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Joint | March 3, 2015 | Committee Room | Joint Appropriations on Health and Human Services Meeting

Full MP3 Audio File

...is one of the social determinants that help, but it is only one of the factors. And the estimates are the clinical care is only responsible for about 20% of the health that people attain. So a little bit more about healthcare, we usually wind up talking about healthcare when we talk about health. And it is important, but it isn’t the primary determinant, so as a country, we spend 17% of our gross domestic product on health, yet we have some of the worst outcomes compared to other developed countries. And the reason is not that our healthcare is poor, but it’s that we’re spending money at the wrong time and in the wrong places, so all of that money is at the end of the health spectrum instead of the beginning of the health spectrum. And it’s important to remember this because if we spend too much on healthcare and focus only on healthcare, then we don’t have the opportunity to address some of those determinants that could actually help us achieve better health outcomes. So healthcare related spending crowds out spending on a number of the other areas that would help us achieve better health outcomes. We spend too much too late. And if we want to get control of our healthcare spending, we need to move it upstream. America’s Health Rankings is a 25 year effort sponsored by the United Health Foundation, the American Health Association and the Partnership for Prevention that compares states on a number of different health indicators. That is the framework that I have used to pull the data that I’ll be talking about. This is an effort that I have the privilege of chairing the Scientific Advisory Committee for this effort. I do have a few copies, I’m leaving them with staff here, but just to let you know that we do have this book if you’d like to take a look at it. It’s published every year. The website, it’s completely available online as well, and the website is listed in multiple slides. One thing about the way that America’s Health Ranking does their job is that they take all of those factors that we were just talking about in terms of the social determinants of health, and identify indicators of each of the factors. And this model that I have on the slide here is a simplified version of a socioecological model, so they take a number of factors for behavior, a number of favorite for community, environment, clinical care and policy, and they look at those as well as outcomes to see, to compare the states. And just graphically that model represents that those four categories of conditions influence the health outcomes. Now, the data that I pulled come from that, so I’ve anchored it in that. You may be interested in a particular piece of data that I don’t present and it’s because it wasn’t in there. That doesn’t mean it’s not attainable, so if there is something that you’re interested in that didn’t come out of there, then we can probably get it to you. So what I have done is to pull NC and six southern neighbors, so we have VA, TN, SC, GA, AL and FL. I’ve also presented on the slides the US data and the US data do come from the America’s Health Ranking, although in a few places I have looked to see what the variation is at the--within the state, looking at the county, and those data come from the County Health Rankings, which is a Robert Wood Johnson founded sponsored effort, and it’s very similar, but looks at data at the county level. So just the truth in advertising, I am a numbers geek and I have tried not to overdo numbers, but when you ask for comparative information on NC and the states that inevitably leads to a lot of numbers, so we have a lot of of data that I will be throwing at you, but mainly I will be leaving with you to consider. And...

It, you know, I just want to say in advance, the picture is not pretty. North Carolina does not fare well when you compare on the number of health outcomes, but I want to also say while it would be easy to be frustrated that's, that's not the purpose of this. There are a lot of smart people already working on this and we'll talk a little bit about that. In most of these cases, we know what to do. We just don't have the stars aligned to be doing it correctly or at the right dose, so we'll talk a little bit more about that as we, as we move on. But we aren't starting from scratch in terms of knowing how to address these conditions. We do have a couple of frameworks I want to orient you to. At the national level, there is an effort called Healthy People 2020. This has been going on for a long time. They set new goals every 20 years, but they define important areas and then set specific measurable objectives and targets. Now, this is a little bit unwieldy. There are over 42 topic areas and 1,200 measures in Health People 2020. So our state has been a little smarter about how we tackle that, and so they've pulled together a group in 2011 to look at those indicators and see if we could make a manageable road map for North Carolina, and that is what they have done. We have this framework called Healthy North Carolina 2020, and what that does is focus in on 40 objectives in 13 different areas, and that serves as our state health improvement plan. Okay, so I know you're gonna be. Sorry. This, I love this. They are balancing ?? I know you're gonna be talking about infants and children later when Dr. Salinty comes and speaks with you, but I do have a few measures that I wanted to share because my perspective is from the national perspective, looking at North Carolina and then those comparison states and when Dr. Salinty comes, she'll be looking more inwardly within the state, and some of the variations within the state. So the most common measure to look at when you talk about healthy babies is infant mortality. This is expressed as the number of deaths to infants less than one year old per 1,000 live births. So it's a little bit different from some of the mortality statistics that you look at. In this indicator, North Carolina does not rank well. We are the 41st state, and when I say these state rankings, one is good, 50 would, would be where we don't wanna be. So you can see that our infant mortality rate is 7.3 deaths per 1000 live births. The US average is 6, so we're above the US average, and you can see that the best southern state is Florida with 6.3. There are two other indicators that follow closely with infant mortality, and these are low birth weight and preterm births, babies that are born too soon and don't weigh enough do not fare well. So in those indicators, North Carolina is also above the national average. You can see at 8.8, and these are percents here, so 8.8% of our babies are low birth weight, and 12% are born too soon. You can see that Virginia has the best rate of the Southern states, so the little red circles are just to highlight and draw your attention to the highest among our neighbors, although I will note that for infant mortality, Alaska has the best in the country, and that is 4.1. Another indicator that we look at when we look at healthy children is immunizations. So childhood immunizations has been called one of the ten greatest achievements in the last century. Immunization has led to a 95% reduction in these reportable, in these communicable diseases of childhood.

