10ideasfor health care

July 2010 | Featured IdeaFamily Pratice in America

10 Ideas for Health CareJuly 2010

National DirectorHilary Doe

National Network CoordinatorTarsi Dunlop

Lead Strategist for Health CareSara John

Managing EditorGracye Cheng

EditorCarolina Delgado

The Roosevelt Institute Campus Network455 Massachusetts Ave NW

Suite 650Washington, DC 20001

Copyright © 2010 by the Roosevelt Institute. All rights reserved.

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

10 ideasfor

Health Care

Congratulations to Ankit Agarwal,

author ofIncreasing Family Practice in America

Nominee forPolicy of the Year

Preventing Type 2 Diabetes: Afterschool Exercise in High-Risk Areas

Kurt Anthony

Establishing Farmers Markets in Low-Access NeighborhoodsGreg Mittl et al

Check-Up on Aisle NineMatt Clark

Healthy San Francisco: A Model Local Public OptionJake Grumbach

Modifying the Mental Health Parity & Addition Equity ActMarissa Gluck and Ashley Morton

Enterprise Liability and Medical Malpractice ReformAngela Gandhi

Organ Donation Policy ReformAgnes Eshak

Increasing Family Practice in AmericaAnkit Agarwal

Proper Management of On-Site Medical WasteAdam Jutha

Solving the Vaccine Shortage through Strategic IncentivesMelody W. Lin

Roosevelt Review Preview: The Next Attack Might Be Our Last

Isaac Lara

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Inside the Issue P

p Letter from Washington

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

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

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

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

Sincerely,

Tarsi DunlopNational Network Coordinator

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

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

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

Health for all,

Sara JohnLead Strategist, Health Care

Strategist’s Note P

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

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

Diabetes is rising at an alarming rate. Currently 23.6 million Ameri-cans, 7.8% of the population, has diabetes.4 Of these cases, 5.7 mil-lion are estimated to be undiag-nosed,5 increasing the burden of the disease as unmanaged diabe-tes quickly progresses to costly late-stage complications. Another disturbing trend is the sudden rise in diabetes among youth. For ex-ample, incidence of developing di-abetes among youth increased 10-fold in the 1990s in Cincinnati.6 This trend continues, as 11.0% of adolescents aged 12-19 are now estimated to have impaired fasting glucose, a prediabetic condition.7 If preventative action is not taken, the expected rise in the prevalence of diabetes in the upcoming years will drain health care resources. Huang et al. predict that in the next 25 years, spending on diabetes treatment will increase from $113 billion in 2009 to $336 billion in 2034, adjusting for inflation.8 With total U.S. health care spending presently at $2.26 trillion, this increase cannot be sustained.9

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

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

Preventing Type 2 Diabetes:Afterschool Exercise in High-Risk AreasKurt Anthony, University of Chicago

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Key Facts The U.S. spends $113 billion on diabetes per •year and is predicted to spend three times as much on the disease in the next thirty years.1Only 36% of American high school students •meet recommended physical activity levels.2In a study of prediabetics, people who have no •symptoms of diabetes but who are likely to de-velop the disease in the future, exercise inter-vention reduced disease incidence by 58%.3

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

Additionally, preventing dia-betes complications will im-prove the quality of life of the participants. Children and ad-olescents are the targeted age group because they have more time to participate in the pro-gram and they are more likely to adopt the exercise habits they are taught- impacting these children not just during the program, but for a lifetime. Schools provide the ideal location for an exercise pro-gram targeting this age group. Limiting the programs to high-risk communities allocates resources where they will be most cost-effective. A pilot program should be created in different rural and urban school settings, with students of different ages, to determine the best practices for such a preventative program.

Endnotes1. Elbert S. Huang et. al., “Projecting the Future Diabetes Population Size and Related Costs for the U.S.,”

Diabetes Care 32, no. 12 (2009), http://care.diabetesjournals.org/content/27/4/998.full (accessed April 25, 2010).

2. Active Living Research, “Active Education: Physical Education, Physical Activity, and Academic Perfor-mance,” Robert Wood Johnson Foundation, http://www.activelivingresearch.org/files/Active_Ed.pdf (accessed April 25, 2010).

3. Center for Disease Control and Prevention, “FAQs, prediabetes,” http://www.cdc.gov/diabetes/faq/prediabetes.htm (accessed April 25, 2010).

4. Center for Disease Control and Prevention, “National Diabetes Fact Sheet, 2007,” http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf (accessed April 25, 2010).

5. Ibid.6. Zachary T. Bloomgarden, “Type 2 Diabetes in the Young,” Diabetes Care 27, no.4 (2004), http://care.

diabetesjournals.org/content/27/4/998.full (accessed April 25, 2010). 7. Glen E. Duncan, “Prevalence of Diabetes and Impaired Fasting Glucose among US Adolescents,”

Archives of Adolescent and Pediatric Medicine 160 (2006), http://archpedi.ama-assn.org/cgi/re-print/160/5/523.pdf (accessed April 25, 2010).

8. Huang et. al.9. Centers for Medicare and Medicaid Services, “National Health Expenditure Fact Sheet,” http://www2.

cms.gov/NationalHealthExpendData/25_NHE_Fact_Sheet.asp (accessed April 25, 2010). 10. William Knowler et. al., “Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or

Metformin,” New England Journal of Medicine 346, no. 6 (2002), http://content.nejm.org/cgi/content/short/346/6/393 (accessed April 25, 2010).

