if someone has a heart attack, you go and you talk to them, or diabetes. i had a friend who recently tried to take his life basically because of the recession. i'm sure there was pour involved. but business. we all know this. these stories are out there. i said absolutely, send flowers. i'm calling. most people don't know what to do. but you do the same thing you would do no matter what the particular illness is, and tchats part of the way we need to educate people. so when i first approached this whole subject, i really was astounded at how we couldn't discuss this publicly and the kind of shame and stigma that was attached to it. i think that's something that we really have to address. we cannot allow it to be trivialized as a character weakness when it is a medical disease. now, part of the answer in combating all of that is in research that's being done and yet to be done, the role that genetics and the environment play in the general siss of the most serious -- in the general siss of the most serious mental illnesses. part relies on access to needed h

unlike doctors and nurses who fight canence or -- cancer or researchers who fight cancer or lupus or diabetes, the border patrol agents are getting shot at and die. whether we want to call it a war or what we want to call it, the individuals who use these individual markets do not wake up one morning and discover that a heroin needle got put in their arms or somehow they were snorting crack in their sleep or snorting cocaine in their sleep. in fact, it is somewhat different and i want to make sure that our men and women of the border patrol understand that there is bipartisan support to making sure that we keep our borders secure that we continue to block illegal markets, that we continue to block terrorists, and you are our first line on our huge borders and we cannot thank you enough for risking your lives for the rest of us. i yield back. the speaker pro tempore: the gentleman yields back his time. ms. sanchez: mr. speaker, i am prepared to close, i yield myself such time as i may consume. the speaker pro tempore: the chair recognizes the gentlewoman from california. ms. sanchez: i thank t

whether a person is making the best efforts to comply with the program, say, to deal with their diabetes or high blood pressure. senator dodd gave an example of someone who has a significant genetic propensity to diabetes and yet even though they might have it, they are keeping it under control. they are an aggressive tester. they are consulting on a regular basis with a diabetic educator. so they are doing all improvable, demonstrative steps. but they still have it. who decides, is it secretary of hhs? is it the employer? is it the person who is -- the self-injured. by the way, i want to promote these employer based initiatives. i think they are outstanding. but you see who decides whether someone is in compliance or making "a" for effort. >> the differential is 20% and the employer sets up the procedures where the person gets prescreening, stops smoking, who pursues healthy lifestyles, gets an economic benefit from the differential. >> we heard one employer talking about -- >> but the decision process won't be any different. it will mean that differential can go up to 30% with the potenti

maybe by avoiding the bypass operation, or reducing the level of complexity of diabetes or preventing it in the first place, it might be a better way to get the better health and lower cost. if you just focus on episode not going to incorporate that. very important element of getting to higher value in health care. so some efforts are focusing more directly on paying for higher value. i'm going to spend a few minutes talking about accountable care organizations and accountability for getting this goal met, getting better outcomes for a population of patient, better health for population of patients at a lower overall cost. and that can be done through a shared savings, so this can be added into current payment systems without radical change to give providers an opportunity to share in the savings that they create when they take steps. they currently are reimbursed or not enough or are being reimbursed exactly for the right patient. whatever it takes to get better outcomes and reduced the average cost of the patients they are treating, should provide better support. it should be channe

organize within neighborhoods based on a database that was available where we know the prevalence of diabetes or high blood pressure or other major conditions. we would organize neighborhood class is where we would teach people about restrictions and improving diet and how to take medicine properly and we would try to have individuals like public health nurses who would check in on people have difficulty with compliance -- >> dee dee single-payer would facilitate that -- >> we would actually have enough money to pay for it. >> i'm going to give dr. angell the chance to answer and then go to mr. klein. >> i'm skeptical about your premise that 70% of care costs go to the chronic disease. >> its 80% and 75%. >> i know at least 30% goes to overhead, administrative costs and profits so all the rest don't go to these chronic diseases but still, to go to your point. we have as i've said a market-driven system that preferentially rewards specialists for doing highly paid tests and procedures. that's why we have more specialists and other countries, way too many specialists and why we have too few primar

