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10 Ideas for Health CareJuly 2011

National Director Hilary Doe

Director of OperationsTarsi Dunlop

Lead Strategist for EducationRajiv Narayan

EditorAmreen Rahman

Alumni ReviewersCarissa Chu Eva DuGoffRob Nelb

Alex Hertel-Fernandez

The Roosevelt Institute Campus NetworkA division of the Roosevelt Institute

455 Massachusetts Ave NW Suite 650Washington, DC 20001

Copyright (c) 2011 by the Roosevelt Institute. All rights reserved.

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

10 Ideas

FOR

Health Care

Congratulations toKatie silvius Mia Przyborowski

authors ofPrioritizing success:

Treating Psychotic Mental Illness

Nominee forPolicy of the Year

Inside the Issue P

A Millennial Remedy for Medicaid’s Rising CostsCharles Sisk

Expand New York’s Telehealth CoverageJannie Trelogan

Prioritizing Success:Treating Psychotic Mental Illness

Katie Silvius and Mia Przyborowski

Student Mental Health and On-Campus PsychotherapyGrant Heskamp

Early Prevention through School ProgramsJohna Coby Jones and Michael Rist

Ensure Health Access in Rural AmericaPatrick Short and Rachel Burns

Health Insurance Toolkits for College GraduatesRahul Rekhi

A Local Opportunity in National Health Care ReformJohn Morgan

An Expanded HIV/AIDS Relief FocusHannah Nemer

“X” Marks the Hot-SpotSameer Sant

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p Letter from Washington

We are pleased and proud to present the third edition of the 10 Ideas Series. Com-prised of six journals, these articles represent the best of our student policy work from across the country. Students are told they are too young to participate in the policy process and that they must wait their turn. Roosevelt’s founders believed, as we do, that the next generation of leaders deserves a voice in current political debates. In the winter of 2009, the Roosevelt Institute Campus Network launched a national ini-tiative called Think 2040, asking young people to design the future they want to inherit. Millennials nationwide contributed their individual visions at campus and regional Think 2040 conversations as well as through Think2040.org, a website designed to capture the values and ideas of a generation. These diverse voices were encapsulated in the recently released Blueprint for Millennial America; this summer we’re proud to publish this set of policy ideas that will move us forward towards our shared vision for 2040. Young people want to reinvent our social safety net to lift Americans up during tough economic times when support is most important. They want to see community needs drive investments in high-speed rail, build local green job corps, and devise a renewable energy market. Millennials identified preventative care and a culture of wellness as a key priority, with more access to fresh food and community health clinics. As future leaders, they want equity in opportunity for all Americans through access to quality education; they see it as vital for long-term economic growth and competitiveness in the world mar-ket. In order to inherit this future, we must start building it today. Roosevelt members research, design and write their policy ideas from a grassroots per-spective; in doing so, they exemplify a generation of committed practitioners who strive to understand public policy in the context of effecting long-term change. Yale is working to support the revitalization of city blocks in New Haven through loans to low-income en-trepreneurs, while the health care policy center collaborated with Young Invincibles to design information toolkits for their graduating peers. Northwestern University received a grant to conduct a survey to establish a baseline of single-use disposable bag usage on campus and is also working with stakeholders in Evanston IL to forgo the use of plastic bags. Students in the DC area are consulting with Teach for America at a low-income Washington D.C high school, and at ASU, they are working to develop a hydroponic gar-den to build a more sustainable university community. Some of the ideas you read here will make their way into state and local government offices or become part of a federal discussion while others may become initiatives through partnerships. We are proud to showcase our students’ ideas and we hope that you feel inspired to join in their efforts.

Tarsi DunlopDirector of Operations

strategist’s Note PStudents in the Roosevelt Institute Campus Network are not just preparing to lead — they’re already writing the future. They’re out in their campuses and communities, identifying issues and opportunities to engage. They’re in city councils, state legislatures, and the U.S. Capitol. These students are going to class, but they’re also researching and writing policy. What you have in your hands are the best student proposals in progres-sive healthcare policy.

The enormous amount of attention and controversy devoted to last year’s Patient Pro-tection and Affordable Care Act might have given the mistaken impression that this law solved our health care debacle, and that there’s little work left to be done. But while the new healthcare law certainly helps, health care policy is still a work in progress. Some members of Congress have grown defiant of reform, states have yet to implement change, and millions of Americans lack the fundamental access to care promised by reform.

As the nation carefully negotiates this impasse, we at Roosevelt are taking healthcare policy back to our communities. These policies work within campuses, neighborhoods, and rural areas. Some use technology to cover hard-to-reach demographics and areas of the country. Some call for a paradigm shift. The ideas found in the next pages run the gamut from proposing new policies to critiquing old ones, make use of best practices across fields, and expand successful local models to larger regions.

It is true that these are only 10 ideas. But we like to view the journal as a springboard for action, and know that many more ideas are still to come.

Rajiv Narayan Lead Strategist, Health Care

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A Millennial Remedy for Medicaid’s Rising CostsCharles Sisk, University of Colorado - Boulder

A health corps comprised of recent pre-med graduates should be created to act as a source of advocates and educators for chronically ill Medicaid recipients.

Increasing enrollment and rising costs require Medicaid to increase its financial sav-ings. In 1982, social scientists James Q. Wilson and George L. Kelling introduced their “broken-windows theory,” which stated that allocating resources to the most indigent of communities creates an impetus for conformity, growth and progress. Recently this model has made its way into healthcare through small-scale, self-insured businesses and organizations. Many physicians and employers are finding that by providing focused and personalized attention to high-risk and high-cost patients, they can reap remarkable sav-ings in costs associated with chronic disease.

Close monitoring of high-cost patients has already been used in a small-scale setting to reduce costs. In 2007 the Casino Workers Union (CWU) of Atlantic City, New Jersey, chose to create a Special Care Center for approximately 1000 of its most expensive members. Staffed with physicians, nurses, physician assistants, and caseworkers, the SCC kept close tabs on all of its patients. The use of caseworkers to thwart chronic disease was revolutionary in that it gave patients a lifeline outside of the center, person-alized the level of care, and ensured that no one fell through the cracks. At the end of one fiscal year, the CWU brought in an independent economist to analyze health costs at the center and found that the small-scale, personalized approach to treating chronic disease decreased costs by 25 percent.5 AmeriCorps’s Community Health Corps (CHC) has been active since 1995 and closely resembles the proposed model. Volunteers work in partnering health clinics and outreach programs as educated intermediaries in under-served communities. The CHC has already proven to be very successful, with over 500 members serving close to 750,000 patients in 2008.6

analysisThe Millennial Remedy program aims to tackle two major issues in the Medicaid system: cost and patient education. Medicaid has become increasingly available to patients with varying degrees of chronic illness ear-lier in their lives. Currently, Medicaid offers very little incentive for healthy lifestyle changes because no conse-quences exist for inaction. This inertia feeds not necessarily on ignorance, but rather on a lack of resourceful health education. Chronic diseases such as heart disease, stroke, cancer, diabetes, and arthritis are among the most common, costly, and preventable of all health problems in the U.S.7 Four health risk behaviors — lack of physical activity, poor nutrition, tobacco use, and excessive alcohol consumption

Key FactsTotal Medicaid spending grew 9% in 2009 •to $373.9 billion, driven by a 7.4% increase in enrollment.1Within Medicaid, 52% of total spending is •highly concentrated on only 7% of recipi-ents who use long-term services.2Healthcare costs for chronic-disease •treatment accounts for over 75% of na-tional health expenditures.3 In 2010, 42,742 students applied to medical school, with an overall acceptance rate of only 45 percent.4

— are all treatable problems and could be tracked quantitatively. With medical school acceptance rates below 50 percent, there are approximately 20,000 students with ex-perience in the basic sciences who aspire to be physicians but are without professional-level education. Science education is the basis for chronic disease mechanisms, medical terminology, and allied patient care, all of which are broached in most undergraduate science programs.