11. Aaron L. Carrel et al., “Improvement of Fitness, Body Composition, and Insulin Sensitivity in Overweight Children in a School-Based Exercise Program,” Archives of Pediatrics and Adolescent Medicine 159 (2005), http://archpedi.ama-assn.org/cgi/reprint/159/10/963.pdf?ck=nck (accessed April 25, 2010).

12. Mary Shaw-Perry et. al., “NEEMA: A school-based Diabetes Risk Prevention Program Designed for African American Children,” Journal of the National Medical Association 99, no. 4 (2007) http://www.sahrc.org/JournalArticles/NEEMA_JNMA-042007.pdf (accessed April 25, 2010).

13. Robert Halpern et. al., “Financing afterschool programs,” The Finance Project (2000), http://www.fi-nanceproject.org/Publications/financing_afterschool_programs.htm (accessed April 25, 2010).

14. National Diabetes Information Clearinghouse, “Financial Help for Diabetes Care,” http://diabetes.niddk.nih.gov/dm/pubs/financialhelp/ (accessed April 25, 2010).

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Talking Points The higher incidence of early-onset diabetes and •undiagnosed diabetes will exacerbate the growing diabetes epidemic.PE classes are being cut in schools, which makes ex-•ercise programs an even higher priority.The programs will save billions of dollars in the long •term from the increased productivity of healthier citizens and less spending on diabetes treatment.

The establishment of farmers’ markets in low-access communities can help establish food security, a healthy community gathering place, and become a springboard for healthier, more active living.

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

AnalysisThe implementation of farmers’ markets can revitalize an entire community, providing individual and collective benefits. Residents of communities that incorporate farmers’ markets witness both short- and long-term advantages to their health, such as the de-velopment of healthier commu-nity eating habits and reduction in chronic disease. Furthermore, economic analyses of farmers’ markets demonstrate that prices of market products typically lie in between wholesale and supermarket prices, indicating that participating local farmers and residents will profit from these markets. Farmers’ markets also provide a unique interface for community interaction and de-velopment. In order to provide a safe and pleasant market area, establishing a farmers’ market requires investment from residents and local organizations. Participation of lo-cal youth can generate a sense of responsibility and dedication to the market while also ensuring its sustainability. Such participation has occurred in the Brooklyn neighbor-hood of Redhook , where local youth have helped to prepare and maintain the market space. This space of community collectivity can be utilized as a type of meeting grounds where community education and communication, such as weekly workshops on health-related topics, can take place.

Establishing Farmers MarketsIn Low-Access NeighborhoodsGreg Mittl, Lauren Hunter, Katie Levandoski, Martin Weaver, Abhinav Gupta, and Karissa Britten - Yale University

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Key Facts There are currently 5,274 farmers’ markets reg-•istered with the USDA in the United States, as compared to 1,755 markets in 1994, and fewer than 100 markets in 1974. 82% of farmers’ markets are self-sustaining—•market income is sufficient to pay for all costs associated with the operation of the market. The average supermarket carrot travels 2,000 •miles from field to table, whereas most farmers’ market produce travels less than 50 miles.

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

StakeholdersAll community members benefit from the addition of farmer’s markets to low-access areas, including many who may not qualify as ‘low income’ but who nonetheless lack consistent ac-cess to affordable, healthy food. The access to fresh produce helps promote healthier diets and lifestyles. Furthermore, invested community members feel a responsibility to sustain the markets and ensure the safety of the surrounding area. This community investment pro-vides the opportunity for eco-nomic stimulus and community revitalization. Farmers will also benefit from the economic security and recognition that comes from a larger customer base. Also, community developers can have a stake in the project, while public health advocates can use farmers’ markets as a venue to raise awareness about healthy diet and exercise.

Endnotes1. U.S. Department of Agriculture, “Farmers Market Program,” http://www.ams.usda.gov (accessed April

19, 2010).2. Agricultural Marketing Service, “Facts about Farmers Markets,” http://www.ams.usda.gov/FactsAbout-

FarmersMarkets (accessed April 19, 2010).3. Global Gourmet, “Facts about Farmers’ Markets,” http://www.globalgourmet.com (accessed April 19,

2010).4. CitySeed, “Market Vendor Information,” http://www.cityseed.org/city_markets/vendor/index.shtml (ac-

cessed April 19, 2010).5. CitySeed, “About CitySeed,” http://www.cityseed.org/city_markets/about/history.shtml (accessed April

19, 2010).6. Added Value, “History,” http://www.added-value.org/overview-of-added-value (accessed April 19,

2010).

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Talking Points Small farms and low-income communities benefit •economically from the added business of farm-ers’ markets. Making food stamps more valuable when ex-•changed for healthy food provides a direct, fo-cused incentive for the purchaser.Farmers’ markets encourage community invest-•ment and the beautification of public spaces; they also provide a consistent, safe space for a variety of public health and wellness outreach efforts.Accessible and affordable fresh produce encour-•ages healthier dietary habits and can reduce chronic disease in a community.Establishing new markets requires the coordi-•nated efforts of community leaders, local govern-ment, and area farmers.

Improve quality and accessibility of care for the uninsured living in medically under-served areas by encouraging partnerships between retail health clinics and commu-nity health centers (CHCs). Combining the ease of access to retail clinics with the scope of services found in CHCs could provide a relatively affordable home for the primary care needs of uninsured individuals.