they pay more when it gets better compliance with diabetes medication or better results and other specific aspects. the challenge is there are some dimensions of important quality of care that even if you get improvements in some specific areas and can be hard to have an impact on overall cost and our overall health outcomes for a population so and many of these demonstrations when we have seen is an impact on specific aspect but may be less of an impact on overall cost because additional payments offset savings that might occur because you've got improved performance. more of an emphasis on trying to bring cost and reducing unnecessary cost directly into the performance incentives. a lot of effort is underway to implement the episode based payment when there is a payment based on a particular procedure like bypass operation and the hospital care, the physicians' services and may be a case based piven for diabetes and these might be adjusted for the illness for the patient but the idea is you get paid the same amount or more if you deliver better quality care and those payments can be righ

prevention, including the quality of ambulatory care, which can check the progression of diabetes, hypertension, or chronic disease, and through this, incidences of stroke and heart attack. at the very end of the causal chain is the world of disparities. the quality of medical care matters much more than the disparity in the quality. in the 6.5 year life expectancy gap and the 4.5 racial gap for women, which are larger when one accounts for the conditions, they are unlikely to be affected on the focus -- with the focus. the preoccupation with trina disparities is an end game, and it simply misses the fact that many minority patients simply find themselves confronting the end game sooner than everyone else. thank you. >> thank you. doctor? >> thank you for the invitation to -- whoops -- to address you today. is this better? thank you, chairman reynolds and co-chairman. my name is sally satel, and i work at a methadone clinic in northeast washington, d.c., and i wanted to give you an overview today of the contours of the health despair to debate. now, what do i mean by debate? there is certainly no c

so even though it has been painful as heart disease or coronary diseases, and diabetes, cancer recovery -- you name it all the ellises that were so familiar with and that have come through kind of their own transitions in being socially acceptable we need to understand that mental illnesses are exactly the same way. we also need to understand that they have unique effects on family members particularly because of the stigma and shame. if you have diabetes to go this is somebody. i have a friend who recently tried to take his life basically because of the recession. i'm sure there was more involved but business -- we all love this, the stories are out there. and i said send flowers, i am calling -- most people don't know what to do but to do the same thing you would do no matter what the particular illness is and that is part of the way to educate people. so when i first approached the whole subject the really was astounded and how we could discuss this publicly and the kind of shame and stigma that was attached to its. i think that is something that we really have to address. cannot all

i do not even know what to say or how to say it. i am a diabetic. i am a long-time diabetic. i have been diabetic for over 30 years. it was so hard for me to get my shivers down. i tried for 30 years. -- it was so hard for me to get my sugars done. i tried for 30 years. i met a man from italy who has been here about 30 years. we're going to have to get more aggressivprogressive. i have already emails barack obama about this same subject. i got my sugars down. my a1c was 15 at one time. everybody in america wanted to be at least six or seven. i almost died. with insulin and the chemical medications combined, i started taking some herbal products. we have to get with it. i saved my kidneys. i saved myself from going on a dialysis machine. i have gone from 15 down to 6.1. my cholesterol -- host: i'm going to have to stop you. that is a lot of information. do you want to summarize in a question? guest: i need to sit down and talk to somebody. i need to show you the evidence and proof. -- caller: i need to sit down and talk to somebody. i need to show you the evidence and proof. i

making sure that they have access, those with cardiovascular problems, as small, or other pulmonary problems with diabetes, that they have access immediately not to primary care but to specialists who will be taking care of them and act with their quality of life would be much better and we could save money. but in order to do that, the way the system is structured right now, we are spending too much money, we are not achieving our goals as we showed. host: stone mountain georgia, lee on the republican line. caller: how are you folks? governor, i just wanted to make swans a brief comment. one is i think it would be in your best interest, with all due respect, to actually think about running for president of kennedy in 2012. i say that not to joke at all -- presidential candidate in 2010. to get your reference -- message out regarding statehood for puerto rico, and also just being in the public eye it would cause more individuals to be concerned about your plight and i do believe taxation without representation is a hypocrisy we do not deserve in this nation. guest: thank you, sir. certainly i will do anyt

is making sure that they have access, those with cardiovascular problems, asthma, or other pulmonary problems with diabetes. that they have access immediately not to the primary care but specialists that will take care of them actually quality of life will be much better and we could be saving some money but for that in order to do that the way the system is structured right now we are spending too much money, not achieving our goals as we should. >> host: georgia, on our republican line. >> caller: good morning, how are you both? >> guest: good. >> caller: i wanted to make two brief comments -- one is that i think it would be your best interest with all due respect to actually think about running for a presidential candidacy in 2012 and i say that not to joke at all. the main thing is to get your message out in reference to state could four puerto rico and also just by you being in the public eye it would cause more individuals to be concerned about your plight and i do believe that taxation without representation is in hypocrisy that we do not deserve this nation. >> guest: thank you, sir,. certainly i w

