1

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 con-
tributed 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 ad-
dressing health issues and creating solutions. Roosevelt Rx offers students a fo-
rum 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 Policy Director

Nate Loewentheil 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 individ-
ual authors and do not represent the views of the editors, the Roosevelt Institu-
tion, 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 11
Robert Nelb, Yale University

Health in a Broader Context:

Incorporating the Social Determinants of Health into Health Reform 13
Saqi S. Maleque, The George Washington University

The Language of Health and Human Rights 17

Shipra Roy, University of Minnesota - Twin Cities

Young Voters’ Role in the Upcoming Election 21

Brad Finnegan, The George Washington University

Shooting Themselves in the Foot:

W hy Empirical Research is Essential to Advocacy 25
Brad Wright, University of North Carolina – Chapel Hill

The Intersection of Science & Policy: A Tobacco Case Study 29

Julia Battocchi, The George Washington University

From Health Security to Health Choices:

A Comparison of the 1993 and 2008 Clinton Health Plans 33
Eva M. Galvan, Yale University

Ideas
Tax-based Automatic Enrollment in Health Care Plans 37
Robert Nelb, Yale University

Reducing Infant Deaths

With Nutritional Outreach for Pregnant Women 39
Alexander Hertel-Fernandez, Northwestern University

No Child Left Idle:

Federal requirements for Physical Education in K-12 Schools 41
Edie Moussa, Virginia Tech, and Eva Galvan, Yale University

Empowering the Public Health Service 43

Louis Graham, University of North Carolina - Greensboro

Creation of an Office to Improve Men’s Health Outcomes 47

Ramon P. Llamas, University of Southern California

Promoting Equity of Health Care Payments 49

Kumar Senthil, Johns Hopkins University

Mandating Documentation of Desires For End-of-Life Care 51

Wendy Mosiman, Wichita State University
Containing Medicare Costs 53
Genia Lindsey, Lake Forest College

Creating a System of Uniform Federal Health Insurance Mandates 55

Jeet Guram, University of South Carolina

Building a Sustainable Comparative Evaluation Institution 57

to Assess Medical Treatments
Jonathan Knoche, University of Wisconsin
Ensure Student Access to Health Insurance 59
Mariza R Hardin, University of New Mexico

Using the HPV Vaccine as a Gateway to Better Health 61

Stephanie Gross, Northwestern University

Loan Repayment Incentives for Community Health Centers 63

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 69
Alexander Hertel-Fernandez, Northwestern University

Appendix: Key Healthcare Statistics

Roosevelt Rx
 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 dis-
cussed 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 strength-
en 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 pub-
lication 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
 11
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 opportu-
nity 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 implementa-
tion 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 articulat-
ing, 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, unchange-
able — 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
12
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 promi-
nent 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 govern-
ment 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 ad-
ministration wasn’t necessarily a spirit of government handouts. Instead, his signature
programs were based on the ideas of shared responsibility and community empower-
ment. 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.
 13
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 in-
dustrialized 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 rea-
sons, 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 in-
fluence on health status, longevity, and quality of life than traditional health care con-
siderations. 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 af-
ford 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 activ-
ity 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 neighbor-
hoods than in African American neighborhoods. Minority and low-income neigh-
borhoods 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
14
discourage commercial development in some areas, the urban planning design that
prevents or allows movement and transportation, or the housing policies that deter-
mine 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 comprehen-
sive 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 deci-
sions 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 poli-
cies 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 biomedi-
cal 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 fund-
ing; 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
 15
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 inter-
agency 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 educa-
tion, 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 in-
cludes 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.
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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
16
 17
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 discus-
sion 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 Organi-
zation, healthcare is a concept that “embraces all the goods and services designed to
promote health, whether directed to individuals or to populations,” a simple defini-
tion 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 neces-
sary 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 guaran-
teed 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 health-
care 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 con-
servatives 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.
18
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 ac-
countability 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 op-
tions 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 pharmaceu-
tical 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 health-
care. 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
 19
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. Inher-
ently, 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 neces-
sary 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 eco-
nomic 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).
20
 21
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 reputa-
tion 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 contin-
ued 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 elec-
tion 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 govern-
ment 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 com-
panies, 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-
22
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 ma-
jor 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 encour-
aged 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 se-
vere 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 partici-
pation 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).
24
 25
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 them-
selves 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. Depart-
ment 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 insti-
tutionally-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 distribu-
tion of the healthcare workforce by paying some or all of the costs of health profes-
sionals’ 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 in-
crease 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 pro-
posals 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. Gov-
ernmental 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 ef-
forts 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?
26
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 effec-
tive 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 pro-
gram 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 lobby-
ing 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 consider-
able 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-inter-
est, 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 dis-
semination 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
 27
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. Collabo-
rations 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 organiza-
tions 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 under-
stood correctly and acted upon appropriately.
Fourth and finally, advocacy organizations that base their arguments on sound re-
search 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 anec-
dotes and simply because “it’s the right thing to do” does not stand up well to counter-
arguments 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, support-
ing 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.
28
 29
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 relation-
ship 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 in-
strumental 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 im-
portant 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 Gen-
eral 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 succes-
sors.” 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: Re-
port 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 smok-
ing 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
30
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 news-
letter 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 addi-
tion 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 respi-
ratory 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 help-
ing 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.
 31
Youth advocates have lobbied for smoke-free campuses and parks, statewide smok-
ing bans, increased tobacco prevention funding, bans on candy-flavored tobacco prod-
ucts, 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 consciousness-
raising events, proves to be a rewarding combination and an effective tool to counteract
the overwhelming influence of the tobacco industry.