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

Retail health clinics began operating in densely populat-ed urban and suburban areas around the year 2000. Op-erating out of grocery stores, pharmacies, or retail chains like Target and Wal-Mart, retail clinics have become popular as a source of vac-cinations and care for minor health problems, such as sore throats. They offer a limited scope of services and are

staffed by nurse practitioners or physician assistants who have their work reviewed by physicians. The use of nurse practitioners is a critical reason why retail clinics are able to keep their operating costs lower than traditional offices while still maintaining quality of care. Despite their lack of physicians, retail clinics have scored higher than primary care offices in some studies on the basis of appropriate treatment for a given condi-tion, mostly due to the willingness of retail clinics to practice evidence-based medicine. Short waiting periods and extended hours of operation allow individuals to seek basic medical attention at their convenience.

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

Check-Up on Aisle NineMatt Clark, University of North Carolina at Chapel Hill

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Key Facts Rural America is home to 20% of the population, 9% •of physicians, and 37% of CHCs. About 90% of retail clinic visits were for simple, •acute conditions and preventive care. About 18% of all visits to primary care settings and •over 13 million trips to the emergency room per year could be handled by retail clinics. The average cost for a typical visit to a retail health •clinic is $110 compared to $166 at a physician’s office and $570 at an emergency department.

StakeholdersState governments consistently facing budget shortfalls can ex-periment with the use of retail health clinics to relieve stress on emergency departments. Chain stores looking to boost their pub-lic image could offer their com-munity low-priced, quality care. Federal funding would likely be necessary for expansion of retail clinics into rural areas.

Next StepsRural areas lacking pharmacy or grocery store chains would have to consider the costs and benefits of adding a mega-retailer to their towns. Tax breaks could be given for retailers who partner with CHCs to offset the added payroll liabilities of clinic personnel. Extensive planning would need to take place, heeding concerns of retailers and CHCs, to establish policies outlining what procedures are to be completed where.

Endnotes1. Michael Gusmano et al., “Exploring The Limits Of The Safety Net: Community Health Centers And

Care For The Uninsured,” Health Affairs, 2002: Vol. 21 No. 6, http://content.healthaffairs.org/cgi/con-tent/full/21/6/188.

2. Roger A. Rosenblatt et al., “Shortages of Medical Personnel at Community Health Centers,” The Jour-nal of the American Medical Association, 2006: Vol. 295 No. 9,

http://jama.ama-assn.org/cgi/content/full/295/9/1042.3. Ateev Mehrotra et al., “Retail Clinics, Primary Care Physicians, And Emergency Departments: A

Comparison of Patients’ Visits,” Health Affairs, 2008: Vol. 27 No. 5, http://content.healthaffairs.org/cgi/content/full/27/5/1272.

4. Ibid.5. Richard Cauchi et al., “Retail Health Clinics: State Legislation and Laws,” National Conference of State

Legislatures, Nov. 2009, http://www.ncsl.org.6. Devon Herrick, “Retail Clinics: Convenient and Affordable Care,” National Center for Policy Analysis,

Jan. 2010: No. 686, http://www.ncpa.org/pub/ba686.7. Ibid

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Talking Points CHCs have trouble finding and retaining prima-•ry care physicians. Additionally, they are unable to handle all of their uninsured patients’ needs. Retail clinics are streamlining communication •between providers by using, almost universally, electronic medical records. Increased competition - via more retail clinics •- could spur cost-cutting measures by primary care offices.Providing primary care in a retail clinic is a first •step towards creating a sense of a “medical home” for uninsured individuals.

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

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

The HCSO contains two policies. First, Supervisor Ammiano created the fund-ing component that requires all firms to “pay or play”: either pay a penalty to the City or provide health insurance for their employees (depending on the number of workers). Second, the Ammiano pol-icy merged an idea from the Director of the Department of Public Health, Mitch Katz, and Mayor Gavin Newsom of a new City-run health access plan (now called Healthy San Francisco) from the recom-mendations of the Universal Healthcare Council, consisting of appointed officials from labor, business, and medicine.

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

Healthy San Francisco:A Model Local Public OptionJake Grumbach, Columbia University

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Key Facts Since its implementation in 2007, San •Francisco’s health access plan has cov-ered 50,000 of its previously 82,000 uninsured residents. 73% of enrollees have incomes below •the federal poverty line, and they utilize primary care appointments more than those with other health coverage. Quarterly fees for the access plan range •from $0 to $450, depending on income.

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

StakeholdersThe initiative remains quite popular among residents and interest groups like labor unions and community orga-nizations. An independent Kaiser Fam-ily Foundation report found that 94% are at least “somewhat satisfied” with the program and 92% would recom-mend it to a friend. Unions and activist groups were instrumental in advocating the policy in San Francisco. However, a restaurant owners organization, the Golden Gate Restaurant Association (GGRA), found the minimum employer health expenditure for firms not pro-viding insurance (currently $1.23 for firms with 20 to 99 workers) punitive. The GGRA filed suit against the HCSO’s employer mandate, claiming the provision violated the federal ERISA law of 1974. The group lost in an appeal as it became clear that San Fran-cisco restaurant owners were passing the costs onto their patrons (who were happy to pay an extra dollar or so for entrees), nullifying the GGRA’s argument that the HCSO’s employer spending requirement was putting them out of business.

