ideas health care

10 for

July 2010 | Featured Idea

Family Pratice in America
 10 Ideas for Health Care
July 2010

National Director
Hilary Doe

National Network Coordinator

Tarsi Dunlop

Lead Strategist for Health Care

Sara John

Managing Editor
Gracye Cheng

Editor
Carolina Delgado

The Roosevelt Institute Campus Network

455 Massachusetts Ave NW
Suite 650
Washington, DC 20001
Copyright © 2010 by the Roosevelt Institute. All rights reserved.

The views and opinions expressed herein are those of the authors. They do not ex-
press the views or opinions of the Roosevelt Institute, its officers, or its directors.
 ideas
10 for

Health Care
 Congratulations to
Ankit Agarwal,
author of
Increasing Family Practice in America

Nominee for
Policy of the Year
 Inside the Issue

P
Preventing Type 2 Diabetes: 8
Afterschool Exercise in High-Risk Areas
Kurt Anthony

Establishing Farmers Markets in Low-Access Neighborhoods 10

Greg Mittl et al

Check-Up on Aisle Nine 12

Matt Clark

Healthy San Francisco: A Model Local Public Option 14

Jake Grumbach

Modifying the Mental Health Parity & Addition Equity Act 16

Marissa Gluck and Ashley Morton

Enterprise Liability and Medical Malpractice Reform 18

Angela Gandhi

Organ Donation Policy Reform 20

Agnes Eshak

Increasing Family Practice in America 22

Ankit Agarwal

Proper Management of On-Site Medical Waste 24

Adam Jutha

Solving the Vaccine Shortage through Strategic Incentives 26

Melody W. Lin

Roosevelt Review Preview: 29

The Next Attack Might Be Our Last
Isaac Lara
p Letter from Washington
We are pleased and proud to present the second edition of the 10 Ideas Series.
Comprised of six journals, these articles represent the best of our student policy work
across the country. Throughout the past year, our national policy strategists have sup-
ported hundreds of students chapters stretching from New England and Michigan to
California and Georgia. As a peer-to-peer network, our student strategy team is unlike
any other - they are both friends and mentors, strategists and promoters. Instead of
waiting for their ideas to be approved in Washington, our Washington team looks to the
field for our most innovative policies - and it is the student network that votes on the
best proposals of the year.

Within this volume, you will find a variety of ideas in motion. Some are new proposals
being spread for the first time; others have already gained traction in their local com-
munity, as our campus chapters work to enact their policies today. Some will rise to
higher prominence in the months ahead, gathering momentum as the idea is adopted
throughout our national network of 8000 members. A few will be adopted by state
legislatures and city councils; some make it all the way to Capitol Hill.

A year ago, one Colorado student published an idea about improving remote access to
health care via unused television waves; the state of California is now working with him
to make that idea a reality. A pair of students in Chicago postulated that their school
could start a revolving loan fund for energy efficient building and development; they
now help administer such a fund at Northwestern.

Whether intensely localized or built for the nation at large, these ideas all have the po-
tential to become realities. We look forward to what comes next for these authors - and
if you can be a part of that change, we hope you’ll join us.

Sincerely,

Tarsi Dunlop
National Network Coordinator
 Strategist’s Note P
What a historic year for health care in the United States. After decades of attempts,
what was once a long shot - even just months ago - is now a reality. The recently passed
health care bill holds promises of increased numbers of insured, fairer practices, and
greater efficiency, a monumental step for our nation’s health care system and the health
of all Americans.

But that’s just one step. With the passage of a national health care bill, attention now
needs to be shifted to the state and local level. Much-needed national reform now
paves the way to address health policy issues that cannot be identified and assessed
by an overarching “one size fits all” policy. There is an incredible variance of problems
and inequities across state, county, and city borders, all of which deserve recognition
and effective policy resolutions.

The students published here provide a wide range of policy solutions to the perva-
sive health inequalities which continue to persist in our nation and in our communities.
These students realize the impact of national health care reform and are already taking
innovative next steps to address outstanding health disparities national reform does
not have the capacity to resolve.

Health for all,

Sara John
Lead Strategist, Health Care
Preventing Type 2 Diabetes:
Afterschool Exercise in High-Risk Areas
Kurt Anthony, University of Chicago

Set up afterschool exercise programs with the goal of reducing the prevalence of
type 2 diabetes.

While most public insurance programs cover diabetes treatment, no public diabetes
prevention program has been successfully developed. An effective diabetes prevention
program that targets at-risk youth should be a national priority because the U.S. health
infrastructure cannot support the cost of the growing type 2 diabetes epidemic.

Diabetes is rising at an alarming

rate. Currently 23.6 million Ameri- Key Facts
cans, 7.8% of the population, has • The U.S. spends $113 billion on diabetes per
diabetes.4 Of these cases, 5.7 mil- year and is predicted to spend three times as
lion are estimated to be undiag- much on the disease in the next thirty years.1
nosed,5 increasing the burden of • Only 36% of American high school students
the disease as unmanaged diabe- meet recommended physical activity levels.2
• In a study of prediabetics, people who have no
tes quickly progresses to costly
symptoms of diabetes but who are likely to de-
late-stage complications. Another velop the disease in the future, exercise inter-
disturbing trend is the sudden rise vention reduced disease incidence by 58%.3
in diabetes among youth. For ex-
ample, incidence of developing di-
abetes among youth increased 10-fold in the 1990s in Cincinnati.6 This trend continues,
as 11.0% of adolescents aged 12-19 are now estimated to have impaired fasting glucose,
a prediabetic condition.7 If preventative action is not taken, the expected rise in the
prevalence of diabetes in the upcoming years will drain health care resources. Huang et
al. predict that in the next 25 years, spending on diabetes treatment will increase from
$113 billion in 2009 to $336 billion in 2034, adjusting for inflation.8 With total U.S. health
care spending presently at $2.26 trillion, this increase cannot be sustained.9

Analysis
After-school exercise programs in high-risk communities provide one of the most cost-
effective solutions to reducing expensive, chronic disease. Lack of physical activity is
known to be a strong predictor for diabetes, and prediabetics and diabetics who start
exercising have better health outcomes.10 In a study of a Wisconsin school-based ex-
ercise program, participants had lower body fat, increased cardiovascular endurance,
and improved fasting glucose compared to the control groups after nine months.11 The
majority of prediabetics who participated in NEEMA, a diabetes prevention program
for high-risk African American children, were not considered prediabetic by the end of
the program.12 Such afterschool exercise programs cost around $2000 per student; dia-
betics spend over $10,000 per year on health care expenses, above and beyond what
insurers and Medicare spend.13, 14

Eligibility for the exercise programs would be based on risk factors. In the Wisconsin
study, participants had a body mass index greater than the 95th percentile for their age

8
group. Other prospective risk factors for eligibility include family history of diabetes,
fasting glucose levels, and obesity.

Additionally, preventing dia-

betes complications will im- Talking Points
prove the quality of life of the • The higher incidence of early-onset diabetes and
participants. Children and ad- undiagnosed diabetes will exacerbate the growing
diabetes epidemic.
olescents are the targeted age
• PE classes are being cut in schools, which makes ex-
group because they have more
ercise programs an even higher priority.
time to participate in the pro- • The programs will save billions of dollars in the long
gram and they are more likely term from the increased productivity of healthier
to adopt the exercise habits citizens and less spending on diabetes treatment.
they are taught- impacting
these children not just during
the program, but for a lifetime. Schools provide the ideal location for an exercise pro-
gram targeting this age group. Limiting the programs to high-risk communities allocates
resources where they will be most cost-effective. A pilot program should be created in
different rural and urban school settings, with students of different ages, to determine
the best practices for such a preventative program.