Speaker changes: in this north ?? fares better than the nation for ?? children immunization what that represents that children age is 19 35 months who have their recommended serious immunization s 72& of the children's have the immunization that is above the state verge that managed to ?? is 64.9 and this represents ?? who have received recommended immunizations ?? so thinking back to the social determinations of other ?? important that re helping children in new ?? one with the age 18 who don't have houses towards the poverty threshold and looking this you can see north Carolina has 26.8 5 of children below poverty ?? ob this so poverty ?? children in poverty re three times ?? in health needs.This is one of measure where lot of variability cross in the state and Robinson county nearly have that ?? 48% yet to ?? county have 15%another indication is high school graduation we could see children who finish high school graduation who finish high school within four years is 795 we re belwo the nation l verge on that are below ?? the highest rte ?? the best rte in the nation achieved in Washington ?? Speaker changes: we re gonna be switching gears now bout adults you have more coming from Dr.?? from her two presentations Speaker changes:on difference and children Speaker changes:so i'm gonna start with mortality i've got here the slides with three ?? these re dtes tht is respired on the numbe of dys per 1000 population so these three count for urter ?? the rtes tht we for mortality is higher thn ten verge ?? you cn see tht some of our southern neighbor hve low only rtes thn we?? i'm gonn go on from therei little bit bot wht else so we re gnn focus on death ?? on efforts t the top of our is ?? understand graphically proportional of who re suffer from the is the smallest or number of suffer or hospitalized in the larger Numbers for chronic ?? for example in the immunity seen

But on medication management, and then there are an even larger amount of people who have risky, risk factors that would lead eventually to them having the condition, and then that largest group at the bottom would be the healthy population. And so, if we focus our resources at the deaths at the top, then we wind up doing extraordinary measures to save a few people, whereas if we were to focus our resources at the population level, and work on preventing some of that movement up the pyramid, then we would have much greater effect. So I'm gonna move away from mortality and start coming down this, this pyramid here and look at first morbidity. I wanna talk about some of the conditions that contribute to our high deaths from heart disease, and they are high blood pressure, high cholesterol, and then diabetes. Now you can see that our rates here are, for high blood pressure, we are higher than the national average actually for all three of these, and then you can see that there are Southern states, Virginia and Georgia, who have better rates than we do. The rank for diabetes for North Carolina for example is 43rd. And again, there's variability by county. In Orange county, the diabetes rate, I believe I've got this right. Yes, is 7%, but in Warren county it is 16%. Another factor that's very important to health, a healthy community and a healthy people is substance abuse and mental health. So there are three indicators in the America's health ranking that deal with this, and they are excessive drinking, drug deaths per 100,000, and then suicides. And if you, if you look at this, the excessive drinking is a measure that North Carolina is a, is below the national average, and in this case below is good. The drug deaths per 100,000 we are also below, but on suicides our rates are higher. And then you can see there are other Southern states for comparison to, to just see what their rates are. So I'm gonna move further down the pyramid now to address conditions that could help us prevent focusing at the end. So what might those conditions be? Well, these three right here are very important conditions. So you have smoking, obesity, and physical inactivity. So why are these important? These are things that we've heard before, but it, it