[Congressional Bills 110th Congress]
[From the U.S. Government Publishing Office]
[S. 3674 Introduced in Senate (IS)]
110th CONGRESS
2d Session
S. 3674
To amend the Public Health Service Act to establish a Wellness Trust.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
October 1 (legislative day, September 17), 2008
Mrs. Clinton introduced the following bill; which was read twice and
referred to the Committee on Health, Education, Labor, and Pensions
_______________________________________________________________________
A BILL
To amend the Public Health Service Act to establish a Wellness Trust.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``21st Century Wellness Trust Act''.
SEC. 2. FINDINGS AND PURPOSE.
(a) Findings.--Congress finds as follows:
(1) Preventable and chronic diseases are the epidemic of
the 21st century. The number of people with chronic conditions
is rapidly increasing and it is estimated that, if there is no
intervention now, by 2025 nearly half of the United States
population will suffer from at least 1 chronic disease. About
70 percent of deaths and health costs in the United States are
attributable to chronic diseases (such as cardiovascular
disease and cancer), some of which may be preventable. Nearly
90 percent of Medicare beneficiaries have some type of chronic
illness.
(2) This affects Americans' health. The United States has
the highest rate of preventable deaths among 19 industrialized
nations and lags behind 28 other nations in life expectancy.
For example, obesity, which is rising rapidly, contributes to a
wide range of problems, from diabetes to stroke to cancer. The
life expectancy for a 20-year old man may be reduced by 17
percent due to obesity. If trends continue, children's life
spans may be shorter than those of their parents for the first
time in about a century.
(3) The wellness gap also affects health care costs. About
78 percent of all health spending in the United States is
attributable to chronic illness, much of which is preventable.
Chronic diseases cost the United States an additional
$1,000,000,000,000 each year in lost productivity, and are a
major contributing factor to the overall poor health that is
placing the Nation's economic security and competitiveness in
jeopardy.
(4) Unlike some health care challenges, proven preventive
services and programs exist. If effective risk reduction were
implemented and sustained by 2015, the death rate due to cancer
could drop by 29 percent. Improved blood sugar control for
people with diabetes could reduce the risk for eye disease,
kidney disease, and nerve disease by 40 percent. Similarly,
blood pressure control could reduce the risk for heart disease
and stroke by 33 to 50 percent.
(5) Yet, only half of recommended clinical preventive
services are provided to adults. About 20 percent of children
do not receive all recommended immunizations, with higher rates
in certain areas. Nearly 70 percent of people with high blood
pressure do not now control it. And racial disparities in use
of prevention exist.
(6) The United States faces low use of preventive services
because of the low value placed on prevention, a delivery
system bent toward fixing rather than preventing problems, and
financial disincentives for prevention. Insurers have little
incentive to invest in preventive services today that will
benefit other insurers tomorrow. This is especially true for
those preventive services that reduce chronic diseases that
develop over a period of several years or decades. The costs of
prevention are incurred immediately but most of its benefits
are realized later, often by Medicare.
(7) There is a low investment in prevention. The United
States spends only an estimated 1 to 3 percent of national
health expenditures on preventive health care services and
health promotion. This has not increased as much as one might
expect since 1929, 1.4 percent, despite the development of
expensive screenings, early interventions, and the growth of
the preventable disease burden.
(8) The workforce to deliver prevention is also
insufficient. The supply of providers who are trained to
emphasize prevention is shrinking. Between 1997 and 2005, the
number of medical school graduates entering family practice
residencies dropped by 50 percent. There is an acute shortage
of community health workers. Between 25 and 50 percent of the
existing Federal, State, and local public health workforce is
eligible for retirement in the next 5 years. As of 2008, more
than 75 percent of the existing public health workforce has no
formal public health or prevention training. There is no
national, uniform credentialing system for public health or
prevention workers that would ensure that these workers are
trained in the basics of preventive care.
(9) A system that promoted full use of high-priority
prevention could save lives. A recent comprehensive assessment
found that 1,200,000 quality-adjusted life years could be saved
by achieving 90 percent use of just the following 3 services:
(A) Smoking cessation counseling.
(B) Use of aspirin to prevent heart attacks.
(C) Screening for colorectal cancer.
(10) A system that promoted full use of high-priority
prevention could reduce costs. For example, complete, routine
childhood vaccination could save up to $40,000,000,000 in
direct and societal costs over time. Promoting screenings and
behavioral modifications in the workplace can lower absenteeism
and, in most cases, health costs to firms. Preventive health
care services could reduce government spending on health care.
If all elderly received a flu vaccine, health costs could be
reduced by nearly $1,000,000,000 per year. Over 25 years,
Medicare could save an estimated $890,000,000,000 from
effective control of hypertension, and $1,000,000,000,000 from
returning to levels of obesity observed in the 1980s.