Endnotes
1. Elbert S. Huang et. al., “Projecting the Future Diabetes Population Size and Related Costs for the U.S.,”
Diabetes Care 32, no. 12 (2009), http://care.diabetesjournals.org/content/27/4/998.full (accessed April
25, 2010).
2. Active Living Research, “Active Education: Physical Education, Physical Activity, and Academic Perfor-
mance,” Robert Wood Johnson Foundation, http://www.activelivingresearch.org/files/Active_Ed.pdf
(accessed April 25, 2010).
3. Center for Disease Control and Prevention, “FAQs, prediabetes,” http://www.cdc.gov/diabetes/faq/
prediabetes.htm (accessed April 25, 2010).
4. Center for Disease Control and Prevention, “National Diabetes Fact Sheet, 2007,” http://www.cdc.gov/
diabetes/pubs/pdf/ndfs_2007.pdf (accessed April 25, 2010).
5. Ibid.
6. Zachary T. Bloomgarden, “Type 2 Diabetes in the Young,” Diabetes Care 27, no.4 (2004), http://care.
diabetesjournals.org/content/27/4/998.full (accessed April 25, 2010).
7. Glen E. Duncan, “Prevalence of Diabetes and Impaired Fasting Glucose among US Adolescents,”
Archives of Adolescent and Pediatric Medicine 160 (2006), http://archpedi.ama-assn.org/cgi/re-
print/160/5/523.pdf (accessed April 25, 2010).
8. Huang et. al.
9. Centers for Medicare and Medicaid Services, “National Health Expenditure Fact Sheet,” http://www2.
cms.gov/NationalHealthExpendData/25_NHE_Fact_Sheet.asp (accessed April 25, 2010).
10. William Knowler et. al., “Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or
Metformin,” New England Journal of Medicine 346, no. 6 (2002), http://content.nejm.org/cgi/content/
short/346/6/393 (accessed April 25, 2010).
11. Aaron L. Carrel et al., “Improvement of Fitness, Body Composition, and Insulin Sensitivity in Overweight
Children in a School-Based Exercise Program,” Archives of Pediatrics and Adolescent Medicine 159
(2005), http://archpedi.ama-assn.org/cgi/reprint/159/10/963.pdf?ck=nck (accessed April 25, 2010).
12. Mary Shaw-Perry et. al., “NEEMA: A school-based Diabetes Risk Prevention Program Designed for
African American Children,” Journal of the National Medical Association 99, no. 4 (2007) http://www.
sahrc.org/JournalArticles/NEEMA_JNMA-042007.pdf (accessed April 25, 2010).
13. Robert Halpern et. al., “Financing afterschool programs,” The Finance Project (2000), http://www.fi-
nanceproject.org/Publications/financing_afterschool_programs.htm (accessed April 25, 2010).
14. National Diabetes Information Clearinghouse, “Financial Help for Diabetes Care,” http://diabetes.
niddk.nih.gov/dm/pubs/financialhelp/ (accessed April 25, 2010).

9
Establishing Farmers Markets
In Low-Access Neighborhoods
Greg Mittl, Lauren Hunter, Katie Levandoski, Martin Weaver, Abhinav Gupta,
and Karissa Britten - Yale University
The establishment of farmers’ markets in low-access communities can help establish
food security, a healthy community gathering place, and become a springboard for
healthier, more active living.

Establishing farmers’ markets in low-access neighborhoods would help revitalize many

inner-city areas. Farmers’ markets are integral components of many communities, pro-
viding access to fresh produce and promoting the development of sustainable agricul-
ture. This is crucial because the World Health Organization places low fruit and vegeta-
ble intake among the top ten risk factors related to mortality. Efforts to establish such
farmers’ markets are underway in New Haven, Connecticut. Since 2004, CitySeed, an
organization dedicated to “engaging and connecting communities through food,” has
been working to develop farmers’ markets across the city, including in low-income ar-
eas. These markets provide access to produce grown exclusively in Connecticut and
sold by farmers themselves. In the effort to increase the consumption of fruits and
vegetables among low-income residents, the CitySeed farmers’ markets became the
first in the state to accept Electronic Benefit Transfer (EBT)/Food Stamps.

Analysis
Key Facts
The implementation of farmers’ • There are currently 5,274 farmers’ markets reg-
markets can revitalize an entire istered with the USDA in the United States, as
community, providing individual compared to 1,755 markets in 1994, and fewer
and collective benefits. Residents than 100 markets in 1974.
of communities that incorporate • 82% of farmers’ markets are self-sustaining—
farmers’ markets witness both market income is sufficient to pay for all costs
short- and long-term advantages associated with the operation of the market.
to their health, such as the de- • The average supermarket carrot travels 2,000
miles from field to table, whereas most farmers’
velopment of healthier commu-
market produce travels less than 50 miles.
nity eating habits and reduction
in chronic disease. Furthermore,
economic analyses of farmers’ markets demonstrate that prices of market products
typically lie in between wholesale and supermarket prices, indicating that participating
local farmers and residents will profit from these markets.

Farmers’ markets also provide a unique interface for community interaction and de-
velopment. In order to provide a safe and pleasant market area, establishing a farmers’
market requires investment from residents and local organizations. Participation of lo-
cal youth can generate a sense of responsibility and dedication to the market while also
ensuring its sustainability. Such participation has occurred in the Brooklyn neighbor-
hood of Redhook , where local youth have helped to prepare and maintain the market
space. This space of community collectivity can be utilized as a type of meeting grounds
where community education and communication, such as weekly workshops on health-
related topics, can take place.

10
The principle obstacles to implementing farmers’ markets include price negotiation,
accessibility, and incentive. Prices must be negotiated between farmers and the com-
munity in order to ensure that each party benefits. The market must be located in an
area that is most accessible to its target residents, preferably near mass transit, parking
lots, and/or green spaces. Advertising and incentivizing food stamp use, whereby food
stamps are more valuable when exchanged for healthy foods, can encourage residents
to shop at the markets.

Stakeholders
All community members benefit
from the addition of farmer’s Talking Points
• Small farms and low-income communities benefit
markets to low-access areas, economically from the added business of farm-
including many who may not ers’ markets.
qualify as ‘low income’ but who • Making food stamps more valuable when ex-
nonetheless lack consistent ac- changed for healthy food provides a direct, fo-
cess to affordable, healthy food. cused incentive for the purchaser.
The access to fresh produce • Farmers’ markets encourage community invest-
helps promote healthier diets ment and the beautification of public spaces; they
and lifestyles. Furthermore, also provide a consistent, safe space for a variety
of public health and wellness outreach efforts.
invested community members
• Accessible and affordable fresh produce encour-
feel a responsibility to sustain ages healthier dietary habits and can reduce
the markets and ensure the chronic disease in a community.
safety of the surrounding area. • Establishing new markets requires the coordi-
This community investment pro- nated efforts of community leaders, local govern-
vides the opportunity for eco- ment, and area farmers.
nomic stimulus and community
revitalization. Farmers will also
benefit from the economic security and recognition that comes from a larger customer
base. Also, community developers can have a stake in the project, while public health
advocates can use farmers’ markets as a venue to raise awareness about healthy diet
and exercise.

Endnotes
1. U.S. Department of Agriculture, “Farmers Market Program,” http://www.ams.usda.gov (accessed April
19, 2010).
2. Agricultural Marketing Service, “Facts about Farmers Markets,” http://www.ams.usda.gov/FactsAbout-
FarmersMarkets (accessed April 19, 2010).
3. Global Gourmet, “Facts about Farmers’ Markets,” http://www.globalgourmet.com (accessed April 19,
2010).
4. CitySeed, “Market Vendor Information,” http://www.cityseed.org/city_markets/vendor/index.shtml (ac-
cessed April 19, 2010).
5. CitySeed, “About CitySeed,” http://www.cityseed.org/city_markets/about/history.shtml (accessed April
19, 2010).
6. Added Value, “History,” http://www.added-value.org/overview-of-added-value (accessed April 19,
2010).

11
Check-Up on Aisle Nine
Matt Clark, University of North Carolina at Chapel Hill
Improve quality and accessibility of care for the uninsured living in medically under-
served areas by encouraging partnerships between retail health clinics and commu-
nity health centers (CHCs). Combining the ease of access to retail clinics with the
scope of services found in CHCs could provide a relatively affordable home for the
primary care needs of uninsured individuals.

Community health centers began as a way to boost the safety net for health care ser-
vices, especially in rural areas. Generally using federal assistance, they offer traditional
primary care treatment options and cater to those on Medicaid, as well as uninsured
individuals. But heads of CHCs claim to meet only 35% of all health needs for unin-
sured patients using the centers’ resources. CHCs especially have trouble providing
specialty services as they sometimes lack appropriate personnel. Retail health clinics
can alleviate some of the stresses on CHCs by treating acute, non-emergency condi-
tions in the neighborhood grocery store or retailer.