Sources
“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.
32
 33
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 compa-
nies 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-
34
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 Clin-
ton’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
36
 37
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 iden-
tifying 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 abil-
ity to opt-out if they choose.
Key Facts
Studies have consistently shown that opt-out • About two-thirds of uninsured
policies have higher rates of enrollment than children in the US are already
opt-in policies. While the most common eligible for Medicaid or SCHIP,
but they are not enrolled.
example used is opt-out 401(k) plans, auto-
• While only 33% of employees
matic enrollment strategies have been used
enroll in a traditional 401(k) plan
in health care. For example, Medicare Part B when they are given the choice to
uses tax information to automatically enroll opt-in, 90% of employees enroll
seniors, and Maryland has recently used tax when they are given the choice to
forms to streamline enrollment in its Medic- opt-out.
aid program.

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.

Tax information is an ideal source for enroll-

Talking Points
ment information since all the information
• Auto-enrollment is most effective
for covering the most disadvantaged that is required to determine eligibility for
in society and also gives individuals Medicaid and SCHIP for most beneficia-
a choice to opt-out. ries in most states is available on individual
• Auto-enrollment connects income tax forms, which virtually all house-
Americans to benefits that they are holds submit annually (including families
already eligible for and helps reduce that are exempt from paying tax).
bureaucracy for enrollment.
• Many states already use tax in- Maintaining the privacy of tax information is
formation and other databases to
a concern, but under current law, the Secre-
verify eligibility, but they don’t use
them to determine eligibility. tary of the Treasury can create an “Opportu-
nity 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.
38
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 en-
rollment 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 informa-
tion to determine eligibility for health insurance programs, enrollment system, Con-
gress 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.
 39
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 nutri-
tional 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 aver-
age, 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.
Key Facts
The leading preventable cause of infant death • One in 71 American mothers
involves pre-term or low birth weight deliver- will lose at least one child, the
ies. In turn, the leading preventable cause of second-highest child death rate of
early, low weight births is maternal malnutri- developed countries.
tion, particularly amongst low-income fami- • Maternal malnutrition and obesity
are linked to many of these deaths,
lies.3 Up to 38.4 percent of American preg-
especially among low-income
nant women, and 68 percent of poor pregnant mothers.
women, are considered malnourished.