Providing underserved communities with a wider array of community-based, coor-dinated care has a combined state and federal savings of approximately $140 bil-lion.8 Those who stand to benefit from such a program are first and foremost the patients; a healthier person enjoys a better quality of life. At the same time, healthier citizens create healthier communities with fewer sick days and lower health expen-ditures incurred by the workforce. With marked increases in their health, these pa-tients would decrease the financial burden on the Medicaid system, with savings in the tens of billions of dollars.9

Next stepsCongress will organize a 501(c)(1) corporation with overhead costs subsidized by the De-partment of Health and Human Services. Regional offices will be established to support health fellows in their community interactions and recruit new fellows from area cam-puses. Stipends will come in the form of AmeriCorps grants, just as in the Community Health Program. Using a training regimen similar to that of Teach for America, health fel-lows will attend summer institutes across the nation at various sites such as the Center for Disease Control in Atlanta, Georgia and the National Institute on Minority Health and Health Disparities in Bethesda, Maryland. These centers already have the space, resources, and staff to train corps members. Also, as with Teach for America, partnership programs will be established with graduate health-education programs to attract poten-tial recruits and promote continued career development.

endnotes1. National Health Expenditures 2009 Highlights, Centers for Medicare and Medicaid Services, Dept. of Health and Human Services, https://www.

cms.gov/NationalHealthExpendData/downloads/highlights.pdf (Accessed February 23rd, 2011).2. Jeffrey S. Crowley et al., “Profiles of Medicaid’s High Cost Populations,” The Kaiser Commission on Medicaid and the Uninsured, http://www.kff.

org/medicaid/upload/7565.pdf, (Accessed February 23rd, 2011).3. The Power of Prevention, Chronic Disease Prevention and Health Promotion, Centers for Disease Control <http://www.cdc.gov/chronicdisease/

overview/index.htm,> (Accessed February 23rd, 2011)4. U.S. Medical School Applications and Matriculants by School, State of legal Residence, and Sex, 2010. Association of American Medical Col-

leges.https://www.aamc.org/download/161128/data/table1-facts2010school-web-pdf.pdf, (Accessed March 27th, 2011)5. Atul Gawande, “The Hot Spotters,” New Yorker, January 24th, 2011, http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_

gawande?printable=true, (Accessed February 23rd, 2011)6.Promoting Health Care for America’s Underserved while Developing Tomorrow’s Health Care Workforce, Community Health Corps, Quick Facts.

http://www.communityhealthcorps.org/client/documents/Fact%20Sheet%20-%20Community%20HealthCorps2.pdf, (Accessed April 18th, 2011).

7. Ibid.8. Coverage for Consumers, Savings for States: Options for Modernizing Medicaid, United Health Center for Health Reform and Modernization.,

Working Paper., April 2010. http://www.unitedhealthgroup.com/hrm/UNH_WorkingPaper3.pdf, (Accessed March 27th, 2011).9. Jack Meyer PhD et al., “Chronic Disease Management: Evidence of Predictable Savings,” Health Management Associates November 2008, http://

www.idph.state.ia.us/hcr_committees/common/pdf/clinicians/savings_report.pdf, (Accessed February 25th, 20111).

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Talking Points•Targeting patients according to pre-•dictors of continued high utilization and offering them personalized edu-cation substantially enhances the op-portunity for systemic savings.Post-graduation civil service models •have already been proven success-ful through programs like Teach for america. The health corps offers a unique and •unprecedented opportunity for pro-spective healthcare professionals to interact with patients and hone their bedside manner.

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Expand New York’s Telehealth CoverageJannie Trelogan, Wesleyan University

Removing restrictions on telehealth coverage by Medicaid in New York can improve access to care for each of the state’s 42 Health Professional Shortage Areas (HPSAs).

Currently, broad, cost-effective availability of telemedicine services is constrained by flaws in regulatory frameworks that generate overlap, inconsistency, and inadequate at-tention to non-rural needs.1 Medicare and the Veterans Administration have made suc-cessful reforms to incorporate telehealth services. Reforming Medicaid is more challeng-ing, however, since individual states set reimbursement policies instead of the federal government.2 New York has 42 Medicaid-eligible areas designated as Health Profes-sional Shortage Areas (HPSAs), areas which have an acute need for telehealth services.3 However, under the state’s current Medicaid policy on telehealth coverage, these areas are not fully eligible for funds.4 Both Medicare and the Department of Veterans Affairs have taken strides to remove barriers to telehealth service.5 Veterans Affairs now oper-ates the world’s largest telehealth program, demonstrating how telehealth technologies can partner successfully with government programs. It accommodates approximately three million veterans living in rural areas and includes an electronic health-record sys-tem used by 14.5 percent of VA patients.6

analysisIn New York, access to telehealth ser-vices is limited to patients who meet a total of eight criteria. Collectively, these criteria form excessively restric-tive parameters that bar a wide variety of groups from receiving reimburse-ment for telehealth services.7 These services have the potential to benefit any group that receives inadequate care due to geographic barriers; in oth-er words, lack of care could be a rural issue due to a lack of nearby medical centers, or an urban one in situations where there is a higher volume of patients than local facilities can support. New York’s telehealth home care policy should change, as previous instances of telehealth adoption show that additional costs are likely to be minimal.8

Next stepsReform of Medicaid regulation and the resulting benefits could be accomplished by the following three steps:

Step 1: Determine a payment schedule that will cover reimbursement for telehealth ser-vices in HPSAs. This schedule should not explicitly exclude particular existing services or procedures from telehealth coverage, since this would result in the need for frequent re-regulation given the speed of innovation in medicine and technology. Medicare provides a model in this step; after it adopted a new national payment scheme for telehealth ser-vices under the Benefits Improvement and Protection Act of 2000, additional spending

Key Factsspending by government agencies (Medi-•care, Medicaid, and the Veterans admin-istration) constitutes 60% of healthcare spending in the United states.13Only 24 states provide reimbursement •for telehealth services through Medic-aid, and each state places a spectrum of restrictions on reimbursement.14

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due to telehealth coverage was between $791,941 and $50,000, according to 2001 data.9 Introducing telehealth did not greatly increase the dollar amount of requests for reim-bursement. These figures indicate that physician consultations occurred with about the same frequency, whether conducted remotely or on location. In addition, this increased cost does not account for the systemic cost-effectiveness of expanding telehealth, with its potential to reduce costs for healthcare providers that serve Medicaid patients. One study estimated cost savings of $4.3 billion a year by modeling a theoretical situation in which telehealth systems providing health services by synchronous video communica-tion were “implemented in emergency rooms, prisons, nursing home facilities and physi-cian offices across the U.S.”10

Step 2: Extend telehealth reimbursement to include HPSAs. Publicize this extension of coverage to inform the current doctors of Medicaid patients. Establish a common framework for cost-effectiveness studies of this extension so that studies can be cross-compared. Allow for review of the effects by requiring the use of Telemedicine Current Procedural Terminology (CPT) codes to track reimbursement for services.11

Step 3: Track the expansion’s effects on the cost of healthcare services, correcting for costs associated with patients that were not receiving care due to their location in an HPSA.

Among existing studies on cost-effectiveness of tele-health technology, the conclusions have been over-whelmingly favorable. Of 55 studies analyzed by the British Medical Journal, 36 percent concluded that telemedicine saves money, 20 percent concluded that telemedicine saves time and money, 16 percent concluded that telemedicine is cost-effective only if a certain threshold is achieved, and only 7 percent concluded that telemedicine does not save money.12

endnotes1. Volkert, Susan E. Telemedicine: RX for the Future of Health Care, 6 MICH. TELECOMM. & TECH. L. REV. 238-239 (2000).2. “Telemedicine Reimbursement Report.” The Center for Telemedicine Law Under contract #02-HAB-A215304 to the Office for the Advancement

for Telehealth, HRSA. October 2003. http://www.hrsa.gov/ruralhealth/about/telehealth/reimburse.pdf3.“Find Shortage Areas: HPSA by State & County.” Health Resources and Services Administration. U.S. Department of Health and Human Services.