bears saying again. Tobacco is responsible for 20% of all deaths. Smokers are more likely to develop diabetes. If you smoke and have diabetes, you're more likely to get heart disease. If you are overweight or obese, you are 10 times more likely to get diabetes. If you are inactive, you are more likely to have heart disease and get certain types of cancer. These guys, if you will pardon the pun, travel in packs, and they go together and there's, they have to be addressed in a comprehensive manner if we want to get control of our chronic disease rates and ultimately our healthcare spending and health of our communities. So I'm wanna start with smoking. This measure represents, for adults, the number, the percentage of adults who are smokers and they have smoked at least 100 cigarettes in their lives and consider themselves current smokers. And in North Carolina our rank is 33rd in the country, and our rate is 20%. You can see that the national average is 19%. There is, again, variation by county. In Jones county, 44% of adults smoke

...44%. In Orange County, 12% spent, so we have a wide variation there. The Healthy North Carolina 2020 goal is 13%. In our youth smoking, this represents high school students who smoked at least one day in the last 30 days. So this is what they call a supplemental measure in the ranking, so it isn’t actually ranked. I don’t know how we compare to other states--I mean to other, I don’t know our ranking, but our value of 15% is lower than the US average, but it is higher than some of our southern neighbors. So now I want to talk about obesity. So obesity in this chart represents the percent of adults who are obese with a body mass index of 30 or higher. Now, if you’ve been reading the news, you know we talk a lot about obesity and overweight, so this is just the obesity piece of that and this is an extreme measure. So it’s only those that are 30--a BMI of 30 or higher. Our rank here at 29%, our rank on this measure is 25. Again, we have variability in Orange County, which is one of our healthiest counties, which is why I keep listing it, is 21%, Robeson County’s rate is 41%. The youth obesity percentage represents high school students who were greater or equal to the 95th percentile for body mass on the growth charts. North Carolina’s value on this, 12.5% is lower than the national average, but it is not the lowest among our southern neighbors. And then the last measure on this slide is physical inactivity. So this represents the percent of adults who did no physical activity, such as running, calisthenics, golf, gardening, walking, nothing but their job in the last 30 days. On this, so you can see we have 26.6% of our adults getting no physical activity and our rank on this is 29. So the last measure that I want to show, show you from in there because Health Rankings is the public health funding measure, so this represents state dollars dedicated to public health as well as federal dollars that have been directed to the state through CDC and HRSA, the Health Resources and Services Administration. If you look at this measure, NC has $49, spends $49.85 per capita, per person on public health funding, and you can see that we are lower than the national average and lower than any of our southern neighbors. In this measure we rank 43rd. Now, there’s a great deal of variability in this measure because as you know, in NC, a lot of the public health spending begins at the local level, and this measure does not capture that. But what that means is that we do not have consistent services across the state because if it’s not funded by the federal government and it’s not funded by the state government, then it is left to the localities to determine how to fund that. And as you can see, with the variability that we have across our counties, some counties are better suited to be able to do that than others. In the most recent survey of local health departments that was done by the state’s Center for Health Statistics, there were 39 health departments who lost staff since 2011, so in the 2013 survey, 39 health departments lost staff, but interestingly, 28 gained staff, so...