Despite the strong connection between maternal malnutrition and infant death, little
government action is directed towards dietary interventions for at-risk pregnant moth-
ers. Poor and disadvantaged mothers are given free or significantly reduced cost prena-
tal 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
Talking Points have adequate training on nutrition
• 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. Previous medical and epidemiological
• This proposal would merely extend existing studies have identified simple dietary
medical benefits to already eligible women counseling, often as little as a two-
without creating new bureaucracy or signifi- hour session, as an inexpensive and
cantly altering administrative function. effective intervention for improving
• This proposal would also offer financial in- maternal and infant outcomes. Med-
centives to nutritional specialists who serve icaid already reimburses nutritional
in low-access areas to at-risk populations. counseling, but this service is severely
40
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 Chil-
dren 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 govern-
ment 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 ma-
ternal malnutrition and obesity, which are both steadily increasing amongst poor popu-
lations. 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 stud-
ies. 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)
 41
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
2008). State officials often ra- problem-solving skills ( Jenson, 2006).
tionalize cutting P.E. and health • Children and adolescents should accumulate at
classes by claiming that scarce least 60 minutes of exercise on all or most days
monetary resources are better of the week (NASPE, 2008).
• 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). How-
ever, 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 attentive-
ness 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 ac-
cess 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 in-
energy 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 aca-
While 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
42
often attain physical exercise and health information through extracurricular activ-
ity; 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 ex-
ercising outside of the lowest requirement. To raise awareness, P.E. and health aware-
ness 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 under-
standing 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.

 43
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 testi-
the 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
influence of career public health and reports
• Historically, top Department of Health and Human
officers within the Department
Services (DHHS) aids and officials either are not for-
of 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,
could begin by expanding the au- policy, or practice.
• Traditionally, some key PHS administrators are
thority and visibility of the Sur-
primarily trained in individual-level medical care even
geon General in directing public though they head population-level health prevention
health policy and education. Ad- agencies.
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 ap-
propriations. 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
• Extending the term of the PHS head will help insulate
During the first half of the 20th
the PHS and its leadership from political pressure. century, the Surgeon General
• 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 respec-
tive responsibilities will lead to better structuring of
model of the PHS as an agency
population health efforts. with effective political control
• The Federal Reserve may be a potentially useful model no longer holds true. The effect
for restructuring the PHS, particularly with its desig- of this political restructuring on
nation as an independent governmental entity.
• Increasing the efficacy of the PHS will lead to more
public health policy has been det-
effective preventative health measures, leading to cost rimental. The Office of the Sur-
geon General is still a constituent
44
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. Reorgani-
zation 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 man-
ner that warns against health threats and presents efficacious promotion and preven-
tion 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, lag-
ging far behind our industrial country peers on nearly every measure. Just as the Fed-
eral 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 influ-
ence 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.
 45

Sources
Associated, Press. “Ex-Surgeon General: Bush Muzzled Me.” 10 July 2007. CBS News. 4 July 2008. <http://
www.cbsnews.com/stories/2007/07/10/politics/main3041857.shtml?source=RSSattr=HOME_3
041857>.
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 <http://www.hhs.gov/about/bios>.
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.
 47
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 examina-
tion 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 obe-
sity compared to
women. Men are Men Women
also more likely to Lifetime Probability of Developing Cancer:
In all sites 1/2 1/3
be uninsured and
also significantly
underutilize HIV/AIDS Prevalence in U.S., 2003 (%): 74 26
medical services.
Men clearly have Mortality Rate for Leading Causes of Death:
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 compre-
hensive 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 ser-
vices. 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 be-
tween sexes. With an Office
Talking Points of Men’s Health, appropriate
• Federal agencies and offices address the needs of vul- funding can be allocated to
nerable 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.
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 contain-
ing 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 popula-
tion 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.
 49
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 self-
payers 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, self-
paying 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-
ing a long-term solution to
this growing disparity. First,
consumers must have access
to a clearly organized hospital
chargemaster file that details
the specific pricing for each
procedure and resource utilized.
Hospitals should state their
prices as a multiple of what
Medicare sets as the calculated
cost of services to the hospital
(Medicare Allowable Costs), so
that consumers will have a clear relative value.
• On average, hospitals charge self-pay patients over
three times the amount deemed reasonable by
Medicare.
• If hospitals collected the full amount that they
charged from every patient, they would have a
profit margin per hospital of 200 percent.
• Hospital costs are rising, but are increasing at a
much slower rate than hospital charges. Public
and private insurers are increasing their payment
relative to increases in hospital costs, while self-
payers must increase payment relative to increases
in hospital charges.

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.

