Roosevelt Rx

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Praise for Roosevelt Rx “Just what the doctor ordered”

“If you are looking for informed, creative health policy thinking by the next generation of America’s leaders, look no further. The students who have contributed to this innovative collective effort have passion and ideas aplenty. But even more important, they are committed to engaging young Americans in the vitally important debate over the future of American health care. The Roosevelt Rx initiative is just what the doctor ordered.” ~ Jacob S. Hacker, Ph.D. Professor of Political Science, University of California, Berkeley Author of The Great Risk Shift

“Gives voice to our future leaders”

“The nation’s young people have much at stake in the ongoing debates over health care policy. This important effort gives voice to our future leaders on one of the most complex policy challenges of our time.” ~ Alina Salganicoff, Ph.D. Vice President, Kaiser Family Foundation

“Offers students a forum to share ideas”

“As the future leaders of America, we students must be offered a voice in addressing health issues and creating solutions. Roosevelt Rx offers students a forum to share ideas and magnify our collective impact.” ~ Tamar Klaiman, MPH (PhD Cand.) Chair, American Public Health Association - Student Assembly

“At the forefront of cultivating future leaders”

“The next generation of leaders can bring a powerful sense of effecting change through their collective voices. Roosevelt Rx is one of those groups that are at the forefront of cultivating future leaders and engaging thought and innovation in engaging policy and offering solutions.” ~ Jay Bhatt, D.O. Past National President, American Medical Student Association

therooseveltinstitution

Student Ideas for Improving Health Policy

therooseveltinstitution 2100 M St, NW Suite 610 Washington, D.C. 20037

Roosevelt Rx

Volume 1 • September 2008 Copyright 2008

Executive Director Nate Loewentheil

Policy Director Caitlin Howarth

Editor-in-Chief Robert Nelb

Policy Editors

Jeet Guram Alexander Hertel-Fernandez Brad Wright

Features Editors Julia Battocchi Mariza Hardin Saqi Maleque Edie Moussa

Associate Editors Jay Bhatt Angelica Dortch Shipra Roy Michelle Tafur

The editors would like to thank Usha Ranji, a principal policy analyst at the Kaiser Family Foundation for her help in reviewing articles for this publication. Any errors are entirely our own.

Printed by Mount Vernon Printing Co. to responsible forestry standards. The opinions expressed within Roosevelt Rx are exclusively those of the individual authors and do not represent the views of the editors, the Roosevelt Institution, or any of the organization’s chapters, centers, advisors, or affiliates.

Contents Preface Issues

A New Deal for Health Care: FDR’s Vision and Values

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Health in a Broader Context: Incorporating the Social Determinants of Health into Health Reform

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The Language of Health and Human Rights

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Young Voters’ Role in the Upcoming Election

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Shooting Themselves in the Foot: W hy Empirical Research is Essential to Advocacy

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The Intersection of Science & Policy: A Tobacco Case Study

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From Health Security to Health Choices: A Comparison of the 1993 and 2008 Clinton Health Plans Eva M. Galvan, Yale University

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Robert Nelb, Yale University

Saqi S. Maleque, The George Washington University Shipra Roy, University of Minnesota - Twin Cities Brad Finnegan, The George Washington University

Brad Wright, University of North Carolina – Chapel Hill Julia Battocchi, The George Washington University

Ideas

Tax-based Automatic Enrollment in Health Care Plans

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Reducing Infant Deaths With Nutritional Outreach for Pregnant Women

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No Child Left Idle: Federal requirements for Physical Education in K-12 Schools

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Empowering the Public Health Service

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Creation of an Office to Improve Men’s Health Outcomes

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Promoting Equity of Health Care Payments

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Mandating Documentation of Desires For End-of-Life Care

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Robert Nelb, Yale University

Alexander Hertel-Fernandez, Northwestern University

Edie Moussa, Virginia Tech, and Eva Galvan, Yale University Louis Graham, University of North Carolina - Greensboro Ramon P. Llamas, University of Southern California Kumar Senthil, Johns Hopkins University

Wendy Mosiman, Wichita State University

Containing Medicare Costs

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Creating a System of Uniform Federal Health Insurance Mandates

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Building a Sustainable Comparative Evaluation Institution

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Genia Lindsey, Lake Forest College Jeet Guram, University of South Carolina

to Assess Medical Treatments

Jonathan Knoche, University of Wisconsin

Ensure Student Access to Health Insurance

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Using the HPV Vaccine as a Gateway to Better Health

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Loan Repayment Incentives for Community Health Centers

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Mariza R Hardin, University of New Mexico Stephanie Gross, Northwestern University Krysten Rosen, University of Florida

Funding for Registered Nurse Education in the Face of a Nursing Shortage: Balancing Volume, Quality, and Distributional Considerations 65 Dan Belsky, University of North Carolina at Chapel Hill

Action

Talking About Health Care Reform on College Campuses Alexander Hertel-Fernandez, Northwestern University

Appendix: Key Healthcare Statistics Roosevelt Rx

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Preface

As the 2008 election heats up, political pundits have talked much about the need for health reform and the surge in turnout from young voters. Yet rarely have they discussed how health care reform impacts young adults, and hardly ever have they asked us what we think. Given the challenges of our time, we cannot afford to stay silent anymore. Now is the time for student action around health reform. Roosevelt Rx is a student-led initiative to give young adults a voice in the health policy debate. Undergraduate and graduate students from all across the country have come together to present their ideas and analyses in this journal, the Roosevelt Institution’s first national publication exclusively on health reform. The prescriptions here are varied but underlying values are the same – we want bold and innovative change to strengthen our health care system and provide quality health care to all Americans. To make our case for health reform, this journal is divided into three sections: issues, ideas, and action. First, we present some background about how health reform impacts students and offer student commentary on the ethical and political issues underlying the current health policy debate. Next, we present a range of student policy ideas for providing access to quality care, controlling costs, and addressing the unique needs of students. Finally, we offer tools for action by discussing how to frame messages of health reform and how the Roosevelt Rx network is working to make a difference in health care. The challenges discussed in this publication may not be entirely new, but as students, we bring a new and needed perspective to the health care debate. We are young enough not to be jaded by the political process or bound by old ways of doing things. We are smart enough to take advantage of the resources of our universities to develop policies that cross disciplinary lines. And we are experienced enough with the health care challenges faced by our own peers to speak out for them and give our generation a voice. Most importantly, however, we are mobilized and ready to push for change. This publication may have started as a core group of dedicated editors, but in just a few months it has grown into a movement of young people dedicated to improving our health care system. Students across the country will be using this publication to organize student debates around health reform on their campuses, and the Roosevelt Rx network, as part of the larger Roosevelt Institution, will continue to serve as a catalyst for students to get involved in progressive policy long after the 2008 campaign concludes. Our generation is stepping up to make its voice heard. -Robert Nelb Editor in Chief

Issues

A New Deal for Health Care: FDR’s Vision and Values Robert Nelb, Yale University

More than 100 years ago, Teddy Roosevelt became the first U.S. president to call for

a national health insurance system, but Teddy’s fifth cousin, Franklin D. Roosevelt, was perhaps the one who best articulated the values and vision needed to implement such a system. This article examines three quotations from FDR that offer insights about the importance of human rights, responsible science, and an active government in ensuring health care for all. Health as a Human Right “In our day these economic truths have become accepted as self-evident. We have accepted, so to speak, a second Bill of Rights under which a new basis of security and prosperity can be established for all—regardless of station, race, or creed. Among these are … The right to adequate medical care and the opportunity to achieve and enjoy good health . . . All of these rights spell security. And after this war is won we must be prepared to move forward, in the implementation of these rights, to new goals of human happiness and well-being. America’s own rightful place in the world depends in large part upon how fully these and similar rights have been carried into practice for our citizens.” Franklin D. Roosevelt State of the Union Address, January 11, 1944

In 1944, as World War II was coming to a close, FDR used his State of the Union address to outline his bold vision for America’s home front in the postwar world. In what came what came to be known as the Second Bill of Rights, FDR emphasized the importance of providing economic security to all by providing everyone access to a good job, a good education, adequate health care, and other important benefits. This Second Bill of Rights never became part of the constitution, but FDR never intended them to be. Instead they were considered self-evident truths as American as the Declaration of Independence and also internationally relevant to all people around the world. Eleanor Roosevelt later incorporated many of these rights, including the right to health care, into the UN declaration of human rights, but the U.S. has never officially ratified the International Covenant on Economic, Social and Cultural Rights. In the absence of a legal mandate requiring health for all, reformers today must find a way once again to make this right self-evident to the American people by articulating, as FDR did, the connection between security and prosperity for all. Knowledge as a Tool for Good “Our Republican leaders tell us economic laws — sacred, inviolable, unchangeable — cause panics which no one could prevent. But while they prate of economic laws, men and women are starving. We must lay hold of the fact that economic laws are not made by nature. They are made by human beings.” Franklin D. Roosevelt Nomination Speech at the Democratic Convention in Chicago, IL, July 2, 1932

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When FDR accepted the Democratic nomination before his first run for president in 1932, the country had been deep in depression for nearly two years yet many prominent economists claimed that this recession was a natural product of business cycles. FDR, however, challenged the notion that government shouldn’t invest in a poor economy and became a champion of a new form of Keynesian economics. While Roosevelt attacks the Republican status quo in the quote above, his critique was much deeper than the usual political bickering. By questioning the origin of economic laws, he questions the role of knowledge in society. FDR was not necessarily opposed to academics (in fact, he was noted for developing a “brain trust” of experts to help him on policy decisions.) However, when dealing with problems like health care, FDR was opposed to experts who remained in the ivory tower and did not actively apply their knowledge to the world’s problems. Today there are many more health policy “experts” than in 1932, but having more experts won’t make people any healthier unless these ideas are tied to action. The Need for an Active Government and an Active Citizenry “Governments can err, presidents do make mistakes, but the immortal Dante tells us that divine justice weighs the sins of the cold-blooded and the sins of the warm-hearted in different scales. Better the occasional faults of a government that lives in a spirit of charity than the constant omission of a government frozen in the ice of its own indifference.” Franklin D. Roosevelt Nomination Speech at the Democratic Convention in Philadelphia, PA, June 27, 1936

In 1936, as FDR sought reelection to his second term, he had to acknowledge his faults. While FDR admitted the potential of mistakes, he stayed true to his principles that the government should help those in need, and he ended up winning reelection in a landslide – winning all but eight electoral votes. The “spirit of charity” that Roosevelt spoke about and practiced throughout his administration wasn’t necessarily a spirit of government handouts. Instead, his signature programs were based on the ideas of shared responsibility and community empowerment. For example Social Security requires individuals to contribute to the system in order to receive benefits, and New Deal programs like the Tennessee Valley Authority, focused government resources on projects that would strengthen a community’s ability to support itself. In health care, this principle of shared responsibility can also be a model for viable reform, but perhaps the most important message from FDR is the need to take action. For the generation young adults today that is so often told that it is apathetic, there is no greater lesson. Sources

Burns, James MacGregor and Susan Dunn. The Three Roosevelts: Patrician Leaders Who Trans formed America. New York: Grove Press, 2001. Sunstein, Cass. The Second Bill of Rights: FDR’s Unfinished Revolution and Why We Need it More Than Ever. New York: Basic Books, 2004.

Health in a Broader Context: Incorporating the Social Determinants of Health into Health Reform Saqi S. Maleque, The George Washington University

Access to health insurance and affordable, quality medical care has been the focus of

health care debates and health care reform agendas for the past several decades. In fact, health in the United States has always been framed in terms of medical care, as evidenced by its large funding priority. The United States pours billions of dollars into its health care system, spending more money per capita than any other country in the world. Yet despite the enormous investment, the U.S. ranks lower than many other industrialized nations on outcomes such as life expectancy and infant mortality, and are disproportionately worse for racial and ethnic minority populations. The question for policymakers then focuses on why the U.S. fails to get a good return on this investment. In truth, rates of disease, illness and chronic conditions can increase for many reasons, including a lack of access to care, high health care costs and poor quality of care. However studies show that income, education, and living environment have greater influence on health status, longevity, and quality of life than traditional health care considerations. Including these social factors into a broader framework of health reform is needed. At its core, Health in All Policies (HiAP) addresses the natural ecological aspect of health. It is based on the recognition that health is determined to a large extent by living conditions and other societal factors. It therefore enlists a horizontal policy strategy that examines the determinants of health that are controlled by policies outside of the health sector and addresses policymaking at all levels of governance. From an economic perspective, addressing chronic conditions exclusively from a health care delivery model has proven to be extremely inefficient. The U.S. cannot afford to sustain the rising level of health care costs necessary to treat preventable illness caused by living conditions and alterable health behaviors. In addition to economists, physicians and other health care professionals are acutely aware of the limitations of treating an individual after the onset of illness. All of these examples point to the same conclusion: prevention efforts need to garner a larger amount of attention in health reform. Social policies and health outcomes are intrinsically interwoven; for example, people who are consistently exposed to poor living conditions in both childhood and adult life are more likely to have heart and lung diseases than those who live in quality housing conditions. Social and economic policies also influence health behaviors, which in turn can lead to chronic conditions. Healthy eating habits and increased physical activity are known to improve health, yet barriers in the environment often prevent many individuals from making healthier choices. For instance, in the south side of Chicago, researchers have found that people living in areas without supermarkets are more likely to be obese or overweight than people who live in close proximity to a supermarket where they have access to fresh fruits and vegetables. Access to healthy food often varies among neighborhoods. There are three times as many supermarkets in wealthy neighborhoods as in poor neighborhoods and four times as many in white neighborhoods than in African American neighborhoods. Minority and low-income neighborhoods often contain fast food outlets instead, making it much less likely for their residents to consume healthy food. With such obvious disparities in community resources for certain populations, health policymakers that fail to address the economic policies that encourage or

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discourage commercial development in some areas, the urban planning design that prevents or allows movement and transportation, or the housing policies that determine the quality and affordability of housing options, are further exacerbating the health inequalities that exist. Where people live, work and play have an important role in health outcomes, and are as vital to prevention as efforts to change health behaviors and increase access to care. Reframing chronic disease prevention through comprehensive community-based improvements can have a deep and long-lasting impact. Using the HiAP model is not necessarily a novel concept; some governments have already incorporated its use in their health reform agendas. Since 2006, the South Australian Cabinet has been working to incorporate HiAP into both internal processes of the government and into discussions with the community to ensure that policy decisions across sectors are made with health impacts in mind. But to adopt HiAP in the U.S., there has to be a sea change of thinking by officials, communities and researchers regarding the importance of the social factors that influence health. It is a fundamental shift in the way we have framed health in the past, but it can be accomplished: 1. Health reform priorities have to include a larger portion of prevention efforts. There has to be a committed and sustainable amount of resources dedicated to prevention of illness and disease, including resources that extend beyond the health care delivery model. Currently, prevention efforts are often overlooked and undervalued, and receive a small amount of federal support. 2. Moving towards a broader framework requires action across sectors. Stakeholders from various agencies and sectors would be required to break through established silos in order to collaborate effectively towards a more systematic and comprehensive approach to population health. The change does not necessarily have to be an expensive one; it can be achieved with small amounts of funding to create local and state level interagency consortiums dedicated to examining the intended and unintended consequences of policies on health. 3. There has to be more flexibility in federal governance and infrastructure, with a larger role for public health in health reform. Currently, the largest amount of federal resources allocated for public health issues are appropriated through Health and Human Services to the National Institutes of Health, an organization that primarily focuses on biomedical research and illness. Prevention policies affecting schools, neighborhoods, and the workplace require funding outside the Health and Human Services budget and reach into agencies such as the departments of Labor, Education, Transportation, and Agriculture. The current structure of the executive branch does not lend itself to cross sector funding; therefore flexible and creative approaches to leverage current resource allocations are necessary.