Retail health clinics began

Key Facts operating in densely populat-
• Rural America is home to 20% of the population, 9%
ed urban and suburban areas
of physicians, and 37% of CHCs.
around the year 2000. Op-
• About 90% of retail clinic visits were for simple,
acute conditions and preventive care. erating out of grocery stores,
• About 18% of all visits to primary care settings and pharmacies, or retail chains
over 13 million trips to the emergency room per year like Target and Wal-Mart,
could be handled by retail clinics. retail clinics have become
• The average cost for a typical visit to a retail health popular as a source of vac-
clinic is $110 compared to $166 at a physician’s office cinations and care for minor
and $570 at an emergency department. health problems, such as sore
throats. They offer a limited
scope of services and are
staffed by nurse practitioners or physician assistants who have their work reviewed by
physicians. The use of nurse practitioners is a critical reason why retail clinics are able
to keep their operating costs lower than traditional offices while still maintaining quality
of care. Despite their lack of physicians, retail clinics have scored higher than primary
care offices in some studies on the basis of appropriate treatment for a given condi-
tion, mostly due to the willingness of retail clinics to practice evidence-based medicine.
Short waiting periods and extended hours of operation allow individuals to seek basic
medical attention at their convenience.

Analysis
By creating a link between retail health clinics and CHCs, states can provide relief for
under-resourced CHCs. Nurse practitioners are easier to attract and retain in rural
areas than physicians, and at a lower cost. Retail clinics would treat everyday problems
at a lower cost than emergency rooms, where many uninsured eventually seek medical
care. Such a partnership would allow CHCs to focus on more specialized or chronic
conditions of uninsured patients and reduce crowding overall.

12
Stakeholders
State governments consistently Talking Points
facing budget shortfalls can ex- • CHCs have trouble finding and retaining prima-
ry care physicians. Additionally, they are unable
periment with the use of retail
to handle all of their uninsured patients’ needs.
health clinics to relieve stress on • Retail clinics are streamlining communication
emergency departments. Chain between providers by using, almost universally,
stores looking to boost their pub- electronic medical records.
lic image could offer their com- • Increased competition - via more retail clinics
munity low-priced, quality care. - could spur cost-cutting measures by primary
Federal funding would likely be care offices.
necessary for expansion of retail • Providing primary care in a retail clinic is a first
clinics into rural areas. step towards creating a sense of a “medical
home” for uninsured individuals.
Next Steps
Rural areas lacking pharmacy or
grocery store chains would have to consider the costs and benefits of adding a mega-
retailer to their towns. Tax breaks could be given for retailers who partner with CHCs
to offset the added payroll liabilities of clinic personnel. Extensive planning would need
to take place, heeding concerns of retailers and CHCs, to establish policies outlining
what procedures are to be completed where.

Endnotes
1. Michael Gusmano et al., “Exploring The Limits Of The Safety Net: Community Health Centers And
Care For The Uninsured,” Health Affairs, 2002: Vol. 21 No. 6, http://content.healthaffairs.org/cgi/con-
tent/full/21/6/188.
2. Roger A. Rosenblatt et al., “Shortages of Medical Personnel at Community Health Centers,” The Jour-
nal of the American Medical Association, 2006: Vol. 295 No. 9,
http://jama.ama-assn.org/cgi/content/full/295/9/1042.
3. Ateev Mehrotra et al., “Retail Clinics, Primary Care Physicians, And Emergency Departments: A
Comparison of Patients’ Visits,” Health Affairs, 2008: Vol. 27 No. 5, http://content.healthaffairs.
org/cgi/content/full/27/5/1272.
4. Ibid.
5. Richard Cauchi et al., “Retail Health Clinics: State Legislation and Laws,” National Conference of State
Legislatures, Nov. 2009, http://www.ncsl.org.
6. Devon Herrick, “Retail Clinics: Convenient and Affordable Care,” National Center for Policy Analysis,
Jan. 2010: No. 686, http://www.ncpa.org/pub/ba686.
7. Ibid

13
Healthy San Francisco:
A Model Local Public Option
Jake Grumbach, Columbia University

A municipal-level employer mandate and health access plan for those without em-
ployer-provided insurance and Medicaid eligibility is an economically feasible way
to cover the uninsured.

The recent health reform legislation was necessary, but severely lacking in certain areas.
With no public option, it permits the continued price gouging of the private insurance
industry. Coverage will not be universal. Undocumented immigrants cannot purchase
insurance. Some critical benefits will not begin until 2014. Although Massachusetts and
Vermont have initiated reforms, other state initiatives like California’s 2004 SB2 bill
have also failed against pressure from insurance and business interests. In an ambitious
display of local action, San Francisco policymakers developed the Health Care Security
Ordinance (HCSO), which has successfully provided cost-efficient and comprehensive
care to about 50,000 of the previously 82,000 uninsured San Franciscans since 2007.

The HCSO contains two policies. First,

Supervisor Ammiano created the fund-
ing component that requires all firms to
“pay or play”: either pay a penalty to the
City or provide health insurance for their
employees (depending on the number
of workers). Second, the Ammiano pol-
icy merged an idea from the Director of
the Department of Public Health, Mitch
Katz, and Mayor Gavin Newsom of a new
City-run health access plan (now called
Healthy San Francisco) from the recom-
mendations of the Universal Healthcare
Council, consisting of appointed officials
from labor, business, and medicine.
Key Facts
• Since its implementation in 2007, San
Francisco’s health access plan has cov-
ered 50,000 of its previously 82,000
uninsured residents.
• 73% of enrollees have incomes below
the federal poverty line, and they utilize
primary care appointments more than
those with other health coverage.
• Quarterly fees for the access plan range
from $0 to $450, depending on income.

Analysis
This combined policy of an employer mandate and a public health access plan is ef-
ficient, both in cost and outcomes, for a number of reasons. First, the health access
plan emphasizes a “medical home,” the particular provider where each enrollee re-
ceives primary and preventative care. Many of these previously uninsured residents
already received emergency care subsidized by taxpayers; with the health access plan,
they are directed towards more cost-effective primary care. Second, the health access
plan does not provide comprehensive insurance. Instead, as it provides all avenues of
comprehensive care only within city limits, municipalities can maintain cost control and
utilize their own systems of public and private hospitals, managed care organizations,
and community clinics. Residents are thus only eligible for the health access plan if they
have been uninsured for two months. Third, the “pay or play” employer mandate levels
the playing field for small businesses, which finally have an affordable option to cover

14
employees. Finally, adults earning below 133% of the federal poverty line will move from
Healthy S.F. to Medicaid under the recent expansion of Medicaid eligibility, saving mil-
lions for the city as the Healthy S.F. pool of enrollees becomes relatively wealthier.

Stakeholders
The initiative remains quite popular Talking Points
• It is more cost-effective to enroll everyone
among residents and interest groups
than to leave residents without insurance;
like labor unions and community orga- each enrollee elects a “medical home” to
nizations. An independent Kaiser Fam- receive primary and preventative care.
ily Foundation report found that 94% • Small businesses, whose health costs are
are at least “somewhat satisfied” with much more than those of large firms, will
the program and 92% would recom- finally have an affordable health care op-
mend it to a friend. Unions and activist tion for their employees.
groups were instrumental in advocating • Young people, part-time workers, non-
the policy in San Francisco. However, union workers, immigrants, and the very
poor—all especially uninsured groups—
a restaurant owners organization, the
have an affordable option with quarterly
Golden Gate Restaurant Association fees based on income level.
(GGRA), found the minimum employer
health expenditure for firms not pro-
viding insurance (currently $1.23 for firms with 20 to 99 workers) punitive. The GGRA
filed suit against the HCSO’s employer mandate, claiming the provision violated the
federal ERISA law of 1974. The group lost in an appeal as it became clear that San Fran-
cisco restaurant owners were passing the costs onto their patrons (who were happy to
pay an extra dollar or so for entrees), nullifying the GGRA’s argument that the HCSO’s
employer spending requirement was putting them out of business.