...What you can see is that we have this divergence here between the counties who can and the counties who can not. Fifty-three local health departments provided care, prenatal care, in this most recent survey, and that was a 29% decrease from 2011. So we are seeing a loss of staffing and a loss of services at the local level. Now, I have recently completed a study in North Carolina that looked at the funding that was provided by local health departments so I looked at local public health funding and outcomes in the state of North Carolina. We specifically looked at infant mortality, and we were able to calculate that the services that the local health departments provided in those communities averted 191 infant deaths in 2008 so these loss of services and loss of staffing at the local level have real world consequences. (Everybody's ignoring that so I'm assuming it's not like a fire alarm or anything. Oh, a ghost, OK). So we've looked at a whole lot of numbers very quickly, but I want to just stop for a minute and say, "OK. So what? What do we do? What works for a healthy NC?" Like medicine, public health is a science, and we do have evidence and we know what works. So we have a base of evidence and interventions for many of these. We know what to do, but we very seldom have either the authority or the funding to fully implement the appropriate dose of the intervention. There are a number of strategies for each of these problems that we've identified, and in some areas the evidence is stronger than others, and where we have good evidence we are implementing evidence based programs. But, as I mentioned, sometimes we are not able to implement them as fully as we would like, but for example with tobacco. This is an area where we have probably more evidence than some of the other areas, but we know that the evidence shows if you have programs and policies to reduce exposure to second hand smoke then you can get better health outcomes. You have programs to prevent youth from smoking. Programs to help people quit smoking. Programs to help pregnant women quit smoking. These are all things that are evidence based and in some cases we are able to do them and in some cases we are not able to do as much as we would like, but in some cases we have done - we have made great strides and we thank you for your support on that. So the important thing is to remember that there are solutions and that monitoring and evaluating the progress is important, and that it takes partnerships across all sectors to work on the social determinants of health because its not only about what happens inside a health facility or a health clinic. I put this slide up here because frequently when I talk with community leaders about a number of health conditions I see eyes glaze over, and hands go up and its, "OK. Now what? There's so many things? How do we move forward?" And I certainly can't imagine sitting in your seats trying to make these recommendations, but I want to offer you just a comfort that there are a number of tools that are out there, and there are processes that have been used all across the country and in communities all across the United States where you can take a look at a range of conditions and look at the number of people effected, the severity, the effectiveness of the interventions, and the return on investment from addressing a problem, and use those tools to help identify where you might find the best place to make investments. And those tools have been used across the country, as I mentioned, and in local communities. And I just mention that just in case that's something you would like more information on. Finally, I just want to close by saying that we rank 37 among all 50 states. I looked at - I gave you the rankings on the individual...

. . . unusual measures. But when they're all rolled up, our ranking comes out to be 37 among the 50 states. And your roll in this is pivotal. What I like to tell my students when they first come to the school is public health is a team sport. So this is not something that public health professionals can go out and do. They can't go out and do public health. It's something we as a community decide to do to protect the health of the public. And so it takes working across all sectors. It takes thinking about those social determinants of health and how every policy - every opportunity we have - might have health impacts, and to think about those and how we might encourage better health outcomes. I also want to leave you with the knowledge that there is evidence for successfully addressing these, but also with the concern that we need sustained and consistent effort to be able to improve our outcomes. The two frameworks that I showed you - the Healthy People 2020 and the Healthy NC 2020 - are ten-year frameworks, so this is not something we can accomplish overnight. We need to take the long view. But it is something that will need consistent effort over time. And then I just want to acknowledge all the support we got from both the Division of Public Health, the State Center, and the Department of Health and Human Services. Thank you. [SPEAKER CHANGES] Thank you, Dr. ?? We will now open up the questions for Senator Heiss. [SPEAKER CHANGES] Thank you, Mr. Chairman. Starting slide number 20 on slide 28, it's the funding per state. And I guess the basic question I wanted to ask is in looking at these states that are listed here: is there any correlation between public health funding and outcomes of health? Based on the state's list here, it would actually show a negative correlation. The more you spend, the worse public health outcomes you have. And as we go through this process and determine where our resources need to be: what mistakes are these other state's as well as us missing in where they're placing their funding? [SPEAKER CHANGES] ?? [SPEAKER CHANGES] Sorry. So that's a great question, and the devil is in the details. So some of the states are spending more. What you are seeing is more the bottom end of the card, though, I will say. I did not show you the full range of what some of the other states are spending. But what we don't know is what they've chosen to focus on. So, for example, Alabama is spending a lot. Their outcomes are poor, but you look at their childhood immunization rates and they're good. So it may be that they've decided to effectively fund a specific dose of certain interventions and not others. I have not done that research, but I can tell you in North Carolina, when we did look specifically at funding, we did see improvements in the infant mortality and we did see improvements in the heart disease