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adopt a new role in which health advice is disseminated by CMS to serve beneficiaries, to lower disease burden, and to save money through prevention. CMS need not develop this health advice from scratch. Prevention guidelines for seniors and health education messages have already been developed by other HHS agencies, but are less familiar to CMS due to stovepiping.

No. 3, looking ahead to the future, the Committee should consider how to redesign communities to support lifestyle change. It does little good to advise a senior to do light gardening or take a daily walk when he or she is surrounded by highways or has no safe place to walk.

Seniors living in poor urban neighborhoods are often miles from a supermarket that offers healthy food choices. Fast food chains predominate, as do billboards that promote cigarettes and alcohol.

Congress should work with the food industry and retailers to explore ways to promote profits and healthy customers.

Ultimately, creating a community that fosters healthy aging requires a partnership across community sectors involving churches, restaurants, park authorities, senior centers, and urban planners.

No. 4, cigarette smoking remains the leading cause of death and cannot be overlooked in any serious discussion of healthy aging. The Committee should look again at the 10 recommendations issued in 2003 by the Department of Health and Human Services' Interagency Committee on Smoking and Health. Setting aside the recommendation on excise taxes, which received a cool reception, the plan includes nine other excellent recommendations that would substantially reduce the death toll from smoking-related illness among seniors.

One example is telephone quit line programs, which give seniors access to high quality assistance in quitting smoking.

No. 5, the failure of so many seniors to receive recommended preventive services is a symptom of a larger problem with the nation's health care delivery system. Experts have warned for years that the quality of health care in America is in jeopardy unless bold system redesigns are undertaken. Mapping the human genome, robotic surgery, and other sensational breakthroughs make the evening news, but Congress could save more lives by directing its attention elsewhere.

Take reminder systems, for example, which alert people when screening tests or vaccinations are due. Such systems are not glamorous, but are among the most effective ways to close the gaps in the delivery of health care. Yet, they are rare in our health care system. You are more likely to get a notice from your car dealership that it is time to change your oil than you are to be notified by your doctor that your mammogram is overdue.

Our research team has shown that making such systems routine would save far more lives than the advances in drug therapies on which billions of dollars are now spent.

I urge Congress to confront the political challenges and to press for modernizing the health care system to deliver consistent highquality care.

No. 6, information technology is an important tool for healthy aging. Congress is already promoting electronic health records to improve record keeping and reduce medical errors, but information technology and web sites for seniors can do far more by empowering consumers with information to make healthy lifestyle choices, learn more about the tests they need, and obtain e-mail reminders when they are due.

Congress should steer the health IT movement beyond its basic role, serving providers as a tool for patient care, to a broader role in helping the public maintain good health.

Finally, No. 7, given the urgency of the problems I have discussed, Congress should increase the funding for AHRQ, the Agency for Healthcare Research and Quality, which receives one penny for every dollar given to NIH. Yet, it is AHRQ that has lead responsibility for asl that we have discussed-prevention guidelines, improving the quality of health care, tracking racial disparities, developing information technology, and so on.

Solving these problems is not a luxury on the margins of NIH. Without the answers, the cutting edge advances made at NIH cannot reach Americans.

Doubling the budget of AHRQ sounds extravagant at this time of belt tightening. But the extra penny taken from the NIH dollar could go much farther in saving lives. The threat to the nation's health and economy posed by the struggling health care system makes it risky public policy to not invest generously in tackling these problems. Thank you.

[The prepared statement of Dr. Woolf follows:]

Written Statement

Steven H. Woolf, M.D., M.P.H.
Professor of Family Medicine, Epidemiology and Community Health

Virginia Commonwealth University

before the

U.S. Senate Special Committee on Aging

June 30, 2005

The inherent logic behind prevention is obvious. The major diseases that claim the lives of Americans and that account so greatly for the rising costs of health care are caused largely by health habits, such as smoking, physical inactivity, and poor diet. Fully 35% of deaths in the United States are caused by three behaviors: tobacco use, poor diet, and physical inactivity. The major diseases of our time can often be detected early and either prevented or made less severe.

Our society spends far too much on treating the end stages of disease and far too little on helping the public avoid getting sick in the first place. As the Governor of Arkansas, Mike Huckabee, has said, rather than building a fence at the top of the cliff, our health care systems keeps sending one ambulance after another to the bottom. Paying for prevention is far more effective than paying for chronic disease care. Whereas treatments for cardiovascular disease can save 4,000-10,000 lives per year, helping Americans to stop smoking would prevent more than 400,000 deaths per year.

This is true for adults and children and it is true for seniors, who are not too old to benefit from prevention. Seniors live longer and live healthier if they abandon unhealthy behaviors, obtain recommended vaccines, and receive certain screening tests to catch diseases in their early stages. For example, lifelong smokers who stop smoking at age 50 live an average of 6 years longer than those who continue smoking beyond that age. Prevention can improve function, postpone chronic disease and disability, and avoid premature death. Recent evidence even suggests that physical activity may delay the onset of Alzheimer's disease. Prevention is an obvious answer to the escalating costs of healthcare. Promoting prevention among seniors should be a major public policy priority.