(11) Investing in community-level interventions that
promote and enable proper nutrition, increased access to
physical activity, and smoking cessation programs can prevent
and mitigate chronic diseases, improve quality of life,
increase economic productivity, and reduce healthcare costs.
(b) Purpose.--The purpose of this Act is to create a 21st century
prevention system called the Wellness Trust that assures access to
clinical and community-level prevention services that improve health,
quality of life, and reduce healthcare costs.
SEC. 3. WELLNESS TRUST.
Title III of the Public Health Service Act (21 U.S.C. 241 et seq.)
is amended by adding at the end the following:
``PART S--WELLNESS TRUST
``SEC. 399KK. DEFINITIONS; ESTABLISHMENT OF WELLNESS TRUST.
``(a) Definitions.--In this part:
``(1) Certified prevention health worker.--The term
`certified prevention health worker' means a licensed health
professional or other health worker deemed certified by the
Trustees.
``(2) Trust.--The term `Trust' means the Wellness Trust
established under subsection (b).
``(3) Trustees.--The term `Trustees' means the members of
the Trust Fund Board appointed under section 399LL(b).
``(b) Establishment of the Wellness Trust.--There is established
within the Centers for Disease Control and Prevention the Wellness
Trust.
``SEC. 399LL. STRUCTURE.
``(a) Trust Fund Board.--The Trust shall be headed by the Trust
Fund Board.
``(b) Composition.--The Trust Fund Board shall be composed of 7
members appointed by the President by and with the advice and consent
of the Senate.
``(c) Date of Appointments.--The initial 7 Trustees shall be
appointed not later than December 31, 2009.
``(d) Staggered Terms.--Of the members first appointed under
subsection (c)--
``(1) 4 shall be appointed for a period of 4 years; and
``(2) 3 shall be appointed for a period of 3 years.
``(e) Vacancies.--A vacancy on the Trust Fund Board--
``(1) shall not affect the powers of the Trust Fund Board;
and
``(2) shall be filled in the same manner as the original
appointment was made.
``(f) Meetings.--The Trust Fund Board shall meet at the call of the
Chairperson.
``(g) Quorum; Required Votes.--A majority of Trustees shall
constitute a quorum for purposes of voting, but a lesser number of
members may hold hearings. The Chairperson shall require a vote of the
Trustees on major decisions regarding prevention priorities, resource
allocation, delivery system structure, and other Trust functions.
``(h) Chairperson and Vice Chairperson.--The Trust Fund Board shall
select a Chairperson and Vice Chairperson from among the Trustees.
``(i) Removal.--A Trustee may be removed by the President only for
cause.
``(j) Recommendations.--The Trustees may submit recommendations
directly to Congress, without opportunity for comment or change by the
Secretary.
``(k) Staff.--The Trustees may employ and fix the compensation of
personnel as necessary. Not more than 5 percent of the funds
appropriated in a fiscal year to the Trust Fund established under
section 399NN may be used to fund the staff, operations, and other
purposes as the Trustees determine appropriate of the Trust Fund Board,
subject to the oversight of the Secretary.
``SEC. 399MM. REPORTS; PLAN FOR DELIVERING SYSTEMS.
``(a) Development of Key Reports.--Not later than 1 year after the
appointment of the Trustees under section 399LL(c), the Trustees shall
submit to Congress and make publicly available the following reports:
``(1) Report on broadening the prevention workforce.--A
report that develops and describes a system for certification
and recertification of `prevention health workers' to
complement the health system as in existence at the time of
such report. Such system may expand certification efforts in
existence at the time of such report for the public health
workforce and community health workers. Such report shall also
examine the impact of State licensing requirements and explore
and describe options for health profession training and
continuing education, 1 or more registries of certified
prevention health workers, and an employment structure that
encourages flexible deployment but protects prevention health
workers' benefits.
``(2) Report on aligning payments with prevention goals.--A
report that examines and describes payment methodologies and
presents options for paying certified prevention health workers
for clinical preventive care that aligns incentives with goals,
as well as payment methodologies for community organizations
involved in the provision of prevention services. Such report
shall address the shortfalls of the payment systems in
existence at the time of such report that have not proven
effective at encouraging the provision of prevention services.
``(3) Report on identifying existing funding for
prevention.--A report that examines and describes the amount of
money spent on prevention by public health, public and private
health insurers, and applicable self-insured health plans (as
defined in section 399OO) during the most recent year for which
such data is available.