History
Talking Points
Since 1980, hospitals
• As hospitals increase the amount that they charge,
private and public insurers are able to negotiate sig- have been increasing fees in
nificant discounts, resulting in a minimal change in their chargemaster files. Re-
expenditures. Self-paying consumers are left to pay gardless of chargemaster fee
for much of the increase in hospital charges. increases, Medicare only pays
• If health care providers increased price transparency, the set Medicare Allowable
consumers would be able to identify and give busi- Cost, while private insurers,
ness to the providers that offered care at the cheap- due to the large number of
est rates, providing market incentives for increased consumers they bring to the
efficiency.
hospital, have the ability to
50
negotiate prices and generally end up paying only slightly more than Medicare. How-
ever, self-pay patients do not normally have the opportunity or the leverage to negoti-
ate 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, govern-
mental regulation would still be necessary to correct instances of market failure. Due
to the presence of multiple insurers, minimal consumer knowledge and price discrimi-
nation, 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 pa-
tients 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
 51
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
his wishes followed regarding care the 1976 Karen Ann Quinlan case, issued
at the end of life. To ensure this, by the New Jersey Supreme Court (Quinlan
a discussion with a trusted friend v. Rochester General Hospital).
or relative about end-of-life wishes • The 1990 Patient Self Determination Act
affirmed a patient’s right to document end-
must 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 deci-
wishes are carried out. The patient sions regarding care at the end of life.
benefits by increasing the likeli-
hood 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 abil-
ity 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
Beginning in 2010, each one of the
to $851 billion by 2017. nearly thirty-four million Ameri-
• Thirty percent (30%) of Medicare funds cans enrolling for Medicare Part D,
are spent in the last year of life, with 40% the prescription drug benefit, will
of that paid to provide care in the last in be required to complete a Health-
the last 4 weeks. care Power of Attorney (HPOA) to
• Studies suggest that less than 30% of com- designate who will make health care
pleted advance directives are ever actually decisions, based on their wishes, if
recorded on patient charts.
they cannot.
52
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 edu-
cation 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 un-
able 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.
 53
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 treat-
ment 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
observed variation in mortality. Key Facts
• Without guidelines for best treatment practices,
Although research has been done physicians often dispense medicine under the
on evidence-based practices, few assumption that more care equals better care.
• Various measurements (including patient satis-
physicians have accepted and
faction, health outcomes, quality of communica-
implemented published guide- tion, 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 aver-
pices of the Center for Medicare age amount of money spent per patient with
and Medicaid Services (CMS) to a chronic disease in the last two years of life,
disseminate treatment guide- ranging from $59,379 in New Jersey to $32,523
lines and criteria, as published in North Dakota. Yet most of this variation can-
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 informa-
tion 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 Prac-
tice (PGP) project. This was CMS’s
first physician pay-for-performance
initiative. One measure of perfor-
mance 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
54
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 clin-
ical 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 of-
fer 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.
 55
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 man-

dates 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 state-
imposed insurance benefit mandates
As the number of mandates has nationwide; there are now over 1,900.
increased, evidence suggests that these In 2001, more than 550 mandates were
policies may be hurting those they are introduced in all states.
• The number of benefit mandates varies
meant to help. For example, a Na-
significantly 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-year-
moral hazard: the mandates have had old male, a basic health plan costs $5,880/
little effect on the number of deliver- year in New Jersey and $960/year in
ies but have increased the incidence Kentucky.
of high-risk multiple births, sug-
gesting 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 One unambiguous effect of mandates

