Roosevelt 2009

ideas
10 for

health
care
 10 Ideas for Health Care
Summer 2009

National Director
Hilary Doe

Chair of the Editorial Board

Gracye Cheng

Director of Center for Health Care

Robert Nelb

National Editorial Board

Clayton Ferrara
Frank Lin
Fay Pappas
Melanie Wright
Yunwen Zhang

The Roosevelt Institute Campus Network

A division of the Roosevelt Institute
2100 M St NW
Suite 610
Washington, DC 20037

Copyright 2009 by the Franklin and Eleanor Roosevelt Institute.

All rights reserved.
The opinions and statements expressed herein are the sole view of the authors and do
not reflect the views of the national organization, its chapters, or affiliates.
 ideas
10
for

health care
This series was made possible
by the generosity of
Mr. Stephan Loewentheil.
 P
Table of Contents
Primary Care

Using Old TV Spectrum to Expand Rural Home Telehealth 8

David Silver

Restructuring the Medicaid All-Or-Nothing Threshold 10

Neil Parikh and Yining “Tommy” Fu

Beneficiary-centered assignment for Medicare Part D 12

Tammie Chau

Preventive Care

Patient-centered Reimbursement for Chronic Diseases 14

Jamie Cohen and Andreas Shepard
•
Nutrition Information at Point of Purchase 16
Kelsey Jones

Extending Prescribing Privileges to Clinical Psychologists 18

Jeremy Ford

Strengthening Community-based Mental Health Care for Veterans 20

Taylor Johnson

Patient-Centered Care

Expanding Personal Control of Electronic Health Records 22

Eva Galvan

Municipal Identification Cards as Gateways to Health Services 24

Lauren Hunter, Greg Mittl, Jessica Becker, and Eva Galvan

Using Biometrics to Coordinate Health Care For Undocumented Patients 26

Yining “Tommy” Fu and Neil Parikh

Year in Review 28
Robert Nelb
p Letter from the Editor
Earlier this year, the Roosevelt Institute Campus Network adopted Think Im-
pact, a model that re-emphasized our organization’s founding goals of looking
to young people for ideas and action, twin forces necessary in the pursuit of
change.

The ideas you will read about in this year’s first 10 Ideas series are the result
of the admirable creativity, hard work, and scholarship of Roosevelters. These
publications—on Defense and Diplomacy, Economic Development, Education,
Energy & the Environment, Equal Justice, and Health—are also a testament to
these authors’ engagement with the world. In environments that can be insular,
Roosevelters show a willingness to look outwards, to think critically about prob-
lems on a local, state, and national level.

But, to this end, these publications should only serve as a starting point of a
greater process. Roosevelters must be willing to act in the communities where
these ideas can most effect positive change. For concepts that you find inspir-
ing, we hope that you are motivated to leverage them for the benefit of your own
campus, city or state, and that you seek out channels and movements through
which to bring these ideas to fruition. And, in instances where you disagree,
we hope that you are challenged to see how you might improve on or adapt an
idea.

Gracye Cheng
Chair of the National Editorial Board
 Strategist’s Note P
T he Roosevelt Institute Campus Network was founded on the premise that
students have great ideas, and in this journal, I think we found some. With so
many people talking about health care reform today, new ideas might seem hard
to find, but our fellows continue to surprise us with their creativity and innova-
tion.

In particular, these ideas are innovative in the way that only students can be.
Although we did not dictate any specific theme for this journal, all of the ideas
seem to offer a new way of using technology to address long-standing challenges
of the health care system. It makes sense that the generation that grew up with
the internet and smart phones would be among the first to think about how
these tools can be used to create a more streamlined, mobile, and personalized
health care system. Unfortunately, students today have not been asked enough
to share their great ideas - we hope to correct that error in these pages and in
our actions every day as Roosevelters.

Perhaps the most exciting thing about student ideas and about this journal is that
these ideas are only the beginning of what we can do. You can expect to hear
much more from these students in the future.

Robert Nelb
Lead Strategist for Health Care
Using Old TV Bandwidth
To Expand Rural Telehealth
David Silver, University of Colorado - Boulder

Develop the bandwidth left unused after the switch to digital television to pro-
vide fast internet access for telehealth programs in rural areas.

Rural communities face significant social and economic barriers to receiving quality
healthcare. Fifteen percent of people in rural areas are below the federal poverty level
compared to 12 percent of urban residents. Rural regions are frequently designated as
Health Professional Shortage Areas (HPSAs). For example, eight Colorado counties have
only one full-time primary care physician – four of which are not accepting new Medicaid
patients. Six additional counties lack even a full-time primary care physician, and one
rural county has no physician.