Finally, and most importantly, an HiAP model will require committed leadership on the national, state and local levels. While HiAP is driven by the public health field, it requires leadership on all levels and across sectors to acknowledge the importance and consequences of non-health sector policies on population health. However, without sustained and effective leadership on the national level, health reform in a broader context will be difficult to accomplish. While broadening health reform may seem daunting, it can be accomplished. There has been rising support and attention to the social determinants of health in the public

and private sector. The CDC recently convened a group of local, state and national entities, called the Healthiest Nation Alliance, to discuss the role of public health in transforming the health system. Some local and state governments have created interagency coalitions that include a wide range of departments, recognizing the need for a more holistic approach to health. Philanthropic agencies have also started to broaden their priorities. The Robert Wood Johnson Foundation has created a Commission to Build a Healthier America, a national commission that is charged with developing recommendations that will improve health by engaging other sectors, such as education, housing and the workforce. In summary, in order to obtain the improvement in health outcomes sought by health reform, we need to approach health with a new way of thinking, one that frames health in a broader more holistic manner. Utilizing a model like HiAP that includes public health initiatives that focus on social factors, such as education, housing, income and the environment is the most promising way to make that change. Sources

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Adler N, Newman K. Socioeconomic Disparities in Health: Pathways and Policies. Health Affairs. 2002; 21(2):60-76. Banks J, Marmot M, Oldfield Z, et al. “Disease and Disadvantage in the United States and in England.” JAMA. 2003 May 3;295(17):2037-2045; Braveman P, Egerter S, et al. Overcoming Obstacles to Health: A Report from the Robert Wood Johnson Founda tion to Commission to Build a Healthier America. Robert Wood Johnson Foundation, Princeton, NJ. February 2008. Cohen R. The Positive Impacts of Affordable Housing on Health: A Research Summary. Center for Housing Policy.2007. The DRA Project: Accelerating Disparity Reducing Advance. Using Healthy Eating and Active Living Initia tives to Reduce Health Disparities. Institute for Alternative Futures. February 2008 Flournoy R, Treuhaft S. Healthy Food, Healthy Communities: Improving Access and Opportunities Through Food Retailing. PolicyLink. Fall 2005 Georgia Health Policy Center. Finding the Voice of Public Health in the National Health Reform Dialogue: An Integrative Model for Health System Transformation. Georgia Health Policy Center. June 2008. Key Themes and Highlights from the National Healthcare Disparities Report. 2006; Lantz P, House J, Lepkowski J, et a;. Socioeconomic Factors, Health Behaviors, and Mortality. JAMA 1998 June 3;279(21):1703-1708. Lillie-Blanton M, Hoffman C. “The Role of Health Insurance Coverage in Reducing Health Disparities in Health Care.” Health Affairs, March/April 2005: 398-408 Link B, Phelan J. Social Conditions as Fundamental Causes of Disease. Journal of Health Science and Social Behavior. Spec. No. (1995):80-94; MacArthur Foundation Research Network on Socioeconomic Status and Health. Reaching for a Healthier Life. John D. and Catherine T. MacArthur Foundation. 2008; Marmot M, Brunner E. Cohort Profile: The Whitehall II Study. International Journal of Epidemiology. 2005. 34:251-6. Mari Gallagher Research and Consulting Group. Examining the Impact of Food Deserts on Public Health in Chicago. LaSalle Bank: Chicago, IL. 2006. McGinnis J, Foege W. Actual causes of death in the United States. JAMA. 1993 Nov 10; 270(18):2207-12 Morland W, Wing S, Diez Roux A. Neighborhoods characteristic associated with the location of food stores and food service places. Am J Prev Med 2002; 22(1):23-9. The Robert Wood Johnson Foundation. Active Living Diversity Project. The Robert Wood Johnson Founda tion, Princeton, NJ. 2003; Satcher D, Higgenbotham . The Public Health Approach to Eliminating Health Disparities. American Journal of Public Health. March, 2008; 98(3): 400-3; Centers for Disease Control and Prevention. Chronic Disease Overview. CDC. Atlanta, Ga. November 2005; Smedley B, Stith A, Nelson A, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academies Press, 2003; Key Themes and Highlights from the National Health care Disparities Report. 2006 Smith T. South Australia’s Strategic Plan and HiAP- perfect partners. Public Health Bulletin South Australia. March 2008; 5(1). Stahl T, Wismar M, Ollila E (eds.), et al. Health in All Policies: Prospects and potentials. Finland: Ministry of Social Affairs and Health, 2006. Wagstaff A, van Doorslaer E. Income Inequality and Health: What Does the Literature Tell Us? Annual Review of Public Health. 2000. 21:543-67

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The Language of Health and Human Rights Shipra Roy, University of Minnesota - Twin Cities

“I know that most men, including those at ease with problems of the greatest complexity, can seldom accept even the simplest and most obvious truth if it be such as would oblige them to admit the falsity of conclusions which they have delighted in explaining to colleagues, which they have proudly taught to others, and which they have woven, thread by thread, into the fabric of their lives.” Tolstoy

The truth can be shaped through the frames of light that mirror its perspectives

– universal truth can be spoken in the language of policy, economics, or simply humanistic terms. This past decade has seen a rise in the level of interest and discussion of healthcare in America, with a framework that builds on the history of an endless debate. Based on the definition of healthcare by the World Health Organization, healthcare is a concept that “embraces all the goods and services designed to promote health, whether directed to individuals or to populations,” a simple definition for a complicated issue. The definition of a right to health was first expressed by President Franklin D. Roosevelt in 1943 through a “Second Bill of Rights” for Americans, declaring “freedom from want” to be one of four essential liberties necessary for human security. His definition of freedom included “the right to adequate medical care and the opportunity to achieve and enjoy good health.” This became one of the tenets of the Universal Declaration of Human Rights that amplified the humanistic aspect of health, as the United Nations General Assembly proclaimed medical care as a right of all people. Relative to programs around the world, we have fallen short of achieving a system that gives every American healthcare as a guaranteed unalienable right. The current status of healthcare in the United States can be discerned from the key facts surrounding the possibility of the implementation of a universal health-care platform; with over forty – five million Americans uninsured (nine million of them children), the programs of Medicaid and Medicare slowly running out of capacity, and skyrocketing costs of pharmaceuticals, the facts surrounding America’s healthcare crisis can be explored in a contemporary context – as a catalog of people, places, and trends, where political philosophy, ideology, and economics frame the current debate into a language of its own. How healthcare is framed or referenced plays a large role in the politics of healthcare reform, and the philosophy that is used to address healthcare includes the recommendations of the liberals and conservatives for improving established policies and bringing novel ideas into the mix. Specific policies are pushed because of the way they are framed to the general electorate, and the language and messaging that is used to convince voters to support either side. Liberals view healthcare through a moral perspective – as a human right, while conservatives emphasize the value of healthcare as a personal choice. When healthcare is framed as a choice versus a human right, the role of the government as a prime contributor is shifted. Conservatives would like to withdraw from government administered initiatives; however, the notion of “big government” is not nearly as dangerous as the escalating threat of the uninsured, and the price we as a nation will pay in both economic and social terms if all of our citizens are not insured.

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The current dialogue on healthcare focuses on cost and coverage, with healthcare framed as a good or a service. The devices of cost and coverage are the main points that base the current dialogue around healthcare, with framing dependent on the key words of commodity and right. Reforming frames in the healthcare debate link the “Healthcare as a Human Right” paradigm with laws and policies that sustain accountability in a democratic manner. Current developments in the healthcare debate offer a framework that shifts analysis of disparities in care to democracy and social justice issues. Health issues can be linked with active social citizenship; the right to health translates to having the right to participate in decisions dealing with one’s health.5 healthcare as a human right is based on a humanist perspective that can be fulfilled through a universal healthcare platform that encompasses every American, and allows the basic right established by the World Health Organization. The options of single-payer or multi-payer plans are modifications of the original goal of any reform initiative – to increase healthcare access. Universal healthcare is not a move toward a larger government bureaucracy; rather it is a move toward greater effectiveness in the current healthcare system. The high cost of private insurance gives some individuals a choice, but leaves millions uninsured. Economically, if the uninsured became insured, they would be able to work and contribute to an increase in production of goods and services. This boost in economic progress would, at the same time, contribute to an increase in pharmaceutical sales. With more savings, a person is likely to spend more money on preventive and patient-based healthcare. Therefore, a universal healthcare - based system would more accurately balance the economics and humanistic aspects of essential healthcare. Commodity signifies a lower level vital, a necessity for which there is demand, with no differentiation between products in quality. The commercialization of healthcare as a consumer-based product is driven by the economics of health. It has become the alternative to universal healthcare, but it only considers monetary costs, not human value. Healthcare, when framed as a commodity, becomes a privilege for those who can afford it, and thus violates the principles set internationally by the WHO and the UN. Framing healthcare as a human right is the best way to proceed in the current debate, because this position is in favor of both the pharmaceutical companies and the consumer. It is important to inform the American public of the complexity of the situation – the dispute itself is not over healthcare, but rather the structure of the healthcare system that is set up to deal with this current situation of rising costs, both in economic and human terms. Healthcare can be viewed from various angles, but framing healthcare as a human right is suitable for both sides in economic terms. In the humanist perspective, making healthcare affordable for all should be a major consideration in passing any legislation. This is a plan that can be agreed upon by both sides, through the social justice angle and economic viewpoint. For economics matters, accountability for products and medical price levels will be more in control. Framing health as a human right will allow more people to become insured; a greater number of insured Americans means more doctor visits, and more medication sold, which in turn leads to an increase in pharmaceutical sales. Therefore, pharmaceutical companies will benefit more if the healthcare as a human right campaign is accepted as social and political policy. In addition, a lack of health insurance is harmful for communities; reduced availability of hospital-based services and providers, and the loss of health services in general, cause an overall decrease in health care delivery

capacity, harming companies that supply products to hospitals and patients. More importantly, there is a loss to the community’s economic base as there is economic loss associated with the poorer health and shorter lifespan of the uninsured. Inherently, this process is proving harmful for the future of our nation and its workforce. The benefits of framing healthcare as a human right allow a standardized notion of healthcare that reaches each and every American, and places this issue as a necessary social justice. The effects of language used to describe health can be seen in the context of presidential election platforms – with the universal healthcare approach receiving both acceptance and criticism in its attempt to bring a change to the rising rate of the uninsured in America. The larger context of American life should be at the heart of this political debate. The rewards of greater understanding of the social and economic aspects of healthcare will be monumental in defining healthcare as a human right in America. Sources

Definition of Healthcare. World Health Organization (Accessed on 18 July 2008). Kaiser Commission on Medicaid and the Uninsured. “Enrolling Uninsured Low-Income Children in Medicaid and SCHIP.” Kaiser Family Foundation. January 2007. “The Right to Health in the United States: What Does It Mean?” Center for Economic and Social Rights, (October 2004). http://cesr.org/ushealthright (Accessed on 20 July 2008). “Universal Declaration of Human Rights.” United Nations General Assembly, (10 December 1948). http://www.un.org/Overview/rights.html (Accessed on 20 July 2008).

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Young Voters’ Role in the Upcoming Election Brad Finnegan, The George Washington University

Throughout the past 50 years, young adults (age 18-30)

1 have had the strong reputation for not engaging in the political process. The steady decline in the proportion of young adults voting in presidential elections from 1964 to 2004 helped solidify this characterization, in spite of this generation’s historic involvement in community service.

Young Voters on the Rise Considerable evidence illustrates that voting participation rates among young adults is changing. In 2004, for example, 42 percent of young adults voted in the presidential election, a nearly ten percent increase from the 2000 election. This trend has continued through the 2008 primaries. According to CNN exit polls, several states reported some of the highest voting rates among young adults in the history of United States. New Hampshire had a turnout rate of more than 40 percent for voters under 30 years old. In fact, on Super Tuesday, Georgia’s young adults had a 21 percent turnout rate, compared to seven percent in 2000—with young adults representing 17 percent of the entire electorate in the state’s Democratic primary. Though these rates remain lower than other segments of the population, young adult voting is on the rise. As young adults continue to vote in higher numbers, their ability to impact election outcomes and encourage discussion of issues they care about will increase. Young voters, more than any other age category, believe government can play an active role in addressing many issues. In particular, young adults are more likely to support universal health care, with 57 percent believing health insurance should come from a government source. The vast majority (87 percent) of young adults believe government should spend more on health care, even if it results in a tax increase. Young adults also overwhelmingly (95 percent) support increased spending on education. Such strong belief in government, and particularly its role in health reform, leads one to wonder why the young adult voice is not more prevalent in the health care debate. The young adult voice seems to go unheard compared to other demographic groups, business, and interest groups, including the pharmaceutical and insurance companies, and the American Association of Retired Persons (AARP). Interests groups such as AARP, gain their strength largely from the voters they represent—serving as a powerful lobbying organization which young voters lack. If young adults consistently vote and maintain high voter turnout rates, they undoubtedly would serve a more significant role not just in the health care debate, but also in other major issues facing the country. Efforts to Increase Voter Turnout Low voter turnout is a problem that many organizations have tried to address. “Rock the Vote,” an organization that uses well known musicians and celebrities to engage young voters and build a coherent voting block, boasts having the largest young adult voter registration drive in recent history. Many other organizations sought to engage young adults, including religious, professional, and political organizations. Whether a Catholic church, synagogue, or evangelical congregation, many religious organizations seek to encourage their young members to vote. Several professional associations have young adult sections, including the American Medical Associa-

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tion (AMA) whose partner organization, the American Medical Student Association (AMSA) promotes their agenda on Capitol Hill. Even AARP has sought to reach out to young voters in their U@50 campaign. Perhaps more successfully, both major political parties engage in outreach to young voters—most notably, the College Democrats and College Republicans. These organizations, seeking to promote their specific agendas to elected officials, tried with varying degrees of success to mobilize their members, including young adults. In all, very few of these strategies fared well in efforts to engage young voters. Keys to Participation More recently, however, studies show the key to higher voter turnout among young adults, involves personal outreach. Using networking as a means to build a coalition seems to serve as an effective outreach mechanism. Young people approached by a classmate, friend, or coworker demonstrate a far greater likelihood to vote. Senator Barack Obama’s enormous success in building support among young voters comes from a grassroots network of younger people that flourished in high schools and on college campuses across the country. Individuals in the network reached out to friends and peers encouraging participation in the election and specifically in Senator Obama’s campaign. Even before announcing his candidacy, young people on Facebook encouraged Senator Obama to run for president. His internet presence has been significant. Along with outreach and networking, another successful tactic entails providing young people with an opportunity for action. This generation of young adults serving as the most involved in community service ever, indicates another key aspect of engaging young people—giving them something to do (or, telling them how they can help). Senator Obama’s campaign—whether promoting cleaning up Midwest towns after severe weather or painting DC public schools—demonstrates success in engaging young people to participate in their communities. The focus on the 2008 presidential election has been intense thus far, and participation from young adults has been profound. Given the unprecedented degree of participation, the 2008 presidential election may result in the highest participation of young adults ever. This level of participation is essential for promoting the issues that young people believe in, including improving our health care system. Young adults casting their votes across the country will significantly effect the election, leading the way to a seat at the table where the voice of young voters impacts important policy decisions that not only pertain to health reform, but also on other important issues facing our nation. Sources “The Constitution of the United States,” Amendment 26. Lowe, A. “Youth Vote Soars In N.H. Primary, - CBS News.” CBS News. http://www.cbsnews. com/stories/2008/01/10/politics/uwire/main3698115.shtml (accessed June 8, 2008). Madland, D, and A Logan. “The Progressive Generation: How Young Adults Think About the Economy.” Center for American Progress. http://www.americanprogress.org/is sues/2008/05/pdf/progressive_generation.pdf (accessed June 9, 2008). Nickerson, Dw. ““Hunting the Elusive Young Voter.” .” Journal of Political Marketing 5 (2006): 47-69. Ramirez, Ricardo. “Giving Voice to Latino Voters: A Field Experiment on the Effectiveness of a National Nonpartisan Mobilization Effort.” The Annals of the American Academy of Political and Social Science 601 (2005): 66-84.

23 Roscow, David. ““Over Three Million Citizens Under the Age of Thirty Participate in Super Tuesday Primaries.” CIRCLE. www.civicyouth.org/PopUps/PR_08_Super%20Tues day.pdf (accessed June 11, 2008). U.S. Census Bureau. ????? Walton, B. ““Volunteer Rates Hit Record Numbers.” USA Today, July 7, 2006. http://www. usatoday.com/news/nation/2006-07-06-volunteers_x.htm (accessed June 11, 2008). “Young Voter Mobilization Tactics: A Compilation of the Most Recent Research on Traditional & Innovative Voter Turnout Techniques.” The George Washington University Gradu ate School of Political Management.. http://www.civicyouth.org/PopUps/Young_Vot

ers_Guide.pdf (accessed June 28, 2008).

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Shooting Themselves in the Foot: W hy Empirical Research is Essential to Advocacy Brad Wright, University of North Carolina – Chapel Hill

In the world of health policy, individuals and organizations tend to arrange themselves along a research-advocacy continuum. At the poles are the purists, who believe that health policy decisions should be driven by either empirical research or unabashed advocacy, but that the two should never meet. Between the two extremes, people seem to recognize that even the most objective researcher can never fully abandon his or her own personal biases. Unfortunately, when it comes to mixing research and advocacy, the focus always remains on advocacy’s ability to taint research, rather than on research’s ability to bolster advocacy. Charles Corry gives a thorough overview of what he calls “advocacy research,” which he defines as advocacy masquerading as research, with the results being clearly biased by the investigator’s preconceived agenda.1 Not surprisingly, the fear of being accused of conducting biased research has convinced most investigators that they must abandon advocacy altogether. Nothing could be further from the truth. This commentary aims to reframe the tension between research and advocacy in a positive light and explores the importance of research to advocacy efforts as it relates to a perennially important topic in health policy: federal funding for health professions training through the Title VII program. The Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (DHHS) provides grants to support the training of health professions students through the Title VII program, so-called because it is authorized by Title VII of the Public Health Service Act. The Title VII label actually applies to a number of programs that provide scholarships, loan repayment, and institutionally-based training programs, many of which are used to increase the enrollment of underrepresented minorities in health professions schools. One well-known Title VII program is the National Health Service Corps, which works to target the distribution of the healthcare workforce by paying some or all of the costs of health professionals’ education in return for their fulfilling a commitment to work in an underserved area after graduation. The programs funded by Title VII are vital to the success of broader efforts to increase access to health care and reduce racial and ethnic disparities in health outcomes, and yet, the amount of funding authorized for Title VII programs annually is only a small fraction of the federal government’s spending on health care. Moreover, even this relatively small amount of funding is perennially threatened as presidential budget proposals look to the program for savings by drastically cutting—or even eliminating— funding for Title VII. The potential for lost funding motivates clinician advocacy groups to action. Governmental affairs arms of groups like the American Academy of Family Physicians, the National Association of Community Health Centers, and the Association of American Medical Colleges, among others, work diligently to lobby members of Congress in hopes of having Title VII funds restored in the final budget bill. Historically, these efforts have paid off. While Congress has made cuts to Title VII, the program has never been completely eliminated. This cycle repeats itself each fiscal year. Two important questions emerge from this scenario. First, why do presidential budgets so often look to cut Title VII? Second, why does Congress so often see fit to restore funding to the program?