September 30, 2009. http://hpsafind.hrsa.gov/HPSASearch.aspx4. “Telehealth Home Care Services (New York Medicaid).” HS-149 Original Effective Date: 1/21/2010. Revision Date: 1/21/2011. Wellcare Health Plans,

Inc. https://www.wellcare.com/WCAssets/corporate/assets/HS149_Telehealth_for_New_York_Medicaid.pdf5. Gupta, Amar and Deth Sao. The Unconstitutionality Of Current Legal BarriersTo Telemedicine In The United States: AnalysisAnd Future Directions Of Its Relationship To National And International Health Care Reform.” February 2010. http://works.bepress.com/cgi/view-

content.cgi?article=1002&context=deth_sao6. Horowitz, Brian T. “Telehealth Technolgoy Is Increasingly Important to US Veterans.” E-Week Mobile. 1 Jul 2010. http://mobile.eweek.com/c/a/

Health-Care-IT/Telehealth-Technology-Is-Increasingly-Important-to-US-Veterans-397177/7. “Telehealth Home Care Services (New York Medicaid).” HS-149 Original Effective Date: 1/21/2010 Revision Date: 1/21/2011. Wellcare Health Plans,

Inc. https://www.wellcare.com/WCAssets/corporate/assets/HS149_Telehealth_for_New_York_Medicaid.pdf8. Elder Van-Hook, Jackie M.S., Samuel G. Burgiss, Ph.D. Robert J. Waters, J.D. “Medicaid Policies on Telehealth Services: A Comparative Analysis.”

June 2006. Prepared for the Maine Health Access Foundation. The Center for Telehealth & E-Health Law. 23-33.9. Eder-Van Hook 11-13.10. Cusack C, Pan E, Hook J, Vincent A, Kaelber DC, Middleton B. The value proposition in the widespread use of telehealth. Journal of Telemedi-

cine and Telecare. 2008;14:167–168. doi: 10.1258/jtt.2007.007043.11. Elder Van-Hook 11.12. Whitten, Pamela S, Frances S Mair, Alan Haycox, Carl R May, Tracy L Williams, S Helmich. “Systematic review of cost effectiveness studies of

telemedicine interventions.” Bmj Clinical Research Ed. (2002). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC115857/.13. Crounse, Bill MD. “Barriers to Health Care Services are being removed: even by Medicare.” Microsoft’s Senior Director, Worldwide Health.

http://blogs.msdn.com/b/healthblog/archive/2009/07/27/barriers-to-telehealth-services-are-being-removed-even-by-medicare.aspx. 14. Volkert 238-239. 15. Ibid 165-172.

Talking Points•standard-setting gov-•ernment action and re-formed regulation are critical to removing bar-riers to telemedicine. Reform of telehealth re-•imbursement regulation can be accomplished at the state level and would improve health-care access in rural and underserved areas.15

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Prioritizing Success: Treating Psychotic Mental Illness Katie Silvius and Mia Przyborowski, Mount Holyoke College

Implementing a Medicaid policy that mandates psychotherapy prior to prescription of antipsychotic medication can decrease costs and improve overall outcomes.

Psychotic mental illnesses like schizophrenia are viewed as chronic conditions and usual-ly managed through frequent hospitalization and heavy medication. This “revolving door” approach incurs significant expenses to the healthcare system, quantified mostly by the cumulative cost of repeated hospitalizations and escalating cost of medication. Most state Medicaid programs have implemented cost-control measures to limit patients’ ac-cess to antipsychotic medication, but such measures have not been effective in mitigat-ing these illnesses.1 In fact, numerous studies have shown that antipsychotic medication actually increases the severity and prevalence of relapse.2 There is also evidence to sug-gest that psychotic illnesses can be treated more effectively without medication.3 States should implement a fail-first policy in which patients are required to try psychotherapy, without antipsychotic medicine, at the intensive outpatient or inpatient level depending on patient need. This policy will reduce Medicaid spending on antipsychotics, reduce the need for recurrent hospitalizations, and result in improved patient outcomes.

Psychotic illness was not always considered a chronic condition. From 1956 to 1986, when psychotherapy (colloquially referred to as “talk therapy”) was the favored treatment, half of all schizophrenic patients in the Unit-ed States could expect a favorable outcome.4 Today, antipsychotic medication has largely displaced psychotherapy, and patient out-look has worsened. Antipsychotic drugs were developed in the mid-1950s. Psychiatrists subsequently embraced the “medical mod-el,” which proposed that biological remedies were the only effective treatment. Since then the medical community has become domi-nated by pharmaceutical corporations driven by financial interest in the use of their medi-cations, despite evidence of the medication’s ineffectiveness when used as the sole meth-od of combating psychotic illness.

analysisMedication is not always the most effective choice in treating psychotic mental illness. Numerous studies have demonstrated that non-drug-based therapies are significantly more effective than antipsychotics. One study in California found that only 8 percent of patients never exposed to antipsychotics were re-hospitalized; in contrast, 73 percent of those who were started on antipsychotics and continued to rely upon them through-

Key Facts●The percentage of americans •diagnosed with a mental illness has increased nearly sixfold since 1955, when antipsychotic medica-tion started becoming standard treatment for schizophrenia.9 ●In 1998, antidepressants and an-•tipsychotics accounted for nearly 19 percent of Medicaid drug reim-bursements, and spending contin-ues to increase.10●In one study the readmission rate •of patients treated with only psy-chotherapy was 20 percent less than that of patients treated with medication.11

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out treatment required re-hospitalization.5 Another study evaluating psychotherapy in schizophrenics found that 80 percent of patients treated with individual psychoanalytic therapy showed significant clinical improvement.6 Currently, the prospect of non-med-icated treatment invokes fear, due to the potentially uncontrollable reactions of schizo-phrenics. However, schizophrenics are at no higher risk of committing violent crime than the general population, even without medication.7

Although the up-front cost of psychothera-peutic treatment may be more expensive, it is more cost-effective in the long term. The monthly cost of the common antipsychotic medication Clozapine is $735.06. Drug treat-ment is expected to continue throughout the patient’s lifetime, and is not anticipated to lead to recovery. In contrast, psychotherapy is seen as a bridge to assist patients in reclaim-ing productive lives, and gradually decreases the need for therapy. According to a New Hampshire social worker, the reimbursement rate for a 50-minute session is $65. Thus the overall cost is lower as schizophrenics may not need therapy for their whole lives, while the same cannot be said for medication.

Next stepsGiven current literature that suggests many patients benefit from psychotherapy, a man-date requiring Medicaid patients to try psychotherapy before medication could render medication an unnecessary expense. Psychotherapy before medication allows patients a chance to recover from mental illness without the damaging effects of a lifetime reli-ance on drugs. It can also decrease reliance upon antipsychotic medication, which will consequently decrease Medicaid’s sizable financial burden. Revising the standard prac-tice of medication as the first or only choice of treatment shifts providers away from a medication-centered model of patient care, and will contribute toward improving the chronic nature of psychotic illness.

endnotes1. Koyanagi, C. et al. “Medicaid Policies to Contain Psychiatric Drug Costs.” Health Affairs, 24:2 (2005):536-442. Karon, B. “Can biological and psychological intervention be integrated into the treatment of psychosis? Probably not.” Ethical Human Psychology

and Psychiatry 8:3 (2006): 225-2283. Irwin, M. “Treatment of schizophrenia without neuroleptics: psychological interventions versus neuroleptic treatment.” Ethical Human Psychol-

ogy and Psychiatry, 6:2 (2004):99-1104. Whitaker, R. Anatomy of an Epidemic. (Crown Publishers: New York, 2010)5. Rappaport, et al. “Are there schizophrenics for whom drugs may be unnecessary or contraindicated?” Int. Pharmacopsychiat. 13 (1978):100-116. Furlan, P. M. and G. Benedetti. “The individual psychoanalytic psychotherapy of schizophrenia: scientific and clinical approach through a clinical

discussion group.” Yale Journal of Biology and Medicine 58 (1985):337-487. Schizophrenia.com: A Non-profit source of information, education, support. Accessed April 20, 2011.8. Ostroff, Monika. Email interview. 5 April 2011.9. Whitaker, R. Anatomy of an Epidemic. (Crown Publishers: New York, 2010)10. Koyanagi, C. et al. “Medicaid Policies to Contain Psychiatric Drug Costs.” Health Affairs, 24:2 (2005):536-54411. Whitaker, L. and Arthur Deikman. “The Empathetic Ward: Reality and Resistance in Mental Health Reform.” Ethical Human Psychology and

Psychiatry. 11:1 (2009):50-62

Talking Points•Mental illness is now a chronic •condition, with most patients put on medication for life.scientific evidence demonstrates •that medication is not only ineffec-tive for treating psychotic mental illness, but adversely affects long-term patient outcomes.Requiring patients to receive psy-•chotherapy before medication will decrease costs and improve overall outcomes for individuals with psychotic mental illness.