but for every individual that you can put on a program of wellness and prevent diabetes from taking place, or at minimum delay the onset, you are changing that person's life for the better. you are making a material difference in the life of that person and their family, but you're also in a more global sense saving money for the health care system and you take that one person times the entire country and the entire group of people who you can delay the onset for not just diabetes but any affliction which they may later get in life, you can prevent injuries if you keep people healthy. the weekend warriors and so forth, joint injuries, arthritis, the onset. these are very costly diseases to treat. and they can be debilitating in many cases, but they can be prevented or at least made better in many cases. so this is the type of thing that we want to incentivize in our health care system for which right now there is no incentive. under our current reimbursement in health care, we reimburse based on the number of times you show up in the doctor's office. their incentive is almost for you to be si

or hispanic. african-american women have higher diabetes, liver disease and hispanics are expected to die more from diabetes which modern medicine can now treat and manage adequately. hypertension in african-american lead to 80% stroke mortality rate, 50% rates of disease and 32% higher rates of renaturl disease. when we initially look at these datas we thought access to care was the suspected reason, however, even in veterans hospitals where access is not as much of an issue, major health disparities continue to exist. studies have shown that physicians are less likely to refer african-american african-american forbes cardiac catheterizations. and current theories on cardiovascular disparities is racial discrimination in treatment, genetics, environment and demographics. there are new theories emerging about the health disparities. first there is epigenetics or changes in the dna by consistent exposures from diet to stress that can be passed from one generation to next. it underscores the cumulative effect of poor socioeconomic conditions, discrimination and inequality of education of opportunitie

if someone has diabetes and can self monitor his or her condition and treated, it costs a lot less and has far better outcomes if you put off carom to when you have to have your leg amputated. the messages about the positive aspects. wellness is definitely a positive step we can take. when the more powerful messages to emerge is the idea that your insurance company should not be able to deny treatment because your 65 years ago where a child has asthma or your of a certain age. i think hitting those refrains when your messaging to the public and talking about a, it is sending the resonates and people understand both from it making sense without it getting into the number of dollars that goes to chronic care management and could, and just highlighting the potential in terms of the wellness and cost savings. >> that is an example of the sort of approach we should have. it is not just about this condition, not just about mental health, but when you link it to diabetes, certain people are expanded greatly in giving people something, it is quicker to understand the idea. they did not -- do n

prevention is a powerful with the public and they get it intuitively that if someone has diabetes and can self monitor his or her condition and treat it it costs a lot less and has a far better outcomes and if you put out here until you have to have a leg amputated so i think the messages about the positive aspects of prevention and wellness is common sense we intend to reinforce and that. in terms of the coverage one of the more powerful messages to emerge through recent things is your insurance company should be able to deny treatment because you're sick five years ago or your child has asthma and so i think hitting does your friends when messaging to the public is something that resonates and people understand both from this makes sense without having taken into the number of dollars that goes to health care management and highlighting the potential both in terms of unwellness and out comes as well as prostrating. >> is an example of the approach to have which is it is not just about this condition that the swing to diabetes and expanding greatly and giving people does m.r. publicly discuss and quicker 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 mil

health care -- and reported that patients with chronic illnesses, such as diabetes, heart disease, were not taking their medicine or not getting the treatments that they needed because they couldn't afford the 25% copay. and massachusetts has almost everybody covered. so when we talk about the health care crisis, it's not just the number of people who have no health insurance; it is people who are underinsured. and you add that together, we have huge numbers of people who are not getting the medical care that they need, when they need it and the result is not only personal suffering; the result is, they end up going to the emergency room, costing the system far more than it should, or they end up in the hospital at highly inflated medical cost. this makes zero sense. and, it is a manifestation of a dysfunctional health care system. but in the midst of all of this, you know, somebody may say, well, you got 46 million uninsured. more underinsured people are dying. but at least we're not spending a lot of money. you know, if you bought an old, broken-down car and you started complaining that it doesn't work well, i wo