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The reason why Title VII is targeted for reduction or elimination so frequently in presidential budgets is simple: evidence in support of Title VII programs is scarce. While there is a small body of literature that finds Title VII programs to be effective in increasing minority enrollment in medical schools and placing graduates in underserved areas, there is an equally small but opposite body of literature that finds Title VII programs to be ineffective. It comes as little surprise that an unproven program faces frequent scrutiny from the Office of Management and Budget, but given the dearth of evidence around Title VII, why does Congress choose to support the program? The reason for this is, again, simple: Congress typically responds to lobbying efforts from powerful, organized interest groups, especially when opposing these groups would be viewed unfavorably by the public. Granted, not many members of the public are aware of the Title VII program, but the organized interests that support Title VII could work very effectively with the media to get the word out that certain members of Congress oppose a program that helps recruit underrepresented minorities to health professions programs and place clinicians in underserved areas. It almost goes without saying that such exposure would be very unfavorable politically. This is a risk most members of Congress are unwilling to take. Still, this process is entirely inefficient. Advocacy organizations spend a considerable amount of time and resources to convince Congress to act in their favor. If instead, advocacy organizations worked to produce sound research on the effectiveness of Title VII, it is likely that the president’s budget would hesitate to cut the program, and thus, extensive lobbying of Congress would become unnecessary. Additionally, the programs housed under the umbrella of Title VII would become more efficient as research is able to distinguish best practices. So, what would this research advocacy look like and how would it work? Loosely speaking, all advocacy relies on some form of research. Organizations rarely go through the trouble of trying to push an agenda or convince policymakers to take their position on an issue without some sort of justification. The problem is, however, that the evidence they use to justify their claims is often weak and ineffectual. While isolated anecdotes and even public opinion can serve to influence policymakers, these types of evidence lack the strength and integrity of more rigorously collected data. Likewise, policymakers tend to be swayed less by organizations acting out of self-interest, unless it happens to coincide with the best self-interests of the policymaker (e.g., campaign contributions, voting support), and more by objective data that is perceived to be less biased in favor of organizational self-interest. Why, then, should advocacy organizations work diligently to incorporate sound research into their efforts? The answer is that advocacy organizations are in a unique position to assist researchers with study design, the conduct of research, and the dissemination of findings. The reward for advocacy organizations comes in the form of increased credibility, stronger arguments when appealing to policymakers, and better results on the issues the organization cares about. First, advocacy organizations tend to be more acutely aware of the unanswered questions in the field of study. Consequently, they know what research needs to be conducted, and what research will most directly influence policy. With this in mind, advocacy organizations can play a vital role in the design of research that is central to their organization’s interests. They can query their members to find out what needs they have, as well as what insights they can offer. Second, advocacy organizations represent a highly connected network of individual

and organizational members that can assist in the conducting of a study in a variety of ways. Individual members may be considered the target population for a study, and thus, by working with the advocacy organization, researchers will gain easier access to their intended sample than they would if they had to contact all persons separately. Member organizations might also serve as study sites. For example, researchers might work with community health centers to survey patients who visit the center. Collaborations between research teams and advocacy organizations will facilitate these types of activities. Third, advocacy organizations are ideally situated to assist in the dissemination of research findings. Many research organizations are not structured with a clear tie to policymakers. Additionally, many research organizations—especially those that are publicly funded (e.g., state universities)—maintain policies that prohibit their staff from engaging in certain types of advocacy efforts. Thus, some of the best research studies are never translated into practice. Advocacy organizations, on the other hand, do maintain government affairs offices and can act as a bridge between research organizations and policymakers. Because of their familiarity with the topic and their knowledge of the policy process, advocacy organizations can interpret sophisticated research findings, translate these findings into more accessible language and concepts, and present this information to policymakers. Furthermore, while the law imposes limits on the amount of lobbying nonprofit organizations may engage in, and prohibits these organizations from endorsing particular political candidates, advocacy organizations do not face the types of apolitical and anti-advocacy policies that often constrain researchers. This greatly increases the likelihood that research findings will be understood correctly and acted upon appropriately. Fourth and finally, advocacy organizations that base their arguments on sound research findings are more likely to be taken seriously, as their claims will be considered more objective and therefore more credible. Advocating on the basis of isolated anecdotes and simply because “it’s the right thing to do” does not stand up well to counterarguments based on cost-effectiveness, technical feasibility, and political feasibility. The facts provided by research provide specificity to what would otherwise be a nebulous appeal for change, and can motivate individuals to take action in cases where they might remain passive if the debate was more vague or abstract. Promoting the findings of a research study also provides the organization with a valuable opportunity to make others aware of the organization and its mission, which can attract new members and additional external support to the organization’s cause. In sum, advocacy organizations need to become more involved in health services research, and researchers need to embrace the opportunity to support the efforts of advocacy organizations while remaining objective in their work. Ultimately, supporting the efforts of advocacy organizations must not necessarily equate to agreeing with the position of the advocacy organization. While some findings may support the advocacy organization’s position, findings which fail to support their position are still supportive insofar as they lead the organization to refine its focus and target only what has been to shown to work, rather than what they believe to work. Together, advocates and researchers working in conjunction with one another have the unique potential to improve the health care system via evidence-based health policy. Sources

Corry, Charles. “ Advocacy Research by Charles E. Corry, Ph.D..” Domestic Violence Against Men In Colorado. http://www.dvmen.org/dv-31.htm.

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The Intersection of Science & Policy: A Tobacco Case Study Julia Battocchi, The George Washington University

The scientific body of knowledge about the known heath risks of tobacco use has

expanded exponentially in the past century. The risks were first discussed by academics and doctors in the 1800s, but it was not until the mid 1900s that a causal relationship between smoking and lung cancer was shown.1 Even still, the implementation of life-saving tobacco control measures has been stymied by industry influences. Youth organizers and other community activists, however, have been and continue to be instrumental in turning common-sense ideas for tobacco control into policies to protect the health of all. The body of scientific evidence on the harms of smoking grew significantly as negative health outcomes increased. In the late 1800s and early 1900s lung cancer was an anomaly, but by the late 1920s and 1930s, physicians had noted a marked growth of cases that were strongly correlated with the rise in smoking.1 In 1940, a German researcher observed that “the extraordinary rise in tobacco use was the single most important cause of the rising incidence of lung cancer.” Renowned researchers Doll and Hill and Hammond and Horn published studies in 1950 and 1958, respectively, which demonstrated a causal link between smoking and lung cancer.1 In 1957, Surgeon General Leroy Edgar Burney, “was the first Federal official to publicly identify cigarette smoke as a cause of lung cancer, issuing statements that paved the way for his successors.” A report, published in 1962 by a committee of the Royal College of Physicians in Britain, “clearly indicted cigarette smoking as a cause of lung cancer and bronchitis and argued that it probably contributed to cardiovascular disease as well.” 3 Surgeon General, Luther Terry produced a report in 1964 entitled Smoking and Health: Report of the Advisory Committee to the Surgeon General of the United States, which came to similar conclusions as the Royal College of Physicians study, but was the first of its kind to be published here. As research methods improved and the causal relationship between smoking and disease was established, policies were crafted and implemented. The 1964 report by the Surgeon General “was also responsible for the passage of the Cigarette Labeling and Advertising Act of 1965, which … mandated the familiar Surgeon General’s health warnings on cigarette packages.” In 1987, Congress passed legislation that banned smoking on commercial flights with a duration of two hours or less, and in 1989 lengthened the time to six hours. Congress passed the Synar Amendment in 1992, which “[required] states to enforce their tobacco minimum age-of-sale laws or risk losing substance abuse block grant funds,” but was also “an important catalyst for the passage of state tobacco-control legislation.” States also enacted laws to restrict smoking and exposure to environmental tobacco smoke. Arizona led the charge, when, in 1973 it, “[restricted] smoking in a number of public places.” Connecticut and Minnesota soon followed, passing laws limiting smoking in restaurants and the Clean Indoor Air Act, respectively. The Clean Indoor Air Act of Minnesota has been replicated and retooled in many other states. By 1990, 45 states had passed smoking laws that included restrictions on smoking in restaurants, on worksites, and public transportation. As governments at all levels began implementing tobacco control policies, there was a powerful backlash from the tobacco industry by the public relations firm Hill & Knowlton and the Tobacco Institute, a tobacco industry trade group. The strategy was

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simple: create doubt. A memo from Hill & Knowlton to the Tobacco Institute read, “The most important type of story is that which casts doubt on the cause and effect theory of disease and smoking.... [Eye-grabbing headlines] should strongly call out the point--Controversy! Contradiction! Other factors! Unknowns…” Stories featuring these headlines were published in “Tobacco and Health Research,” an industry newsletter disseminated to scientists and doctors across the country. In 1972, The Tobacco Institute circulated a press release asserting that the Surgeon General’s report from that same year, “insults the scientific community” and was “another example of ‘press conference science’ – an absolute masterpiece of bureaucratic obfuscation.” In addition to casting doubt on the scientific evidence that was growing stronger, the tobacco industry thwarted policy by lobbying and funneling money into political campaigns. When in 1971 the Civil Aeronautics Board mandated the creation of nonsmoking sections and “[banned] smoking on flights of 2 hours or less,” their actions were almost immediately reversed thanks to the work of lobbyists and members of Congress. The tobacco industry also gained influence through generous contributions: from 1999 to 2006, $170,579.411 was spent on lobbying Congress; between August 2000 and August 2006, “527 groups” received $6,269,596; from January 1997 to August 2007, $34,759,294 was given to federal candidates, political parties, and committees; in the 2005 to 2006 election cycles, $87,799,773 went to state ballot measure committees to defeat initiatives including excise tax raises and indoor smoking bans. Despite the tobacco industry’s best efforts, comprehensive tobacco control policies have been passed and are continuing to make their way through the legislature. Yet, despite these advances, tobacco use remains a source of costly health care expenditures and continues to decrease the quality of life for smokers and nonsmokers alike. The picture of tobacco-related morbidity, mortality, and economic burden is clear: tobacco use is the number one preventable cause of death, causing approximately 438,000 deaths annually; its death toll is higher than the combined total deaths caused by human immunodeficiency virus, illegal drug use, alcohol use, motor vehicle injuries, suicides, and murders combined. Tobacco use not only affects adults’ health in dramatic ways, but also poses serious risks to children and adolescents that are less commonly known. Youth who smoke are less physically fit both in terms of performance and endurance; have more respiratory illnesses than their nonsmoking peers; have a faster decline in lung function; experience impaired lung growth, a higher incidence of chronic coughing, wheezing, shortness of breath, and produce more phlegm; have faster resting heart rates; and may exhibit early signs of heart disease and stroke. Just as young adults are greatly affected by the adverse health effects of smoking, they can also have an incredible impact on promoting policy. Advocacy has played an important role in raising awareness about the negative health effects of tobacco as well as increasing the visibility of the issue. Starting at age 20, flight attendant Patty Young, campaigned tirelessly for smoke-free airlines, encouraging concerned patrons to contact their representatives, testifying at three congressional hearings, and helping to find a lawyer to argue a successful class action lawsuit on behalf of nonsmoking flight attendants who suffered from chronic health problems related to their exposure to environmental tobacco smoke at work. In part because she saw her own health deteriorating, and because she had lost both parents to tobacco-related disease, Young became a powerful advocate for smoke-free flights for all.

Youth advocates have lobbied for smoke-free campuses and parks, statewide smoking bans, increased tobacco prevention funding, bans on candy-flavored tobacco products, and increases cigarette taxes; have testified before state legislatures; and spoken to tobacco industry executives about marketing practices. Youth today, just like the Patty Youngs of prior generations are also motivated by the loss of loved ones and the desire to prevent future generations from starting to smoke. For many of these young leaders, policy, especially when coupled with outreach, peer education, and consciousnessraising events, proves to be a rewarding combination and an effective tool to counteract the overwhelming influence of the tobacco industry. Sources

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“2008 Youth Advocates of the Year Awards.” Campaign for Tobacco-Free Kids. http://www.tobaccofreekids. org/campaign/yayas/2008/index.shtml. “40th Anniversary of the First Surgeon General’s Report on Smoking and Health.” Department of Health and Human Services, Centers for Disease Control and Prevention. http://www.cdc.gov/ MMWR/preview/mmwrhtml/mm5303a1.htm Arday, D.R., Giovino, G.A., Schulman, J., Nelson, D. E. Mowery, P. and Samet, J.M. “Cigarette Smoking and Self-Reported Health Problems among U.S. High School Seniors, 1982-1989,” American Journal of Health Promotion 10, 2 (1995): 111-116. Borio,G. “Secret Tobacco Document Quotes,” http://www.tobacco.org/Documents/DocumentQuotes.html. Campaign Contributions by Tobacco Interests, Annual Report: September 2007, (Washington, DC: Tobacco-Free Kids Action Fund; Common Cause, 2007), http://tobaccofreeaction.org/ contributions/Report_2007_09/Contributions_2007_09.pdf. The Health Consequences of Smoking, A Public Health Service Review: 1967 (Washington, DC: United States Public Health Service, Office of the Surgeon General, 1967). The Health Consequences of Smoking: 1969 Supplement to the 1967 Public Health Service Review (Washington, DC: United States Public Health Service, Office of the Surgeon General, 1969). The Health Consequences of Smoking: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. “Leory Edgar Burney (1956-1961),” United States Department of Health and Human Services, Office of the Surgeon General. http://www.surgeongeneral.gov/about/previous/bioburney.htm. “Luther Leonidas Terry (1961-1965),” United States Department of Health and Human Services, Office of the Surgeon General. http://www.surgeongeneral.gov/about/previous/bioterry.htm. National Cancer Institute. “Strategies to Control Tobacco use in the United States: A Blueprint for Public Health Action in the 1990s.” Tobacco Control Monograph No. 1. (Bethesda, MD: U.S. Depart ment of Health and Human Services, National Institutes of Health, National Cancer Institute, 1991). Preventing Tobacco Use Among Young People: A Report of the Surgeon General. Atlanta, GA: U.S. De partment of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1994. Redhead, S.C., Austin-Lane, J. Tobacco Control: Enforcement and Effectiveness of Federal and State Youth Access Laws (Washington D.C. : Congressional Research Service, Library of Congress, 1998). Spiro, S.G., Silvestri, G.A. “One Hundred Years of Lung Cancer,” American Journal of Respiratory and Critical Care Medicine 172, 1 (2005): 523-29. Tobacco Institute. Untitled Press Release. Legacy Tobacco Documents Library (TIMN0120602-0603). http://legacy.library.ucsf.edu/tid/jvg92f00/pdf. Tough Times for Tobacco: Tobacco Bans, Tax Increases Pass, Despite Big Tobacco Campaign Donations. Helena, MT: The National Institue on Money in State Politics, 2007, http://www.followthe money.org/press/Reports/200710221.pdf. Witschi, H. “A Short History of Lung Cancer,” Toxicological Sciences 64, 1 (2001): 4-6. Young, P. “No Excuses: Reducing the Risk of Preventable Injury and Disease,” Chap. 5, In Moments in Leadership: Case Studies in Public Health Policy and Practice, edited by B. DeBuono, A. R. Gonzalez and S. Rosenbaum, 101-113. New York: Pfizer Inc, 2007.