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Student Mental Health And On-Campus PsychotherapyGrant Heskamp, University of North Carolina at Chapel Hill

Students of state universities should have access to unlimited on-campus psychother-apy in order to receive adequate and convenient mental health care.

Mental health disorders are the leading cause of disability in the United States.1 While many state universities include the cost of university-provided psychotherapy, or “talk therapy,” in student fees, there is often a cap on the number of sessions (see table). University psychologists acknowl-edge that many students need additional sessions, and often refer them to profes-sional psychologists in the area. However, studies of mental health disorders show that changing treatment methods and set-tings mid-therapy can negatively affect the patient.2

University Session Cap

The University of North Carolina, Chapel Hill 8The University of Virginia 10The University of Florida 12The University of Wisconsin, Madison 10The University of South Carolina 12*The University of California, Berkeley 5*

* Denotes a university that provides sessions on a fee-for-service basis after cap.

analysisAfter exhausting the allowance for brief, university-provided therapy, students are often referred to psychologists in the community. However, studies show that after beginning treatment it can be harmful for a patient to change treatment methods or settings. Uni-versities should establish fee-for-service programs for students who seek on-campus treatment beyond the session cap.

The revenue generated from paid psychotherapy sessions would defray the cost of in-creasing the number of paid hours per week or hiring the additional staff necessary to accommodate students seeking longer-term care. At most universities students are re-quired to have health insurance, which could also make these sessions more affordable for students. An additional four sessions a month at $60-$80 per session would generate $240-$320 per month per patient to defray the costs of expansion. This estimate does not account for the change in fringe benefits.

Key Factsaround 15 percent of americans use •mental health services each year.4 during the 2009-2010 academic •year, 12.2 percent of students at the University of North Carolina, Chapel Hill used mental health services on campus.5 Roughly 25 percent of students that •are evaluated by UNC Counseling and Wellness services are referred to services in the community.6

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Students seeking extra sessions are likely to be those with the greatest need for treat-ment. Switching psychologists to continue therapy may be detrimental to their mental health and counterproductive to treatment. On-campus services are far more conve-nient for students than off-campus services, which often require commuting.

An alternative option is to raise the number of sessions covered by student fees. How-ever, a cap is inflexible and an increase in fully-funded sessions would likely lead to a significant increase in student fees amidst increased tuition and university budget cuts already occuring across the nation. A combination of a cap increase and a fee-for-service program may be appropriate, but a cap increase alone would be neither sufficient nor sustainable.

It is unlikely that demand for on-cam-pus mental health services would in-crease uncontrollably as most students would not seek treatment indefinitely. Even when psychotherapy is unlimited and free, the national estimate is that a typical adult schedules 11 sessions.3 The current cap for services at UNC falls short of this average. Therefore, making additional on-campus sessions available reflects a more holistic and comprehensive approach to student mental health. University students at state institutions seeking on-campus psychotherapy would benefit from these policy changes, as they would experience a greater level of accesible care.

Next stepsExpanding university mental health services to include a fee-for-service option is crucial to providing the psychological care that many students need. Such a program should be implemented gradually, gauging how staffing and hours should change to accommo-date students seeking care beyond the current session cap. This approach to on-campus psychological care should be presented to the University of North Carolina Board of Governors to be considered for implementation on the 16 campuses that comprise the system. A similar proposal should be considered at other public universities, including the University of Virginia, the University of Florida, and the University of Wisconsin.

endnotes1. National Institute of Mental Health. “Statistics.” http://www.nimh.nih.gov/statistics/ index.shtml (accessed February 24, 2011).2. Meyer, Mortimer M., and Ruth S. Tolman. 1963. “The Reactions of Patients to Enforced Changes in Therapists.” Journal of Clinical Psychology 19,

no. 2: 241-243. Academic Search Premier, EBSCOhost (Accessed March 5, 2011).3. Manning, WG, KB Wells, N Duan, JP Newhouse, and JE Ware. “How Cost Sharing Affects the Use of Ambulatory Mental Health Services.”

The Journal of the American Medical Association. 1986; 256(14): 1930-1934 (Accessed February 25, 2011). http://jama.ama-assn.org/con-tent/256/14/1930.abstract#cited-by

4. Weiten, Wayne. Psychology: Themes and Variations. 7 ed. Belmont, CA: Thomson Wadsworth, 2008.5. UNC Campus Health and Wellness Services. http://campushealth.unc.edu/ (accessed February 25, 2011).6. Ibid.

Talking Points•student mental health is a key health is-•sue that needs proactive attention.a fee-for-service program should be of-•fered to students who seek additional on-campus psychotherapy sessions beyond the university cap.This program would provide a greater lev-•el of care and accessibility for students.such a system would not significantly •strain demand or increase student fees.

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Early Prevention Through School ProgramsJohna Coby Jones and Michael Rist, Wheaton College

The implementation of a nationwide afterschool program that teaches preventative healthcare skills and tools in all public elementary schools would decrease the overall cost of health care.

The cost of health care is rising. The average per capita annual expense rose from $1106 in 1980 to $6280 in 2004.1 Diabetes and heart disease rank among the top chronic ill-nesses that incur the most expenses. In 2006, cardiovascular diseases claimed the lives of 831,272 people in the United States alone.2 Coronary heart disease is the single lead-ing cause of death in the United States today.3 With regular exercise and a healthy diet, most forms of diabetes and heart disease can be managed if not altogether prevented, but in order to bring about this change, good habits must be fostered from a young age. By the age of four, children are capable of engaging in scientific investigations, making observations, and comparing data.4 By the age of five, children can ask analytical ques-tions and weigh their options, making this the opportune time to expose children to important life skills and healthy habits.5 Implementing afterschool programs in all public elementary schools that teach children how to exercise and how to eat right would drive down healthcare costs due the amount that preventive care can save when compared to the current system of acute care management.

The program’s goal would be to make exercise and eating well fun. The pro-gram would teach children games that incorporate health information without making learning cumbersome, and will allow young children to consciously learn about what a healthy lifestyle is. Ideally, local governments should fund this program and implement it as part of the public school system.

Health topics have been taught in schools since the late 1960s, but they are not a universal requirement. Today, only 19.6 percent of states require elementary school students to be tested on health topics.6 The Edible Schoolyard is one example of a learning environment where children learn about the importance of nutrition. The Edible Schoolyard is a nonprofit organization that teaches children about growing, harvesting, and preparing nutritious, seasonal produce. Established in 1995 in Berkley, California, the Edible Schoolyard now has affiliations in many areas across the country. Skills taught in the Edible Schoolyard help children de-velop an appreciation of the natural world, in addition to promoting the environmental and social wellbeing of the community.7

analysisThe proposed afterschool program will teach children at a young age what it means to lead healthy lifestyles. The program will also teach parents how to provide a healthy environment for their child. A counselor from the Department of Health and Human Ser-

Key FactsHealth care expenses in the United •states rose from $1106 per person in 1980 ($255 billion overall) to $6280 per person in 2004 ($1.9 trillion overall).8 The cost of cardiovascular diseases in •the United states, including healthcare expenditures and lost productivity from deaths and disability, was estimated to be more than $503 billion in 2010.9

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vices, with the permission of the parents, will go to the household of children involved in the program and help their families make healthy meal plans on the same budget they currently maintain. This will both benefit the family and create jobs within the Depart-ment of Health. This proposal is geared more towards nutritional education for par-ents and children and is desirable on a much larger scale than what is currently in place through organizations like the Edible Schoolyard. Not only are the children learning steps to pre-vent illness such as diabetes and heart disease, but their parents are also learning how to change their own lifestyles and provide healthier food for their children. From an economic standpoint, the savings on cardiovascular disease alone would be enormous. Boosting the overall health of the nation’s youngest generation will also have a sub-stantial financial benefit in the long term, since it will improve quality of life into adulthood.