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

Endnotes1. “News and Updates,” in HeartBeat: A publication for Healthy San Francisco participants: San Francisco

Department of Public Health, 2009.2. Heather Knight, “Healthy San Francisco Rates High in Satisfaction,” San Francisco Chronicle, Aug. 26,

2009, D2. 3. “Healthy San Francisco,” in Key Facts, edited by Kaiser Commission on Medicaid and the Uninsured:

Kaiser Family Foundation, 2009.4. Ibid.5. “Status Report on the Implementation of the San Francisco Health Care Security Ordinance,” San

Francisco: Department of Public Health, Office of Labor Standards Enforcement, and City Control-ler’s Office, 2009.

6. John Iglehart, “Medicaid Expansion Offers Solutions, Challenges,” Health Affairs 29, no. 2 (2010): 230-32.

7. Knight, D2. 8. Brian P. Goldman, “San Francisco Health Care Security Ordinance: Universal Health Care Beyond

Erisa’s Reach?” Stanford Law & Policy Review 19, no. 2 (2008): 361-76.

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Talking Points It is more cost-effective to enroll everyone •than to leave residents without insurance; each enrollee elects a “medical home” to receive primary and preventative care. Small businesses, whose health costs are •much more than those of large firms, will finally have an affordable health care op-tion for their employees.Young people, part-time workers, non-•union workers, immigrants, and the very poor—all especially uninsured groups—have an affordable option with quarterly fees based on income level.

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

For years, there has been enormous inequity between mental and physical disorders in terms of insurance coverage. On January 1st, 2010, the Mental Health Parity and Addic-tion Equity Act of 2008 (MHPAEA) came into effect in order to provide Americans with mental health care coverage that better matches the patient’s needs. The Act ensures that group health plans covering fifty or more employees will have mental health and substance abuse treatment benefits that are identical to general health care benefits. Despite this new legislation, many Americans, especially lower-income and the unem-ployed, are left without adequate access to the mental health care that they need. The following significant health care challenges and disadvan-tages remain unaddressed: a) the MHPAEA covers only larger businesses, those with fifty or more employees; b) mental health and substance abuse disorders listed in the DSM-IV-TR are covered only at the dis-cretion of the employer, leav-ing some employees without necessary care; and c) benefits cease upon termination of em-ployment.

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

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

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

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Key Facts Most insurance companies cap the number of •therapy sessions at 20 per year.5Over 25 percent of Americans suffer from a men-•tal health disorder, with 6 percent of Americans suffering from a serious mental health condition.6Mental health disorders are the leading cause of •disabilities for Americans ages 15 – 20.7Most states do not offer the same insurance cov-•erage and benefits for mental health care as they do for general health care.8

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

StakeholdersThe American public would benefit from the proposed modifications to the current version of the MHPAEA. They would have increased access to necessary therapy, medications, and other sup-port systems. In addition, the American public would save money, as health insurance expenses and co-payments will decrease.

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

Endnotes1. U.S. Department of Health and Human Services, “The Mental Health Parity and Addiction Equity Act,”

http://www.cms.gov/HealthInsReformforConsume/04_TheMentalHealthParityAct.asp (accessed April 19, 2010).

2. EJ Freeman, LJ Colpe, TW Strine, S Dhingra, LC McGuire, LD Elam-Evans, et al., “Public Health Surveil-lance for Mental Health, Prev Chronic Dis 2010, 7(1), http://www.cdc.gov/pcd/issues/2010/jan/09_0126.htm (accessed April 19, 2010).

3. North Carolina Institute of Medicine, “NC Consumer’s Guide to Health Plan Selection,” http://www.nciom.org/hmoconguide/index.html, (accessed April 19, 2010).

4. National Conference of State Legislatures, “State Laws Mandating or Regulating Health Benefits,” http://www.ncsl.org/IssuesResearch/Health/StateLawsMandatingorRegulatingMentalHealthB/ta-bid/14352/Default.aspx (accessed April 19, 2010).

5. Ibid.6. Ibid.7. North Carolina Institute of Medicine, “NC Consumer’s Guide to Health Plan Selection.” 8. Ibid., National Institute of Mental Health. “Statistics” http://www.nimh.nih.gov/health/topics/statistics/

index.shtml (accessed April 26, 2010).

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Talking Points North Carolina no longer caps the number of therapy •sessions a person can attend. Other states with simi-lar legislation include Maine, Minnesota, New Hamp-shire, and Rhode Island. Several other states are cur-rently considering adopting similar legislation.Under the current version of the Act, insurers who •offer both physical and mental health services can still enforce coverage limits specific to mental health care, including high copayments and inadequate ac-cess to mental health care options.

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

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

The term “enterprise liability” is associated with joint liability litigation. Joint liability liti-gation is intended to help individuals harmed in cases in which direct accountability is dif-ficult to determine. Veterans Affairs hospi-tals and Health Maintenance Organizations (HMOs) currently utilize enterprise liability—patients who have suffered from medical er-rors in a veterans hospital prosecute the U.S. government instead of their physician. The Clinton administration’s proposed health plan recommended managed care and en-terprise liability as a means of regulation and quality control. Due to the increased prevalence of managed care, enterprise liability is necessary to lower health care costs and improve quality of care.