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From Health Security to Health Choices: A Comparison of the 1993 and 2008 Clinton Health Plans Eva M. Galvan, Yale University

To analyze the changing politics of healthcare, it is useful to note how proposals for

universal health care have changed over time. There is perhaps no better case study than Senator Hillary Rodham Clinton who helped lead the last major national effort for universal health care while she was first lady and who recently presented a new plan for universal health care coverage during the 2008 presidential campaign. Because of its length and public sector involvement in a traditionally private sector domain, the Clintons’ 1993 universal health care proposal could not win approval in Congress. Responding to the political climate, Senator Clinton has proposed a new plan in during the 2008 primary, which would ensure health care coverage for every American, while encompassing the ideals of both Democrats and Republicans. 1993 Clinton Proposal On September 22, 1993, President Clinton gave a State of the Union Address to the Joint Session of the Congress on “Health Security for All Americans.” During this time, Hillary Clinton headed President Clinton’s Task Force for National Health Care Reform. The health plan proposed by the Task Force aimed to improve and streamline our nation’s health care delivery systems while providing health care to all Americans. The detailed legislation proposed a business mandate, a National Health Board and health alliances (“regional” and “corporate”), standardized benefits from employers, and a cap on government spending. Within the health alliances, private insurance companies would have needed state certification demonstrating that they met the minimum health benefits packages requirement.1 Despite the existence of a National Health Board, critics of the plan predicted disparities among the states, which could impose different regulations on both the qualifications for health plans and the function of alliances.2 In addition, the National Federation ofIndependent Businesses, among others, opposed the plan’s business mandate, arguing that such provisions would put limits on free enterprise and result in widespread bankruptcy, especially among small businesses. Opponents of the plan also emphasized that ambitious control of health care by government would increase bureaucratic costs.3 The regional health alliances, for example, would serve a nebulous purpose that critics said would add to administrative expenditures. Moreover, doctors and patients would have less choice in methods of treatment because the plan could cut government spending to keep costs in line with the Consumer Price Index. In the shadow of such a universal health plan, opponents argued, private practice would all but disappear.4 2008 Clinton Proposal Nearly 15 years later, Senator Clinton has presented her “American Health Choices Plan.” With this plan, she reiterates the need to decrease health expenditures, improve quality, and streamline health delivery systems. Echoing the sentiments contained in Franklin D. Roosevelt’s “Second Bill of Rights,”5 Senator Clinton delivered a speech in 2007 proclaiming that health care is a right for every person, not just a privilege for the wealthy. Accordingly, her new plan would prevent discriminatory refusal of cover-

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age for those with pre-existing or possible future genetic conditions6 because they, above all, require continuous, comprehensive, and affordable medical treatment. Even more significantly, Senator Clinton’s proposal would ensure the freedom to choose among coverage plans—a choice that the 1993 plan lacked. Also in contrast to the 1993 plan, her new proposal would guarantee universal health care without a complex system of boards and alliances. Though the plan still would require minimum benefits for covered individuals, it would give Americans the option to stay with their private insurance companies with the caveat that private insurance companies meet standards consistent with the Federal Employees Health Benefits Plan. Senator Clinton’s 2008 plan would also provide tax credits to businesses that subsidize health care costs of individual employees.7 Preventative medicine, required in the new plan would preemptively treat future illnesses or health conditions. To fund the $110 billion health care plan, Senator Clinton proposes raising taxes and diminishing President George Bush’s tax cuts for the wealthy.8 While waiting for congressional approval of her universal health care proposal, Senator Clinton has worked to advance legislation on the Children’s Health Insurance Program and on health care for first responders and veterans.9 Conclusion Senator Clinton’s 2008 “American Health Choices Plan,” addresses many failings of the Clinton administration’s 1993 proposal, and thus may very well become a blueprint for the next administration. The framing and the mechanisms of the policies have changed, but the underlying values are still the same – quality, affordable health care for all. Sources “Hillary Revisits Healthcare.” Washington Times. (18 Sept. 2007) http://www.washingtontimes.com/ (ac cessed July 12, 2008). Andrews, Michelle “The Politics of Healthcare.” U.S. News & World Report 1 Oct. 2007, Vol. 143, Issue 11. Angell, Marcia “The Beginning of Health Care Reform: The Clinton Plan.” New England Journal of Medi cine, (1993): 329: 1569-1570. http://content.nejm.org (Accessed July 11, 2008). Birn, Anne-Emanuelle; Brown, Theodore M.; Fee, Elizabeth; and Lear, Walter J. “Struggles for National Health Reform in the United States.” American Journal of Public Health. 2003; 93 (1): 86-91. Cerne, Frank “Leaders analyze Clinton plan, piece by piece: HMOs & reform.” Hospitals & Health Networks 67, no. 24 (December 20, 1993): 20. http://www.proquest.com/ (accessed July 12, 2008). Charatan, Fred “Hillary Clinton Unveils Plan for Healthcare Reform.” BMJ (29 Sept. 2007): 335 http:// www.bmj.com/ (accessed July 11, 2008). DoBias, Matthew “Clinton health plan, take two.” Modern Healthcare, September 24, 2007, 12. http://www. proquest.com/ (accessed July 11, 2008). Moffit, Robert E “A Guide to the Clinton Health Plan.” The Heritage Foundation (19 Nov. 1993). http:/ www.heritage.org/ (Accessed July 11, 2008). Roosevelt, Franklin D. “The Economic Bill of Rights,” 11 January 1944 State of the Union Address to Congress. The Public Papers & Addresses of Franklin D. Roosevelt. Samuel Rosenman, ed.,1950; Vol XIII. NY: Harper, 40-42.

Ideas

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Tax-based Automatic Enrollment in Health Care Plans Robert Nelb, Yale University

Tax information can be used a means to streamline enrollment in public and private health insurance programs. Any health care plan that aims to cover all Americans will not be able to achieve this goal using traditional enrollment methods that rely on lots of paperwork and other burdens for the beneficiary. Automatic enrollment, the process of electronically identifying eligible beneficiaries and enrolling them by default, is a promising new strategy that can help expand health care coverage to all, while still giving individuals the ability to opt-out if they choose. Studies have consistently shown that opt-out policies have higher rates of enrollment than opt-in policies. While the most common example used is opt-out 401(k) plans, automatic enrollment strategies have been used in health care. For example, Medicare Part B uses tax information to automatically enroll seniors, and Maryland has recently used tax forms to streamline enrollment in its Medicaid program.

Key Facts • About two-thirds of uninsured children in the US are already eligible for Medicaid or SCHIP, but they are not enrolled. • While only 33% of employees enroll in a traditional 401(k) plan when they are given the choice to opt-in, 90% of employees enroll when they are given the choice to opt-out.

Not only are auto-enrollment policies effective for health care, but they are also politically appealing because they emphasize good government, transcend debates over mandated coverage, and may be a particularly effective vehicle for covering all uninsured children – two-thirds of whom are eligible but not enrolled in Medicaid or SCHIP. Talking Points • Auto-enrollment is most effective for covering the most disadvantaged in society and also gives individuals a choice to opt-out. • Auto-enrollment connects Americans to benefits that they are already eligible for and helps reduce bureaucracy for enrollment. • Many states already use tax information and other databases to verify eligibility, but they don’t use them to determine eligibility.

Tax information is an ideal source for enrollment information since all the information that is required to determine eligibility for Medicaid and SCHIP for most beneficiaries in most states is available on individual income tax forms, which virtually all households submit annually (including families that are exempt from paying tax).

Maintaining the privacy of tax information is a concern, but under current law, the Secretary of the Treasury can create an “Opportunity Option” on federal tax forms for citizens to provide authorization (if they choose) for states to use the information on their tax forms to streamline enrollment in public programs and tax subsidies for private health insurance. Once the enrollment process is made easier, millions of uninsured Americans can be expected to sign up for health coverage.

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History Personal income tax information is stored electronically by the IRS, but under the Internal Revenue Code §6103c, the IRS is not allowed to release an individual’s tax information to other government agencies without a waiver signed by that individual. Many states, however, currently include similar waivers on Medicaid an SCHIP enrollment forms to verify eligibility, and Maryland recently added an option to its state tax form for families to allow the state to use their tax information to help facilitate enrollment in SCHIP (although families still need to fill out an additional paper form, so the process is not fully automatic). Analysis While millions of Americans are already eligible but not enrolled in public health insurance programs, the costs of actually providing this coverage are a major barrier preventing states from increasing enrollment. Fortunately, the evidence does suggest that states would be able to achieve significant administrative cost savings through a more streamlined enrollment system. Fourteen billion dollars of excess U.S. health spending is due to enrollment and administration processes in public health insurance programs, according to a study by the McKinsey Global Institute and a recent study in Health Affairs found that administrative costs for health insurance enrollment would be cut by 40-60% under an streamlined enrollment system, suggesting that tax-based automatic enrollment would not be as expensive as many think. Next Steps While legislative changes are not necessarily required to allow the use of tax information to determine eligibility for health insurance programs, enrollment system, Congress could take steps to encourage this practice by clarifying the authority of IRS and by providing grants to states to implement tax-based enrollment systems.

Sources Carlos Angrisano et al, “Accounting for the Cost of Health Care in the US,” McKinsey Global Institute, January 2007, http://www.mckinsey.com/mgi/reports/pdfs/healthcare/MGI_US_HC_synthesis. pdf. Gerry Fairbrother et al, “Costs Of Enrolling Children In Medicaid And SCHIP,” Health Affairs, 23(1) 2004. Lisa Dubay, John Holahan, and Allison Cook, “The Uninsured and The Affordability of Health Insurance Coverage,” Health Affairs 26(2007): w22-w30. Stan Dorn, “Automatic Enrollment Strategies.” Robert Wood Johnson Foundation. August 2007, http:// www.statecoverage.net/pdf/autoenrollment.pdf.

Reducing Infant Deaths With Nutritional Outreach for Pregnant Women Alexander Hertel-Fernandez, Northwestern University

The federal government should aid states to offer dietary and nutritional counseling for pregnant at-risk, low-income mothers. Pregnant women who are already identified as at-risk or needy through the receipt of means-tested subsidies ought to be informed of possibilities for nutritional counseling already covered by Medicaid. The United States has the second worst newborn and child mortality rate among all developed countries despite having more neonatal specialists and facilities than any other country in the world. Infant death rates for low-income, poorly educated, and minority mothers in the United States are significantly higher than the national average, surpassing the rates for many developing countries in Latin America and Eastern Europe. These disadvantaged populations account for nearly half of all infant deaths across the United States. Any intervention to reduce the national infant death rate must focus on these at-risk mothers. The leading preventable cause of infant death involves pre-term or low birth weight deliveries. In turn, the leading preventable cause of early, low weight births is maternal malnutrition, particularly amongst low-income families.3 Up to 38.4 percent of American pregnant women, and 68 percent of poor pregnant women, are considered malnourished.

Key Facts • One in 71 American mothers will lose at least one child, the second-highest child death rate of developed countries. • Maternal malnutrition and obesity are linked to many of these deaths, especially among low-income mothers.

Despite the strong connection between maternal malnutrition and infant death, little government action is directed towards dietary interventions for at-risk pregnant mothers. Poor and disadvantaged mothers are given free or significantly reduced cost prenatal care under Medicaid or state-funded programs, but obstetrician-gynecologists are often not in a position to offer guidance on nutrition. In a recent survey, the majority of prenatal and gynecologists did not have adequate training on nutrition Talking Points • Nutritional and dietary counseling has or weight management for expectant already been proven to be a highly effective mothers. Thus there is an important and inexpensive method of improving child gap between nutritional counseling heath outcomes. and at-risk populations. • Medicaid already covers nutritional therapy, but it is severely underutilized by poor pregnant women. • This proposal would merely extend existing medical benefits to already eligible women without creating new bureaucracy or significantly altering administrative function. • This proposal would also offer financial incentives to nutritional specialists who serve in low-access areas to at-risk populations.

Previous medical and epidemiological studies have identified simple dietary counseling, often as little as a twohour session, as an inexpensive and effective intervention for improving maternal and infant outcomes. Medicaid already reimburses nutritional counseling, but this service is severely

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underutilized, particularly by poor pregnant women. Thus, this proposal would merely expand access to existing benefits to already eligible patients. Means-tested programs such as Food Stamps, Temporary Aid to Needy Families, and Women, Infants and Children could be used to identify and recruit eligible pregnant women, thereby requiring no new bureaucracy and little changes to existing infrastructure. To encourage the provision of nutritional counseling, and ensure equitable access in all regions, the federal government ought to provide financial incentives for nutritional specialists in low-access areas. History and Analysis The United States still retains a high level of infant and child deaths, particularly amongst poor and minority mothers. A leading cause of child death and disease is maternal malnutrition and obesity, which are both steadily increasing amongst poor populations. However, existing programs that provide medical services to needy pregnant women largely neglect nutritional and dietary counseling. Such counseling programs have proven to be inexpensive and effective in previous medical and public health studies. Although no federal program specifically offers dietary counseling for pregnant women, Medicaid already subsidies nutritional therapy for qualifying individuals. Thus, existing means-tested programs ought to work with Medicaid and Medicaid providers to encourage all eligible pregnant women to take advantage of nutritional and dietary therapy. To ensure equitable access across different geographic regions, this proposal would offer financial incentives to nutritional specialists who serve low-access, at-risk populations. This proposal can initially be implemented at the state-level, through coordination with state Medicaid and means-tested programs. Federal implementation could be coordinated by the Centers for Medicaid and Medicare Services. Sources

Adam Gilden Tsai, Sharad Mansukani, Andrew Cucchiara, and Michael Schaffer. “Availability of Nutrition Services for Medicaid Recipients in the Northeastern United States: Lack of Uniformity and the Positive Effect of Managed Care.” American Journal of Managed Care, 9 (2003): 817-821. CDC WONDER data 2008. http://wonder.cdc.gov. Gareth Jones, Richard W. Steketee, Robert E. Black, Zulfiqar A. Bhutta, and Saul S. Morris, “How many child deaths can we prevent this year?” The Lancet, 362 (2003):65-71. I. Guelinckx, R. Devlieger, K. Beckers, and G. Vansant, “Maternal obesity: pregnancy complications, gesta tional weight gain and nutrition,” Obesity Reviews, 9, 2 (2008):140-50. José Villar, Mario Merialdi, A. Metin Gu lmezoglu, Edgardo Abalos, Guillermo Carroli, Regina Kulier, and Mercedes de Oniz. “Nutritional Interventions during Pregnancy for the Prevention or Treat ment of Maternal Morbidity and Preterm Delivery: An Overview of Randomized Controlled Trials.” The Journal of Nutrition, 133 (2003): 1606-1625. M. L. Power, M. E. Cogswell, J. Schulkin. “Obesity prevention and treatment practices of U.S. obstetrician- gynecologists.” Obstetrics and Gynecology,108 (2006): 961-968. “Saving the Lives of Children Under Age 5.” State of the World’s Mothers 2007: Save the Children. (2006)

No Child Left Idle Federal requirements for Physical Education in K-12 Schools Edie Moussa, Virginia Tech, and Eva Galvan, Yale University

By including mandates for physical education and health classes in the reauthorization of the No Child Left Behind Act, Americans will increase equity in academic achievement. The overall mission of the No Child Left Behind (NCLB) Act of 2001 is to increase equity in access to academic achievement (NCLB, 2001). Academic achievement requires a balanced curriculum, including physical education (P.E.). Yet within the last two decades, schools have struck P.E. and health classes from the Key Facts K-12 curriculum in the majority of • Exercise, even if only walking or running laps, schools across the nation (NASPE, stimulates and improves working memory and problem-solving skills ( Jenson, 2006). 2008). State officials often ra• Children and adolescents should accumulate at tionalize cutting P.E. and health least 60 minutes of exercise on all or most days classes by claiming that scarce of the week (NASPE, 2008). monetary resources are better • Only 27 of the 50 states provide specific P.E. used to pay for what they believe requirements for all grades, which rarely are leads the way to higher academic enforced (NASPE, 2008). achievement ( Jenson, 2006). However, evidence shows that exercise helps children learn through increased blood flow to the brain (Yancey et al., 2007). After exercising, children demonstrate less disruptive behavior, show more attentiveness to their course subjects, and overall increased academic performance (Yancey et al., 2004 and 2007). Moreover, dedicated P.E. and health classes in K-12 curriculum gives children and adolescents the opportunity to lead healthy lives and increases access to academic achievement. No child should be “left behind” and deprived of the chance to attain academic success. In staying consistent with American democratic values of equity along with Talking Points NCLB’s objectives, Congress • Children have shorter attention spans, high should amend the Act to inenergy levels, and need physical activity during clude P.E. and health course the school day ( Jenson, 2006). provisions during the Act’s • Though adolescents have longer attention spans, reauthorization in 2009, as a they also need physical exercise and health part of every K-12 school’s information to give them the opportunity to curriculum. achieve academically and to lead healthier lives (Yancey et al., 2004 and 2007). • P.E. and health course provisions included in Analysis NCLB will increase equity in access to acaWhile most states have one demic success. general required year of high school P.E. and health class, others do not provide any statewide requirements. Not only are these requirements hardly enough to keep kids active and stimulate their ability to learn, but also, states typically do not enforce these requirements. Children from higher income localities

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often attain physical exercise and health information through extracurricular activity; whereas, children from poorer areas in many instances simply go without exercise ( Jenson, 2006) despite mounting evidence showing a link between physical exercise and higher academic performance. Ultimately, P.E. and health information affects academic achievement, future opportunities, and quality of life. In order for NCLB to increase equity in academic success, every child should have access to a balanced K-12 curriculum that includes P.E. and health related classes, regardless of the child’s economic status. Next Steps The first step in pursuing equitable access to academic achievement requires mandating P.E. and health class provisions in the reauthorization of NCLB. In addition, schools in poorer localities should receive adequate funding to implement P.E. and health courses. Because students and parents often do not fully understand the benefits from exercising, many students reluctantly fulfill required P.E. credits and do not extend exercising outside of the lowest requirement. To raise awareness, P.E. and health awareness teachers should give talks regularly to students on complications that can arise from lack of exercise and unhealthy lifestyles. Teachers should supplement these talks with visual PowerPoint presentations or video clips to keep students stimulated, and they should encourage asking questions to allow students to pursue a fuller understanding of the long-term consequences of the choices they make, even at school age. Sources

A. K. Yancey, J. E. Fielding, G. F. Flores, J. F. Sallis, W. J. McCarthy, L. Breslow, “Creating a public health infrastructure for physical activity promotion: a challenge to chronic disease control policy.” American Journal of Preventative Medicine, 32, 1 (2007): 68-78. A. K. Yancey, S. K. Kumanyika, N. Ponce, W. J. McCarthy, J. E. Fielding, J. P. Leslie, “Population-based inter ventions engaging communities of color in healthy eating and active living: a review.” Prevention of Chronic Disease, 1, 1 (2004): A09. Epub [serial online]. “Comprehensive School Physical Activity Program,” National Association for Sport and Physical Education, (2008) http://www.aahperd.org/naspe/pdf_files/CSPAP_Online.pdf. Eric Jenson, Enriching the Brain (San Francisco: John Wiley and Sons, Inc.,2006). No Child Left Behind Act, §1001. 20 U.S. Code 6301.