This program would affect public elementary school children and their families. The co-operation of the Department of Health and Human Services and the Department of Education would be needed to enact such an afterschool program, in addition to the cooperation of local government and public elementary schools across the nation.

Next stepsIn order to produce the most savings for the healthcare system, this program should be implemented as soon as possible. Ideally, this program would be implemented in every public elementary school. However, at-risk areas where there are high percentages of families on Medicaid and/or high levels of heath disease and diabetes should be the first to receive this program.

endnotes1. Department of Health and Human Services. “Overview Medicaid Program - General Information.” Centers for Medicare & Medicaid Services.

http://www.cms.gov/MedicaidGenInfo/ (accessed February 25, 2011). 2. “Cardiovascular Disease Statistics.” American Heart Association. N.p., n.d. Web. 21 Apr. 2011. <www.americanheart.org/presenter.

jhtml?identifier=4478>.3. Ibid.4. “Your Five Year Old . Child Development Tracker.” PBS: Public Broadcasting Service. http://www.pbs.org/parents/childdevelopmenttracker/five/

index.html (accessed February 25, 2011). 5. Ibid.6. “Guidelines for School Health Programs to Promote Lifelong Healthy Eating.” Centers for Disease Control and Prevention. N.p., 14 June 1996.

Web. 21 Apr. 2011. <http://www.cdc.gov/mmwr/preview7. “About Us | Edible Schoolyard.” Web. 21 Apr. 2011. http://edibleschoolyard.org/about-us8. Ibid.9. Ibid.

Talking Points•Heart disease and diabetes •are preventable.Not all schools in the United •states conduct a mandatory health class, and a minority of states require health educa-tion as part of an elementary-school curriculum.

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Ensure Health Access in Rural AmericaPatrick Short and Rachel Burns, University of North Carolina at Chapel Hill

Cure for America, designed as a federal scholarship available to graduating college students, aims to increase the number of health professionals in underserved parts of rural America.

Rural America has long suffered from limited healthcare options, stemming from a lack of ac-cess to healthcare professionals. Many rural resi-dents often have to travel long distances to reach a primary care doctor. There are 2,157 Health Pro-fessional Shortage Areas, places with a shortage of health providers due to geographic, institution-al, or demographic constraints, in rural regions compared to 910 in urban regions.1 Residents of underserved and rural areas have a higher preva-lence of chronic diseases.2 Not only is the rural population sicker, it is also generally poorer. The average per capita income in rural areas is $7,417 lower than in urban areas.3 Health and fiscal disparities impede rural populations from receiving the same quality of care as their fellow Americans in more densely populated areas. Increasing the number of health professionals in rural and underserved areas would not only help solve many of these pressing issues – it would also redefine the role of healthcare in rural America at large.

analysisThe proposed program, “Cure for America,” would identify graduating college seniors taking pre-med or another health-related course of study. In exchange for guaranteed financial aid for medical school, program participants will work in an underserved rural area for a fixed number of years and will be funded accordingly. The proposed program would provide students who are unable to financially bear medical school loans with an opportunity to pursue a career as a health professional while serving an underserved rural community.4 This program would funnel passionate, competent applicants to the areas that need health professionals the most.

A similar model, the National Healthcare Service Corps, already provides loan support and aid to aspiring medical professionals after medical school. In contrast, Cure for America has the advantage of identifying passionate students with an interest in rural health early on and incentivizing them to pursue a career in healthcare while stabilizing their immediate financial future.

Next stepsThrough the creation of this federal scholarship, both the rural and underserved popu-lations of America will receive greater access to health providers. Health professional schools will also receive an influx of engaged students with several years of real-world post-undergraduate experience. Cure for America will help empower students to pursue a health profession while filling a critical void in our national healthcare system. Greater

Key Facts•Nearly 20 percent of the U.s. •population, around 66 million people, lives in rural areas, but only 9 percent of the na-tion’s physicians practice in these communities.5 almost one quarter of all U.s. •medical students graduate with an educational debt of $200,000 or more.6

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access to health professionals in underserved areas will facilitate more frequent visits and encourage preventive care. Each year, Cure for America will fund 500 medical stu-dents. Implementing this program on a national scale will drastically improve access to care, alleviate financial strains on rural communities, and improve their access to preven-tive and chronic care.

endnotes1. “NRHA - What’s Different about Rural Healthcare?” NRHA - National Rural Health Association Home Page. Web. 27 Feb. 2011. <http://www.

ruralhealthweb.org/go/left/about-rural-health/what-s-different-about-rural-health-care>.2. Jones, Carol. “Rural Populations Have Higher Rates of Chronic Disease - Amber Waves June 2010.” USDA Economic Research Service - Home

Page. Web. 20 Feb. 2011. <http://www.ers.usda.gov/AmberWaves/June10/Findings/RuralPopulationsDisease.htm>.3. Ibid.4. Influence of Income, Hours Worked, and Loan Repayment on Medical Students’ Decision to Pursue a Primary Care Career.” Journal of the

American Medical Association. Web. 1 Mar. 2011. <http://jama.ama-assn.org/content/271/12/914.full.pdf html>.5. NRHA - What’s Different about Rural Healthcare?” 6. “Kavilanz, Parija. “Why the U.S. Faces a Shortage of Rural Physicians.” CNN. 26 Mar. 2010. Web. 1 Mar. 2011. <http://money.cnn.com/2

Talking Points•Cure for america would help solve rural america’s increasing shortage of health pro-•fessionals.The Cure for america program would provide financial aid, mentoring, and programs •focusing on rural healthcare for undergraduate seniors applying to medical school or with demonstrated interest in the medical professions.Roughly 7,438 family-practice physicians are needed to fill the gap in care for under-•served and rural areas.

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Health Insurance Toolkits for College GraduatesRahul Rekhi, Rice University

The federal government should offer, fund, and help distribute health insurance tool-kits for recent college graduates.

Currently, young adults between 18 and 30 — often referred to as “young invincibles” — constitute one of the largest subsets of the uninsured in America.1 It is estimated that 34 percent of college graduates will spend some time uninsured in the year after gradua-tion.2 However, 41 percent of graduates nationwide say they would choose to buy health insurance if they could find an affordable plan.3

Addressing the high rate of uninsurance among young adults is an important community health problem facing state and federal officials. These young adults can balance out state insurance risk pools because of their relatively robust health. From the public-health perspective, as many as two-thirds of all young adults who were uninsured at some point in the past year reported going without needed medical care because of cost.4

analysisOne reason many college graduates do not purchase insurance is because they lack ba-sic knowledge of health insurance. A study of college graduates found that fewer than half of college graduates felt they could confidently define key health insurance terms like premiums (45 percent), lifetime coverage limits (30 percent) and coinsur-ance (20 percent). The majority of recent college graduates incorrectly believe that the average health-plan premium on the individual market is $227 per month. In fact, that number is 38 percent higher than the average monthly premium for individual policies ($161).5 Interestingly, when asked what they viewed as a “fair” price for their health-insurance plans, the graduates’ estimates were far closer to the actual average insurance monthly premium — in most cases, even a little higher.7 This study suggests that young adults may be willing to purchase health in-surance, but only if they are provided with the requisite tools, information, and guidance to assess the options available to them. Seven million young adults across the country might, in fact, purchase health insurance coverage if only they knew that they could af-ford it.8

The Department of Health and Human Services should work to develop and fund health-insurance toolkits to be distributed by college administrators. The health insurance in-dustry has repeatedly proven to be a black box to college graduates, so health insurance toolkits can help demystify the industry and insurance system. These kits can help gradu-ates navigate the purchasing process, educate them about the options available, and ultimately help them select a health plan that best suits their needs.