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

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

Enterprise Liability And Medical Malpractice ReformAngela Gandhi, University of California San Diego

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Key Facts Enterprise liability holds hospitals, •instead of doctors, accountable for medical errors.Over 150,000 reports were filed •against doctors in 2006.91 in 6 who file a deserving claim do •not receive adequate payment.10

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

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

Next Steps Enterprise Liability is something that will take time to fully implement, but the first step is for doctors and hospi-tals to contact legislators and advocate for this type of medical malpractice re-form. Since many malpractice laws vary by state, enterprise liability needs to be implemented on a state-by-state basis, and according to each states’ particular medical malpractice system. Additional-ly, enterprise liability cannot completely replace the current medical malpractice system as there will still likely be cases in which doctors make egregious mistakes out of negligence entirely of their own accord. These are actions for which the hospital cannot be held liable. Over time, enterprise liability can be enacted as a form of legislation that will serve as a much better solution to the current medical malpractice system.

Endnotes1. M. Mello, D. Studdert, “The medical malpractice system: structure and performance, “ In: W. Sage, R.

Kersh, eds. Medical Malpractice and the US Health Care System, 1st Ed, New York, NY: Cambridge University Press, (2006):13.

2. Mello, “The medical malpractice system: structure and performance,”14.3. J.J. Segal, and M. Sacopulos, “A Modified no-Fault Malpractice System can Resolve Multiple Healthcare

System Deficiencies “ Clinical Orthopaedics and Related Research 467, no. 2 (Feb, 2009): 420-426. 4. Karl. A. Boedecker, J.Kasulis, F. Morgan, J. Stoltman, “The History of Enterprise Liability,” CHARM

Archive, 8 (1999): 205-222 5. J. Bernstein, D. MacCourt, and B. D. Abramson, “Topics in Medical Economics: Medical Malpractice,”

The Journal of Bone and Joint Surgery 90, no. 8 (2008): 1777- 1782. 6. William M. Sage, “Enterprise Liability and the Emerging Managed Health Care System, “ Law and Con-

temporary Problems 60, no. 2 (1997): 15.7. Sage, “Enterprise Liability and the Emerging Managed Health Care System,” 35.8. Sage, “Enterprise Liability and the Emerging Managed Health Care System,” 4.9. US Department of Health and Human Services, National Practitioner Data Bank 2006 Annual Report,

Health Resources and Services Division, 2006.10. D. Studdert, M. Mello, A. Gawande, T. K. Gandhi, A. Kachalia, C. Yoon, A. L. Puopolo, and T. A. Brennan,

“Claims, Errors, and Compensation Payments in Medical Malpractice Litigation, “ The New England Journal of Medicine 354, no. 19 ( 2006): 2024-2033.

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Talking Points Enterprise liability lowers costs incurred •through unnecessary medical errors by physicians.Enterprise liability lowers the rates of •malpractice insurance for doctors. Enterprise liability decreases the inci-•dence of defensive medicine.Enterprise liability better enables pa-•tients to receive adequate compensation for medical malpractice.

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

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

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

While 85 percent of Americans say they support donation, less than 30 percent have designated themselves as donors.8 Obtaining consent continues to be a ma-jor difficulty that hinders the organ dona-tion process. Low registration numbers are not an indication of an unwillingness to become an organ donor, but rather a lack of information about how to register and the magnitude of the current donor shortage.

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

In a study by Johnson and Goldstein, they demonstrate that there is a difference of 60 percentage points between those who become donors from an opt-out method and those who become donors from an opt-in method.9 The study suggests that changing the default to consent in the United States could increase the rate of donations by add-ing thousands of donors a year.

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

Organ Donation Policy ReformAgnes Eshak, Macaulay Honors College at Queens College

20

Key Facts One organ donor can save up to eight •lives.2More than 9,500 people in New York •State are in need of organ transplants.3In 2008, there were only 373 deceased •organ donors in New York State.4

About 540 New Yorkers die each year •because of a shortage of donors.5

Next StepsA new organ donation system can be modeled after Spain’s policy, which is truly a best practice example. According to the Council of Europe, Spain has one of the best organ donation programs in the world. It employs a “weak” presumed consent law, in which everyone is assumed to be a donor, but family members of the deceased person may opt-out.10

Countries that use a “strong” pre-sumed consent law, in which the family of the deceased person has no say about organ donation, fare even better in organ donation rates. Austria uses this system and has the highest organ donation rate in the world.11

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

1. Sam Crowe and Eric Cohen, “Organ Donation Policy,” The President’s Council on Bioethics, (Sept. 2006), http://www.bioethics.gov/background/organ_donation.html#part1 (accessed April 3, 2010).

2. New York Organ Donor Network, “Organ & Tissue Donation – Statistics,” New York Organ Donor Net-work, Inc., http://www.donatelifeny.org (accessed April 25, 2010).

3. Ibid.4. Ibid.5. Ibid.6. Crowe and Cohen, “Organ Donation Policy.”7. New York Organ Donor Network, “Organ & Tissue Donation – Statistics.”8. Ibid.9. Ibid.10. Annabel Ferriman, “Spain tops the table for organ donation,” British Medical Journal 26 Apr, 2010.

http://findarticles.com/p/articles/ mi_m0999/is_7269_321/ai_67581417 (accessed April 25, 2010).11. D. Goldstein and E.J. Johnson, “Do defaults save lives?,” Science 302 (2003):1338–9.