hospitalization. Those are two outcomes that we looked at. [SPEAKER CHANGES] ?? [SPEAKER CHANGES] Hello. [SPEAKER CHANGES] And along those lines, we get a lot of recommendations of where we need to spend more funds and those type of things. But I don't think anybody who thinks we're getting all this additional money this year - from where it's coming in . . . but where are we investing funds that are least effective? Where are those funds that are in the system that would best be redirected to other services? [SPEAKER CHANGES] Yeah, I think that's the holy grail: where can we cut and then put those funds in a better place? I don't know the answer to that, but I do think that we have people who can help look at the areas. I think it's important to evaluate everything we do. We know we don't have money growing on trees. I know you're struggling to try to figure out how we can fund basic services. These are complicated questions, and I think it's important to use the data to drive us. So, first, focus on the evidence base and be sure we've got evidence-based programs. And then look for being . . . [recording ends abruptly]

Remember that we have the outcomes that we're hoping to achieve. [SPEAKER CHANGE] Senator McKissick. [SPEAKER CHANGE] Senator Hise and I, I seem to think our minds are running along parallel paths this morning, because my question was pretty much focused on pretty much on one of the same characteristics here. I mean, given the fact that we have limited revenues, assuming that the only thing you may see is modest increases of 1% or 2%, I mean, knowing that we've historically focused so much of our resources towards this and kind of in the life and related health expenses and things of what I call the back end of the curve. How would we go about re-prioritizing to see how to best utilize those monies in a more effective way to achieve a better health outcomes? How do we sit there and approach all of this data to give it some meaningful analysis that really helps us reallocate our existing revenues so we can get a bigger bang for the buck, or greater health related outcomes? [SPEAKER CHANGE] Thank you . . . Oops. [SPEAKER CHANGE] Yes, mam. [SPEAKER CHANGE] Sorry, I'm . . . [SPEAKER CHANGE] I think all questions are coming your way. [SPEAKER CHANGE] Okay, thank you. I appreciate that question. I could not tell you the answer that's clearly something that you will have to struggle with, but that is why I included the slide about the process. There are processes that can be used, and I think that the professionals that we have at the state could be tasked with helping lead some of you through that process. It is a trade off and I do recognize that. There are some things that are more expensive than others, and there are some things that are clearly more effective than others. Its a matter of taking a holistic look at that and, as you say, I appreciate even the question because its the type of thinking that I think will get us where we need to go, which is prioritize. [SPEAKER CHANGE] One quick follow up. [SPEAKER CHANGE] Allow. [SPEAKER CHANGE] And, its on that same chart on page 28 here, dealing with North Carolina spending $49.85 per ca-pita, now you indicated that that did not include local funding. If we did include local funding do you have any idea where would then rank at that time, so its more of an apples to apples comparison rather than an apples to oranges. [SPEAKER CHANGE] Well, I can tell you where we ranked in 2008 because I did just, well not ranks, but what the number was, it was about $80 per person, but that was on the average. Now, I can't say this is apples to apples because this type of variation goes on in other states as well. So, some states that you know are centrally funded and then some states have a more distributed model, like we do, where its a combination of local and state funding, so this variation it might even be worse if you added the local funding in from other states, that I don't have. If you're following me on that one, but the variation across the state was about three fold. So, even if you looked at the average, now this is a little bit different year because that was in 2008, the data that I had. But, there was still an extraordinary variation across counties, some counties had well over $100 per person and some that had well, well, less then this average that you see here. [SPEAKER CHANGE] Well, thank you for that excellent report. [SPEAKER CHANGE] Thank you and committee members I'll just tell you that I've got eight more of this, ask questions, so the limit is to shorten it possibly up. Senator Robinson. [SPEAKER CHANGE] Thank you, Mr. Chair, and thank you for that report and the comprehensiveness. One of the things, I've got kind of a two fold question that is apparent in your report and as, quote a health practitioner I can relate to that and see it. Is the impact of poverty, starts at childhood, starts with infant mortality and how that impacts straight throughout life, one of the things that you didn't cover in that and my question is, as we get into, and you didn't do age breakdowns, youth, etc. We know that habits, in terms of physical activity, health, etc. Impact, have you looked at any of the data regarding youth, in terms of

[SPEAKER] The kind of disease rates. We know smoking may be one of those, I see that all the time or hear it in statistics. What are some of the other factors regarding youth? Because as a child grows then into adulthood, we carry those habits as we get older, so that you look at some of the health indicators regarding youth, what are some of those behaviors? What's the impact, in terms of over that age span? Have you looked at any of that data in North Carolina? [SPEAKER CHANGES] I did not look at that for this report. Partially because Dr. Cilenti, who is with our Maternal and Child Health Department at the school, is scheduled to give two different presentations to this group. One is on the infant, the zero to birth, the infant mortality, and then the other is zero to five. And so she will be focusing on that. But I will say that you have pointed out one of the important conditions and that's poverty. It's this whole community environment, so we know that as children grow out of that five and up, then they need healthy places to play, they need places to get physical activity that are safe, they need to have efforts to keep them from smoking. Injuries are one of the highest risk for our youth, so that's an important thing as well. That and drinking, which- [SPEAKER CHANGES] Just one follow-up Mr. Chair. [SPEAKER CHANGES] Follow up. [SPEAKER CHANGES] The other