• 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 policy-
holders; protections would be put in place
to ensure that families with health insur-
ance did not lose existing benefits unless
they willingly switched to a plan designed
under the new requirements.
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 insur-
ance mandates would help ensure that
mandates can achieve their original
goal of improving access to quality,
affordable health care. The federal gov-
56
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 legisla-
tion 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 regula-
tory 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 state-
level, 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 applica-
tion and more universal, since federal law should be able to override ERISA limita-
tions. 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 pro-
posed 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.
<http://www.times.com/>.
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).
<http://www.nber.org/>.
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. <http://www.kaisernetwork.org/>.
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.
 57
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. Key Facts
spends more on health care than other • Of the $320 million budget of the
Agency for Healthcare Research and
industrialized nations. Once new treat-
Quality (AHRQ), only $15 million is
ments and technologies are introduced,
devoted to comparative research.
they are often used indiscriminately, • Per capita Medicare spending in 2000
in the absence of comparative studies was $10,550 in Manhattan, New York,
showing their benefits against available but only $4,823 in Portland, Oregon.
options. The health care industry needs These variations are due not to differ-
better information on how new treat- ences in price but primarily to differ-
ments compare with existing options ences in patterns of practice. Even after
with respect to health outcomes and cost controlling for differences in age, sex,
and race, the higher-spending region did
of care.
not have better health outcomes.
• Estimates for the amount wasted on
According to Elliot Fischer, chief over-treatment in the US range from 20
investigator of the Dartmouth Atlas to 30 cents on every health care dollar
Project, if Congress instituted nation- spent.
wide hospital practices similar to those
employed in more conservative regions,
then Medicare spending (and health care spending overall) could decrease by approxi-
mately 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
introduced to the market, physicians and a higher risk of medical error. Thus,
need to know which innovations are by fully funding and politically insulating
enough of an improvement over existing an institution to comparatively evalu-
options to justify the increase in cost. ate treatments, Congress would reduce
• Creating an independent and fully- health costs and ensure the best quality
funded comparative effectiveness insti- of care for all Americans.
tution will reduce medical costs while
ensuring that Americans receive the best History
quality health care.
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
58
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 sub-
stantial 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.
 59
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 Appli-

cation 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 Educa- Key Facts
tion, ensures that all eligible • Young adults (age 19-29) have the highest unin-
individuals can benefit from sured rate of any age group.
federally-funded or federally- • About 1.7 million (20%) US college students ages
guaranteed educational loans. 18-23 were without health insurance in 2006.
Federal Student Aid partners • Only 11% of young adults have public coverage
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 par-
student financial assistance ent employer sponsored plans that have an age limit
programs to provide money on coverage.
for college eligible students • One in ten uninsured young adults had more than
and families. $700 in out-of-pocket medical expenses in 2005.
• Nearly 40% of young adults with some degree of
The FAFSA, accessible online, health problems are uninsured, whereas only 27% of
young adults in excellent or very good health lack
is a comprehensive form that
insurance.
asks applicants to provide • The federal government processes over 14 million
extensive information about FAFSAs and disburses more than $80 billion in
their family’s income, previ- financial aid to students annually.
ous year’s income taxes, assets,
family size, the number of
family members attending college and other qualifying information. Using this infor-
mation, 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-
60
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 insur-
ance. 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 becom-
ing 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 depen-
dent 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 par-
ent’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>.
 61
Using the HPV Vaccine as a Gateway to Better Health
Stephanie Gross, Northwestern University

Colleges can use the opportunity presented by HPV vaccination to en-

courage 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 se-
verely 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.
nity presented by vaccination to inform • In 2007, only 55.8% of college women
women of the other services a women’s reported having had a routine gyneco-
health clinic offers in order to establish logical exam in the past year.
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.

Talking Points Through this initiative, colleges and

• Regular pap smears and gynecological universities can place women’s health as
exams save lives. an integral part of the care people expect
• Young people are highly likely to be from their doctors and health insur-
uninsured, and young women may ance. Some barriers exist, though; not
forgo basic reproductive health services all employer-sponsored health insurance
when they feel it is unnecessary or too plans cover contraception, leading to
expensive.
higher costs for those women who have
• HPV vaccine delivery is a unique op-
portunity for health care providers to
been unable to prevent an unintended
reach out to young women to promote pregnancy. And though women certainly
lifelong reproductive health. 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.

History
Existing health centers on college campuses usually do provide women’s health ser-
vices. Though some schools explicitly prohibit contraception where it conflicts with
62
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 main-
stream 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 col-
lege 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
 63
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 improv-
ing 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 prob- Key Facts

lems expanding to serve more people
and to reach other areas. This can be
partly attributed to the fact that CHCs
have difficulty recruiting and retaining
clinical workers. In 2006 the average
CHC had 13.3% vacancy rate in its
full-time physician positions. CHCs also
experience staff shortages of other types
of clinicians. When faced with cum-
bersome student loans, many students
cannot afford to make significantly less
money working in a CHC. Implement-
ing a loan repayment incentive program
will help recruit clinicians to work in CHCs, thereby allowing CHCs to develop and
optimize their impact.
• The annual cost of care for a CHC
patient is $515. This is 10 times less
than the average per capita spending on
personal health care.
• Community health center care is more
cost-efficient because patients are 11%
less likely to be hospitalized and 19%
less likely to use the emergency room for
preventive conditions.
• In 2006, 13.3% of CHC physician posi-
tions were vacant. Critical clinical staff-
ing problems limit CHC expansion.