Empowering the Public Health Service

Louis Graham, University of North Carolina - Greensboro

Increase the efficacy of the Public Health Service (PHS) by making the head of PHS an appointment with a lifetime term and establishing criteria for PHS leadership to have formal training in population health research and practice. Recent Surgeons General have Key Facts been less visible in cautioning • On July 10, 2007, three former Surgeons General testithe country about health risks, fied before Congress that they were pressured by White owing chiefly to the reduced House officials to weaken or suppress scientific findings and reports influence of career public health • Historically, top Department of Health and Human officers within the Department Services (DHHS) aids and officials either are not forof Health and Human Services mally trained in the health sciences; or their previous (DHHS). Efforts at reform careers do not include experience in health research, policy, or practice. could begin by expanding the au• Traditionally, some key PHS administrators are thority and visibility of the Surprimarily trained in individual-level medical care even geon General in directing public though they head population-level health prevention health policy and education. Adagencies. ditionally, granting the Surgeon General greater autonomy from the executive branch by making the position an extended term appointment would alleviate current political pressures that have severely impeded effective public health policy. The Office of the Surgeon General should be given financial and resource independence by allowing the Surgeon General to work with Congress directly for appropriations. Instituting these changes would lead to a reduction in healthcare costs by increasing the efficacy of the PHS in promoting preventive measures. Specifically, the PHS would be better positioned to effectively guide evidence-based health legislation development and implementation. This will ultimately lead to improved population health outcomes for the American people. History and Analysis Two main branches of the Department of Health and Human Services (DHHS) house most of the federal entities responsible for the public’s health: the Public Health Service (PHS) and the Health Care Financing Administration. Talking Points During the first half of the 20th • Extending the term of the PHS head will help insulate century, the Surgeon General the PHS and its leadership from political pressure. • Allowing the PHS head to negotiate directly with had administrative control of the Congress on legislation and appropriations and better PHS. However, the historical aligning PHS leadership qualifications with respecmodel of the PHS as an agency tive responsibilities will lead to better structuring of with effective political control population health efforts. • The Federal Reserve may be a potentially useful model no longer holds true. The effect for restructuring the PHS, particularly with its desigof this political restructuring on nation as an independent governmental entity. public health policy has been det• Increasing the efficacy of the PHS will lead to more rimental. The Office of the Sureffective preventative health measures, leading to cost geon General is still a constituent

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of the DHHS, but is devoid of any significant responsibility or resources. Extending the term of the Surgeon General, granting the PHS more independence through the allowance of direct legislative and appropriations accord with Congress, and establishing clear leadership eligibility criteria will prevent weakened or suppressed public health reports and censorship of important scientific information. Reorganization and restructuring will enable the PHS to craft and implement a quality and effective national health agenda, strategic plan, and processes to carry out its mission unfettered by political pressure, which will ultimately increase efficiency and lower healthcare costs. Specifically, the PHS would be able to disseminate quality scientific information through reports, speeches, and release of study findings in a timelier manner that warns against health threats and presents efficacious promotion and prevention strategies to the public before health hazards become worse and more costly to address. The Federal Reserve could serve as a useful model for a new PHS, particularly to the degree that it is designed to be independent within the government. The Federal Reserve was established by the Federal Reserve Act in response to a series of financial panics during the turn of the century. Our population’s health is similarly in crisis, lagging far behind our industrial country peers on nearly every measure. Just as the Federal Reserve is charged with fostering a sound banking system and healthy economy, the PHS is charged with fostering a sound wellness system and healthy society. The PHS would greatly benefit from an extended term appointment for the Surgeon General, in a similar fashion to the Federal Reserve Chair. The goal of Congress in shaping the Federal Reserve Act was to keep politics out of monetary policy, so that economic principles rather than political considerations, were the driving force for setting and achieving overarching economic aims, goals, and objectives. In fact, in 1935 Congress realized how the lack of sufficient autonomy and authority affected the board’s ability to carry out its functions and increased its authority and influence through the Banking Act of 1935. Additionally, each Federal Reserve Chair and members of the board have had formal training in economics and extensive experience in the financial industry, and most also have significant policy backgrounds. Likewise, the head of the PHS and all affiliated agencies should be formally trained and have extensive experience in population health research and service provision. Audience Policy makers, practitioners, and patients should all care about this change because they will all benefit from having a more powerful and autonomous PHS with qualified leadership. Next Steps 1. Establish rules and regulations for congressional over-site and accountability of an independent PHS. 2. Convene a federal commission comprised of leading population health researchers, practitioners, and policy makers, to devise DHHS and PHS leadership qualifications, training standards, and eligibility criteria.

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Associated, Press. “Ex-Surgeon General: Bush Muzzled Me.” 10 July 2007. CBS News. 4 July 2008. . Dutton, Paul V. France’s model healthcare system. The Boston Globe (2007). August 11th. Embassy of France. The French Healthcare System (2007). http://www.info-france-usa.org/atoz/health.asp. Federal Reserve Board: Frequently Asked Questions – Federal Reserve System. http://www.federalreserve. gov/generalinfo/faq/faqfrs.htm#7 (accessed 7/23/08) http://www.federalreserve.gov/generalinfo/faq/faqbog.htm#1 (accessed 7/23/08) http://www.federalreserve.gov/aboutthefed/default.htm (accessed 7/23/08) “HHS Leadership Biographies.” U.S. Department. 4 July 2008 . Meltzer, Allan H. A History of the Federal Reserve : Volume 1, 1913 -- 1951. Chicago: University of Chicago Press (2003). Mullan, Fitzhugh. “Federal Public Health, Semi Re-Invented.” American Journal of Public Health 87.1 (1997): 21-24. Navarro, Vincente, Carles Muntaner, Carme Borrell, Joan Benach, Agueda Quiroga, Maica Rodriguez, Nuria Verges, and M I. Pasaria. “Politics and Health Outcomes.” Lancet 368 (2006): 1033- 1037.

Creation of an Office to Improve Men’s Health Outcomes Ramon P. Llamas, University of Southern California

An Office of Men’s Health at the state level will promote health equity for men and boys through tailored, evidence-based approaches. Preliminary data from the National Center for Health Statistics indicate that US life expectancy at birth reached a record high of 78.1 years in 2006. Further examination of those statistics, however indicates a stark disparity in health outcomes: the life expectancy for white and black men was 76 and 70 years respectively compared to the life expectancy for white and black women of 81 and 76.9 years, respectively. Men consistently suffer higher probabilities of developing cancer, heart disease, HIV/AIDS, smoking, and obesity compared to Men Women women. Men are Lifetime Probability of Developing Cancer: also more likely to In all sites 1/2 1/3 be uninsured and also significantly underutilize HIV/AIDS Prevalence in U.S., 2003 (%): 74 26 medical services. Mortality Rate for Leading Causes of Death: Men clearly have Heart Disease: 288.6 190.3 distinct health Cancer: 233.3 160.9 needs that are not currently being Uninsured Rates in 2004 (%): 53.5 46.5 met by traditional health policies. Analysis The Department of Health and Human Services (HHS) is structured to be comprehensive in its coverage of different segments of the population. A quick glance at the department’s organizational chart highlights the various agencies created to address issues among populations considered as vulnerable, including children, the elderly and the indigent, among others. Under the Office of Public Health and Science (OPHS), distinct offices for women and minorities exist for the delivery of public health services. 17 years after the Office of Women’s Health (OWH) was created by President George H.W. Bush to improve the health of American women, disparities between the sexes still persist, with men’s health systematically lower than that of women. Therefore, an Office of Men’s Health, modeled after the successful Office of Women’s Health (OWH), would be a worthwhile approach to diminish health disparities between sexes. With an Office of Men’s Health, appropriate Talking Points funding can be allocated to • Federal agencies and offices address the needs of vulnerable populations including children, the elderly, fund gender-specific health the indigent, women and minority populations. education and promotion • Statistical data indicate that men consistently fall programs targeted to improve behind women in important health measures. men’s health outcomes, in• Therefore, an Office of Men’s Health, modeled cluding prostate cancer, heart after the Office of Women’s Health (OWH), is a disease and HIV. worthwhile approach to diminish health disparities between the sexes.

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48 Next Steps An Office of Men’s Health can be implemented on the state level. Each state has a public health department, under which an Office of Men’s Health can be established and while the process of full implementation may be gradual, a website containing health education on men’s health issues and links to community resources would provide immediate outreach. Currently, Illinois and Maryland have such websites dedicated to address men’s health issues. Subsequently, state and local public health departments need to begin a thorough assessment and analysis of their male population in order to allocate funds to support community-based interventions designed to improve targeted men’s health outcomes. Only after successful implementation of men’s health programs in several states will support on the national level follow. A small strategic investment in prevention efforts could result in significant savings in future medical costs for each state; an estimated return of $5.60 for every $1 invested. Furthermore, a return of investment of $1 over and above the cost of the program can be observed in as little as 1-2 years11. Madera County’s Tobacco Education Program in California, for example, was able to reach 46,500 people in the 2007-2008 fiscal year through a combination of media, educational intervention and magnet events with a relatively small budget of $149,77612. Sources CDC. Fact Sheet: Adult Cigarette Smoking in the United States: Current Estimates. 2007. Retrieved from: http://www.cdc.gov/tobacco/data_statistics/Factsheets/adult_cig_smoking.htm. CDC & NCHS. Utilization of Ambulatory Medical Care by Women: 1997–98. 2001. Vital and Health Statistics, Series 13, Number 149. CL Ogden, et al. Overweight and Obesity in the U.S. 1999-2004. JAMA. 2006, V295:13, 1549-1555. County of Madera. “Budget for the Fiscal Year 2008-2009: Health and Tobacco Education Program.” 2008. Men’s Health Network. “Premature Death Among Men.” 2006. Heron MP, Hoyert DL, Xu J, Scott C, Tejada-Vera B. Deaths: Preliminary data for 2006. National Vital Statistics Reports. 2008, V56:16. Hyattsville, MD: National Center for Health Statistics. Pleis JR, Lethbridge-Çejku M. Summary health statistics for U.S. adults: National Health Interview Sur vey, 2006. National Center for Health Statistics. Vital Health Statistics, 10(235). 2007. Trust for America’s Health. “Prevention for a Healthier America: Investments in Disease Prevention Yield Significant Savings, Stronger Communities.” July 2008.

Endnotes 1. American Cancer Society. Cancer Statistics 2007 – A Presentation from the American Cancer Society. 2. Centers for Disease Control and Prevention (CDC). HIV and AIDS in the United States: A Picture of Today’s Epidemic. 2003. Retrieved from: http://www.cdc.gov/hiv/topics/surveillance/united_ states.htm. 3. The Men’s Health Network (MHN). “The Silent Health Crisis.” 2006. 4. MHN. “Lack of Health Insurance.” 2006.

Promoting Equity of Health Care Payments Between Insurers and Self-Payers Kumar Senthil, Johns Hopkins University

Set a maximum rate of charge for each healthcare procedure so that selfpayers are not charged exorbitant amounts compared to health insurers. This rate should be denoted as a multiple of Medicare Allowable Cost. There is an enormous discrepancy between what health insurers and self-pay patients are expected to pay for healthcare services. Using data from 2004, in many cases, selfpaying patients must pay 2.5 times the fee that health insurers pay. Moreover, this gap between the amount charged for self-payers and insurers has been steadily increasing since the mid-1980s. The federal government must Key Facts take two steps toward develop• On average, hospitals charge self-pay patients over ing a long-term solution to three times the amount deemed reasonable by this growing disparity. First, Medicare. • If hospitals collected the full amount that they consumers must have access charged from every patient, they would have a to a clearly organized hospital profit margin per hospital of 200 percent. chargemaster file that details • Hospital costs are rising, but are increasing at a the specific pricing for each much slower rate than hospital charges. Public procedure and resource utilized. and private insurers are increasing their payment Hospitals should state their relative to increases in hospital costs, while selfprices as a multiple of what payers must increase payment relative to increases Medicare sets as the calculated in hospital charges. cost of services to the hospital (Medicare Allowable Costs), so that consumers will have a clear relative value. Federal legislation should also work toward setting an official ceiling for any hospital charge in order to limit the payments expected from self-pay patients. For example, instead of being able to constantly increase the chargemaster prices, hospitals will not be able to bill any more than 1.5 times the Medicare Allowable Cost. This will still be higher than what public and private insurers pay, but substantially lower than what self-pay patients are currently expected to pay. Talking Points • As hospitals increase the amount that they charge, private and public insurers are able to negotiate significant discounts, resulting in a minimal change in expenditures. Self-paying consumers are left to pay for much of the increase in hospital charges. • If health care providers increased price transparency, consumers would be able to identify and give business to the providers that offered care at the cheapest rates, providing market incentives for increased efficiency.

History Since 1980, hospitals have been increasing fees in their chargemaster files. Regardless of chargemaster fee increases, Medicare only pays the set Medicare Allowable Cost, while private insurers, due to the large number of consumers they bring to the hospital, have the ability to

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negotiate prices and generally end up paying only slightly more than Medicare. However, self-pay patients do not normally have the opportunity or the leverage to negotiate prices and are consequently charged the high fees listed in the chargemaster file. Some initiatives have been successful in lessening the disparity between self-payers and insurers. In Maryland, the Health Services Cost Review Commission has set prices, so that public insurers, private insurers and self-payers in the state pay identical hospital rates. This policy has resulted in Maryland having the lowest charge-to-cost ratio in the country. Analysis Developing price transparency will enable market economics to play a greater role in the healthcare industry. One of the major barriers to market independence in this sector is consumers’ lack of information on prices. However, if prices were available in a clear, concise and organized manner, consumers would be able to compare costs between healthcare providers and choose the cheapest, most efficient options. This would provide strong incentives for increased efficiency among providers. Although increased transparency would improve the quality of the competitive market, governmental regulation would still be necessary to correct instances of market failure. Due to the presence of multiple insurers, minimal consumer knowledge and price discrimination, artificial price ceilings must be set in order to protect the best interests of the self-paying consumers. In order to not drastically affect hospital revenue, the ceiling prices for self-pay patients will still be greater than what public and private insurers pay, but substantially less than what self-payers are currently expected to pay. Future legislation should work to further narrow this financial gap. Next Steps The most important next step is to determine what exactly this ceiling rate should be. Numerous calculations must go into what constitutes a fair price, both for the payer and for the hospital or healthcare provider. This ceiling may differ by region, cost of labor and living, and patient population for each provider. Sources

Anderson, Gerard F. “From ‘Soak The Rich’ to ‘Soak The Poor’: Recent Trends in Hospital Pricing.” Health Tracking. 2007

Mandating Documentation of Patient Desires For End-of-Life Care Wendy Mosiman, Wichita State University

Require documentation of end of life wishes, known as advance directives (AD), and the designation of a Healthcare Power of Attorney to reduce Medicare expenditures. Studies estimate that two thirds of all Americans facing terminal diseases do not want care to be focused on extending their lives indefinitely, yet documentation of those wishes or a specific decision maker is sorely lacking. The care these patients desire is often palliative. However, many Americans die while in physical distress, receiving expensive and aggressive care that they do not want and that is not likely to prolong their lives significantly. Key Facts

Every citizen has the right to have • A patient’s “right to die” was established in the 1976 Karen Ann Quinlan case, issued his wishes followed regarding care by the New Jersey Supreme Court (Quinlan at the end of life. To ensure this, v. Rochester General Hospital). a discussion with a trusted friend • The 1990 Patient Self Determination Act or relative about end-of-life wishes affirmed a patient’s right to document endmust take place. That person must of-life wishes. then be designated as the Healthcare • Fewer than 25% of Americans have a Power of Attorney (HPOA) who has formal document outlining either what care the legal ability to ensure that those is to be provided or who should make deciwishes are carried out. The patient sions regarding care at the end of life. benefits by increasing the likelihood that end-of-life wishes will be followed, the patient’s family benefits through assurance that they are following the wishes of their loved one, and health care providers benefit by having a clearly defined plan. History and Analysis Just half a century ago, decisions about what care should be provided in the case of terminal illness were not necessary. Everything that could be done was done. In recent decades, technological advancements have developed that have led to the ability of medical professionals to keep a body alive even though all but the most basic functions of the brain have ceased. Talking Points • The Medicare budget is predicted to rise to $851 billion by 2017. • Thirty percent (30%) of Medicare funds are spent in the last year of life, with 40% of that paid to provide care in the last in the last 4 weeks. • Studies suggest that less than 30% of completed advance directives are ever actually recorded on patient charts.

Beginning in 2010, each one of the nearly thirty-four million Americans enrolling for Medicare Part D, the prescription drug benefit, will be required to complete a Healthcare Power of Attorney (HPOA) to designate who will make health care decisions, based on their wishes, if they cannot.