``(b) Plan for Delivery Systems.--Not later than 1 year after the
appointment of the Trustees under section 399LL(c), the Trustees shall
establish a plan for delivering and financing prevention priorities and
implement pilot programs. Such plan shall include--
``(1) identifying effective delivery systems based on
evidence and expert judgment to determine how best to deliver
priority clinical and community-based prevention activities;
``(2) assessing the current capacity of effective delivery
systems and actions necessary to ensure adequate infrastructure
and capacity to deliver priority clinical and community-based
prevention activities as determined by the Trust; and
``(3) identifying cost-saving clinical and community-based
interventions to implement before December 31, 2011, which
shall include evidence-based interventions in obesity,
diabetes, heart disease, or cancer.
``SEC. 399NN. INFRASTRUCTURE AND PRIORITIES.
``(a) Designating National Prevention Priorities.--The Trustees
shall issue a ranked list of designated `prevention priorities'. The
inclusion of an activity on such list shall be based on the potential
of such activity to improve health and the cost effectiveness of such
activity. Such list shall--
``(1) include clinical preventive services and community-
based interventions; and
``(2) be used by the Trustees to--
``(A) determine what prevention services shall be
paid for through the Trust Fund under section 399OO;
``(B) allocate resources within the Trust;
``(C) educate the public on critical prevention
priorities; and
``(D) emphasize coverage and use within existing
authorities.
``(b) Creation and Support of Infrastructure.--The Trustees shall
establish and otherwise support and sustain the infrastructure for an
effective wellness system, including the following components:
``(1) Central source of prevention information.--A
centralized, national, easily accessible information
clearinghouse on prevention priorities. Such information
clearinghouse shall be made available in multiple media and
updated regularly and shall connect individuals, health care
providers, and others to national and local resources.
``(2) Developing, implementing, and maintaining the
electronic prevention record.--If no nationwide interoperable
electronic medical record system exists, a privacy-protected
electronic prevention record or registry to--
``(A) track provision of prevention over the course
of individuals' lifetimes;
``(B) facilitate reimbursement of certified
prevention health workers; and
``(C) assist in evaluations of the efficacy of the
policies of the Wellness Trust.
``(3) Training and credentialing prevention health
workers.--Training for prevention health workers through
agencies such as the Health Resources and Services
Administration and the Centers for Disease Control and
Prevention. The Trustees shall--
``(A) provide funding to such agencies through the
Trust Fund under section 399OO;
``(B) establish a central registry of certified
prevention health workers; and
``(C) encourage such workers to access additional
training.
``SEC. 399OO. FUNDING FOR WELLNESS TRUST.
``(a) Initial Funding.--There is authorized to be appropriated and
there is appropriated to the Trust Fund Board such sums as may be
necessary to carry out sections 399MM and 399NN and other activities
necessary for the implementation of this part.
``(b) Establishment of Wellness Trust Fund.--Not later than January
1, 2011, there shall be established in the Treasury of the United
States a trust fund to be known as the `Wellness Trust Fund' (referred
to in this section as the `Trust Fund'), consisting of such amounts as
are appropriated or credited to the Fund as provided under this
section.
``(c) Appropriations to the Fund.--
``(1) Fiscal year 2011.--There is hereby appropriated to
the Trust Fund for fiscal year 2011 an amount equal to the
amount spent by all Federal health programs to pay for
prevention services (as defined by the U.S. Preventive Services
Task Force) in the most recent year for which complete data is
available, as estimated by the Trustees.
``(2) Fiscal year 2012.--There is hereby appropriated to
the Trust Fund for fiscal year 2012 the amount appropriated to
the Trust Fund for the previous fiscal year, increased by the
annual percentage increase in the medical care component of the
consumer price index (United States city average) for the 12-
month period ending with April of the preceding fiscal year.
``(3) Fiscal year 2013 and subsequent years.--There is
hereby appropriated to the Trust Fund for fiscal year 2013 and
each subsequent fiscal year an amount equal to the sum of--
``(A) the amount appropriated to the Trust Fund for
the previous fiscal year, increased by the annual
percentage increase in the medical care component of
the consumer price index (United States city average)
for the 12-month period ending with April of the
preceding fiscal year.
``(B) the amount collected by the Secretary from
health insurance issuers and applicable self-insured
health plans under subsection (d) for the fiscal year;
and
``(C) the amount associated with prevention
priorities for State and local spending, under-use, and
the uninsured for the fiscal year, as estimated by the
Trustees (which shall not exceed the amount equal to 10
percent of the amount otherwise appropriated to the
Trust Fund for the fiscal year).
``(4) Availability.--Amounts appropriated pursuant to this
subsection shall remain available until expended.