Next Steps
The dualistic employer mandate and access plan model can work in any metropoli-
tan area, though costs must be tailored to reflect the level of uninsured residents and
the capabilities of the existing health care safety net. Already equipped with universal
health care for children and workers at firms with government contracts, as well as an
extensive clinic system, San Francisco was especially suited for this approach. Union-
ized cities like Las Vegas and New York could be the next to adopt an HCSO policy.

Endnotes
1. “News and Updates,” in HeartBeat: A publication for Healthy San Francisco participants: San Francisco
Department of Public Health, 2009.
2. Heather Knight, “Healthy San Francisco Rates High in Satisfaction,” San Francisco Chronicle, Aug. 26,
2009, D2.
3. “Healthy San Francisco,” in Key Facts, edited by Kaiser Commission on Medicaid and the Uninsured:
Kaiser Family Foundation, 2009.
4. Ibid.
5. “Status Report on the Implementation of the San Francisco Health Care Security Ordinance,” San
Francisco: Department of Public Health, Office of Labor Standards Enforcement, and City Control-
ler’s Office, 2009.
6. John Iglehart, “Medicaid Expansion Offers Solutions, Challenges,” Health Affairs 29, no. 2 (2010): 230-
32.
7. Knight, D2.
8. Brian P. Goldman, “San Francisco Health Care Security Ordinance: Universal Health Care Beyond
Erisa’s Reach?” Stanford Law & Policy Review 19, no. 2 (2008): 361-76.

15
Modifying the Mental Health Parity
& Addiction Equity Act of 2008
Marissa Gluck & Ashley Morton, University of North Carolina at Chapel Hill

The Mental Health Parity and Addiction Equity Act should be modified in order to
further improve the quality, availability, and cost of mental health care available for
citizens of the United States of America.

For years, there has been enormous inequity between mental and physical disorders in
terms of insurance coverage. On January 1st, 2010, the Mental Health Parity and Addic-
tion Equity Act of 2008 (MHPAEA) came into effect in order to provide Americans with
mental health care coverage that better matches the patient’s needs. The Act ensures
that group health plans covering fifty or more employees will have mental health and
substance abuse treatment benefits that are identical to general health care benefits.
Despite this new legislation, many Americans, especially lower-income and the unem-
ployed, are left without adequate access to the mental health care that they need.
The following significant health
care challenges and disadvan-
tages remain unaddressed: a) Key Facts
the MHPAEA covers only larger • Most insurance companies cap the number of
businesses, those with fifty or therapy sessions at 20 per year.5
more employees; b) mental • Over 25 percent of Americans suffer from a men-
tal health disorder, with 6 percent of Americans
health and substance abuse
suffering from a serious mental health condition.6
disorders listed in the DSM-IV- • Mental health disorders are the leading cause of
TR are covered only at the dis- disabilities for Americans ages 15 – 20.7
cretion of the employer, leav- • Most states do not offer the same insurance cov-
ing some employees without erage and benefits for mental health care as they
necessary care; and c) benefits do for general health care.8
cease upon termination of em-
ployment.

Analysis
The MHPAEA does not ensure coverage of all mental health and substance abuse dis-
orders. As more than 25 percent of Americans suffer from a diagnosed mental health
disorder and many more go unidentified, a large, vulnerable population is in danger of
going untreated. It is inherently unfair that the Act permits the employer to decide
which medical conditions will be covered. Furthermore, most insurance companies limit
number of therapy sessions per year to 20, while others allow as many as 30. These
arbitrary caps become especially damaging when patients require certain medications,
such as selective serotonin uptake inhibitors, that require a sometimes lengthy, care-
fully monitored trial and error period to determine the correct medication and the
proper dosage. Beyond the number of therapy sessions necessary for treatment, there
is little to no policy protecting a person’s right to mental health coverage.

North Carolina no longer caps the number of therapy sessions to which a person is
entitled. Maine, Minnesota, New Hampshire, and Rhode Island have similarly addressed
this issue and several other states are considering adopting similar legislation. How-

16
ever, under the current version of the Act, insurers who offer both physical and mental
health services still may enforce de facto coverage limits on access to mental health
care by establishing high co-payments and other obstacles to obtaining adequate ac-
cess to mental health treatment. Until additional measures are taken to make viable
options available for patients who become unemployed and to treat mental health in
the same manner as physical health, Americans will not be adequately serviced by the
health care industry.

Stakeholders
The American public would
benefit from the proposed
modifications to the current
version of the MHPAEA.
They would have increased
access to necessary therapy,
medications, and other sup-
port systems. In addition, the
American public would save
money, as health insurance
expenses and co-payments
will decrease.
Talking Points
• North Carolina no longer caps the number of therapy
sessions a person can attend. Other states with simi-
lar legislation include Maine, Minnesota, New Hamp-
shire, and Rhode Island. Several other states are cur-
rently considering adopting similar legislation.
• Under the current version of the Act, insurers who
offer both physical and mental health services can
still enforce coverage limits specific to mental health
care, including high copayments and inadequate ac-
cess to mental health care options.

Next Steps
There is an ongoing challenge to promote parity between mental health and physical
health care in the eyes of insurers. It is essential that mental health care receive the
same attention and benefits as general health care does. The MHPAEA should be ex-
panded to cover all employees, regardless of the size of the business. The MHPAEA
should also prohibit the opportunity for employers to select which mental health disor-
ders to cover. All mental health and substance disorders should be treated in the same
fashion and receive the appropriate care and coverage.

Endnotes
1. U.S. Department of Health and Human Services, “The Mental Health Parity and Addiction Equity Act,”
http://www.cms.gov/HealthInsReformforConsume/04_TheMentalHealthParityAct.asp (accessed April
19, 2010).
2. EJ Freeman, LJ Colpe, TW Strine, S Dhingra, LC McGuire, LD Elam-Evans, et al., “Public Health Surveil-
lance for Mental Health, Prev Chronic Dis 2010, 7(1), http://www.cdc.gov/pcd/issues/2010/jan/09_0126.
htm (accessed April 19, 2010).
3. North Carolina Institute of Medicine, “NC Consumer’s Guide to Health Plan Selection,” http://www.
nciom.org/hmoconguide/index.html, (accessed April 19, 2010).
4. National Conference of State Legislatures, “State Laws Mandating or Regulating Health Benefits,”
http://www.ncsl.org/IssuesResearch/Health/StateLawsMandatingorRegulatingMentalHealthB/ta-
bid/14352/Default.aspx (accessed April 19, 2010).
5. Ibid.
6. Ibid.
7. North Carolina Institute of Medicine, “NC Consumer’s Guide to Health Plan Selection.”
8. Ibid., National Institute of Mental Health. “Statistics” http://www.nimh.nih.gov/health/topics/statistics/
index.shtml (accessed April 26, 2010).

17
Enterprise Liability
And Medical Malpractice Reform
Angela Gandhi, University of California San Diego

Enterprise Liability, which holds hospitals accountable for having physicians with
high numbers of medical errors, shifts risk from individual physicians to hospitals and
abates current problems with the medical malpractice system, including defensive
medicine, high physician liability insurance premiums, and inefficient justice for pa-
tients receiving negligent treatment.

Medical malpractice is meant to foster physician accountability and ensure that pa-
tients who have been wrongfully harmed receive proper treatment. The current medi-
cal malpractice system is failing to meet these goals. The current system of medical mal-
practice results in an excessive amount of litigation, which contributes to unreported
medical errors. Anywhere between 50,000 and 60,000 medical malpractice cases are
open in the country at any given time. Therefore, the current medical malpractice sys-
tem creates unnecessary litigation, physician stress, uncompensated patients, and no
mechanism to control future errors.

The term “enterprise liability” is associated

with joint liability litigation. Joint liability liti- Key Facts
gation is intended to help individuals harmed • Enterprise liability holds hospitals,
in cases in which direct accountability is dif- instead of doctors, accountable for
ficult to determine. Veterans Affairs hospi- medical errors.
• Over 150,000 reports were filed
tals and Health Maintenance Organizations
against doctors in 2006.9
(HMOs) currently utilize enterprise liability— • 1 in 6 who file a deserving claim do
patients who have suffered from medical er- not receive adequate payment.10
rors in a veterans hospital prosecute the U.S.
government instead of their physician. The
Clinton administration’s proposed health plan recommended managed care and en-
terprise liability as a means of regulation and quality control. Due to the increased
prevalence of managed care, enterprise liability is necessary to lower health care costs
and improve quality of care.