Key Facts34% of college graduates will spend •time uninsured after graduation.9 Less than half (48%) of recent col-•lege graduates can define key health insurance terms.10 If they could find an affordable plan, •41% of recent graduates would buy health insurance.11

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This initiative complements current policy ef-forts. It can readily gain support from the in-surance industry and public health advocates. After all, any successful toolkit will make buy-ing into insurance easier and more attractive to recent college graduates, a high-target pool for companies given their relative health. Though health-insurance toolkits do exist, such as ones offered by the U.S. Chamber of Commerce and United Steelworkers Union, none currently target the “young invincibles” demographic. This toolkit will address this public health omission by tailoring its contents to suit the particular needs of the American youth.

Next steps and Implementation ChallengesA health insurance toolkit would have to be both comprehensive in scope and readily accessible to American youth. A toolkit would also include state-specific information on how one can stay on his or her parent’s health insurance plan until the age of 26, what to look for when buying individual insurance, key insurance terms, what government-funded insurance plans are available, where to find a local community health center, and how the provisions of the Affordable Care Act impact individuals.

Learning from past education initiatives, healthcare toolkits should be easily available through social media, web applications, and smart-phone applications. Partnerships with governmental agencies and nonprofit organizations can aid rapid and effective material dissemination. In particular, college administrators are well positioned to distribute tool-kits through campus-wide graduation “care packages.”

endnotes1. United States Census Bureau, “Economics and Statistics Administration,” http://www.census.gov/compendia/statab/.2. The Commonwealth Fund, “2010 Commonwealth Fund International Health Policy Survey - The Commonwealth Fund.” The Commonwealth

Fund, http://www.commonwealthfund.org/Content/Surveys/2010/Nov/2010-International-Survey.aspx.3. National Association of Colleges and Employers, “NACE - Moving On 2010: Student Approaches and Attitudes Toward the Job Market for the

Class of 2010.” NACEWeb.org, http://www.naceweb.org/Products/2010_Student_Survey.aspx.4. The Commonwealth Fund, “2010 Commonwealth Fund International Health Policy Survey - The Commonwealth Fund.” The Commonwealth

Fund, http://www.commonwealthfund.org/Content/Surveys/2010/Nov/2010-International-Survey.aspx.5. EHealth, “EHealthInsurance 2010 College Graduates Survey: No Work, No Health Insurance, No Clue / EHealth.” Health Insurance News Articles

and Information / EHealth, http://news.ehealthinsurance.com/pr/ehi/ehealthinsurance-2010-college-158921.aspx.6. Ibid.7. Ibid.8. The Commonwealth Fund, “2010 Commonwealth Fund International Health Policy Survey.”9. National Association of Colleges and Employers, “NACE - Moving On 2010.”10. EHealth, “EHealthInsurance 2010 College Graduates Survey: No Work, No Health Insurance, No Clue / EHealth.”11, The Commonwealth Fund, “2010 Commonwealth Fund International Health Policy Survey.”

Talking Points•College graduates don’t un-•derstand the intricacies of the health-insurance market.Toolkits provide a low-cost, high-•utility means of educating youth.More college graduates with •health insurance will lower premi-ums for everyone, especially be-cause recent graduates tend to be relatively healthy and balance out insurance risk pools.

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Comprehensive healthcare policy should incorporate free clinics into existing federal-funding networks, building avenues for collaboration between private providers and federally qualified health centers (FQHCs).

While free health clinics did not receive much research or policy attention until recently, FQHCs have been government’s primary tool to address the plight of the uninsured. As Med-icaid expands under the Affordable Care Act, the federal government will allocate another $11 billion to these health centers to cover the newly insured.1 Funded by the U.S. Bureau of Primary Health Care, FQHCs are subject to Section 330 of the 1996 Public Health Services Act. As public entities, they must follow federal guidelines that include 24/7 coverage, payment via a schedule of fees, and a requirement that a majority of the board of directors be com-prised of center patients.2

Free clinics, unlike FQHCs, function as private nonprofits and can operate with more flexibility. Though only open for limited hours, these clinics typically do not charge their patients. In contrast, FQHCs follow a sliding scale of fees from $5 to $87, depending on the patient’s poverty level.3 Anyone who earns over 200 percent of the federal pov-erty level — still below what is considered a living wage — receives no discount at all. Cost sharing for health services increases adverse health consequences among poorer patients, the target demographic of both health centers and free clinics. Geographic limitations also compound the increasing demand for free clinics.4 In North Carolina, FQHCs only offer coverage to 42 of the state’s 100 counties.5 To fill this gap, the 70-plus free clinics stretched across North Carolina offer the best and often the only accessible alternatives in underserved regions.6

analysisBuilding formal relationships between free clinics and public providers would strengthen the national healthcare framework. The Safety Net Advisory Council in North Carolina seeks to level the funding playing field between free clinics and FQHCs by incorporating free clinics under the Section 330 umbrella. Converting free clinics to FQHCs, however, does not address the plight of patients who cannot afford FQHC services. In response, the Blue Cross-Blue Shield Foundation proposes a symbiotic approach.7 In this model, an FQHC leases space within a free clinic and provides both a more comprehensive care regimen and a constant stream of revenue. The free clinic can broker deals with the health center so that the latter becomes an in-house referral center with discounted rates for uninsured patients.

Integrate Local Free Clinics Into National Health Care ReformJohn Morgan, Davidson College

Key Facts•46 million americans lack basic •health insurance.10 14.9% of americans reported •that they were unable to visit a doctor last year due to cost.11 Over 1000 free clinics serve •1.8 million patients nationwide, versus 6 million covered by FQHCs.12 In North Carolina, the state with •the largest number of free clin-ics in the country, clinics offer $71 million in services.13

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While effective collaboration could counter both the geographic and financial limitations of FQHCs, logistical concerns might leave free clinics doubtful of success.8 Effective collaborations do not solve the funding crisis, since free clinics and FQHCs draw from the same pool of private money and only FQHCs receive public funds. Any symbiotic relationship will require an equal playing field for resources, particularly in the grant structure that currently favors FQHCs.

Criticism of the collaborative model sheds light on a fundamental need for free clinics to be integrated into the system, legally and financially, as formal healthcare providers. Recent healthcare reform relies on the belief that free clinics will no longer be needed under the new system. More likely, however, free clinics will still form a crucial part of the healthcare safety net where the FQHCs fail to address financial and geographic weaknesses. Free clinics currently receive no federal funding despite providing services to one-third the number of patients that FQHCs receive.9 The government must open grants to free clinics specifically in order to make the grant process more equitable and more ben-eficial to the uninsured.