History
Loan repayment incentive programs have been used across the country to recruit teach-
ers 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 The federal government currently

• 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.
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
64
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 expan-
sion. However, research completed by the University of Washington, the University of
South Carolina, and the National Association of Community Health Centers demon-
strate 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 ac-
cepting jobs in CHCs.

Next Steps
Local and state governments should work with CHCs and private organizations to de-
velop 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 <http://www.boston.com/news/local/articles/2008/05/12/Loan_effort_lures_recruits_to_
health_centers/>.

Massachusetts Community Health Center Primary Care Loan Repayment Programs. Massachusetts League
of Community Health Centers. 3 July 2008 <http://www.massleague.org/ClinicalCorner/
CareerOpportunities-Loan.htm>.

National Association of Community Health Centers. American Health Centers: Making Every Dollar Count.
2006. 3 July 2008 <http://www.nachc.com/client/documents/issues-advocacy/policy-library/
research-data/fact-sheets/Cost-Effectiveness-Fact-Sheet-12-06.pdf>.

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 <http://www.gwumc.edu/sphhs/departments/healthpolicy/chsrp/down
loads/7471.pdf>.
 67
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 ad- Volume
dress the looming nursing shortage. Investment should efficiently produce RNs.
However, while there are currently
several paths to RN licensure, the Quality
allocation of resources across Newly educated RNs must be prepared for the
program types remains a conten- technical complexity of modern medicine.
tious issue. In distributing scarce
resources to support RN education, Equitable Distribution
policy makers should consider the Tthe enlarged RN supply should better allocate
following three elements at right. these professionals to practice in underserved
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 ac- ficient space in 2007. Over the past two
counted for nearly 52 percent of practic- decades, bachelor of science nursing
ing RNs in 2004, and accounted for 54
(BSN) programs have also increased
percent of those newly licensed in 2007.
(Wendt, 2008)
their share, accounting for 36% of newly
• These programs are massively oversub- licensed nurses in 2007. Graduate pro-
scribed, with 75 percent of qualified grams offering licensure and foreign RN
applicants being turned away due to education programs accounted for the
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 bach-
elor’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 gradu-
ate degree than either associate degree or diploma educated RNs,3 making them more
68
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 associ-
ate 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 de-
partments. These settings, while they require competent professionals, often do not in-
volve 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 statisti-
cally 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 priori-
ties 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 certifica-
tion, 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) pro-
grams, primarily in community colleges and in private technical institutes, now provide
the largest share of RN education.4 Associate degree nursing programs are oversub-
scribed, 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 bach-
elor’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 propor-
tions 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 de-
partments. These settings, while they require competent professionals, often do not in-
volve 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
 69
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 pro-
posals are communicated can be just as important as the content of the policies them-
selves. 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 reform-
ers 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 exten-
sive 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, con-
sistently 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.
70
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 prescrip-
tion 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 over-
loaded 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 paper-
work. 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 lead-
ers 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 in-
sured, and saving billions by cutting administrative costs and moving to electronic medi-
cal records. We need leaders who will hold insurance companies accountable, guarantee-
ing 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 afford-
ability. 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 ‘govern-
ment’) 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 get-
ting 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 cur-
rent 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
 73
turning to HSAs because they have no other affordable choice. What is often inexpen-
sive 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 leader-
ship 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; Social-
ized 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 re-
forming 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 Ameri-
cans, 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 Ameri-
can 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 ex-
emptions 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.
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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 tool-
kits 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 work-
ing 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.rooseveltinsti-
tution.org/rx. Visit http://rooseveltinstitution.org/_joinroosevelt to join the
Roosevelt Institution network or to start a chapter at your school. Please e-mail
rooseveltrx@rooseveltinstitution.org with any questions you may have.