Analysis
Physicians will bear some of the cost from an enterprise liability system, as it dimin-
ishes physician autonomy. Hospitals will bear the risk for malpractice, which will reduce
medical errors by encouraging open communication and lower-risk medical techniques.
Doctors will fear enterprise liability as hospitals will have the ability to recommend
certain medical procedures which are lower in risk, but do not have the authority to
mandate them. Furthermore, hospitals are able to rank doctors based on their level
of medical errors. An increase in the authority of hospitals will create additional costs
for physician autonomy in hand with increased regulation and risk pooling. Therefore,
enterprise liability decreases physician autonomy, but minimizes defensive medicine
and fear of lawsuits.

Patients benefit from enterprise liability, as hospitals purchase larger malpractice insur-

18
ance policies than individual physicians. Many individual physicians have malpractice
insurance policies that only cover a small portion of settlements, resulting in inade-
quate compensation for patients. Thus, patients receive more adequate compensation
when hospitals have larger insurance policies. Furthermore, physicians benefit because
liability insurance premiums decrease if hospitals bear some risk.

Additionally, hospitals may implement policies to decrease the likelihood of medical

errors or negligence. Hospitals can implement experience ratings, by which physicians
are incentivized to improve patient care. Hospitals can also monitor the actions of phy-
sicians, creating committees to collaborate and curb medical errors. Reducing medical
errors attracts patients, thus benefitting the hospital. Additionally, curbing medical er-
rors increases hospital efficiency, as time is used to treat additional patients. Ultimately,
enterprise liability improves quality of care and lowers patient and hospital costs.

Next Steps
Enterprise Liability is something that Talking Points
will take time to fully implement, but • Enterprise liability lowers costs incurred
the first step is for doctors and hospi- through unnecessary medical errors by
tals to contact legislators and advocate physicians.
for this type of medical malpractice re- • Enterprise liability lowers the rates of
malpractice insurance for doctors.
form. Since many malpractice laws vary
• Enterprise liability decreases the inci-
by state, enterprise liability needs to be dence of defensive medicine.
implemented on a state-by-state basis, • Enterprise liability better enables pa-
and according to each states’ particular tients to receive adequate compensation
medical malpractice system. Additional- for medical malpractice.
ly, enterprise liability cannot completely
replace the current medical malpractice
system as there will still likely be cases in which doctors make egregious mistakes out of
negligence entirely of their own accord. These are actions for which the hospital cannot
be held liable. Over time, enterprise liability can be enacted as a form of legislation
that will serve as a much better solution to the current medical malpractice system.

Endnotes
1. M. Mello, D. Studdert, “The medical malpractice system: structure and performance, “ In: W. Sage, R.
Kersh, eds. Medical Malpractice and the US Health Care System, 1st Ed, New York, NY: Cambridge
University Press, (2006):13.
2. Mello, “The medical malpractice system: structure and performance,”14.
3. J.J. Segal, and M. Sacopulos, “A Modified no-Fault Malpractice System can Resolve Multiple Healthcare
System Deficiencies “ Clinical Orthopaedics and Related Research 467, no. 2 (Feb, 2009): 420-426.
4. Karl. A. Boedecker, J.Kasulis, F. Morgan, J. Stoltman, “The History of Enterprise Liability,” CHARM
Archive, 8 (1999): 205-222
5. J. Bernstein, D. MacCourt, and B. D. Abramson, “Topics in Medical Economics: Medical Malpractice,”
The Journal of Bone and Joint Surgery 90, no. 8 (2008): 1777- 1782.
6. William M. Sage, “Enterprise Liability and the Emerging Managed Health Care System, “ Law and Con-
temporary Problems 60, no. 2 (1997): 15.
7. Sage, “Enterprise Liability and the Emerging Managed Health Care System,” 35.
8. Sage, “Enterprise Liability and the Emerging Managed Health Care System,” 4.
9. US Department of Health and Human Services, National Practitioner Data Bank 2006 Annual Report,
Health Resources and Services Division, 2006.
10. D. Studdert, M. Mello, A. Gawande, T. K. Gandhi, A. Kachalia, C. Yoon, A. L. Puopolo, and T. A. Brennan,
“Claims, Errors, and Compensation Payments in Medical Malpractice Litigation, “ The New England
Journal of Medicine 354, no. 19 ( 2006): 2024-2033.

19
Organ Donation Policy Reform
Agnes Eshak, Macaulay Honors College at Queens College

Restructuring the organ donation policy in New York State from required consent to
presumed consent, while still providing an opt-out option, can significantly increase
organ donation and lives saved.

The current organ donation policy in New York requires potential donors to show their
intent to become an organ donor by designating it on their driver’s license or non-driver
ID. This can be done either when obtaining or renewing the license or ID at the Depart-
ment of Motor Vehicles. Potential donors can also register with their state registry.
Although New York State recognizes the indication on the driver’s license as intent
to become an organ donor, one’s family can still veto the decision post mortem.6 To
combat this possible veto, organ donation networks rely on potential donors to inform
their families of their intent. Consequently, organ donation networks are ineffective
and unreliable.

While there is an official organ donation registry, where legally binding decisions can
be made, it is not effective. Only 5.8 percent of New York State’s total population has
enrolled in the registry.7

While 85 percent of Americans say they

support donation, less than 30 percent
have designated themselves as donors.8
Obtaining consent continues to be a ma-
jor difficulty that hinders the organ dona-
tion process. Low registration numbers
are not an indication of an unwillingness
to become an organ donor, but rather a
lack of information about how to register
and the magnitude of the current donor
shortage.
Key Facts
• One organ donor can save up to eight
lives.2
• More than 9,500 people in New York
State are in need of organ transplants.3
• In 2008, there were only 373 deceased
organ donors in New York State.4
• About 540 New Yorkers die each year
because of a shortage of donors.5

Analysis
Because there is such a discrepancy between those who are willing to become organ
donors and those who are registered organ donors, a new organ donation system needs
to be implemented.

In a study by Johnson and Goldstein, they demonstrate that there is a difference of 60

percentage points between those who become donors from an opt-out method and
those who become donors from an opt-in method.9 The study suggests that changing
the default to consent in the United States could increase the rate of donations by add-
ing thousands of donors a year.

If the state implements a presumed consent policy, in which residents are automatically
considered for donation and can opt-out if they choose, the number of donors will sig-
nificantly increase and hundreds of lives will be saved every year.

20
Next Steps
A new organ donation system can be modeled after Spain’s policy, which is truly a best
practice example. According to the Council of Europe, Spain has one of the best organ
donation programs in the world.
It employs a “weak” presumed
consent law, in which everyone is
assumed to be a donor, but family
members of the deceased person
may opt-out.10
Countries that use a “strong” pre-
sumed consent law, in which the
family of the deceased person
has no say about organ donation,
fare even better in organ donation
rates. Austria uses this system and
has the highest organ donation
rate in the world.11
Talking Points
• Although there is an organ donation registry in
New York, it fails to reach the adequate number
of potential donors to fill the organ donation
needs of the city.
• Restructuring the organ donation policy in New
York will save hundreds of lives every year.
• Changing the organ donation policy in New
York to an opt-out system is feasible, as dem-
onstrated by the population’s overwhelming
support for donation and its success in other
countries, such as Spain and Austria.

Those who wish to opt-out should be able to do so through forms at the Department
of Motor Vehicles that they are given when obtaining or renewing their license. In addi-
tion, the option of dissent should be provided on health insurance forms and be avail-
able online through the registry website.

Endnotes
1. Sam Crowe and Eric Cohen, “Organ Donation Policy,” The President’s Council on Bioethics, (Sept.
2006), http://www.bioethics.gov/background/organ_donation.html#part1 (accessed April 3, 2010).
2. New York Organ Donor Network, “Organ & Tissue Donation – Statistics,” New York Organ Donor Net-
work, Inc., http://www.donatelifeny.org (accessed April 25, 2010).
3. Ibid.
4. Ibid.
5. Ibid.
6. Crowe and Cohen, “Organ Donation Policy.”
7. New York Organ Donor Network, “Organ & Tissue Donation – Statistics.”
8. Ibid.
9. Ibid.
10. Annabel Ferriman, “Spain tops the table for organ donation,” British Medical Journal 26 Apr, 2010.
http://findarticles.com/p/articles/ mi_m0999/is_7269_321/ai_67581417 (accessed April 25, 2010).
11. D. Goldstein and E.J. Johnson, “Do defaults save lives?,” Science 302 (2003):1338–9.