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Talking Points Although there is an organ donation registry in •New York, it fails to reach the adequate number of potential donors to fill the organ donation needs of the city. Restructuring the organ donation policy in New •York will save hundreds of lives every year.Changing the organ donation policy in New •York to an opt-out system is feasible, as dem-onstrated by the population’s overwhelming support for donation and its success in other countries, such as Spain and Austria.

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

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

With the average educational debt of graduating medical students now in excess of $150,000, graduates in-creasingly choose medical special-ties as a career path, neglecting the lower paying specialty of fam-ily practice. Medical professionals warn that, because of this alarming trend, the United States may suffer a shortage of at least 40,000 family care practitioners by 2025. Areas with a larger population of primary care doctors provide an emphasis on comprehensive patient-focused care, greater accessibility to care, more frequent preventative care, and better coordination of care with specialists when necessary.

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

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

Increasing Family Practice in AmericaAnkit Agarwal, Boston University

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Key Facts Areas with the most family physicians per per-•son spend over 20% less on Medicare Part B reimbursements per person and have better health outcomes than areas with the least number of family physicians per person. Only 20% of U.S. physicians are family practice •physicians, whereas most highly industrialized countries have nearly double that percent. Less than 8% of U.S. medical graduates choose •family practice residencies, whereas 19% of IMGs choose family practice residencies.

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

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

Endnotes1. Ted Epperly, “AAFP Statement: 2009 Resident Match Results Sharpen Focus on Family Physician Shortage, Health System Reform -- 2009

-- American Academy of Family Physicians,” Home Page -- American Academy of Family Physicians, http://www.aafp.org/online/en/home/media/releases/newsreleases-statements-2009/2009-resident-match-results-sharpen-focus-on-family-physician-shortage.html (accessed April 19, 2010).

2. Brian Hedger, “ PROFESSION Med school seniors headed for primary care see a challenging future,” American Medical Association - Phy-sicians, Medical Students & Patients (AMA), http://www.ama-assn.org/amednews/2009/03/30/prsc0330.htm (accessed April 19, 2010).

3. “AMA - Medical Student Debt,” American Medical Association - Physicians, Medical Students & Patients (AMA), http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/medical-student-section/advocacy-policy/medical-student-debt.shtml (accessed April 19, 2010).

4. Jack M Colwill, James M Cultice, and Robin L Kruse, “Will Generalist Physician Supply Meet Demands Of An Increasing And Aging Popula-tion?” Health Affairs 27, no. 3 (2008): 232-241, http://content.healthaffairs.org/cgi/reprint/27/3/w232.pdf (accessed April 19, 2010).

5. Barbara Starfield, “Population Health Outcomes - Is the Role of Family Physicians Important?” October 29, 2009, http://www.cfpc.ca/local/files/CME/FMF_2009/Dr.%20Starfield%20slides.pdf (accessed 1/09/10).

6. “Results and Data 2008 Main Residency Match,” National Resident Matching Program, www.nrmp.org/data/resultsanddata2008.pdf (ac-cessed April 19, 2010).

7. Elie A Akl, Reem Mustafa, Fadi Bdair, and Holger J Schünemann, “The United States Physician Workforce and International Medical Gradu-ates: Trends and Characteristics,” Journal of General Internal Medicine 22, no. 2 (2007): 264-268, http://www.springerlink.com/content/u126021v3n536098/ (accessed April 19, 2010).

8. “Exchange Visitors,” US Department of State, http://travel.state.gov/visa/temp/types/types_1267.html (accessed April 19, 2010).9. “Temporary Workers,” US Department of State, http://travel.state.gov/visa/temp/types/types_1271.html (accessed April 19, 2010).10. “US Health Care Spending: Comparison with other OECD Countries,” CRS report for Congress, assets.opencrs.com/rpts/

RL34175_20070917.pdf (accessed April 18, 2010).11. Barbara Starfield, “Population Health Outcomes - Is the Role of Family Physicians Important?” October 29, 2009, http://www.cfpc.ca/

local/files/CME/FMF_2009/Dr.%20Starfield%20slides.pdf (accessed 1/09/10).12. “Update on Bills Regarding H1B Cap,” Murthy Law Firm : U.S. Immigration Law, http://www.murthy.com/arc_news/a_billh1.html (accessed

April 19, 2010).13. “AAFP Reviews 2010 Medicare Physician Payment Schedule -- AAFP News Now -- American Academy of Family Physicians,” American

Academy of Family Physicians, http://www.aafp.org/online/en/home/publications/news/news-now/government-medicine/20091208cms-2010-ltr.html (accessed April 19, 2010).

14. Barbara Starfield, “Population Health Outcomes - Is the Role of Family Physicians Important?,” October 29, 2009, http://www.cfpc.ca/local/files/CME/FMF_2009/Dr.%20Starfield%20slides.pdf (accessed 1/09/10).

15. Barbara Starfield, “Population Health Outcomes - Is the Role of Family Physicians Important?,” October 29, 2009, http://www.cfpc.ca/local/files/CME/FMF_2009/Dr.%20Starfield%20slides.pdf (accessed 1/09/10).

16. Boccuti, Cristina, and Marilyn Moon. “Comparing Medicare And Private Insurers: Growth Rates In Spending Over Three Decades.” Health Affairs 22, no. 2 (2003): 230-237. http://faculty.arts.ubc.ca/revans/384USmedicare.pdf (accessed May 17, 2010).

