list of disease specific because i think then you run the risk of, okay, we haven't included whatever the disease is. but i think certainly when it comes to alzheimer's and we recognize the impact to our health care costs and then this

orphan disease als is one that quitely where we're just now beginning to see the cost to will will va system, it's something we should be thinking about. but to the extent where so many people can live far berth lifestyles, healthier, more accommodating if they can be at home. instead of a nursing home situation. wherever we can provide respite care or financial help through tax credits or other ideas for those providers, those people in that home