21
Increasing Family Practice in America
Ankit Agarwal, Boston University

Rein in health care costs in America by reforming visa restrictions on foreign medical
graduates entering family practice and re-allocating a share of Medicare reimburse-
ments from other medical specialties to family practice.

Currently, family practice physicians in the United States constitute only 20% of the
total physician workforce. Since 1998, the number of U.S. medical students entering
family practice has dropped by over 50%, further exacerbating the future shortage
of family practice physicians. Unchecked, this problem could significantly undermine
the effectiveness and financial feasibility of the U.S. health care system. Increasing the
family practice workforce is essential, especially in light of the new health care bill that
gives millions of Americans better and expanded access to medical care.

With the average educational debt

Key Facts
of graduating medical students now • Areas with the most family physicians per per-
in excess of $150,000, graduates in- son spend over 20% less on Medicare Part B
creasingly choose medical special- reimbursements per person and have better
ties as a career path, neglecting health outcomes than areas with the least
the lower paying specialty of fam- number of family physicians per person.
ily practice. Medical professionals • Only 20% of U.S. physicians are family practice
warn that, because of this alarming physicians, whereas most highly industrialized
trend, the United States may suffer countries have nearly double that percent.
• Less than 8% of U.S. medical graduates choose
a shortage of at least 40,000 family
family practice residencies, whereas 19% of
care practitioners by 2025. Areas IMGs choose family practice residencies.
with a larger population of primary
care doctors provide an emphasis
on comprehensive patient-focused care, greater accessibility to care, more frequent
preventative care, and better coordination of care with specialists when necessary.

The solution to this problem is twofold. First, the U.S. should make it easier for interna-
tional medical graduates (IMGs) to obtain a permanent visa if they enter a family prac-
tice residency in the U.S. IMGs currently make up 25% of the U.S. physician workforce,
and 37% of family practice residency positions are filled by IMGs. Currently, IMGs
pursuing family medicine are given a J1 visa, requiring them to return to their home
countries after completing residency training. Changing U.S. visa laws to ensure that
IMGs pursuing family medicine are all given H1B visas, which lead to permanent resi-
dent status, would significantly boost the number of IMGs interested in family practice.
Second, the U.S. should re-allocate Medicare funding to increase reimbursement rates
for family practice services, making family practice more attractive to U.S. doctors. In
the U.S., only 12-15% of medical expenditures are spent on family practice, whereas the
equivalent in other highly industrialized countries is 20% or higher. ,

Changing visa laws to admit more high demand workers is common. For example, the
quota for H1B visas was increased significantly during the late 1990s and early 2000s to
accommodate the large influx of high-tech workers during the dot-com bubble. Increas-
ing funding for primary care has long been a political goal to control health care costs.

22
However, due to financial budgetary constraints, only menial increases in family prac-
tice services have been issued by the Centers for Medicare and Medicaid Services.

Analysis
Initially, the recommended changes in policy Talking Points
would be budget-neutral. Application fees for • Increasing family practice physi-
H1B visas would cover the costs of issuing a cians in the U.S. is a budget-neutral
higher number of H1B visas. There is no asso- way to control health care costs
and better health outcomes.
ciated additional cost with issuing physicians
• Increasing family practice will im-
H1B visas instead of J1 visas. Increased Medi- prove access to and choice of phy-
care funding for family practice physicians sicians for patients.
would be offset by slightly decreased funding
for specialty physicians. Although it is not op-
timal to decrease funding for specialty care, these changes are essential to decrease
health care costs and yield better health outcomes by providing basic, essential medi-
cal care to our country. The number of family practice physicians in a community is posi-
tively correlated with the overall life expectancy of the community, while the number
in other specialties is not. Primary care providers are also associated with more cost-
effective care and earlier detection of diseases, such as colorectal or breast cancer.

Endnotes
1. Ted Epperly, “AAFP Statement: 2009 Resident Match Results Sharpen Focus on Family Physician Shortage, Health System Reform -- 2009
-- American Academy of Family Physicians,” Home Page -- American Academy of Family Physicians, http://www.aafp.org/online/en/
home/media/releases/newsreleases-statements-2009/2009-resident-match-results-sharpen-focus-on-family-physician-shortage.html
(accessed April 19, 2010).
2. Brian Hedger, “ PROFESSION Med school seniors headed for primary care see a challenging future,” American Medical Association - Phy-
sicians, Medical Students & Patients (AMA), http://www.ama-assn.org/amednews/2009/03/30/prsc0330.htm (accessed April 19, 2010).
3. “AMA - Medical Student Debt,” American Medical Association - Physicians, Medical Students & Patients (AMA), http://www.ama-assn.
org/ama/pub/about-ama/our-people/member-groups-sections/medical-student-section/advocacy-policy/medical-student-debt.shtml
(accessed April 19, 2010).
4. Jack M Colwill, James M Cultice, and Robin L Kruse, “Will Generalist Physician Supply Meet Demands Of An Increasing And Aging Popula-
tion?” Health Affairs 27, no. 3 (2008): 232-241, http://content.healthaffairs.org/cgi/reprint/27/3/w232.pdf (accessed April 19, 2010).
5. Barbara Starfield, “Population Health Outcomes - Is the Role of Family Physicians Important?” October 29, 2009, http://www.cfpc.ca/
local/files/CME/FMF_2009/Dr.%20Starfield%20slides.pdf (accessed 1/09/10).
6. “Results and Data 2008 Main Residency Match,” National Resident Matching Program, www.nrmp.org/data/resultsanddata2008.pdf (ac-
cessed April 19, 2010).
7. Elie A Akl, Reem Mustafa, Fadi Bdair, and Holger J Schünemann, “The United States Physician Workforce and International Medical Gradu-
ates: Trends and Characteristics,” Journal of General Internal Medicine 22, no. 2 (2007): 264-268, http://www.springerlink.com/content/
u126021v3n536098/ (accessed April 19, 2010).
8. “Exchange Visitors,” US Department of State, http://travel.state.gov/visa/temp/types/types_1267.html (accessed April 19, 2010).
9. “Temporary Workers,” US Department of State, http://travel.state.gov/visa/temp/types/types_1271.html (accessed April 19, 2010).
10. “US Health Care Spending: Comparison with other OECD Countries,” CRS report for Congress, assets.opencrs.com/rpts/
RL34175_20070917.pdf (accessed April 18, 2010).
11. Barbara Starfield, “Population Health Outcomes - Is the Role of Family Physicians Important?” October 29, 2009, http://www.cfpc.ca/
local/files/CME/FMF_2009/Dr.%20Starfield%20slides.pdf (accessed 1/09/10).
12. “Update on Bills Regarding H1B Cap,” Murthy Law Firm : U.S. Immigration Law, http://www.murthy.com/arc_news/a_billh1.html (accessed
April 19, 2010).
13. “AAFP Reviews 2010 Medicare Physician Payment Schedule -- AAFP News Now -- American Academy of Family Physicians,” American
Academy of Family Physicians, http://www.aafp.org/online/en/home/publications/news/news-now/government-medicine/20091208cms-
2010-ltr.html (accessed April 19, 2010).
14. Barbara Starfield, “Population Health Outcomes - Is the Role of Family Physicians Important?,” October 29, 2009, http://www.cfpc.ca/
local/files/CME/FMF_2009/Dr.%20Starfield%20slides.pdf (accessed 1/09/10).
15. Barbara Starfield, “Population Health Outcomes - Is the Role of Family Physicians Important?,” October 29, 2009, http://www.cfpc.ca/
local/files/CME/FMF_2009/Dr.%20Starfield%20slides.pdf (accessed 1/09/10).
16. Boccuti, Cristina, and Marilyn Moon. “Comparing Medicare And Private Insurers: Growth Rates In Spending Over Three Decades.”
Health Affairs 22, no. 2 (2003): 230-237. http://faculty.arts.ubc.ca/revans/384USmedicare.pdf (accessed May 17, 2010).
17. DH Mark, MS Gottlieb, BB Zellner, VK Chetty, and JE Midtling, “Medicare costs in urban areas and the supply of primary care physicians,”
Journal of Family Practice 43, no. 1 (1996): 33-39, http://www.ncbi.nlm.nih.gov/pubmed/8691178 (accessed April 18, 2010).
18. “Workforce Summary – General Practitioners,” National Health Service, docs.google.com/viewer?a=v&q=cache:C13za-lGkwkJ:www.wrt.
nhs.uk/index.php/component/docman/doc_download/46-general-practitioners+30,936+general+practitioners&hl=en&gl=us&pid=bl&s
rcid=ADGEESgfdPtOS7JhxuxBWACcXov9ExGG-CWaA3NdzUDSw-nO401cuBmERXz5gM-pv4RJDnNtP7Yhh1E3jGTSkJlIte9-qxZi-
M02aKQwWpV7q5lzuYzS53g3deukr2wlt5yDIl2kcGdwz&sig=AHIEtbRnzzTFKBMKnL-cbR3A2z7AS9J5ZA (accessed April 19, 2010).
19. Barbara Starfield, “Population Health Outcomes - Is the Role of Family Physicians Important?,” October 29, 2009, http://www.cfpc.ca/
local/files/CME/FMF_2009/Dr.%20Starfield%20slides.pdf (accessed 1/09/10).
20. “Results and Data 2008 Main Residency Match,” National Resident Matching Program, www.nrmp.org/data/resultsanddata2008.pdf
(accessed April 19, 2010).