Home telehealth – the use of

remote monitoring of patients’ Key Facts
blood pressure, glucose levels,
• Broadband delivery reaches only 31% of the
and other patient information in
rural population compared to 50% in urban
the electronic system – allows
and suburban areas, but virtually all Americans
rural access to more central-
have access to television.
ized health care professionals
• Rural wireless networks transmitting in the TV
who can anticipate and prevent
band can cover four (4) times the area, and at a
avoidable problems. A study
higher quality of service, than a network trans-
completed by the Veterans’
mitting in current unlicensed bands.
Association found that home
• A 2009 VA study found a 25% reduction in the
telehealth reduced the average
average number of days hospitalized and a 19%
number of days hospitalized by
reduction in hospitalizations for patients using
25% and cut overall hospitaliza-
home telehealth.
tions by 19%.

A major barrier to telehealth in

rural areas has been the lack of access to high-speed internet. Telecommunications com-
panies fail to wire low-population density regions for internet because high infrastructure
costs and low usage yield minimal returns. But the switch to digital television (DTV) could
provide high-speed internet access – along with its many health and community benefits
– to rural communities on the waves that television broadcasters no longer use. With a
simple adapter, communities will be able to access the internet wherever they have a
cable TV. Telecommunications companies currently deliver internet on waves identical
to those that television broadcasters use, but at a higher frequency. The frequency of
these waves make them much less efficient to send over long distances, as the informa-
tion on the waves is easily distorted. Because of its lower frequency, television spectrum
broadcasts can cover four times the area of higher-frequency signals with higher speeds
and quality of service. On November 4, 2008, the FCC voted for the television spec-
trum to be unlicensed after the switchover to digital television in 2009. Google, Intel,
and Microsoft are currently working on devices that harness the television spectrum for
broadband, commonly referred to as “white space”. The greatest successes have come in
geographic locations with few preexisting television stations, i.e. rural areas. Rural health-
care providers – and more generally, rural communities – should give great consideration
to the use of this new technological resource. High-speed internet access is imperative
for the development of telehealth, as demonstrated by the Colorado Telehealth Net-
work’s roughly $11-million investment for wiring rural health clinics and critical access hos-
pitals for broadband. However, this investment is not enough to fully implement home
telehealth strategies – transportation issues to health clinics and hospitals still remain a
problem for many rural residents.

That rural Americans own significantly fewer computers per capita than their counter-
parts poses a challenge to implementing this strategy. However, Federal programs are
already in place that subsidize computer purchases in rural areas. Congress should look
to these programs to provide home telehealth patients with computers.

Talking Points Next Steps

• Broadband is now a utility comparable to elec- Congress should fund a grant
tricity, phone lines, and water. It is vital to not only program to help rural provid-
health outcomes, but educational, economic and ers purchase adapters so as
community development as well. to use the TV cables that they
• Telehealth technology promises to increase pre- already have to create inter-
ventive care measures through home telehealth active telehealth portals. This
and collaboration with centralized healthcare program could be funded and
specialists. incorporated into the existing
• The switch to DTV will allow citizen access high- rural health center program.
speed internet wherever there are TV cables.

Sources
Brennan, D. M., B. E. Holtz, N. R. Chumbler, R. Kobb, and T. Rabinowitz. “Visioning technology for the future of telehealth.” Telemedicine and
e-Health 14, 9 (November 2008): 982-985.
Colorado Health Institute. Data. Retrieved April 7, 2009, from http://datacenter.coloradohealthinstitute.org/data.jsp
Horrigan, J. B. “Broadband adoption in 2007.” Pew Internet and American Life Project. Retrieved April 7, 2009, from http://www.pewinternet.org/
Press-Releases/2007/Broadband-Adoption-in-2007.aspx
LaRose, R., J. L. Gregg, S. Strover, J. Straubhaar, and S. Carpenter. “Closing the rural broadband gap: promoting adoption of the internet in rural
America.” Telecommunications Policy 31, (2007): 359-373.
Lennett, B. “Rural broadband and the TV white space.” Issue brief #22. New America Foundation: Wireless Future Program, June 2008. 4 p.
NAS Recrutiment Communications. “NAS insights: physician recruitment report.” Retrieved April 7, 2009, from http://www.nasrecruitment.com
MicroSites/healthcare/Articles/featureH5b.html
Spire, M. A review of physician recruitment and training in rural America. Washington, D.C. Washington Health Policy Fellowship Program, August
2000. 16 p. Retrieved April 7, 2009, from http://www.unmc.edu/Community/ruralmeded/fedstloc/RecrRet/national_view_recruitment.htm
U.S. Census Bureau. State and County QuickFacts. Retrieved April 7, 2009, from http://quickfacts.census.gov/qfd/states/08000.html
United States Department of Veterans Affairs. VA data show home health technology improves access to care. January 2009. http://www1.va.gov/
opa/pressrel/pressrelease.cfm?id=1637 (accessed April 7, 2009).
Seshamani, M. V. (2008). Hard times in the heartland: health care in rural America. Retrieved May 6, 2009, from HealthReform.gov: http://www.
healthreform.gov/reports/hardtimes/