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The advance directives (AD) documents that will also be required at Medicare Part D enrollment could be revised yearly at re-enrollment, anytime on-line, or anytime by contacting Medicare directly. The “Medicare and You” booklet, both the print and web versions, will be revised to include AD information. However, written and video education alone is not enough. Group meetings currently designed to offer information about Part D could be expanded to include AD information. The existing Medicare Call Center will be another avenue to ask questions, receive information and guide the decision-making process regarding HPOA and AD. Audience The parties most interested in this change to Medicare Part D will be recipients and their families. The health care profession, including the AMA, ANA and AHA, will benefit from a designated decision maker for end of life care when the patient is unable to communicate. Members of Congress should favor this additional requirement as the opportunity for cost savings for Medicare overall exist, as well as the value added support of Americans individual values and personal priorities concerning death. Next Steps Congress should act to amend the Medicare Prescription Drug, Improvement, and Modernization Act to add the HPOA requirement for eligibility to participate in Medicare Part D. Medicare recipients must be educated as they begin the process of discovering, clarifying, and communicating what is important at the end of life. HPOA designees also need to be informed about advocating on the patients behalf according to their wishes. The Medicare web based information concerning HPOA decisions must be made instantly available to hospitals and nursing homes so that end of life care is provided as recipients desire. Sources

Colby, W. H. (2006). Unplugged. New York: American Management Association. Congressional Budget Office. (2007). The Budget and Economic Outlook: Fiscal years 2008-2017. Retrieved May 10, 2008, from http://www.cbo.gov/ftpdocs/77xx/doc7731/01-24-BudgetOutlook.pdf Jezewski, M. A., Meeker, M. A., Sessanna, L., & Finnell, D. S. (2007). “The Effectiveness of Interventions to Increase Advance Directive Completion Rates.” Journal of Aging Health, 19(3), 519-536. Lynn, J. (2004). Sick to death and not going to take it anymore! Reforming health care for the last years of life. Berkley: The University of California Press. Raphael, C., Ahrens, J., & Fowler, N. (2001). “Financing end-of-life care in the USA.” Journal of the Royal Society of Medicine, 94(9), 458-461. The Pew Research Center. (2006). “Strong Public Support for Right to Die.” Retrieved April 24, 2008, from http://people-press.org/reports/display.php3?ReportID=266 Twohig, J. S., & Byock, I. (2004 ). “Aligning values with practice.” Health Progress, 85(4), 27-33.

Containing Medicare Costs by Implementing Best Practice Guidelines Genia Lindsey, Lake Forest College

Begin a Medicare pilot program that will deploy best-practice agents to educate physicians on evidence-based clinical practices. The intent is to change physicians’ behavior in managing illnesses and to save money. When physicians are unsure of the best course of care, many tend to increase treatment under the assumption that more care creates better outcomes. However, in the Dartmouth Atlas Project’s most recent report, researchers found that more intensive care does not always lead to better outcomes. Indeed, mortality is often higher in areas in which more resources are used, with variations in severity of illness only accounting for only a small fraction of the Key Facts observed variation in mortality. • Without guidelines for best treatment practices,

physicians often dispense medicine under the Although research has been done assumption that more care equals better care. on evidence-based practices, few • Various measurements (including patient satisphysicians have accepted and faction, health outcomes, quality of communicaimplemented published guidetion, and continuity of care) indicate that greater lines. To make this research more use of resources is not always associated with readily available, best-practice better care. agents will work under the aus• There is tremendous variation in the average amount of money spent per patient with pices of the Center for Medicare a chronic disease in the last two years of life, and Medicaid Services (CMS) to ranging from $59,379 in New Jersey to $32,523 disseminate treatment guidein North Dakota. Yet most of this variation canlines and criteria, as published not be explained by differences in price, disease by organizations such as the prevalence, or patient preferences. Agency for Healthcare Research and Quality (AHRQ) and the American College of Physicians (ACP). Best practice agents will employ tactics similar to those of pharmaceutical representatives. They will cultivate relationships with physicians, dispel myths, and help to establish incentives for physicians who implement the guidelines. The intent will be to change physicians’ behavior so as to lower costs and improve care.

Talking Points • One barrier to eliminating unnecessary treatments is physicians’ lack of knowledge of and adherence to scientifically proven treatment guidelines. • Pharmaceutical representatives have been extremely effective in bringing information to physicians and altering their behavior. Best-practice representatives will model their efforts off pharmaceutical representatives’ tactics.

History Variations of this idea have been tried in Medicare demonstration projects, one being the Physician Group Practice (PGP) project. This was CMS’s first physician pay-for-performance initiative. One measure of performance was improvements in quality of care, and one participating physician group’s strategy for improvement was to implement evidence-based practice models. This group has disseminated

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information on best-practice models through internal guidebooks, nurse educators, and management and peer reviews. Though preliminary results have been promising, a final report has not been released. Analysis If best practice representatives are able to successfully change behavior, results could be dramatic. Treatment uniformity could eliminate ineffective procedures and reduce overall costs. Private insurance companies may seek to implement this type of program as well. However, there will be challenges to implementation. Physicians may be reluctant to adhere to the advice of uncertified medical professionals and resistant to oblige by clinical standards. They may feel that guidelines will diminish their autonomy. While these concerns may be warranted, physicians can be assured that best practice representative will be highly trained and specialized. Additionally, CMS will take into account the vicissitudes of medicine by allowing physicians flexibility in adhering to guidelines. Next Steps CMS should wait for the results of the PGP project before proceeding, as they may offer useful insights and directions. After analyzing the PGP results, CMS should begin identifying and training best-practice representatives. They should be individuals who have a medical background or are seeking to enter the field. Representatives should choose a condition or area of study and begin an intensive training course, similar to the training of pharmaceutical representatives; the training and work method of best practice representatives should be modeled off that of pharmaceutical representatives. Paying for this program may be expensive, but possible funding streams are available and there may be some offsets, such as money saved through eliminating unnecessary treatments. Another possibility would be to introduce this program under a larger health care reform package financed through the expiration of the Bush tax cuts. Sources Department of Health and Human Services. “Physician Group Practice Demonstration: First Evaluation Report.” 2006. http://www.cms.hhs.gov/DemoProjectsEvalRpts/downloads/PGP_Final_Con gress.pdf. Garber, Alan. “Evidence-Based Guidelines As a Foundation For Performance Incentives.” Health Affairs Policy Journal, no. 1, 2005. http://content.healthaffairs.org/cgi/content/ full/24/1/174?ijkey=khuayL.OU2/GI&keytype=ref&siteid=healthaff. Lind, Keith, & Williams, Jackson. Future of Medicare: Report on Expert Views. AARP Public Policy Institute, May 2007. Manchanda, Puneet & Honka, Elisabeth. “The Effects and Role of Direct-to- Physician Marketing in the Pharmaceutical Industry: An Integrative Approach.” Yale Journal of Health Policy, Law, and Ethics, V:2, 2005. http://www-personal.umich.edu/~pmanchan/Advertising_files/Manchanda_ Honka_%20Final.pdf. Wennberg, John; Fisher, Elliot; Goodman, David; & Skinner, Jonathan. “Tracking the Care of Patients with Severe Chronic Illness.” The Dartmouth Atlas of Health Care 2008. http://www.dartmouthat las.org/atlases/2008_Chronic_Care_Atlas.pdf. United States Government Accountability Office. End of Life Care: Key Components Provided by Programs in Four States. December 2007. http://www.gao.gov/new.items/d0866.pdf.

Creating a System of Uniform Federal Health Insurance Mandates Jeet Guram, University of South Carolina

Creating a federal evidence-based set of health insurance benefit mandates can reduce unnecessary variation in state-level mandates and expand access to quality, affordable health care nationwide. Due to information asymmetries between insurers and consumers, insurers may undervalue the benefits of certain services and neglect to cover them. State insurance benefit mandates, which require private insurance plans sold within a state to cover specific services or providers, are intended to prevent this from happening. Although some regulation of benefits is needed, the number of mandates in many states has grown exponentially in recent years. In 2001, for example, more than 550 mandates were introduced in all states, making it difficult for policy makers to assess the Key Facts effects of each new requirement. • In 1991 there were about 850 stateimposed insurance benefit mandates

nationwide; there are now over 1,900. As the number of mandates has In 2001, more than 550 mandates were increased, evidence suggests that these introduced in all states. policies may be hurting those they are • The number of benefit mandates varies meant to help. For example, a Nasignificantly by state. Some states have as tional Bureau of Economics Research few as 13 while others have as many as 62. study found that mandates for infertil• Variations in mandates contribute to ity services have induced significant variations in costs: for a healthy 25-yearmoral hazard: the mandates have had old male, a basic health plan costs $5,880/ year in New Jersey and $960/year in little effect on the number of deliverKentucky. ies but have increased the incidence of high-risk multiple births, suggesting over-utilization. Moreover, a study in Health Affairs found that mandates might increase health disparities among the insured, since the already privileged are the most likely to utilize newly mandated services. Talking Points • Access to affordable health insurance coverage should not vary by the state that you live in. • Federal evaluation of health insurance mandates will allow for a more rigorous review of the economic and public health implications of these mandates. • This policy would only affect new policyholders; protections would be put in place to ensure that families with health insurance did not lose existing benefits unless they willingly switched to a plan designed under the new requirements.

One unambiguous effect of mandates is that they increase insurance costs, sometimes leaving consumers to choose between no coverage and a plan charging for many services they will never use. The Council for Affordable Health Insurance has estimated that mandates add 20% to 50% to the cost of health-insurance policies. A nationwide system of health insurance mandates would help ensure that mandates can achieve their original goal of improving access to quality, affordable health care. The federal gov-

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ernment has more resources than states to conduct a rigorous review of the economic and public health impacts of new mandates, and the broader scope of federal legislation means that inter-state disparities in price brought about by state-level mandates would be eliminated. History In 1945, Congress passed the McCarran-Ferguson Act, which gave states regulatory control of the health insurance industry. The Employment Retirement Income Security Act (ERISA) in 1974, however, limited states from regulating self-insured employer-sponsored health plans (those plans, typically offered by large employers, designed and administered by the employer). In response to the large number of health insurance mandates proposed on the statelevel, some states, such as California, have created standardized processes to rigorously evaluate both the economic and public health impacts of proposed mandates. Most states do not have the ability to conduct such an extensive evaluation. Analysis State regulation of health insurance mandates may have the benefit of allowing the states to act as laboratories for new policies, but the large disparities in the number of mandates between states suggests that few states are learning from each other. Federal regulation, on the other hand, offers the advantage of being consistent in its application and more universal, since federal law should be able to override ERISA limitations. As state mandates are replaced with federal guidelines, however, it is important to ensure that individuals who already have health insurance do not lose their existing benefits and that any changes to the status quo are supported by rigorous evidence. Next Steps Implementing this policy would be politically difficult and would take time. The first step would be developing a bipartisan committee of experts at the federal level to evaluate the costs and benefits of existing mandates and the anticipated effects of proposed ones (similar to MedPac or the comparative effectiveness institute that Congress is considering). Once a clear set of evidence-based recommendations is developed, Congress can begin the process of replacing state mandates with a uniform set of federal requirements. Sources

Andrews, Michelle. “Paying a Price for Pared-Down Health Plans.” The New York Times 15 June 2003. . Bundorf, M K., Melinda Henne, and Laurence Baker. “Mandated Health Insurance Benefits and the Uti lization and Outcomes of Infertility Treatments.” National Bureau of Economic Research (2007). . Cubanski, Juliette, and Helen H. Schauffler. Mandated Health Insurance Benefits: Tradeoffs Among Ben efits, Coverage, and Costs? California Health Policy Roundtable. The Henry J. Kaiser Family Foundation, 2002. . Elkins, Benjamin R. “The Regulation of Private Health Insurance by the States - with Special Attention to Mandated Benefits.” Yale College Chapter of the Roosevelt Institution. 2006. Folland, Sherman, Allen C. Goodman, and Miron Stano. The Economics of Health and Health Care. 5th ed. Uper Saddle River, N.J.: Prentice Hall, 2007. Richman, Barak D. “Insurance Expansions: Do They Hurt Those They are Designed to Help?” Health Af fairs 26 (2007): 1345-1357.

Building a Sustainable Comparative Evaluation Institution to Assess Medical Treatments Jonathan Knoche, University of Wisconsin

Congress should support an institution that comparatively evaluates medical treatments, revealing the practices and treatments that are both efficient and effective. Utilization of the newest, most expensive technology is a major reason the U.S. spends more on health care than other industrialized nations. Once new treatments and technologies are introduced, they are often used indiscriminately, in the absence of comparative studies showing their benefits against available options. The health care industry needs better information on how new treatments compare with existing options with respect to health outcomes and cost of care.

Key Facts • Of the $320 million budget of the Agency for Healthcare Research and Quality (AHRQ), only $15 million is devoted to comparative research. • Per capita Medicare spending in 2000 was $10,550 in Manhattan, New York, but only $4,823 in Portland, Oregon. These variations are due not to differences in price but primarily to differences in patterns of practice. Even after controlling for differences in age, sex, and race, the higher-spending region did not have better health outcomes. • Estimates for the amount wasted on over-treatment in the US range from 20 to 30 cents on every health care dollar spent.

According to Elliot Fischer, chief investigator of the Dartmouth Atlas Project, if Congress instituted nationwide hospital practices similar to those employed in more conservative regions, then Medicare spending (and health care spending overall) could decrease by approximately thirty percent. In higher spending regions—which provide comparatively more care but often have poorer survival and worse outcomes—patients have increased Talking Points exposure to hospital-acquired infections • As expensive new treatments are rapidly and a higher risk of medical error. Thus, introduced to the market, physicians by fully funding and politically insulating need to know which innovations are an institution to comparatively evaluenough of an improvement over existing ate treatments, Congress would reduce options to justify the increase in cost. • Creating an independent and fullyhealth costs and ensure the best quality funded comparative effectiveness instiof care for all Americans. tution will reduce medical costs while ensuring that Americans receive the best quality health care.

History Political pressure and an absence of resources have hampered comparative assessment efforts. For instance, the Agency for Healthcare Policy and Research (AHCPR) was begun in December 1989 to evaluate technology and outcomes. However, in 1994, when the AHCPR reported that there was inadequate evidence to support commonly performed back surgeries, its funding was almost eliminated at the behest of disgruntled orthopedic surgeons and neurosurgeons. While AHCPR survived, its name was changed to the Agency

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for Healthcare Research and Quality (AHRQ), and this new agency generally avoids controversial issues. Only a small portion—$15 million—of its $320 million budget is dedicated to comparative research. Analysis Significant geographic differences exist in medical practices that do not lead to substantial improvements in health outcomes. A limited amount of evidence is available about which treatments work best and whether the added benefits of more-effective but more-expensive services justify their added costs. Financing a comparative effectiveness institution will require combined funding from Congress and Medicare Trust Funds. Additionally, funding obtained by imposing a fee on health expenditures would offer both stability and fairness, placing the cost of the program on the beneficiaries. Although the fee may lead to slight short-term increases in health costs, the comparative effectiveness institution would decrease costs substantially in the long-run. Americans might worry that, as the agency releases information and physicians change practice patterns, insurers will not cover treatments that are newer and marginally better, but significantly more expensive. To allay this fear, insurers could still subsidize the more expensive treatments, but have a slightly higher copayment which would allow beneficiaries to decide for themselves whether the added benefits were worth the added costs. Next Steps Many Congressional leaders have talked about creating a comparative effectiveness agency, but sustaining this program is just as important. As history shows, consistency in funding is necessary to help ensure that the institution be able to pursue research without undue influence from interest groups. Sources

Dartmouth Atlas of Healthcare Project Web site (Accessed August 12, 2008, at http://www.dartmouthatlas. org) Emanuel, Ezekiel, Victor Fuchs, Alan Garber. “Essential Elements of a Technology and Outcomes Assess ment Initiative.” JAMA. 2007; 298 (11): 1323-1325. Fischer, Elliot S. “Medical Care—Is More Always Better?” N Engl J Med 2003;349: 1665-1667. Neumann, Peter J. “Getting Better Value for Our Health Spending, a Value Deficit in U.S. Health Care.” NIHCM Foundation. Expert Voices, July 2007. “Research on Comparative Effectiveness of Medical Treatments.” Congressional Budget Office, December 2007. Wilensky, Gail. “Developing a Center for Comparative Effectiveness Information.” Health Affairs, Web Exclusive (November 7, 2006): w572-w585.

Using Federal Student F inancial Aid to Ensure Student Access to Health Insurance Mariza R Hardin, University of New Mexico

Including questions about health insurance coverage on the Free Application for Student Aid (FAFSA) can help ensure that the cost of health insurance coverage is adequately factored into student financial aid and can ultimately help reduce the number of students who lack adequate health insurance coverage. Each year after January 1st, students planning to attend college begin their search for financial aid. Approximately 14 million students use the Free Application for Federal Student Aid (FAFSA) to determine their eligibility for financial aid. Federal Student Aid, an office of the US Department of EducaKey Facts tion, ensures that all eligible • Young adults (age 19-29) have the highest uninsured rate of any age group. individuals can benefit from • About 1.7 million (20%) US college students ages federally-funded or federally18-23 were without health insurance in 2006. guaranteed educational loans. • Only 11% of young adults have public coverage Federal Student Aid partners compared to 28% of children, because low-income with postsecondary schools, adults are ineligible for Medicaid unless they are financial institutions and other pregnant, custodial parents, or disabled. participants in the Title IV • The majority of students (67%) are covered by parstudent financial assistance ent employer sponsored plans that have an age limit programs to provide money on coverage. • One in ten uninsured young adults had more than for college eligible students $700 in out-of-pocket medical expenses in 2005. and families.