17. DH Mark, MS Gottlieb, BB Zellner, VK Chetty, and JE Midtling, “Medicare costs in urban areas and the supply of primary care physicians,” Journal of Family Practice 43, no. 1 (1996): 33-39, http://www.ncbi.nlm.nih.gov/pubmed/8691178 (accessed April 18, 2010).

18. “Workforce Summary – General Practitioners,” National Health Service, docs.google.com/viewer?a=v&q=cache:C13za-lGkwkJ:www.wrt.nhs.uk/index.php/component/docman/doc_download/46-general-practitioners+30,936+general+practitioners&hl=en&gl=us&pid=bl&srcid=ADGEESgfdPtOS7JhxuxBWACcXov9ExGG-CWaA3NdzUDSw-nO401cuBmERXz5gM-pv4RJDnNtP7Yhh1E3jGTSkJlIte9-qxZi-M02aKQwWpV7q5lzuYzS53g3deukr2wlt5yDIl2kcGdwz&sig=AHIEtbRnzzTFKBMKnL-cbR3A2z7AS9J5ZA (accessed April 19, 2010).

19. Barbara Starfield, “Population Health Outcomes - Is the Role of Family Physicians Important?,” October 29, 2009, http://www.cfpc.ca/local/files/CME/FMF_2009/Dr.%20Starfield%20slides.pdf (accessed 1/09/10).

20. “Results and Data 2008 Main Residency Match,” National Resident Matching Program, www.nrmp.org/data/resultsanddata2008.pdf (accessed April 19, 2010).

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Talking Points Increasing family practice physi-•cians in the U.S. is a budget-neutral way to control health care costs and better health outcomes.Increasing family practice will im-•prove access to and choice of phy-sicians for patients.

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

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

Dioxins are toxic man-made chemicals released as by-products of waste incineration. These chemicals cause severe health risks that may affect hu-man development. Waste incin-erators release a fair amount of dioxins, regardless of whether or not they meet the United States Environmental Protec-tion Agency’s (EPA) regulations. Dioxins and other pollutants are released into the atmosphere, increasing the risk of exposure to surrounding populations and residential communi-ties. The lack of national regulation results in varying waste regulation among states. However, a national decision to establish an incinerator registry – an official record of medical waste incinerators across the United States – would allow the EPA to monitor the levels of infectious and non-infectious waste incineration.

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

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

Proper Management of On-Site Medical WasteAdam Jutha, University of North Carolina at Chapel Hill

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Key Facts The number of medical waste incinerators cur-•rently operating in the United States is unknown.6Hospitals generate about 2.1 to 4.8 million tons of •medical waste per year, of which 10 to 15 percent is considered infectious waste.7Since 1987, United States’ incinerator emissions •have decreased by 99.9%.8Research from Germany’s Ministry of the Environ-•ment shows that incinerator plants produced 33% of all dioxins in 1990 compared to only 1% of all dioxins in 2000.9

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

To minimize the negative effects of in-cinerator waste dioxins affecting neigh-boring communities, regular incinerator checks need to be scheduled. This will ensure that specific guidelines are met. According to the Ministry of the Environ-ment of Germany, “in 1990 one third of all dioxin emissions in Germany came from waste incineration plants, for the year 2000 the figure was less than 1%.” A significant decrease in dioxin emis-sions has also been noted by the United States EPA, claiming that a 99.9% reduc-tion in total emissions has occurred over the past two decades due to increased emis-sion regulations. While this decrease suggests a great deal of regulations and mea-sures have already been put in place, enforcing regular checks would ensure proper management of medical waste incinerators. At present, Germany requires incinerator checks every six months, allowing for authorities to ensure medical waste incinerators meet regulations and do not significantly impact surrounding communities. The United States should put similar regulations in place to provide neighboring communities and hospital residents with a safe environment in which to carry out daily activities.

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

1. U.S. Congress, Office of Technology Assessment, Issues in Medical Waste Management – Background Paper, OTA-BP-O-49 (Washington, DC: U.S. Government Printing Office, 1988), 15.

2. Milton R. Beychok, “A data base for dioxin and furan emissions from refuse incinerators,” Atmospheric Environment 21 (1987): 29-36.

3. Scottish Environmental Protection Agency, “Incineration of Waste and Reported Human Health Effects” (Glasgow: Health Protection Scotland, 2009), 15.

4. Federal Ministry for Environment, Nature Conservation and Nuclear Safety, “Waste incineration – A potential danger? Bidding farewell to dioxin spouting” (Berlin: The German Federal Environment Min-istry, 2005), 3.

5. U.S. Congress, Office of Technology Assessment, 15.6. Beychok, 29-36.7. U.S. Congress, Office of Technology Assessment, 15.8. Beychok, 29-36.9. Federal Ministry for Environment, Nature Conservation and Nuclear Safety, 3.

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Talking Points Dioxins and pollutants released into the •atmosphere increase the health risk to surrounding populations and residential communities.A registry would allow the EPA to track •and monitor medical waste incinerators across the country to improve function-ing and efficiency.Regular checkups ensure medical facili-•ties and hospitals remain committed to following best practices.