increased attention and these risk factors increase the risk of diabetes in america and cardiac arrest the disease. diagnose when three or more diabolic this orders occurs simultaneously. our analyses demonstrate that extraordinarily high metabolic syndrome problems exists among our cohort and among those nearly half of the women and over a third maine hung metabolic syndrome and the national average about 25%. these traits suggest continued pitcher differences in diabetes. notably with the prevalence of metabolic systems inevitably declines with higher household income and educational attainment. attention is likely this a most treatable and controllable risk factor however controlling hypertension and to define operationally as reducing blood pressure to 140 over 90 is a problem particularly african-americans and are reports of a widening disparities and the success of hypertension control between blacks and whites. the control rates are much less than desirable from african-americans and this is seen as the figure in the text. nationwide wall 70 percent of whites who are treated for hypertension and gone could control

speaker, envision this, that individual develops high blood pressure or maybe in addition to that high blood pressure develops type 2 diabetes. maybe the diabetes comes first and then the high blood pressure. and then ar that develops coronary artery disease and then all of a sudden the company goes out of business. and that individual is out of work, out of insurance and desperately needs it. but because of these pre-existing conditions, once cobra runs out, how are they going to get health insurance? how are they going to afford, struggling maybe to find a new job, but how are they going to be able to go out with no tax deduct -- deductibility and purchase a health insurance plap that's three and four times the amount of a standard plan for everybody else? what i would say, madam speaker, to the association of health insurance plans, why don't you grant those individuals credible coverage just like we did in medicare part d, the prescription drug benefit? if you have a credible insurance plan that covers prescription drugs, say on a supplemental plan, and then you lose that after four or five years, then you shouldn't be p

there might be a government plan or private plan coming out of this that might be able to help you. but diabetesparticularly adult onset is controllable if you watch your weight, exercise, watch what you eat. and continue in this case to take your medication. i don't know why you should not be able to find something out there. but you want to look for an employer with the health care plan. good luck. host: our conversation is head of the republican mainstream organization and we have a caller from wisconsin. caller: good morning. i will respond concerning the pool. i think the issue is not discussed adequately in the media. people are voting on the inadequate intermission. america spends more than any other nation on health care yet we rank no. 37 in outcomes. every other major industrialized nation in the world has some sort of a public plan to provide for health care for all the citizens. it seems to me that our system is not working. that is empirical right there. the other thing -- i realize it is expensive and will be tough to afford, but we afforded it an adventure is iraaq and a bailout s

effective to treat diabetes than it is to treat the results of diabetes untreated and undiagnosed, for example, if somebody suffered from kidney failure or stroke. those are extraordinarily expensive thing, much less expensive and so much better for the live of americans if we can address these problems before they get to that case. yet insurance companies have fought at the state level the covering of testing for diabetes and even in a couple of states successfully the coverage for the supplies for the treatment of diabetes that has been diagnosed. we worry, too, and, you know, this is one of the topics i'm sure that those of you who have been visiting have heard about the strain of the baby boomers on medicare. but we know many of the people entering medicare have as many as five chronic conditions, some of them untreated because they said i don't need to get health insurance, in three years i'm going to be on medicare. so something ends up not getting treated, and by the time they get in medicare, we're talking about a much more expensive treatment than we might have had had we had a more timely diagnosis understanding that's not goin

caller: and sews or a did not get a chance to speak with linda douglass. i am in diabeticand i have kidney problems. i was beginning to have liver problems and eye problems, all kinds of problems. diabetes is a most monstrous of diseases. i wrote a letter and sent it to michelle and barack obama on march 17 and i have not heard anything of to now, nearly the end of june. and i know kathleen sebelius, but she was just appointed about a month and a half ago. i'm so glad that you had linda douglass on because i wanted her to go and look for my letter. how can i get her direct number or e-mail or fax number? host: you can call the white house. by the way, you can go to whitehouse.gov. we're talking about the white house health-care plan and ronald is joining us from raleigh, north carolina. caller: good morning, first, let me sarah on vacation and i do not want everyone to -- let me say i am on vacation and i do not want everyone to think that federal employees are the only ones on the phone. my question is, what does what does the government think it has the right to pay for

diabetes and treated, and on diagnosed. for example of someone has suffered from kidney failure or a stroke those are extraordinarily expensive things, much less expensive and so much better for the lives of americans of we can address these problems before they get to that case yet insurance companies have thought that the state level, the covering of testing for diabetes and even in a couple of states successfully, the coverage for the supplies for the treatment of diabetes that has been diagnosed. we have wehrey too, and it is one of the topics i am sure that those of you visiting have heard about the strain of the baby boomers on medicare but you know that medicare, many people entering medicare has as many as five chronic conditions, some untraded because they said i don't need to get health insurance and in three years i'm going to be on medicare. so it's something hands up not getting treated and it gets worse, so by the time they get into medicare we are talking about a much more expensive treatment then we might have if we had more timely diagnosis. understanding this timely diagnosis is not going to say this money i