end of that that I wanted to mention. When we look at data in North Carolina, you mention Orange County several times, in terms of, and we know the income rate is totally different from Robeson or Warren or whatever. But have we taken those models that have worked, for instance in infant mortality in one county. I know we made progress in Guilford, one of those areas we focused on. But, have we taken any of the models that work in one county replicated them in another or have there been factors of funding or whatever. Do you know any of that? [SPEAKER CHANGES] I couldn't speak to the specifics of that, but I do think that's something that maybe Dr. Cilenti or some of our division staff that would be here when she speaks would be able to address that. But I do know the people who work at the local health department level do try to share best practices, but of course there is the variation in funding. So that- [SPEAKER CHANGES] Representative Insko. [SPEAKER CHANGES] Thank you Mr. Chairman. I actually have two questions. One is, and I'd like to ask them both because you may not answer one of them. But one of them is if we don't have any money, are there policies that we could deal with that would have an effect. A lot of these diseases that you've talked about are lifestyle diseases. Or maybe this is the same question. So, are there policies that we could take that would help intervene with obesity and cardiovascular disease and cancer and the diseases, we know smoking is one thing. We know obesity is one thing, and so that sort of leads me to the second question. So we have passed bills controlling vending machines, what's in vending machines in public schools, for example. But why don't we do that in all public-owned buildings? We might not want to do it in privately-we probably wouldn't do it in privately-owned buildings, but public-owned buildings, it seems to me like there are some policies that we could deal with that would help intervene in some of these issues. The other thing then is that that gets into this question of, this tension between individual liberty and common good. And can you make a case for why we should be concerned at all about the community health? Why is it a common good? Why should that even be important to us? Why isn't that just an individual decision that people live with? Why do we need it at the community level? [SPEAKER CHANGES] Well I appreciate that question. I actually, I'm in public health, so yes I'm going to come out saying health is a common good, and I think when we look at how we live and work as a community, the fact that we have a number of factors that would influence how that ill effect is held.

If we have a healthy community, then we can get better jobs here. You can raise the standard of living. If you have poor health outcomes, you're not going to get those jobs. So it's actually in the state's best interest to have a healthy population so that we can be competitive as a state. Aside from our humanistic belief that everyone deserves to leave a long and healthy life, this tension between our individual rights and calling these individual behaviors, I think is something that we wrestle with in public health because yes, we are Americans. We do have our freedoms and we do believe in that, but what happens is that we have a lot of forces that are trying to get us to change our will. That's certainly happened with tobacco. So we had a lot of advertising money and a lot of other forces that pushed people to take up behaviors that were not healthy. What we need, and this is where your question is going, is the healthy thing to be the easy thing. And that's where the policies come in place. So having smoke-free workplaces makes it easy for people who want to quit, and most people who smoke want to quit. It makes it easy for them to quit if they have a smoke-free workplace. So, yes, some of the things we've done around tobacco, and there are other areas where we could look at that. There is a movement called Health in All Policies where actually health is a consideration of any policy that is introduced, and I think that's a wonderful way to understand how we can be sure that we are considering the impact of health in everything we do. Not just when we're spending money on health programs. [SPEAKER CHANGES] Senator Tucker. [SPEAKER CHANGES] Thank you, Mr. Chairman. Doctor, thank you for your report this morning, and when I ask a question, I do it in all due respect, and perhaps you were not prefaced on this meeting and what you bring to us? I am extremely disappointed in an answer of I don't know. We sit as a mechanical contractor, retired air force pilot, statistician, former county commissioner, and try to, from a 50,000 foot level, try to understand the complexity of what goes on in public health. I would prefer that you would tell me what are the top three things that we can spend our money on and reduce in other areas? Such as you mention tobacco and cessation programs. We cut those two years ago, but yet we continue to fund some high-cost alcohol treatment programs throughout the state. I would prefer you to tell me, ma'am, as 20 years in this business and having to work in the health department, if we were to do a state match and perhaps redirect monies to public health where they could hire more OBs to deal with women in their pregnancy to reduce infant mortality rate? I see what you've done here for us, and you tell us where we rank, but I'm looking for areas with no new money to be able to reduce areas that we're not getting an ROI and placing dollars in those. And I would expect, with your academic credentials and all these smart people you mentioned earlier that were working on all these things and these evidence-based programs, you could suggest at least three areas, looking at our budgets and the monies we've spent over the years, that we could reduce and then we would get a bigger bang for our buck. That's what I was looking for out of your presentation. And perhaps you weren't told that, and I would ask for probably an unacademic response by shooting from the hip from 20 years experience in telling me what you would do if I was looking at this from where I look at? [SPEAKER CHANGES] Well, I'm sorry to disappoint you. I do aim to please, and so that is not what I thought I was asked to come talk about. I admit that these are complicated decisions, and I understand that you are looking for guidance, and I think that we can provide that. That would require an assessment of the spending that had been done, and I have not looked at the spending that has been done on every program in North Carolina.