• Nearly 40% of young adults with some degree of health problems are uninsured, whereas only 27% of young adults in excellent or very good health lack insurance. • The federal government processes over 14 million FAFSAs and disburses more than $80 billion in financial aid to students annually.

The FAFSA, accessible online, is a comprehensive form that asks applicants to provide extensive information about their family’s income, previous year’s income taxes, assets, family size, the number of family members attending college and other qualifying information. Using this information, the applicant’s Expected Family Contribution (EFC) is determined. The EFC represents what the student and their family is expected to pay towards the annual costs of their education, and it is used—in conjunction with the cost of attendance—to determine whether the student qualifies for aid. The cost of attendance is calculated by the addition of cost of tuition, books, transportation, room and board, personal expenses, and applicable fees. The equation used to determine the amount of financial need received is: Cost of Attendance — Expected Family Contribution (EFC) = Financial Need Because so many students file the FAFSA each year, it has the potential to serve as a screening mechanism for student health insurance coverage. By simply adding ad-

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ditional questions on health insurance coverage to the FAFSA, Congress can enable universities to identify uninsured students who will need coverage while in school. Furthermore, recognizing the significant expense of health insurance, colleges and universities should update the amount budgeted for a basic coverage premium that is included in the cost of attendance. By using a more accurate figure for the cost of insurance premiums, cost of attendance will increase, and students’ and families will have a more accurate expense figure of the cost to attend school and have health insurance. By allowing universities access to their student health care coverage information, university administrators can determine the best way to ensure that all students have health insurance and implement a process through which students would be covered by a school plan that is sufficient for their needs as a student. History and Analysis Requiring students to have health insurance as a prerequisite to enrollment is becoming a policy for many public and private universities. In 2007-2008, 30% of colleges required student to have health insurance. While this is a big step to reducing the number of students who are uninsured, many college students today face the challenge of obtaining health insurance. Over 67% of insured students are covered as a dependent on their parents’ policy. In 2006, 20% of college students aged 18 through 23 were uninsured and part-time students, nonwhite students, and students from families with lower incomes were more likely than others to be uninsured. Young adults, and particularly students, are difficult to cover because they are too old to stay on their parent’s insurance plan, they cannot afford university insurance plan premiums, and they are unemployed or work at low-income jobs that do not provide insurance. Including a more accurate cost of health insurance in the cost of attendance will help students afford to purchase university health plans. Next Steps Despite the benefits of youth, students need health care just like everyone else. While students may not be thinking directly about their health care needs, asking questions each year through the FAFSA can at the very least serve as a reminder that health care should be considered in addition to the cost tuition and cost of living. Therefore, the US Department of Education should reformat the FAFSA to include questions about the student’s insurance coverage during college and incorporate the cost of health insurance into calculating a student’s financial need. Sources Free Application for Federal Student Aid. “About Us.” 15 July 2008 <www.fafsa.ed.gov>. Schwartz, Karyn and Tanya Schwartz. “Uninsured Young Adults: A Profile and Overview of Coverage Op tions.” Kaiser Commission on Medicaid and the Uninsured, ( June 2008),< http://www.kff.org/ uninsured/upload/7785.pdf>. United States Government Accountability Office, Report to the Committee on Health, Education, Labor, and Pensions, US Senate. “Most College Students Are Covered through Employer-Sponsored Plans, and Some Colleges and State Are Taking Steps to Increase Coverage.” 10 July 2008 < http://www.gao.gov/new.items/d08389.pdf>.

Using the HPV Vaccine as a Gateway to Better Health Stephanie Gross, Northwestern University

Colleges can use the opportunity presented by HPV vaccination to encourage lifetime reproductive health in college women. The proliferation the HPV vaccine has spread awareness of sexual health issues and brought reproductive health into the mainstream as a priority for all young adults. Campaigns on and off college campuses have already successfully encouraged many women to be vaccinated in what might be the first time they actively care for their reproductive and sexual health. Widespread use of the vaccine has the potential to severely curtail the effects of cervical cancer, a common cause of infertility, and the CDC has recommended that girls aged 11 and 12 years receive the vaccine. The vaccine can also prevent most forms of genital warts. But the HPV vaccine’s potential is not Key Facts limited to its medical benefits. Doctors, • 13,870 women will die from cervical nurses and other health professionals cancer in 2008. must take advantage of the opportu• 18% of adolescent girls have HPV. • In 2007, only 55.8% of college women nity presented by vaccination to inform reported having had a routine gynecowomen of the other services a women’s logical exam in the past year. health clinic offers in order to establish women’s health as a lifelong practice and priority. This proposal aims to coordinate reproductive health efforts around the delivery of the HPV vaccine. The program will only be effective if the schools can ensure funding to cover the cost of the vaccination, which exceeds $150 for each of the three necessary doses, for all students, those who can demonstrate financial need, or those who lack insurance. Through this initiative, colleges and universities can place women’s health as an integral part of the care people expect from their doctors and health insurance. Some barriers exist, though; not all employer-sponsored health insurance plans cover contraception, leading to higher costs for those women who have been unable to prevent an unintended pregnancy. And though women certainly need reproductive and sexual health care as they leave college and enter the work force, especially if they are sexually active, fully 27% of women ages 19 to 24 are uninsured. Fostering an appreciation for the ways they can improve their quality of life through women’s health services, colleges can produce more mindful citizens, consumers, and voters. Talking Points • Regular pap smears and gynecological exams save lives. • Young people are highly likely to be uninsured, and young women may forgo basic reproductive health services when they feel it is unnecessary or too expensive. • HPV vaccine delivery is a unique opportunity for health care providers to reach out to young women to promote lifelong reproductive health.

History Existing health centers on college campuses usually do provide women’s health services. Though some schools explicitly prohibit contraception where it conflicts with

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the school’s religious mission, many schools do make contraception, pap smears, and other reproductive health services accessible to campus women. In 2007, though, only 55.8% of college women reporting having had a routine gynecological exam in the past year. Today, the HPV vaccine is offered on campuses across the country, and many of these schools have taken steps to encourage their students to get the vaccine. However, a concerted initiative is needed to universalize access to the HPV vaccine, and more broadly, reproductive health services and education. Analysis This policy won’t reach every college-aged woman--many colleges, especially two-year community colleges, lack health centers, do not offer students health insurance, or do not habitually provide their populations with vaccinations or other health care services. Further, many women will simply choose not to seek out the vaccination, for personal reasons, out of cost concerns, or for lack of awareness. And, in 2005, only 39% of 18 to 24 year olds even attended college, meaning this plan would not impact the majority of college-aged women. However, by reaching those women who do come into contact with college health centers, it is possible to bring women’s health more into the mainstream as a necessity for every woman, regardless of income or education level. Next Steps Given the disparate nature of American colleges and universities, funding initiation of this plan could occur at the local, state, or national level. Additionally, consortiums of universities—such as the Committee on Institutional Cooperation or “Big Ten Plus” in the Midwest—could drive implementation. The federal government could provide tax incentives for these institutions to implement comprehensive reproductive health services. Allocation of federal money, particularly for small or public schools, will ensure that this plan reaches women in institutions that might otherwise lack funding for such a program. Key leaders and stakeholders in the field, such as the American College Health Association, can take steps to make women’s health a priority on college campuses nationwide. Sources American College Health Association National College Health Assessment. “Reference Group Executive Summary.” Fall 2007. http://www.acha-ncha.org/docs/ACHA-NCHA_Reference_Group_Ex ecutiveSummary_Fall2007.pdf “Equity in Prescription Coverage and Contraception Coverage.” The Planned Parenthood Federation of America. April 2007. http://www.plannedparenthood.org/issues-action/birth-control/insurance- coverage-for-birth-control/reports/prescription-insurance-6548.htm. “HPV Vaccine: Implementation and Financing Policy in the U.S.” The Henry J. Kaiser Family Foundation. February 2008. http://kff.org/womenshealth/upload/7602_02.pdf Ottenritter, Nan. “National Study on Community College Health.” American Association of Community Colleges Research Brief. 2002. http://www.aacc.nche.edu/Content/ContentGroups/Research_ Briefs2/Bridges_no_CDCv2.pdf

Loan Repayment Incentives for Community Health Centers Krysten Rosen, University of Florida

The expansion of community health centers can help lower health care costs. To enable this expansion, loan repayment incentive programs should be implemented to improve clinician recruitment and retention. Community health centers (CHCs) have proven to be valuable tools against many of the health care problems facing the United States today. For example, CHCs have a strong impact on health care costs. By increasing access to primary care and improving chronic disease management, CHCs decrease the use of emergency rooms and the rate of hospitalization.. In addition to controlling health care costs, CHCs have been proven to increase access to health care and to decrease racial disparities in health care. Unfortunately, CHCs are having probKey Facts lems expanding to serve more people • The annual cost of care for a CHC and to reach other areas. This can be patient is $515. This is 10 times less partly attributed to the fact that CHCs than the average per capita spending on personal health care. have difficulty recruiting and retaining • Community health center care is more clinical workers. In 2006 the average cost-efficient because patients are 11% CHC had 13.3% vacancy rate in its less likely to be hospitalized and 19% full-time physician positions. CHCs also less likely to use the emergency room for experience staff shortages of other types preventive conditions. of clinicians. When faced with cum• In 2006, 13.3% of CHC physician posibersome student loans, many students tions were vacant. Critical clinical staffcannot afford to make significantly less ing problems limit CHC expansion. money working in a CHC. Implementing a loan repayment incentive program will help recruit clinicians to work in CHCs, thereby allowing CHCs to develop and optimize their impact. History Loan repayment incentive programs have been used across the country to recruit teachers to work in inner city schools, to recruit lawyers to work in public service, and to recruit physicians to work in rural areas. These programs have had enormous success and have laid the foundation for the creation of a loan repayment incentive program to recruit doctors, nurse practitioners, physician assistants, and other clinicians to work in CHCs. Talking Points • Community health centers have proven to be effective tools to lower total health care costs, increase health care access and reduce health disparities. However, their expansion has stalled because of clinician recruitment and retention problems. • A loan repayment incentive program instituted in Massachusetts in 2007 recruited 47 clinicians to work in CHCs.

The federal government currently supports the National Health Service Corps to place doctors in underserved areas. However, this program has not been properly aligned with the needs of CHCs. Therefore in 2007, Bank of America, Partners Health Care, and the Massachusetts League of Community Health Centers came together to create a loan repayment program for clinicians

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who commit to working in a CHC. During the first year of this program, an amazing 47 clinicians were recruited. Analysis Studies have shown that CHCs lower the health care costs of individuals, decrease the uncompensated care costs imposed on local governments, and save Medicaid roughly 30% in annual spending per beneficiary. This provides a strong basis for CHC expansion. However, research completed by the University of Washington, the University of South Carolina, and the National Association of Community Health Centers demonstrate that CHC expansion is critically limited due to understaffing and the likelihood of future shortages. The success of loan repayment programs directed towards other professions and the achievements of the Massachusetts recruitment program illustrate the potential impact that sa loan repayment program could have on increasing the number of clinicians accepting jobs in CHCs. Next Steps Local and state governments should work with CHCs and private organizations to develop a loan repayment program for their area and pull together the necessary financial resources. When creating a loan repayment program the partnerships should be sure to consider program sustainability, and a method to ensure efficient dispersal of program enrollees to understaffed clinics. Sources

Cooney, Elizabeth. “Loan Effort Lures Recruits to Health Centers.” The Boston Globe May-June 2008. 3 July 2008 . Massachusetts Community Health Center Primary Care Loan Repayment Programs. Massachusetts League of Community Health Centers. 3 July 2008 . National Association of Community Health Centers. American Health Centers: Making Every Dollar Count. 2006. 3 July 2008 . Rosenbaum, Sara, J.D., and Peter Shin, Ph.D. Health Centers Reauthorization: An Overview of Acheivements and Challenges. Kaiser Commission on Medicaid and the Uninsured. The Henry J. Kaiser Family Foundaton. 3 July 2008 .

Funding for Registered Nurse Education in the Face of a Nursing Shortage: Balancing Volume, Quality, and Distributional Considerations Dan Belsky, University of North Carolina at Chapel Hill

Due to dire forecasts for the supply of registered nurses (RNs) as the baby boom generation moves into retirement, nursing education programs currently enjoy the attention of policy makers and workforce planners. Providing additional resources to nursing education programs to Volume increase output is necessary to adInvestment should efficiently produce RNs. dress the looming nursing shortage. However, while there are currently Quality several paths to RN licensure, the Newly educated RNs must be prepared for the allocation of resources across technical complexity of modern medicine. program types remains a contentious issue. In distributing scarce Equitable Distribution resources to support RN education, Tthe enlarged RN supply should better allocate policy makers should consider the these professionals to practice in underserved following three elements at right. areas.

History Of the three principal educational paths to RN licensure in the United States, hospital based diploma programs are the oldest. These programs accounted for the initial education of 63% of RNs in 1980, but have declined since then, and accounted for only 4% of RNs newly licensed in 2007. Associate degree nursing (ADN) programs, primarily in community colleges and in private technical institutes, now provide the largest share of RN education.4 Associate degree nursing programs are oversubscribed, with 75 percent of the nearly 150,000 qualified applicants turned away from Key Facts RN education programs due to insuf• Associate Degree Nursing programs acficient space in 2007. Over the past two counted for nearly 52 percent of practicdecades, bachelor of science nursing ing RNs in 2004, and accounted for 54 (BSN) programs have also increased percent of those newly licensed in 2007. their share, accounting for 36% of newly (Wendt, 2008) licensed nurses in 2007. Graduate pro• These programs are massively oversubgrams offering licensure and foreign RN scribed, with 75 percent of qualified education programs accounted for the applicants being turned away due to insufficient program capacity in 2007. remaining 6% of RNs licensed in 2007. (National League for Nursing, 2005)

Analysis Both policy workshops and advocacy groups have advocated for a distribution of resources that increases the share of bachelor’s degree registered nurses (BSNs) in the workforce. These arguments center on the greater likelihood of BSNs will serve as nursing faculty and purported benefits to quality of care. One of the major barriers to expanding RN education is a shortage of qualified faculty. Nurses with their bachelor’s are more likely to go on to earn a graduate degree than either associate degree or diploma educated RNs,3 making them more

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likely candidates for faculty positions in the future. In addition, a recent study showing an association between higher proportions of BSNs on staff (as compared to associate degree or diploma educated RNs) and reduced mortality among surgical patients6 suggests that RNs with four years’ training provide higher quality care in acute care hospital settings. While BSNs may provide the most advanced RN services, at least in one state they do not meet certain distributional goals. Although some evidence points to superior care from BSNs in hospitals,6,7 much of the need for RNs comes from long term care facilities, home care or hospice, mental health facilities, prisons, and county health departments. These settings, while they require competent professionals, often do not involve the highly technical medicine practiced in acute care hospital settings. Evidence from North Carolina’s Health Professions Data System shows BSNs are less likely to practice in these settings; overall, BSNs are substantially less likely to practice in rural areas and in federally designated health professions shortage areas. Transitioning to a majority-BSN educated RN workforce could both decrease workforce diversity, with implications for cultural competence, particularly in community health care settings. In North Carolina, over half of BSNs practiced in one of the state’s five most populous counties in 2006, as compared to under one third of associate degree educated RNs. Associate degree nursing programs offer the opportunity of middle class employment to low income and educationally disadvantaged students. These students are statistically more willing to practice in rural, poor, and underserved areas and in settings that may be less appealing to BSNs. Moreover, by training health professionals locally, ADN programs enhance the cultural competence of the health care workforce.

Next Steps Currently, state policy initiatives focus heavily on BSN programs. Balancing the priorities of volume, quality, and distribution requires more investment in associate degree education for RNs. Growing the supply of BSN education is important to developing a nursing workforce prepared to deliver 21st century medicine and train future nurses; however, BSNs alone will not meet the needs of rural and underserved areas or elder care. In much of the U.S. health care system, the push to achieve the highest quality medicine possible has taken priority over assuring that all people can receive a basic standard of care. Nursing education should ameliorate, not exacerbate, this situation. Sources

Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH (2003). Educational levels of hospital nurses and surgical patient mortality. JAMA, 290:1617-1623. Buerhaus PI, Potter V, Staiger DO, French J, Auerbach DI (2008). “The Future of the Nursing Workforce in the United States: Data, Trends, and Implications.” Sudbury, MA: Jones & Bartlett. Buerhaus PI, Staiger DO, Auerbach DI (2000). Implications of an aging registered nurse workforce. JAMA, 283:2948-2954. Health Resources and Services Administration (2005). “The Registered Nurse Population: Findings from the March 2004 National Sample Survey of Registered Nurses.” Washington DC: U.S. Depar ment of Health and Human Services. Johnson JH (1988). Differences in the performances of baccalaureate, associate degree, and diploma nurses: a meta-analysis. Research in Nursing & Health, 11:183-197. National League for Nursing (2005). Press Release: “Despite encouraging trends suggested by the NLN’s comprehensive survey of all nursing programs, large number of qualified applications continue to be turned down.” http://www.nln.org/newsreleases/index.htm, accessed May 7, 2008. Wendt A, Eich M (2008). “2006-2007 RN continuous practice analysis.” National Council of State Boards of Nursing Research Brief, 34:13-20.