treatment you offer a payment with a prime condition like diabetes, but instead paid well for how you treat the overall disease. we need to create incentives or physicians to team up because we know that when that happens, it results in a healthier patient. we need to give doctors bonuses for good health outcomes. we're not promoting just more treatments but better care. and we need to rethink the cost of a medical education and do more to report medical students who choose a career as a primary care physician -- [applause] ♪ (singing) instead of the more lucrative tasks. [applause] >> that's why we are making a substantial investment in the national health service corps that will make medical training more affordable for primary care doctors and nurse practitioners so they aren't drowning in debt when they enter the workforce. [applause] >> somebody back there is drowning in debt. [laughter] >> the second structural reform we need to make is improve the quality of medical information making its way to doctors and patients. we have the best medical schools, the most sophisticated labs, the most advanced training of any nation on the globe. ye

diabetes, lung disease, and strokes can be prevented. only a fraction of every health care dollar goes to prevention or public health. that is starting to change with the investment we are making in wellness programs that can help us avoid diseases that harm our health and the health of our economy. investments in electronic records and prevent care -- preventive care are ordinary steps. they will only make a dent in the epidemic of rising costs in this country. despite what some have suggested, the reason we have these spiraling costs is not simply because we have an aging population. demographics do account for part of rising costs because older and sicker societies pay more on health care than younger people. there is nothing wrong in us taking better care of ourselves. what accounts for the bulk of our costs is the nature of our health care delivery system itself. a system where we spend vast amount of money on things that do not make people more healthy. a system that automatically equates more expensive care with better care. a recent article showed how texas is spending twice as much as el paso county. not bec

diabetes. now i will need to cover the need to stay alive. i am 61 years old. i do not fall under medicare or medicaid. the gentleman that i work for, honest, good man, a republican, cannot afford insurance for those i work with because of a guy like me. get real. this is easy. host: will the spending policies of the obama policy to help a guy like this in kansas? guest: yes, the health care policies will. to make it possible for those who need health care coverage to get it. that is essentially the long term plan. john is right when he says that things have to be paid for. costs do not disappear. you will not get health care for free. on the other hand, there are many savings to be had. we keep talking -- i have been talking about getting the most effective treatments and being efficient. there is a huge amount of administrative waste. some keep government investments can begin to rectify that. there are problems because doctors do not have access to the comprehensive medical history of those they're treating which ends up with costly problems. the caller -- it is people like the caller who

lifestyle or their kids don't get into the lifestyle of eating sugar and fattening foods all the time, all the rest, it has an enormous impact on what happens to them when they get older. diabetes -- we know this is a major problem. we can turn that around, and later the heart risk that goes with it, the stroke risk that goes with high blood pressure. these things can be controlled. we took a first step in the direction of prevention when we passed the bill on smoking which for the first time will give the food and drug administration the ability to regulate cigarettes and keep these products away from our kids who are lured into smoking -- and then you know how it is -- because i'm sure everyone knows someone who has this addiction. clearly, if we have preveftion as the name of the game, we're going to -- clearly, if we have prevention as the name of the game, we're going to see a decrease in costs, we're going to see healthier families and lower premiums. so the question is, if we do nothing, can we sustain what's happening? we can. i-- we can't.we ought to make se insurance companies are kept honest. how do you do that? it seems to me you want to make sure that we have some

in each of the elements of how diabetes should be treated and scoring that and then the minnesota committed to measurement making that visible to the consumer on-line or you can go and see how one clinic for says another is performing and this is just a quick depiction of what that looks like given presenting in washington d.c. but literally you can go and break -- the names are on there and you can see how one compares to the next through an element called helms' court and this is just a valuable piece of data for the reform of the system. winfrey look at minnesota and think about it as a model for the country a lot of it is built around how integrated the delivery system is so hospitals in the twin cities in particular have the physicians employed by the hospital, ancillary services employ the hospitals and these are very tightly integrated systems so they're in position to take on a global payment and to manage that much more actively than perhaps would have been the case and number of years ago some and we talked about this feels like something we have tried before a thing this system is in a different place and is a different dialogue with the sy