This was always true but is especially pertinent now, a time when Americans are growing older in greater numbers. The aging of the baby boom population, combined with advances in medical care, is carving out a future in which a larger number of seniors will suffer the health complications associated with chronic diseases, such as heart failure, diabetes, and cancer. Promoting prevention is intelligent planning for the future.

Primary versus secondary prevention

Two forms of prevention deserve emphasis among seniors: primary prevention and secondary prevention. Primary prevention refers to actions by asymptomatic persons to prevent disease from occurring in the first place. Examples include good health habits, such as regular physical activity, eating wisely, and stopping cigarette smoking. As already noted, one out of three deaths in the United States is caused by these habits. The rising rate of obesity further threatens to cut short the life expectancy of Americans.

Another example of primary prevention is immunizations, such as influenza (flu) vaccine and pneumococcal vaccine, which prevent seniors from getting infections such as pneumonia, a leading causes of death.

Secondary prevention refers to screening tests and other strategies to detect diseases in their early stages. Examples include mammograms, screening for colon cancer, and measurement of bone density to detect osteoporosis. Some of these tests can reduce death rates from diseases by 20-30%. Although screening tests can be beneficial in reducing morbidity and mortality from diseases, the benefits of early detection are limited because, by definition, the disease process is already underway.

Clinical preventive services refer to efforts at primary and second prevention that are undertaken by doctors and other healthcare providers in clinical settings, such as doctors' offices. Efforts by Congress to expand coverage of clinical preventive services under Medicare have gone a long way to improving seniors' access to immunizations and screening tests.

Prevention is an undertaking that extends beyond the clinical setting, however. To be effective communities must provide a web of integrated services to help citizens sustain healthy behaviors. Ideally, a person who chooses to become physically active should find a community working together to support the effort. The individual's physician might recommend exercise, but local media and advertising can reinforce the message, employers can offer incentives, and the “built environment” (e.g., neighborhood walkways) can be redesigned to foster outdoor activity. A diverse collaboration is required to give citizens a seamless support system for healthy diet, physical activity, smoking cessation, and alcohol moderation. It includes not only local health systems but also school boards, park authorities, worksites, churches, bars, restaurants, theaters, sports centers, grocers and other retail outlets, voluntary organizations, senior centers, news media, advertisers, urban planners, and the leaders who set direction for these sectors.

Gaps in prevention among seniors

Both primary and secondary prevention among today's seniors falls short of the ideal, claiming lives in the process. Unhealthy behaviors are prevalent among older adults. Primary prevention, among the most effective strategies to reduce the burden of chronic disease, is practiced by a minority of seniors. For every 100 adults age 65 and older, 25 are obese, 25 engage in no leisure-time physical activity, and 10 smoke cigarettes. Fully 4.5 million seniors smoke cigarettes.

Gaps in immunizations are substantial. One out of three seniors has never received pneumococcal vaccine, which can significantly reduce the incidence of pneumonia and pneumococcal infections and is therefore recommended for all adults age 65 and older. In 2003, 30% of older adults had not received a flu shot in the prior year.

Efforts by Congress to expand coverage for preventive services under Medicare have gone a long way to remove a major barrier that has limited the ability of seniors to receive recommended immunizations and screening tests. Many of the preventive services recommended for seniors by the U.S. Preventive Services Task Force are now covered under Medicare. The Medicare Modernization Act (MMA) of 2003 introduced the “Welcome to Medicare" visit for new beneficiaries and expanded coverage for cardiovascular and diabetes screening. But coverage alone does not ensure the delivery of clinical preventive services. The General Accountability Office reports that only 10% of Medicare beneficiaries have been screened for cervical, breast, and colon cancer and also immunized against influenza and pneumonia. Insurance is not the only barrier to receiving clinical preventive services.

Health disparities among seniors

Some seniors are more apt than others to enjoy good health habits and obtain clinical preventive services. For example, a recent study by Dr. Clark Denny and colleagues, in the May issue of the American Journal of Public Health, reported that Native Americans age 55 and older are 1.5-2 times more likely than whites of the same age to be obese, to be inactive, and to smoke cigarettes. Similar disparities in unfavorable risk factors exist among African American, Hispanic, and other seniors in minority groups.

According to a recent study by Dr Paul Hebert and colleagues in the April issue of Health Services Research, 67% of white beneficiaries have received a recent flu shot but only 53% of Hispanic and 43% of African American beneficiaries had been vaccinated. Other investigators reported that, whereas pneumococcal vaccine is received by 66% of white Medicare beneficiaries above age 65, only 51% of African Americans in the same age group have been vaccinated. In 2001, 30% of Medicare beneficiaries had received a home stool test for colon cancer, but the same was true of only 20% of Medicare beneficiaries without a high school education.

Death rates are higher and life expectancy lower among seniors who are members of racial and ethnic minority groups or who are of low socioeconomic status. Americans age 65-74 are almost 50% more likely to die in the next year if they are African American than if they are white. Medical advances, the research enterprise in which our society invests billions of dollars per year, do save lives. But more lives could be saved by solving the causes of these disparities. In a study published by our team at Virginia

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