Next stepsSection 330 of the Public Health Services Act should be amended to recognize the distinct importance of free clinics and promote an equitable environment for healthcare provid-ers. FQHCs should be required to support local free clinics to fill persistent gaps in ac-cess. Section 330 should outline a system of discounted referrals within free clinics and earmark funding for FQHC collaboration. Implementing effective health care reform will require legislation to fix the remaining holes in the safety net.

endnotes1. Money, E. Benjamin. “North Carolina’s Safety Net in the New World of Health Reform.” North Carolina Medical Journal 7, no. 3 (2010): 246-249.2. United States Department of Health and Human Services, Health Resources and Services Administration. “Summary of Key Health Center

Program Requirements.” 2009.3. (Darnell 2010)4. Rand Corporation. “The Health Insurance Experiment: A Classic RAND Study Speaks to the Current Health Reform Debate.” 2006. http://www.

rand.org/pubs/research_briefs/RB9174/index1.html.5. (Money 2010)6. North Carolina Association of Free Clinics. What is a Free Clinic? n.d. http://www.ncfreeclinics.org/free_clinic.aspx (accessed February 17, 2011). 7. (Money 2010)8. Crawford, Rory, interview by John Morgan. Executive Director, HealthReach Community Clinic (June 21, 2010)9. (Darnell 2010)10. The Henry J. Kaiser Foundation. State Health Facts. 2011. http://www.statehealthfacts.org11. (The Henry J. Kaiser Foundation 2011)12. Darnell, Julie S. “Free Clinics in the United States: A Nationwide Survey.” Archives of Internal Medicine 170, no. 11 (2010): 946-953.13. Ibid

Key Facts• The $5 FQHC minimum may not •seem like a lot, but for chronically ill patients, the aggregate costs rise quickly. They have no choice but to turn to free clinics.While both free clinics and FQH-•Cs compete for the same private funds, only FQHCs receive sup-port from the federal govern-ment. That political favoritism must be erased to maximize ac-cess for america’s poor.FQHCs often occupy large, cen-•tral campuses. In rural areas, transportation weakness limits access, generating high demand for smaller, more accessible free clinics. Health care reform must improve the supply side.

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The United States should remove the Anti-Prostitution Mandate from the President’s Emergency Plan for AIDS Relief (PEPFAR) relief program, and instead actively sup-port condom distribution to sex workers.

In 2003, President Bush pledged $115 billion for global HIV/AIDS prevention through the creation of PEPFAR. While PEPFAR has been heralded for its overall work in Africa, PEPFAR’s anti-prostitution provision, which aid-receiving organizations must sign, has met with significant criticism. The so-called “prostitution pledge” forces organizations to explic-itly oppose prostitution, which is often interpreted as a prohibition of condom distribution to sex work-ers.1 Contending that it violates the First Amend-ment, several organizations sued the U.S. govern-ment in order to lift the prostitution pledge. One court placed an injunction on the enforcement of the pledge on U.S.-based organizations that perform both domestic and foreign work. However, foreign organizations must still comply with the provision’s restrictions.2

analysisWhile the United States invests heavily in HIV/AIDS relief and prevention, the refusal to address prostitution as a primary cause of sexual infections limits the effectiveness of aid. Currently, to qualify for PEPFAR funds, an organization must explicitly oppose sex workers, which due to ambiguous guidelines is often interpreted as the prohibition of condom use or distribution.3 Even if government auditors accept condom distribution as viable under PEPFAR, organizations are hesitant to receive funds without explicit government confirmation, which the provision does not grant. The Office of the Global AIDS Coordinator, through PEPFAR, isolated confusion over the United States’ position on condoms as one of the key factors of condom shortages.4 Organizations that sign the pledge are prohibited from using both federal grants and private funds to provide AIDS relief and health education to prostitutes.5 Thus, organizations are unable to address the link between HIV/AIDS and prostitution.

Without the barriers of the anti-prostitution pledge, money could be used more ef-fectively to better address the root of HIV/AIDS proliferation. Peer-reviewed medical studies suggest that prostitution “defines the AIDS pandemic more than other factors.”6 Ignoring such a linchpin in the fight against AIDS is counterproductive. Additionally, the pledge creates inefficiencies within NGOs. Developing nations will most benefit from the removal of the prostitution pledge, as they have the highest prevalence of HIV/AIDS. According to a study based in southern Africa, where prostitutes have access to con-doms, less than 0.1 percent of female prostitutes are infected.7 Other developing nations should receive similar access to methods of HIV/AIDS prevention, and foreign NGOs

An Expanded HIV/AIDS Relief FocusHannah Nemer, University of North Carolina at Chapel Hill

Key Facts•In areas of western africa, •over one in five sex work-ers live with HIV.10 Globally, fewer than 80 •percent of sex workers used a condom with their last client.11 In senegal, when transport •workers engaged in peer education that encom-passed sexual health relat-ing to sex workers, 42.2 per-cent of the corresponding sex workers’ clients agreed to use a condom - up from 2.2 percent.12

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that currently receive aid under the pledge will be able to better address the sexual health of prosti-tutes and related populations. NGOs formerly un-able to receive United States aid would also have access to significant PEPFAR funds.

Next stepsThe U.S. should enact legislation that would re-move the prostitution pledge in its entirety from aid requirements, though it may be most politically feasible to wait until the next PEPFAR reauthoriza-tion to remove the pledge. Congress must, if not fully remove, at least add greater clarity to the con-ditions for aid, explicitly allowing sex worker-based condom distribution. The U.S. should also pass leg-islation that encourages outreach to sex workers to help break the taboos associated with condom use.8

To better transition towards comprehensive prosti-tution policies, the U.S. should also establish clearer guidelines for organizations to de-termine if they meet the changes in aid requirements. Organizations such as the Center for Health and Gender Equity have already begun to define rights that prostitutes should be guaranteed, including governmental support of condom distribution, prostitute union-ization, and the criminalization of the client rather than the prostitute.9 By removing the prostitution pledge and focusing on condom distribution, the U.S. can guarantee basic rights and more effectively prevent the spread of HIV/AIDS.

endnotes1. “Making Prevention Work: Lessons from Zambia on Reshaping the U.S. Response to the Global HIV/AIDS Epidemic” Sexuality Informa-

tion and Education Council of the United States. Accessed April 28, 2011. Last Modified post-August 2009. http://siecus.org/index.cfm?fuseaction=Feature.showFeature&FeatureID=1767

2. “Human Trafficking, HIV/AIDS, and the Sex Sector Human Rights for All.” Change Center for Health and Gender Equity. Accessed February 25, 2011. Last modified October 2011. http://www.genderhealth.org/files/uploads/change/publications/Human_Traffick-ing_HIVAIDS_and_the_Sex_Sector_12_3_2010FINAL.pdf.

3. “President’s Emergency Plan for AIDS Relief (PEPFAR): PEPFAR funding restrictions.” AVERT. Accessed April 28, 2011. http://www.avert.org/pepfar.htm

4. David Bryden. “Condom gap “quite disturbing” according to PEPFAR.” Science Speaks: HIV & TB News. Accessed April 28, 2011. Last modified February 2, 2011. http://sciencespeaksblog.org/2011/02/02/condom-gap-quite-disturbing-according-to-pepfar/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+ScienceSpeaksHivTbNews+%28Science+Speaks%3A+HIV+%26+TB+News%29

5. Ibid.6. “Prostitution Defines AIDS Pandemic More Than Other Factors” Peer Reviewed News for Medical Professionals. Accessed March 27,

2011. http://www.rxpgnews.com/aids-research/Male-circumcision-overstated-as-prevention-tool-against-AIDS_39994.shtml7. Ibid.8. “Human Trafficking, HIV/AIDS, and the Sex Sector Human Rights for All.” Change Center for Health and Gender Equity. 9. Ibid.10. “Human Trafficking, HIV/AIDS, and the Sex Sector Human Rights for All.” 11. “Sex Workers and HIV Prevention.” Avert. Accessed February 25, 2011. http://www.avert.org/sex-workers.htm.12. Overs, Cheryl. “Sex Workers: Part of the Solution.” The World Health Organization. Accessed April 9, 2011. Last Modified 2002. Ac-

cessed via http://www.who.int/hiv/topics/vct/sw_toolkit/context/en/index3.html.PDF13. Where Prostitutes Also Fight AIDS, Monte. “Where Prostitutes Also Fight AIDS.” The Washington Post. Accessed February 25, 2011.

Last modified March 2, 2006. http://www.washingtonpost.com/wpdyn/content/article/2006/03/01/AR200603002316.html.14. “Prostitution Puts U.S. and Brazil at Odds on AIDS Policy.” New York Times. Accessed February 25, 2011. Last modified July 24, 2005.

http://www.nytimes.com/2005/07/24/international/americas/24brazil.html.