There are some easy, easy wins. I do think you mentioned tobacco and that is a place where we know that it’s important to help people who want to quit, so we have the quit line. Can we reach all the people we want to reach? These are questions that we need to answer. I don’t have the top three; I think that is a charge that this committee was expecting and I think we could probably reconsider--maybe I’m not the right person, but maybe I can get with the right people--so I can say I don’t know, but perhaps can I can also say we can get back to you because I think you’re going to hear some more data. And I think that those are when you have heard sort of the full complement of what you have asked for, you then like to look at additional data about moving things around. I think that’s a little different type of engaging that, but. [SPEAKER CHANGES] Well, thank you, I just didn’t know what you were asked to do or not do. It would be my charge for you to get with your professional folks that are really smart people you tell me about, and give us as a committee the top three things that we could spend our money on, and then the places were our return on investment is not so high that we can move those dollars over with the understanding that we have no new money based on the growth we’ve had in the Medicaid program in Jan/Feb, which is tracked at 8-9%, it’s gonna eat us alive. We’re gonna need to move things around and be effective. I do like your term sending money upstream, I do understand that and realize that, but and I do realize the cultural impact to North Carolina. I grew up in eastern NC eating fried chicken, and bbq, and breadsticks and working in the tobacco field. And I understand what that did to me culturally. As I grow up, I still belong--I’ve got a 16-year-old’s appetite that my grandmother gave me from the clean plate club, and a 65-year-old body. 
But that’s what happens to us as we go along and gain weight and have these other things. I did stop smoking at 30, but you need to tell us those things because we have got to have this information and we have got to have it now, doctor. Thank you, Miss J??. [SPEAKER CHANGES] Representative ??. [SPEAKER CHANGES] Thank you, Mr. Chairman. Minor comments, I’ve been in the health insurance and employee benefits business for 38 years. And there’s one area that could be very beneficial and would cost very little money, and that’s for your office and the state health director’s office to partner up with say the National Federation of Independent Business, maybe the NC Chamber, but they tend to just look at big employers. 
But under 50 employees, as most people know, are 85% of our employees are employed someplace that has 50 or less employees. Now, what we have told people, starting about five years ago, if you will put in a wellness plan and make it as mandatory as you can under federal law...now the state employees health plan has done that for state employees, so that’s fine. So I’m talking about private employers and nonprofits. To help those people to be able to put in wellness plans, they have no one to help them. Now, we do help our smaller clients with that. We have vendors that we go to and they will do the wellness plans for them. But people all the time say I need to cut my health insurance premium. Well, they doubled in the last five years, and they doubled in the five years before that and they’ll keep on doing that. I said there’s one thing you can do, you can put, well two, you can put in a smoker’s cessation program and you can bar smoking from your company premises, okay. The other thing is put in a wellness program, and basically what they are, you probably know, but some of these folks may not know, is you say if you participate in this wellness program, you will pay 20% less on your health insurance. Of the total cost, not just what the employers kick in the total cost, and so it in other words, if you don’t, you’re gonna be paying a lot of extra bucks, big bucks. And that program is very simple. They hire an outside vendor that will come in and do blood draws on the premises, and the employees will fill out online (if they can do it online, if they can’t then they can fill it out on paper), and it asks about 65 questions -- medications, family history, lifestyle, all these things. Well what we found out, the first one we put in...