``(d) Assessment of Health Insurance Issuers and Applicable Self-
Insured Health Plans.--
``(1) In general.--Beginning in fiscal year 2013 and on an
annual basis thereafter, the Secretary shall, subject to
paragraph (2), assess and collect a fee from each health
insurance issuer and each applicable self-insured health plan
in an amount equal to the estimated amount spent by such health
insurance issuer and self-insured health plan, respectively,
for prevention services (as defined by the U.S. Preventive
Services Task Force).
``(2) Collection amount adjustment beginning in fiscal year
2013.--The amount determined under paragraph (1) shall, on an
annual basis, be increased by the annual percentage increase in
the medical care component of the consumer price index (United
States city average) for the 12-month period ending with April
of the preceding fiscal year.
``(e) Definitions.--In this section:
``(1) Applicable self-insured health plan.--The term
`applicable self-insured health plan' means any plan for
providing accident or health coverage if--
``(A) any portion of such coverage is provided
other than through an insurance policy; and
``(B) such plan is established or maintained--
``(i) by 1 or more employers for the
benefit of their employees or former employees;
``(ii) by 1 or more employee organizations
for the benefit of their members or former
members;
``(iii) jointly by 1 or more employers and
1 or more employee organizations for the
benefit of employees or former employees;
``(iv) by a voluntary employees'
beneficiary association described in section
501(c)(9) of the Internal Revenue Code of 1986;
``(v) by any organization described in
section 501(c)(6) of such Code; or
``(vi) in the case of a plan not described
in the preceding clauses, by a multiple
employer welfare arrangement (as defined in
section 3(40) of the Employee Retirement Income
Security Act of 1974), a rural electric
cooperative (as defined in section 3(40)(B)(iv)
of such Act), or a rural telephone cooperative
association (as defined in section 3(40)(B)(v)
of such Act).
``(2) Health insurance issuer.--The term `health insurance
issuer' means an insurance company, insurance service, or
insurance organization (including a health maintenance
organization, as defined in paragraph (3)) which is licensed to
engage in the business of insurance in a State and which is
subject to State law which regulates insurance (within the
meaning of section 514(b)(2) of the Employee Retirement Income
Security Act of 1974).
``(3) Health maintenance organization.--The term `health
maintenance organization' means--
``(A) a federally qualified health maintenance
organization (as defined in section 1301(a));
``(B) an organization recognized under State law as
a health maintenance organization; or
``(C) a similar organization regulated under State
law for solvency in the same manner and to the same
extent as such a health maintenance organization.
``SEC. 399PP. INSURING PREVENTION PRIORITIES.
``(a) Wellness Trust as Primary Payer for Prevention Services.--The
Trust shall enter into contracts with certified prevention health
workers to reimburse such workers for the prevention services
designated by the Trustees under section 399NN(b) as prevention
priorities.
``(b) Priorities.--The Trustees shall develop annual and 5-year
targets for prevention priorities, budgets to achieve these targets,
and a list of what shall be included for funding. Such targets shall
include a set-aside for community-based services.
``(c) Eligible Individuals.--Pursuant to the contracts described
under subsection (a), the Trust shall reimburse certified prevention
health workers for the prevention services described under such
subsection provided to all individuals who are United States citizens
or legal immigrants, without regard to the insurance status of such
individuals.
``(d) Development, Refinement, and Change of Payment Systems.--The
Trustees shall determine payment methodologies for prevention
priorities. Such payment methodologies shall correspond to the
following tiers of activity:
``(1) Competitive contracting authority.--The Trustees
shall have a competitive contracting authority for the national
delivery system activities.
``(2) Direct payment systems.--The Trustees shall develop
different payment methodologies for the various designated
prevention services. These payment systems shall take into
account existing rates, rates for similar services, and whether
geographic adjustment is needed. Such systems shall link the
priority of the service with payments.
``(3) Use of state and local grant systems.--The Trustees
shall utilize existing grant programs where feasible to
distribute funds from the Trust Fund for prevention priorities.
``(4) Reports from federal programs.--Programs that receive
funding for prevention priorities through the Trust Fund shall
report annually to Congress on the extent to which this funding
displaces existing spending on prevention priorities.
``(e) Partnership With Medicare and Other Insurers.--The Trustees
shall determine the most efficient way to transfer funds from the Trust
Fund to certified prevention health workers. In making such
determination, the Trustees shall carry out the following:
``(1) Coordination with medicare.--The Trustees shall
examine the use of Medicare systems for direct payments to
certified prevention health workers. Any additional
administrative cost associated with the use of the payment
systems, including those of a broader set of providers, shall
come from the Trust Fund.
``(2) Contract with other insurers.--To the extent that
Medicare program, private insurers, or States prove that such
program, insurer, or State has the capacity to deliver
prevention priorities in a cost effective manner, the Trustees
may contract with such entity for delivery of prevention
services covered under this Trust Fund.''.
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