Talking Points•acknowledging the reality of •prostitution makes HIV/aIds prevention efforts more ef-fective. Prostitutes often transmit HIV to clients, who may then also pass the virus on to others. Prostitutes can serve as •“peer educators,” informing other sex workers how to practice safe sex.13 Brazil, a country that incor-•porates sex workers into its public-health programs, has one of the most successful HIV-prevention programs in the developing world.14

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Lower healthcare spending in America using health information exchanges to identify the costliest fee-for-service Medicare beneficiaries for risk-targeted primary care.

Presently, 10 percent of Medicare beneficiaries account for 58 percent of Medicare costs.1 Of these, 20 percent suffer from more than five chronic conditions, often lack effective primary care, and consequently frequent the emergency room.2 The result is an inefficient healthcare system that cannot sustainably support the 32 million newly insured Americans3 under the Affordable Care Act (ACA).

Hospital and emergency room visits guzzle healthcare dollars and represent failures of primary care to prevent or manage illness. Medical hot-spotting draws upon statistics-based policing (CompStat) by cost-profiling the highest-risk patients and offering inten-sive primary care to maximally avert costlier medical intervention.4 By design, this ben-efits a narrow segment of the population, which, to some, challenges its equity. However, hot-spotting is analogous to hospital intensive care, thus only suited for patients whose conditions necessitate vigorous attention.

While pilots across care settings report significant success toward reducing costs, initia-tives for wider deployment are fundamentally limited by a lack of access to patients’ health information.5 As a result, high-risk patients in particular continue to receive dis-jointed, episodic care from multiple providers that do not communicate. The French healthcare system employs an input-able health insurance card (carte vitale) that con-tains patients’ current medical information, which enables providers to better coordi-nate care.6 As live-streaming databases, networks of interoperable health information exchanges (HIEs) will facilitate similar care-coordination by circumventing barriers be-tween providers, fostering collaboration, and revealing best practices.7 These improve-ments can help scale hot-spotting initiatives across the country.

analysisAmerican healthcare encourages short-term health management rather than health main-tenance,8 which has fostered tremendous inefficiencies. Risk-targeted intervention will facilitate such health maintenance and pro-duce better health outcomes that will allevi-ate strains on struggling systems. In addition, model programs across care settings remain popular among physicians, who report high-er job satisfaction, as well as patients, who enjoy better quality of life.9

HIEs could also help realize a less expensive, paperless system. While Medicare overhead is comparatively low, private insurance over-head adds up to 20 percent to each medi-

“X” Marks the Hot-Spot Sameer Sant, University of Texas - Dallas

Key Facts•High-risk patients routinely receive •uncoordinated, duplicative service with diminishing health return, re-vealing serious inefficiencies in the healthcare system.13Patients with multiple chronic con-•ditions can cost up to seven times more than those with one condi-tion.14Hot-spotting initiatives have pro-•duced 56% cost-reductions in Camden, NJ, one of the poorest U.s. cities,15 as well as 7% annual net savings at Massachusetts Gen-eral Hospital, one of the best hos-pitals in the country.16

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cal bill.10 HIEs can interface with existing heath information technologies like electronic medical records to further tighten spending that does not directly finance medical services. Economic analy-ses estimate these savings to amount in excess of $200 billion per year, evidently sufficient to cover the remaining uninsured.11 Thus, HIEs could pay for themselves and help institute other proposed care-innovations such as Accountable Care Orga-nizations (ACOs).

Next stepsLocal health departments should partner with in-formation technology firms and leverage their da-ta-management expertise to install HIEs: secure information hubs where providers can document patients’ medical information, including treatment regimens and outcomes. To protect privacy, pa-tients should be issued cards that grant only their selected providers access to their HIE-records. HIEs will inform cost-profiling based on Medicare reimbursements for analysis by metrics such as hospitalization rates—practices extend-able to private insurance. The results will identify the highest-risk patients that should be offered enrollment in care programs tailored to their specific medical needs. Section 3022 of the ACA authorizes the Medicare Shared Savings Program for ACOs, which rewards ACO members a share of every dollar they save Medicare.12 The Centers for Medicare and Medicaid Services could provision similar gains-sharing benefits to reward cost-reductions, not just a rein in on their growth.

endnotes1. Henry J. Kaiser Family Foundation, “Kaiser Fast Facts, Figure 8.8: Distribution of Medicare Fee-for-Service Beneficiaries and Medicare Spending.”

2006. http://facts.kff.org/chart.aspx?cb=58&sctn=169&ch=1800 (accessed May 6, 2011).2.Gawande, Atul, A. “The Hot Spotters.” The New Yorker, January 24, 2011, 1-10.3. DeParle, Nancy-Ann. “The Affordable Care Act Helps America’s Uninsured.” September 16, 2010. http://www.whitehouse.gov/blog/2010/09/16/

affordable-care-act-helps-america-s-uninsured (accessed April 22, 2011).4. Gawande, Atul, A. “The Hot Spotters.”5.Ibid6. Reid, T.R. The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care. New York, NY: The Penguin Press, 20097. Brenner, Jeffrey. “Camden Coalition of Healthcare Providers: Health Information Exchange Links Medical Information Across Camden.” Updated

2011. http://www.camdenhealth.org/programs/health-information-exchange/ (accessed May 6, 2011).8. Grundy, Paul. “The Multi-Stakeholder Movement for Primary Care Renewal and Reform.” Health Affairs. 29. 5 (2010), 791-98, http://content.

healthaffairs.org.libproxy.utdallas.edu/content/29/5/791.full.pdf+html. (accessed February 21, 2011).9. Gawande, Atul, A. “The Hot Spotters.”10. Reid, T.R. The Healing of America.11. Krugman, Paul. “One Nation, Uninsured.” June 13, 2005. http://www.nytimes.com/2005/06/13/opinion/13krugman.html (accessed May 4, 2011).12. Centers for Medicare and Medicaid Services, “The Website for Information on the Medicare Shared Savings Program.” Last Modified April 7,

2011. https://www.cms.gov/sharedsavingsprogram/30_Statutes_Regulations_Guidance.asp#TopOfPage (accessed April 8, 2011).13. Gawande, Atul, A. “The Hot Spotters.”14. Stanton, Mark W. “The High Concentration of U.S. Health Care Expenditures U.S. Department of Health and Human Services: Agency for

Healthcare Research and Quality - Research in Action”. 19 (2006), http://www.ahrq.gov/research/ria19/expendria.htm#Introduction. (accessed April 3, 2011).

15. Goldsmith, Trevor. “Health Affairs Blog: Camden’s Roadmap To Reform.” March 29, 2011. http://healthaffairs.org/blog/2011/03/29/camdens-road-map-to-reform/ (accessed May 6, 2011).

16. McCall, Nancy. “Evaluation of Medicare Care Management for High Cost Beneficiaries (CMHCB) Demonstration.” September 2010. http://www.cms.gov/reports/downloads/McCall_MGH_CMHCB_Final_2010.pdf (accessed April 3, 2011).

17. Grundy, Paul. “The Multi-Stakeholder Movement for Primary Care Renewal and Reform.”18. Congress of the United States, “Evidence on the Costs and Benefits of Health Information Technology.” Congressional Budget Office. (2008),

1-46, http://www.cbo.gov/ftpdocs/91xx/doc9168/05-20-HealthIT.pdf. (accessed May 6, 2011).19. Pear, Robert. “New York Times Money & Policy: Industry Pledges to Control Health Care Costs.” May 10, 2009. http://www.nytimes.

com/2009/05/11/health/policy/11drug.html?_r=1&hp=&adxnnl=1&adxnnlx=1304679886-8nice+XQEC9+PHMefQj2eg (accessed May 6, 2011).

Talking Points•Risk-reduction among the •costliest patients will maxi-mize aversions of expensive medical services, particularly hospital or emergency room visits.Risk-targeted primary care •facilitates a necessary shift in healthcare delivery toward long-term care-management, which is essential to sustain universal healthcare.17HIes are potentially budget-•neutral ways18 for american healthcare to feasibly deliver on its promise19 to reduce spending by $2 trillion over the next decade.

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