23
Proper Management of On-Site Medical Waste
Adam Jutha, University of North Carolina at Chapel Hill

Track and manage the use of on-site medical waste incinerators to prevent incinera-
tor emissions from re-entering medical facilities.

Medical facilities and hospitals produce significant infectious and non-infectious wastes
that need to be appropriately disposed. Hospitals generate between 2.1 and 4.8 million
tons of medical waste per year. Ten to fifteen percent of this medical waste falls under
the definition of infectious waste – waste that consists of pathogens or body parts.
However, in many facilities, all collected medical waste – that is, a mix of infectious and
non-infectious waste – is disposed of in medical waste incinerators. The potential for
complete pathogen destruction and the problems associated with the incineration of
mixed medical wastes have not been properly evaluated. As such, the available data is
rather limited in providing procedures and appropriate regulations.

Dioxins are toxic man-made Key Facts

chemicals released as by- • The number of medical waste incinerators cur-
products of waste incineration. rently operating in the United States is unknown.6
These chemicals cause severe • Hospitals generate about 2.1 to 4.8 million tons of
health risks that may affect hu- medical waste per year, of which 10 to 15 percent
man development. Waste incin- is considered infectious waste.7
erators release a fair amount of • Since 1987, United States’ incinerator emissions
dioxins, regardless of whether have decreased by 99.9%.8
• Research from Germany’s Ministry of the Environ-
or not they meet the United
ment shows that incinerator plants produced 33%
States Environmental Protec- of all dioxins in 1990 compared to only 1% of all
tion Agency’s (EPA) regulations. dioxins in 2000.9
Dioxins and other pollutants are
released into the atmosphere,
increasing the risk of exposure to surrounding populations and residential communi-
ties. The lack of national regulation results in varying waste regulation among states.
However, a national decision to establish an incinerator registry – an official record of
medical waste incinerators across the United States – would allow the EPA to monitor
the levels of infectious and non-infectious waste incineration.

Although figures have decreased over the years, the amount of dioxins released into
areas neighboring an incinerator is relatively high. On-site incinerators have the poten-
tial to emit high levels of emissions and pollutants into the air. Studies and evaluations
are not available to properly assess the risks associated with pollutants from incinera-
tor sources compared to other sources. The lack of information and national research
pertaining to on-site medical waste incinerators is in itself a significant problem.

Analysis
Although only a few studies have been completed and presented with research find-
ings, noticeable findings are actively present in environmental and activist organiza-
tions. A major challenge associated with proper medical waste incineration in hospital
areas is the potential for incinerator emissions to enter hospital air-conditioning ducts
and ventilation systems. Most on-site hospital incinerators have short stacks, which

24
may increase the chance of pollutant airflow back into hospital air circulation. Mandat-
ing a tall height for on-site incinerator smoke stacks for health care and medical facili-
ties would prevent and decrease the chance of re-entry into the hospital’s ventilation
system. On-site incinerators are currently placed a short distance away from a medical
facility, which also suggests close proximity to residential communities.

To minimize the negative effects of in- Talking Points

cinerator waste dioxins affecting neigh- • Dioxins and pollutants released into the
boring communities, regular incinerator atmosphere increase the health risk to
checks need to be scheduled. This will surrounding populations and residential
ensure that specific guidelines are met. communities.
According to the Ministry of the Environ- • A registry would allow the EPA to track
ment of Germany, “in 1990 one third of and monitor medical waste incinerators
all dioxin emissions in Germany came across the country to improve function-
ing and efficiency.
from waste incineration plants, for the
• Regular checkups ensure medical facili-
year 2000 the figure was less than 1%.” ties and hospitals remain committed to
A significant decrease in dioxin emis- following best practices.
sions has also been noted by the United
States EPA, claiming that a 99.9% reduc-
tion in total emissions has occurred over the past two decades due to increased emis-
sion regulations. While this decrease suggests a great deal of regulations and mea-
sures have already been put in place, enforcing regular checks would ensure proper
management of medical waste incinerators. At present, Germany requires incinerator
checks every six months, allowing for authorities to ensure medical waste incinerators
meet regulations and do not significantly impact surrounding communities. The United
States should put similar regulations in place to provide neighboring communities and
hospital residents with a safe environment in which to carry out daily activities.

Next Steps
Congress should work to establish a registry of all medical waste incinerators in the
United States to enforce strict regulations and to reduce the amount of possible pol-
lutant re-entry into air-conditioning and ventilation systems. These programs could be
funded and promoted through the United States Environmental Protection Agency.

Endnotes
1. U.S. Congress, Office of Technology Assessment, Issues in Medical Waste Management – Background
Paper, OTA-BP-O-49 (Washington, DC: U.S. Government Printing Office, 1988), 15.
2. Milton R. Beychok, “A data base for dioxin and furan emissions from refuse incinerators,” Atmospheric
Environment 21 (1987): 29-36.
3. Scottish Environmental Protection Agency, “Incineration of Waste and Reported Human Health Effects”
(Glasgow: Health Protection Scotland, 2009), 15.
4. Federal Ministry for Environment, Nature Conservation and Nuclear Safety, “Waste incineration – A
potential danger? Bidding farewell to dioxin spouting” (Berlin: The German Federal Environment Min-
istry, 2005), 3.
5. U.S. Congress, Office of Technology Assessment, 15.
6. Beychok, 29-36.
7. U.S. Congress, Office of Technology Assessment, 15.
8. Beychok, 29-36.
9. Federal Ministry for Environment, Nature Conservation and Nuclear Safety, 3.

25
Solving the Vaccine Shortage
Through Strategic Incentives
Melody W. Lin, University of California San Diego

Through carefully laid out incentives for pharmaceutical companies and appropriate
government intervention, the U.S. can effectively combat the pressing issue of annual
vaccine shortages.

Pharmaceutical enterprise is a flourishing multibillion dollar global marketplace, but the

vaccine market consists of only 2% of the industry.1 In order to focus the pharmaceutical
business’s attention on the continued, timely development of vaccines, the U.S. govern-
ment needs to address the interests of the industry. These interests include the suste-
nance of profit, lesser liability, and reduced government regulation. With such concerns
addressed by the government, pharmaceutical companies will be better prepared to
reassess and modify their market plans and to direct more capital to the production of
vaccines.