The Raleigh Durham Airport was a phenomenal success and still is a phenomenal success and I tell these other employers that it's the only way you can keep your health insurance premiums in line. There is no other way. A way that most employers do, they switch from Blue Cross on year to United the next year to Wellpath the next year to Signa the next year. No way to do anything. So if you could partner with these organizations, maybe it would take two or three employees. You can allocate your own services. The county health departments, and I have been a county commissioner, the county health departments are mainly oriented towards poor type people, and rightfully so. So we need to, if we tackle this at the workplace, it is so cost effective, very little money, and you're covering, you're going after millions of other people. [SPEAKER CHANGES] So I guess that was more of a statement than a question. Senator Pate. [SPEAKER CHANGES] Thank you mister chair. Is it Dr, how do you pronounce your last name? Shank. [SPEAKER CHANGES] Shank, like golf. [SPEAKER CHANGES] Okay. Thank you very much, I'm, that was not my question. [SPEAKER CHANGES] A bad golf swing. [SPEAKER CHANGES] I had that in my day. I had a shank. [SPEAKER CHANGES] Dr. Shank, we've heard from over the news media for the last couple of months or maybe three, four, five months now since the Fall season began that doctors, health providers are turning people away from their health services if they have not had their influenza shots because they're afraid of infecting the people who are in there who they might run across. Secondly, we have heard some reports that measles and other childhood diseases are apparently on the increase because the immunizations for that are not universal. Some people are making the decision not to have their child inoculated, or vaccinated or whatever the proper term is. Are there dangers to the public in these precautions being taken, and should we take a harder look at maybe enforcing what needs to be done to see if we can't eradicate or at least minimize these diseases among our population? [SPEAKER CHANGES] Thank you for that question. The immunizations is, as I mentioned, one of the greatest victories that we've had, but we do have these pockets where people have refused to immunize their children because they're afraid of, of stories that they've heard about links with other diseases, and, and so some states have taken strong stands on removing the option for parents to, making it more difficult for parents to decline. There is a thing called herd immunity, and so if you get a certain percentage of the population immunized, it protects the vulnerable. So we need to achieve those because children are not fully protected even if they're getting their immunizations if they haven't had the full series, and people who are undergoing chemotherapy or some other conditions that have reduced, or compromised status can be vulnerable. And so it is important to the state to achieve that, and there have been other states that have taken stronger stands on that. [SPEAKER CHANGES] Follow up. [SPEAKER CHANGES] Follow up. [SPEAKER CHANGES] So then in your position, what would you recommend to us that we do in North Carolina? [SPEAKER CHANGES] I'm gonna punt that down the road to our child health expert Dorothy Salinty is coming, and she will be talking about immunizations, so if I could hold that one, I would do that. [SPEAKER CHANGES] Members, we have about three minutes left, so I've got three, Representative Van Duyn. [SPEAKER CHANGES] Mine is really quick and kind of a comment, not so much a question. I'm curious, is there any data over the history of the evaluation of the life span that looks at causes, because I understand that years ago, when your lifespan was 40, 44, 45 years, you were dying for a lot of, from a lot of things

Speaker changes:?? it looks like we have succeeded in life style and I'm curious in knowing what could have happened in terms influences in life span and what we done with that and i can get with you later if ?? short answer find Speaker changes:so there is short answer the history of is one of the great things we do ?? and that is killing lot of people and so the some of the things that we have done in improving the moralities it impacts lifespan in that early age and that involves and wide expectancy i think some of the expectancy in the coming days ? is important to keep in mind as your talking about children that actually can impact life expectancy and population Speaker changes:follow up Speaker changes:this is really questioned to say this is lot of really represents sitting out in the audience health care organizations ?? have reputations we are gong to be ?? lot of them with this new approach we are taking with looking third questions what re you doing can you measure that are you doing for the dollars that we give you I'd like to ?? with in the public health ?? to people that they would make people lot easier if they didn't bet up on us because we change the way we do things in terms of who gets money who doesn't gets money that is extremely ?? our lives is to only ?? north Carolina Speaker changes:senator ?? Speaker changes:thank you Mr chair this is follow up ?? that my be one answered the later session regarding the slide on page 17 ?? north Carolina immunization has break outing how many people re opting out because they have to opt for how many for those who visible that is policy that is something policy stamp point that we could something to do with if people are opting out that's another financial situation issue that we should do with different way that detail is very important if visible so i don't know if you have it now can be brought later if not i think ht is something later to be dealt into i can pass that question to senator ?? Speaker changes:thank you i think you should relieve Mr.Chair because that is brief Speaker changes: thank you ? Speaker changes: thank you for all of you do Speaker changes: ?? is adjourned