Action

Funding for Registered Nurse Education in the Face of a Nursing Shortage: Balancing Volume, Quality, and Distributional Considerations Dan Belsky, University of North Carolina at Chapel Hill

Due to dire forecasts for the supply of registered nurses (RNs) as the baby boom generation moves into retirement, nursing education programs currently enjoy the attention of policy makers and workforce planners. Providing additional resources to nursing education programs to increase output is necessary to address the looming nursing shortage. However, while there are currently several paths to RN certification, the allocation of resources across program types remains a contentious issue. In distributing scarce resources to support RN education, policy makers should consider the ollowing three elements at right. History Of the three principal educational paths to RN certification in the United States, hospital based diploma programs are the oldest. These programs accounted for the initial education of 63% of RNs in 1980, but have declined since then, and accounted for only 4% of RNs newly licensed in 2007. Associate degree nursing (ADN) programs, primarily in community colleges and in private technical institutes, now provide the largest share of RN education.4 Associate degree nursing programs are oversubscribed, with 75 percent of the nearly 150,000 qualified applicants turned away from RN education programs due to insufficient space in 2007. Graduate programs offering certification and foreign RN education programs accounted for the remaining 6% of RNs licensed in 2007. Analysis Both policy workshops and advocacy groups have advocated for a distribution of resources that increases the share of bachelor’s degree registered nurses (BSNs) in the workforce. These arguments center on the greater likelihood of BSNs will serve as nursing faculty and purported benefits to quality of care. One of the major barriers to expanding RN education is a shortage of qualified faculty. Nurses with their bachelor’s are more likely to go on to earn a graduate degree than either associate degree or diploma educated RNs,3 making them more likely candidates for faculty positions in the future. In addition, a recent study showing an association between higher proportions of BSNs on staff (as compared to associate degree or diploma educated RNs) and reduced mortality among surgical patients6 suggests that RNs with four years’ training provide higher quality care in acute care hospital settings. While BSNs may provide the most advanced RN services, at least in one state they do not meet certain distributional goals. Although some evidence points to superior care from BSNs in hospitals,6,7 much of the need for RNs comes from long term care facilities, home care or hospice, mental health facilities, prisons, and county health departments. These settings, while they require competent professionals, often do not involve the highly technical medicine practiced in acute care hospital settings. Evidence from North Carolina’s Health Professions Data System shows BSNs are less likely to practice in these settings; overall, BSNs are substantially less likely to practice in rural

Talking About Health Care Reform on College Campuses Alexander Hertel-Fernandez, Northwestern University

As the failures of previous health care reform efforts demonstrate, how policy proposals are communicated can be just as important as the content of the policies themselves. Extensive polling suggests that the American public is overwhelming in favor of progressive health care reform, now more than ever in the face of growing costs, stark inequities, and a growing population without insurance. Thus the challenge for reformers and advocates—Roosevelt Rx included—is to find specific narratives and language that resonate with Americans. The Herndon Alliance, a national non-partisan, non-profit coalition of 100 minority, faith, advocacy, business, and health care groups, has been essential in conducting extensive survesys, polling, and focus group research into the best ways to talk about health care reform. Roosevelt Rx has partnered with Herndon to help our members effectively communicate their policy ideas to fellow students, policymakers, and the general public. This section is designed to serve two purposes: 1. Provide an actionable guide to convey health reform effectively to the general public based on the Herndon Alliance’s original research; and 2. Provide a toolkit for Roosevelt members to lead focus groups and dialogues on their own campus chapters to find the best ways of engaging the young adult population.

Effective General Narratives The following progressive narratives, reproduced from Herndon Alliance research, consistently out-performed conservative narratives amongst all demographic groups. Using these can make policy proposals, op-eds, presentations, and dialogues more effective.

Working Families Can’t Afford the Care They Need

I believe that people who work for a living ought to be able to take their kids to a doctor, and people who are retired, ill, or temporarily out of work shouldn’t risk losing their life savings because of one illness. We’re not just talking about poor people. We’re talking about middle class Americans who are getting squeezed. Too many people have to think twice before switching jobs or starting a business because they’re worried about insurance. We need comprehensive reform, not a band-aid. That means requiring insurance companies to put more money into patient care and preventing those companies from excluding patients because of “pre-existing conditions,” overriding doctors’ judgment. It means giving us choices among plans so we can decide what’s best for our own families, including the choice to keep our current doctor. It means limiting out-of-pocket spending so no one loses their life’s savings because of a hospital bill. And it means giving small businesses tax breaks to offset the costs of covering their employees, and requiring big businesses to offer coverage to their employees.

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A Family Doctor for Every Family

I believe in a family doctor for every family. It’s not right that hard-working Americans are struggling to afford health care and prescription drugs, while we’re strangling small businesses with the cost of their employees’ health care. The market hasn’t solved this problem, and it’s not going to as long as big insurance and drug companies are profiting at our expense. But we don’t need to replace managed care bureaucracy with government bureaucracy. We need common sense reform that gives people more choices, not less, including the choice to stay with the doctor they have now. We need to make insurance companies compete with each other to keep costs down and quality up, and give people the option to buy into the same plan members of Congress get, because if it’s good enough for Congress, it’s good enough for the people they represent. And we need government to set high standards to keep deductibles low, stop insurance companies from cherry-picking patients by excluding people with “pre-existing conditions,” and guarantee preventive care like cancer screening that cuts long-term costs and saves lives.

Neutralizing Common Attacks The following attacks are the most common refrains from coalitions opposed to reform. Of the three, immigration and bureaucracy are the most devastating. These are best dealt with by bringing the failure of the current system back to the forefront. Attack:

Health care reform will increase taxes and raise costs

“We need to make health care more affordable, but trying to add nearly 50 million uninsured people to the system all at once with a big new government program is a recipe for disaster. It will cost billions in taxes, and hospitals and doctors will be even more overloaded than they are now. It punishes families and businesses who are already working hard to pay for health care by adding billions in new taxes and raising their costs.”

Response:

Health care reform helps hard working middle class families afford health care and get peace of mind.

“Middle class Americans are having a harder time making ends meet, and we need to cut health care costs. If that means cutting the profits of insurance companies and requiring big businesses to contribute to the health insurance of their employees, my sympathy is with people who work for a living. Health care premiums have nearly doubled for the average family at the same time that insurance company profits have more than doubled. If we don’t do something now, our costs will double again. And that’s not even counting the billions we already pay in federal and state taxes for expensive emergency room visits for people with no insurance who end up driving up costs because they don’t get preventive care. It’s time to put some money back in the pockets of working Americans and give us all peace of mind about the health of our families.”

71 Attack:

Health care reform will create big and inefficient government bureaucracy.

“This isn’t health care “reform,” it’s socialized medicine—another big government bureaucracy like the IRS or the DMV, operating inefficiently and costing taxpayers hundreds of billions of dollars. It’s just one more step toward government intrusion in yet another place where it doesn’t belong. We’ll all end up paying higher taxes and getting substandard health care, with long waits to see our doctor, and lots of red tape and paperwork. Keeping health insurance in the private sector is the only way to guarantee that we have the best health care in the world.”

Response:

It’s the bureaucrats from the insurance companies who are currently standing between Americans and their doctors.

“If you want to see what bureaucracy and red tape look like, try reaching a person on the phone the next time you call your own insurance company, and try getting them to explain why they won’t pay $800 of some medical treatment your doctor ordered. We need leaders willing to take on the insurance companies, by setting clear, high standards for what’s covered, preventing them from requiring patients to jump through hoops just to get insured, and saving billions by cutting administrative costs and moving to electronic medical records. We need leaders who will hold insurance companies accountable, guaranteeing us all more choices, better care, and no more of those 45-minute phone-calls. And if we stopped wasting doctors’ time with paperwork so they had more time for patients, and stopped forcing people who used to have insurance into emergency rooms for basic care, we wouldn’t have to worry about overloading our system.”

Attack:

Health care reform proposals aiming for universal coverage reward law-breaking by giving health care coverage to illegal immigrants at taxpayers’ expense.

Responses:

This is the most devastating attack, since it evocates powerful images and emotions with many Americans. The best rebuttals address this issue head on and redirect the conversation back to affordability. Understanding the emotion behind this question is important; counter by demonstrating that this argument avoids the real issue, which is about providing affordable health care for all Americans, not settling the immigration debate. Since most believe that immigrants do not pay for their health care, stressing that immigrants will pay their fair share of costs is helpful.

“I have no intention of letting politicians who want to score political points hold our health care hostage to the immigration problem. We need common sense solutions to immigration. But with all the partisan bickering, immigration reform isn’t going to happen overnight, and working families need leadership on health care reform, and they need it now.” OR “America’s immigration system is broken, and we need leadership (stronger than ‘government’) to fix it. That isn’t likely to happen overnight, and until those changes are made, we can’t let the immigration issue divert us from making sure that you, your neighbors, and everyone else gets quality, affordable health care. Everyone in America will and should pay an amount they can afford for health care. All of us - including immigrants – will be required to pay our fair share.”

72 Connecting the Economy to Health Care Reform Linking the issue of health care to the economy is essential to building momentum for reform. Many Americans are losing sight of the need for reform in light of broader economic trends, and this shift is reflected in politicians’ agendas, despite the fact that rising health costs and insecurity are responsible for much of the economic crunch. In order to sustain voter interest and political capital in health care reform, we have to successfully place the need for reform within the broader economic downturn. Issue Linkage: Connect affordability of care and prescription drugs, the family budget crunch, and rising unemployment. Use household and family language (eg: your family, your job, your insurance), not the national level picture, to connect with voters. Talk about the beneficiaries of reform: hard working middle class families who are getting squeezed by the rising costs of gas, health care, prescription drugs, and groceries. Remind voters that the current system is not working for people like them. Present specific aspects of the current insurance system that are failing the middle class (e.g., preexisting conditions, high deductibles, people afraid of making a job change because they will lose their insurance coverage). People strongly identify with statements about what rising costs are doing to their families, and they strongly support the message that people who work ought to be able to afford to take their kids to a doctor. Generating and Channeling Frustration: Insurance and drug companies are recording huge profits while ordinary Americans are being squeezed by higher costs. These facts increase anger and motivate change. Supporting Small Businesses: Small business owners are very unhappy about the current health care system and are an important swing constituency. They are viewed very positively by the American public. Talk about the fact that most small business owners want to do right by their employees by offering them good health insurance programs, but the cost is prohibitive. We’re strangling small businesses and American ingenuity as people stay in safe but unfulfilling jobs that have health care, rather than helping people do what Americans are great at: starting a business with a little capital, a lot of elbow grease, and a good idea.

Combating Privatization Conservatives have aggressively promoted private Health Savings Accounts (HSAs) as a solution to rising costs and lack of coverage while letting Americans take charge of their own insurance and bringing more competition into the system. Health Savings Accounts are portrayed as a distinctly American solution in direct contrast to so-called socialized medicine. The Disconnect: While the description used above appeals to many, the reality does not. People do not like or want high deductible health plans. Most employers do not subsidize HSA deductibles and most people cannot afford the high deductible. Moderate-income people with a limited budget face hard and uncomfortable choices when a child gets sick or a medicine is needed. In addition, many small businesses are

turning to HSAs because they have no other affordable choice. What is often inexpensive initially can become a big problem for employees and employers when employees have children, and as employees age. A Successful Approach: The anger over unaffordable high deductibles and bad choices for their family and kids motivates people to change. Young and healthy people need to think of their older and sicker friends and family, who through no fault of their own have developed cancer or other medical problems. Remind voters that HSAs mean high deductible insurance and unaffordable care. Talk about the anguish a family faces when it has to make impossible choices because they cannot afford the deductible, especially during an economic downturn or a rough time for the family’s finances. Example: I don’t know about you, but I can’t afford high deductibles. My mother/ brother/cousin who has cancer can’t afford her/his gas, food and medicines now and certainly won’t be able to afford a high deductible. She (he) has worked all her life, paid her taxes and it’s not fair that she doesn’t have affordable health care when she needs it most. It’s time we had the choices we deserve for prices we can afford. We need leadership to make sure the health care system works for us. Language to use (and avoid): Positive Perceptions: Quality affordable health care; Health care for all; American health care; Sliding scale; Prevention; Smart investments; Investments in the future; Choice; Rules; Guaranteed; Giving people control and peace of mind; Comprehensive package; Affordable health plans; A choice between private and public plans; Government as enforcer, watchdog, rule-setter Negative Perceptions: Universal health care; universalized medicine; Socialized medicine; system like Medicare, Medicaid, Social Security; Canadian (European)-style health care; Free; Flat rate; Wellness; Inexpensive, cheaper; Competition; Regulations Required; Government health care for all; Basic health care; Medicare for all; Government health care; public health plan; federal health plan

Finding Out What Works with Young Adults Mobilization of the 18-25 year old demographic will be essential for successfully reforming the American health care system. Despite the importance of this group, little research has focused explicitly on their perspectives and opinions regarding health care. The Roosevelt Institution is in a unique position to conduct such research given its presence on over 75 campuses nationwide. On the following page you will find a list of questions (both closed and open-ended) for conducting focus groups or dialogues on college campuses to gauge students’ perspectives, opinions, and ideas regarding health care reform. More comprehensive surveys and focus group discussion questions can be obtained from Roosevelt Rx upon request.

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How does health care fit within a vision of the American dream? Would you be willing to support a guarantee affordable, quality health care for all Americans, even if it means raising taxes or creating a major role for the federal government? What sorts of specific health issues are you most concerned about? How do they think these issues will be addressed by health care reform? Which plan would you typically support? “An approach that would guarantee affordable health insurance coverage for every American with a choice of private or public plans that cover all necessary medical services, paid for by employers and individuals on a sliding scale.” (Guaranteed Affordable Choice) “A Health Savings Account program that would provide tax-deductible savings accounts to all Americans if they purchase a private insurance plan with at least a thousand dollar deductible.” (Health Savings Account) “An approach that would provide tax credits that will reimburse individuals and families for 25 to 50 percent of the cost of their private health insurance policies.” (Tax Credits) “A single government-financed health insurance plan for all Americans financed by tax dollars that would pay private health care providers for a comprehensive set of medical services.” (Single Payer) What features of a plan would you support? • No one could deny people with pre-existing conditions • Employers and individuals could keep current plan • All plans required to provide standard package with preventative care • Guaranteed affordable private or public plan on sliding scale for payment • Employers would be required to offer all employees public and private plan • Costs would be controlled by competition and negotiation Would you be willing to finance a Guaranteed Affordable Coverage (GAC) plan with payroll taxes? What sort of a sliding scale would they support? How important are exemptions or lower rates for small businesses? What are your biggest concerns about health care reform? Cost Quality Bureaucracy Effect on small businesses Illegal immigrant use of the system Coverage Specific issues (mental health, reproductive health, other)

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Appendix: Key Facts and F igures on Healthcare Young adults are the age group most likely to be uninsured

Source: Kaiser Commission on Medicaid and the Uninsured/ Urban Institute analysis of March 2007 CPS. Available at www.kff.org/uninsured/7778-01.cfm

America spends more than any other country on health care, but compared to other countries, the burden of out-of-pocket spending falls disproportionately on the sickest adults.

Source: OECD Health Data, 2006. Available at www.oecd.org/health/healthdata

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Source: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults.

Major shortages in the health care workforce are expected in coming years because of the retirement of the baby boom generation and the low number of students entering primary care and public health professions.

Source: Association of Schools of Public Health. Available at www.asph.org/shortage. Used with permission.

77 Young adults today, the millennial generation, are more likely to support bold government action on health reform than prior generations.

Source: Center for American Progress analysis of the National Election Survey and the General Social Survey. Adapted from David Madland and Amanda Logan. “The Progressive Generation: How Young Adults Think About the Economy” Center for American Progress, May 2008. Available at http://www. americanprogress.org/issues/2008/05/pdf/progressive_generation.pdf

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Roosevelt Rx Roosevelt Rx is the health policy center of the Roosevelt Institution, the nation’s first student think tank. Roosevelt Rx aims to be a catalyst for student ideas and student organizing around the issue of health care reform. Roosevelt Rx is: • A network of hundreds of undergraduate and graduate students across the country who are interested and engaged in health care issues. • A publication of top student policy ideas and analysis about how health reform uniquely impacts young adults. • A series of student-led workshops and trainings to educate and inspire student to take action around health reform. Past events • On March 14, 2008, Roosevelt Rx organized a National Student Health Policy Forum at the Kaiser Family Foundation’s Barbara Jordan Conference Center in Washington, DC. Over 100 students attended to help kick off the new network. • On May 24, 2008, the Northwestern University chapter of the Roosevelt Institution held a health policy writing workshop in Chicago. • On September 19, 2008, Roosevelt Rx held a student health policy briefing in the Hart Senate Office Building in Washington, DC and released this new journal. Upcoming Events • During the fall 2008, Roosevelt Rx will be disseminating health policy toolkits to students across the country to encourage them to organize debates on their campuses about health reform and the 2008 election. • Throughout the 2008-2009 academic year, Roosevelt Rx fellows will be working with researchers from Academy Health to conduct a multi-centered research study on the global and local implications of the health care workforce shortage. • Much more! As a student-led organization, Roosevelt Rx is always expanding and exploring new ways to achieve its mission of adding a student voice to the health reform debate. Get involved To find out how to get involved with Roosevelt Rx, visit www.rooseveltinstitution.org/rx. Visit http://rooseveltinstitution.org/_joinroosevelt to join the Roosevelt Institution network or to start a chapter at your school. Please e-mail [email protected] with any questions you may have.