The U.S. Health Resources and Ser-

vices Administration of the Depart- Key Facts
ment of Health and Human Resourc- • According to a 2003 study funded by the
es (HHS) should expand the number CDC, approximately 300 out of 400 doc-
of vaccines covered in the presently tor’s offices in 12 states reported problems
in consistently obtaining enough Prevnar,
effective Vaccine Injury Compensa-
a vaccine used to prevent pneumonia and
tion Program (VICP), which ensures meningitis in children.8
that people suffering from del- • In 2002, 5 of the recommended childhood
eterious side-effects from a recom- vaccinations continued to face shortages;
mended vaccine are appropriately the Hib vaccine is still facing a shortage.9
compensated by the Vaccine Trust • In 2009, the U.S. produced less than 20% of
Fund.2 According to a research study the H1N1 vaccines it had hoped to supply by
from the Journal of Health Politics, the end of the year.10
Policy and Law, vaccine availability
and childhood immunization rates
improved during the early years after the VICP was implemented.3 Litigation against
manufacturers of vaccines has virtually ceased since the VICP started and vaccine pro-
duction has been shown to have increased noticeably.4 Expanded coverage of a greater
number of vaccines will bolster the continuance of less adversarial liability issues and
encourage manufacturers to undergo further production for a wider range of vaccines.
Further, the Department of Justice, which represents HHS, should establish a regulato-
ry compliance defense against tort suits, given that a vaccine has met the strict require-
ments set out by the FDA; if a vaccine is FDA-approved, it should be safe for usage.5

Next, government agencies should hamper their demands in attaining vaccines at un-
realistically discounted prices in most circumstances. It takes about $700 million to de-
velop a vaccine, and 60% of the cost cannot be recovered due to the nature of vaccine
production. Miscalculations of an upcoming strain for the new flu season may devastate
a company as the money spent to produce a now useless vaccine is unrecoverable,
causing many manufacturers to leave the vaccine industry.6 Overregulation further

26
forces companies to leave
vaccine production and in Talking Points
some cases has aggravated • In 2003, the Institute of Medicine reported that the
number of vaccine manufacturers for the U.S. mar-
the vaccine shortage. For
ket had plunged from 26 in 1967 to 4 in 2002.11
example, in 1991, the FDA or- • The world’s vaccine market is small, making up less
dered the removal of thime- than 2 % of the pharmaceutical market.12
rosol from vaccines, even • Because of continuing shortages, deferrals are set
though the risk of no vacci- for certain vaccines and priority levels are set for
nation heavily overshadowed high-risk patients. Thus, highly preventable infec-
the risk of thimerosol. This tious diseases can again pose a threat, and physicians
regulation created a 25% re- are unable to optimally care for their patients.13
duction in crucial childhood • Since the start of the Vaccines for Children Program
(VCP) in 1993, government has demanded bulk sup-
vaccines and also heavily af-
plies of vaccines at greatly discounted prices, caus-
fected manufacturing costs, ing many manufacturers to drop out.14
profits and efficiency.7 Low
market prices, high risk costs
and overregulation discourages companies from entering the vaccine industry and
forces many companies to drop out. Therefore, artificially low prices demanded by the
government and overregulation must be reevaluated.

Next Steps
The government should offer profitable rewards for timely product innovation and re-
search. Rewards can be given through tax credits to cut development costs, marketing
exclusivity of a given drug or patent term extensions. HHS should expand the VICP to
cover vaccines directed toward the more elderly population, such as the zoster vac-
cine, due to life expectancy increases. Regulation on pharmaceutical companies should
also be cut back and potentially streamlined with neighboring countries to create a
global market and support competition between foreign and domestic manufacturers.
This would also allow greater access to vaccines from foreign countries and foster inter-
national pharmaceutical development. Finally, transparency about vaccine availability
must be communicated and pharmaceutical companies should be required to give ad-
vance notice to HHS in the event of withdrawal from the vaccine industry.

Endnotes
1. Robert Goldberg et al., “MI Conference Series 7 - Solving the Vaccine Shortage: Market Solutions or Government Intervention?,” Manhat-
tan Institute For Policy Research, http://www.manhattan-institute.org/html/mics7.htm (accessed January 6, 2010).
2. U.S. Health Resources & Services Administration, “HRSA - National Vaccine Injury Compensation Program,” U.S. Health Resources &
Services Administration, http://www.hrsa.gov/vaccinecompensation (accessed January 10, 2010).
3. Derry Ridgway, “No-Fault Vaccine Insurance: Lessons from the National Vaccine Injury Compensation Program,” Journal of Health Politics,
Policy and Law 24, no. 1 (1999): 59-90. http://jhppl.dukejournals.org/cgi/content/abstract/24/1/59 (accessed January 10, 2010).
4. U.S. Department of Justice. “DOJ Vaccine Compensation Program - About the Program,” United States Department of Justice, http://
www.justice.gov/civil/torts/const/vicp/about.htm (accessed January 11, 2010).
5. Goldberg et al., “Solving the Vaccine Shortage.”
6. Natasha Metzler, “Understanding Demand, Not Just Supply, Key to Solving Flu Vaccine Shortages,” Pharmaceutical Executive, http://
pharmexec.findpharma.com/pharmexec/article/articleDetail.jsp?id=283406 (accessed January 11, 2010).
7. Matt Baumann, “What’s Behind Vaccine Shortages?,” National Center for Policy Analysis NCPA, http://www.ncpa.org/pub/ba655 (ac-
cessed January 6, 2010).
8. Medical Letter on the CDC & FDA. “Vaccine shortage study exposes “patchwork” system.(Prevnar),” AccessMyLibrary, http://www.ac-
cessmylibrary.com/article-1G1-98044576/vaccine-shortage-study-exposes.html (accessed January 11, 2010).
9. Shannon Stokley et al., “Impact of vaccine shortages on immunization programs and providers,” American Journal of Preventive Medicine
26, no. 1 (2004): 15-21. http://www.ajpm-online.net/article/S0749-3797(03)00286-1/abstract (accessed January 6, 2010).
10. Denise Grady, “Officials See a Shortage in Vaccine for Swine Flu,” The New York Times, http://www.nytimes.com/2009/10/17/health/17flu.
html (accessed January 7, 2010).
11. Linda Gorman, “Vaccine “Public Option Plan” Has Produced Shortages of Vaccines,” Independence Institute: Patient Power, http://www.
patientpowernow.org/2009/11/08/vaccine-public-option-plan-shortages/ (accessed January 11, 2010).
12. Goldberg et al., “Solving the Vaccine Shortage.”
13. Ibid.
14. Gorman, “Vaccine “Public Option Plan.””

27
Roosevelt Review Preview:
The Next Attack Might Be Our Last
Isaac Lara, Columbia University

Abstract
This year marks the 25th anniversary since the worst industrial disaster in history. On
December 3, 1984, a tank at a UCIL pesticide plant in Bhopal, India discharged a tox-
ic cloud of gas into the atmosphere, immediately killing 8,000 people and sickening
500,000. Another 25,000 people died soon afterwards from long-term exposure to
the toxic methyl isocyanatae. Some victims were blinded, their eyes having burst out of
their sockets; others’ lungs had melted upon contact with the toxic gas. This incident
illustrates the deadly risk an insecure chemical plant poses to the public.

However, this is not an Indian or a third-world problem. In the U.S., more than 15,000
chemical plants and other facilities store large amounts of hazardous materials at their
sites. In New Jersey - the most densely populated state with a huge petrochemical
industry - one chemical company’s 180,000 pounds of sulfur dioxide could form a toxic
cloud that would threaten 12 million residents and cause them to suffer a fate like those
did at Bhopal. Some experts worry that jihadist extremists might explode these facili-
ties and transform them into weapons of mass destruction the same way that 9/11 hi-
jackers used commercial airliners as missiles to attack Americans.

Besides inflicting massive casualties and overwhelming our healthcare system, such a
crime would also cost millions of dollars in cleanup efforts and recovery. Government
today has failed to enact legislation that establishes national safety standards at chemi-
cal facilities. Only after the U.S. begins requiring companies to substitute hazardous
materials in their chemical manufacturing processes with safer ones, enhancing coun-
terterrorism measures around industrial zones, and exposing security vulnerabilities at
chemical facilities will the U.S. be truly safe.

To read more, visit www.rooseveltinstitute.org for the full white paper,

part of the forthcoming Roosevelt Review.

29
www.rooseveltcampusnetwork.org