the diabetes center, rebuilding together programs, and the tyler elementary school partnership fund. that is just a partial list of the grants that are foundation had given out in the last year or two. in addition, the steps we do with our players and with their coaches and managers in the neighborhood is extremely important. this year alone we will give out between 50,060 thousand tickets to d.c. kids. we will hold six free clinics, baseball and softball at our ballparks. we had six different drives for different things. every month we choose another cause to get behind. this is jim. we are working with the american cancer society. i can go on and on. we originally went through hundreds of programs. my favorite is a new one. we tried to kick it off on a small base. we've been able to grant it up. this is the d.c. high school initiative. it is one of the few things have been able to get the mayor and council president to agree on. we all of the d.c. high school initiative. every d.c. public high school, their baseball team is having a full baseball team practice at our expense at nationals park. it is a great thrill for the kids. it is a great motivator for the kids. each high-

or mow in 2007 in 2008. and studies confirmed that found some uninsured have a disastrous impact on health and wellness, especially for people who live with chronic conditions like cancer, diabetes, asthma. of course these diseases and others require a regular and routine care to manage. we also know that african-american women are nearly four times more likely than white women to die during childbirth, or from pregnancy convocations, and that the infant mortality rate for african americans and american indian and alaska natives are more than two-time hires than that for whites. and so today we have more and more, and you will hear more of these statistics from members of the tri-caucus and we have decided that once again, we will introduce our bill, the health equity and accountability act of 2009 because it will begin to close many of these tragic disparities. there was a report in 2002 unequal treatment, many of those recommendations which again, our nation's leading health disparity elimination experts championed. this was a member, in 2002, we are now and 2009. so we're sitting in a very clear message that health care equity, disparities, must be included in any health care

diabetes center, rebuilding together program, thurgood marshall academy and the tyler elementary school partnership project. that is just a partial list of the grants our foundation have given out in the last year or two. in addition to that, the stuff we do with our players, with our coaches and manager in the neighborhood is extremely important. this year alone we are going to give out between 50 and 60,000 tickets to the d.c. kids. we are going to hold six free clinics, baseball and softball, boys and girls at the ballpark. we have six different drives over the course of the year raising money for different things and every month we choose another cause to get behind. this is june so we are working with the american cancer as society and leukemia and i can go on. as i said we literally do hundreds of programs. my favorite is a new one this year we tried to kick it off. we've really been able to ramp up and that's this year's d.c. high school initiative. one of the only things i've been able to get the mayor and city council to agree on. we all love the d.c. high school initiative and under this program every d.c. public high school their baseball team is invited to come and spend the day having

diabetes and even pregnancy and what do these conditions have in common that would cause you to investigate patients with these conditions, for a possible rescission? you have 1400 different conditions, which would trigger or in your documents, which will trigger an investigation. >> chairman, an investigation does not mean that a rescission actually occurs. for example, in 2008, there were over 16,000 investigations triggered, 92% of those were dismissed. and, no action was taken. >> but why do you have 14 tifrn conditions, which trigger an investigation? what is the common theme amongst these 1400 that would trigger an investigation? >> i would say there is no common theme other than these are conditions that had the applicant disclosed their knowledge of a condition at the time of the initial underwriting, we may have taken a different underwriting action. and, so that is what the investigation really is about. is to determine, did the applicant have the condition, did they know about the condition -- >> i thought you said you did pre-screening before, screened them beforehand. >> we do -- >> why do you have to go back, if you screened them before and there wasn't a problem why would you have a list of

diabetes, asthma, and mental health disorders. over 133 million americans suffer from at least one of these chronic diseases. over 75% of all medicare expenditures can be attributed to patients with five or more chronic conditions. just 10 years ago, these beneficiaries counted for only 50% of the medicare costs. so something's wrong. we have to fix this problem. we have to make sure that people can hopefully prevent some of these chronic diseases we might want to do that in a number of ways. i know there's discussion about wellness programs for prevention, we've seen some very good models, some larger employers and insurance companies are working harder to incentivize people to eat right, exercise, prevent some of these conditions from worsening. but clearly we have a long way to go and we have much work to do to make sure we help folks with chronic diseases be able to be healthier to get better to not have the disease get any worse and of course in that process, it'll save them money and it'll save all of us the high cost of taking care of patients. any of us who ever visited a renal dialysis cent every know if we can do more to make sure that somebody who, for example, is early diagno