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

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

The U.S. Health Resources and Ser-vices Administration of the Depart-ment of Health and Human Resourc-es (HHS) should expand the number of vaccines covered in the presently effective Vaccine Injury Compensa-tion Program (VICP), which ensures that people suffering from del-eterious side-effects from a recom-mended vaccine are appropriately compensated by the Vaccine Trust Fund.2 According to a research study from the Journal of Health Politics, Policy and Law, vaccine availability and childhood immunization rates improved during the early years after the VICP was implemented.3 Litigation against manufacturers of vaccines has virtually ceased since the VICP started and vaccine pro-duction has been shown to have increased noticeably.4 Expanded coverage of a greater number of vaccines will bolster the continuance of less adversarial liability issues and encourage manufacturers to undergo further production for a wider range of vaccines. Further, the Department of Justice, which represents HHS, should establish a regulato-ry compliance defense against tort suits, given that a vaccine has met the strict require-ments set out by the FDA; if a vaccine is FDA-approved, it should be safe for usage.5

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

Solving the Vaccine Shortage Through Strategic IncentivesMelody W. Lin, University of California San Diego

26

Key Facts According to a 2003 study funded by the •CDC, approximately 300 out of 400 doc-tor’s offices in 12 states reported problems in consistently obtaining enough Prevnar, a vaccine used to prevent pneumonia and meningitis in children.8In 2002, 5 of the recommended childhood •vaccinations continued to face shortages; the Hib vaccine is still facing a shortage.9In 2009, the U.S. produced less than 20% of •the H1N1 vaccines it had hoped to supply by the end of the year.10

forces companies to leave vaccine production and in some cases has aggravated the vaccine shortage. For example, in 1991, the FDA or-dered the removal of thime-rosol from vaccines, even though the risk of no vacci-nation heavily overshadowed the risk of thimerosol. This regulation created a 25% re-duction in crucial childhood vaccines and also heavily af-fected manufacturing costs, profits and efficiency.7 Low market prices, high risk costs and overregulation discourages companies from entering the vaccine industry and forces many companies to drop out. Therefore, artificially low prices demanded by the government and overregulation must be reevaluated.

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

Endnotes1. Robert Goldberg et al., “MI Conference Series 7 - Solving the Vaccine Shortage: Market Solutions or Government Intervention?,” Manhat-

tan Institute For Policy Research, http://www.manhattan-institute.org/html/mics7.htm (accessed January 6, 2010).2. U.S. Health Resources & Services Administration, “HRSA - National Vaccine Injury Compensation Program,” U.S. Health Resources &

Services Administration, http://www.hrsa.gov/vaccinecompensation (accessed January 10, 2010).3. Derry Ridgway, “No-Fault Vaccine Insurance: Lessons from the National Vaccine Injury Compensation Program,” Journal of Health Politics,

Policy and Law 24, no. 1 (1999): 59-90. http://jhppl.dukejournals.org/cgi/content/abstract/24/1/59 (accessed January 10, 2010).4. U.S. Department of Justice. “DOJ Vaccine Compensation Program - About the Program,” United States Department of Justice, http://

www.justice.gov/civil/torts/const/vicp/about.htm (accessed January 11, 2010).5. Goldberg et al., “Solving the Vaccine Shortage.” 6. Natasha Metzler, “Understanding Demand, Not Just Supply, Key to Solving Flu Vaccine Shortages,” Pharmaceutical Executive, http://

pharmexec.findpharma.com/pharmexec/article/articleDetail.jsp?id=283406 (accessed January 11, 2010).7. Matt Baumann, “What’s Behind Vaccine Shortages?,” National Center for Policy Analysis NCPA, http://www.ncpa.org/pub/ba655 (ac-

cessed January 6, 2010).8. Medical Letter on the CDC & FDA. “Vaccine shortage study exposes “patchwork” system.(Prevnar),” AccessMyLibrary, http://www.ac-

cessmylibrary.com/article-1G1-98044576/vaccine-shortage-study-exposes.html (accessed January 11, 2010).9. Shannon Stokley et al., “Impact of vaccine shortages on immunization programs and providers,” American Journal of Preventive Medicine

26, no. 1 (2004): 15-21. http://www.ajpm-online.net/article/S0749-3797(03)00286-1/abstract (accessed January 6, 2010).10. Denise Grady, “Officials See a Shortage in Vaccine for Swine Flu,” The New York Times, http://www.nytimes.com/2009/10/17/health/17flu.

html (accessed January 7, 2010).11. Linda Gorman, “Vaccine “Public Option Plan” Has Produced Shortages of Vaccines,” Independence Institute: Patient Power, http://www.

patientpowernow.org/2009/11/08/vaccine-public-option-plan-shortages/ (accessed January 11, 2010).12. Goldberg et al., “Solving the Vaccine Shortage.”13. Ibid.14. Gorman, “Vaccine “Public Option Plan.””

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Talking Points In 2003, the Institute of Medicine reported that the •number of vaccine manufacturers for the U.S. mar-ket had plunged from 26 in 1967 to 4 in 2002.11The world’s vaccine market is small, making up less •than 2 % of the pharmaceutical market.12Because of continuing shortages, deferrals are set •for certain vaccines and priority levels are set for high-risk patients. Thus, highly preventable infec-tious diseases can again pose a threat, and physicians are unable to optimally care for their patients.13Since the start of the Vaccines for Children Program •(VCP) in 1993, government has demanded bulk sup-plies of vaccines at greatly discounted prices, caus-ing many manufacturers to drop out.14

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

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

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

To read more, visit www.rooseveltinstitute.org for the full white paper,part of the forthcoming Roosevelt Review.

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Roosevelt Review Preview:The Next Attack Might Be Our LastIsaac Lara, Columbia University

www.rooseveltcampusnetwork.org