9
Restructuring the Medicaid
All-or-Nothing Threshold
Neil Parikh and Yining “Tommy” Fu, Rice University

Extending Medicaid coverage on a sliding scale to low-income families that

earn just above their Medicaid category’s income threshold can help remove the
perverse incentive to not meet one’s earning potential solely to receive medical
benefits.

The idea of a sliding scale fee for low-income patients is currently undergoing testing in
Massachusetts (those making more than 150% of the FPL), and so far has proven to be
effective – only 2.8% of residents are uninsured and spending from the Health Safety Net
Fund dropped by 38% in just two years. Despite this cost cut, it must be noted that Mas-
sachusetts still leads all other states in health care spending at $6,683 per capita.

Estimate of those affected

Considering the average price of Key Facts
individual health insurance premi- • An estimated 3.6 million Americans have fi-
ums (nearly $5,000), it is those in- nancial incentive to lower their income just
dividuals who qualify under a Med- to gain Medicaid benefits because their
icaid eligibility group, and earn less earnings above the eligibility threshold are
than $5000 above the Medicaid less than the value of health insurance.
eligibility level that have the incen- • In 2007, only 47% of families earning less
tive to purposefully remain below than $40,000 were offered employer-spon-
the income threshold to obtain sored health insurance.
Medicaid benefits. Income distri- • Medicaid spends on average $2,142 per
bution tables and current Medicaid adult Medicaid enrollee. Private insurance,
numbers lead to an estimate of ap- meanwhile, charges an average premium of
proximately 3.6 million adults with $4,700 for each adult enrollee.
the incentive to intentionally lower
their income for medical benefits.
However, the number of potential beneficiaries from this policy is much greater as even
adults outside the [IEL, IEL + 5000] range would have the chance to join the program –
albeit, at a higher premium.

The total number of people affected by this policy is dependent on personal prefer-
ences, in-depth analysis of state-by-state income distributions, and specific state-by-state
income thresholds, and may be addressed after the policy is implemented. In the mean-
while, covering the 3.6 million adults that are the most affected by the policy would cost
$7.7 billion. This estimate does not include the premiums paid by patients, which would
likely lower the overall cost.

Possible Mechanism
Because each state sets its own income thresholds for Medicaid eligibility, this proposal
would affect patients in each eligibility group and in each state slightly differently. The
proposal would offer Medicaid benefits at a subsidized premium – x% of y, where ‘x’
represents the percentage that the patient’s income is higher than the income eligibility
threshold, and ‘y’ represents a flat rate at approximately the individual insurance premium.

Sample Scenario (Non-working parents in California: $21,203 Income Threshold)

Talking Points Next Steps

• Medicaid provides full medical benefits (opera- Considering Medicaid’s struc-
tions, prescriptions, visits) to all qualifying individ- ture, it is crucial for state leg-
uals earning less than a state-controlled thresh- islators to become involved in
old, but offers nothing for similar individuals who this type of policy revision and
earn just above the threshold. rethink their eligibility criteria.
• The majority of Americans considering Medicaid Consistent with the existing
assistance work low-income jobs. Unlike pro- matching scheme, this revised
fessionals and other white collar workers, these proposal will incentivize state
Americans are unlikely to see $5,000 in immedi- governments to increase their
ate raises or bonuses. Therefore, it is possible income threshold, so that the
that these workers will perpetually remain below federal government will sub-
the threshold, in fear that once they rise above it, sidize the health coverage of
they will lose health insurance. even more people.

Sources
“Estimates of the Number of Uninsured Children Who Are Eligible for Medicaid or SCHIP.” Congressional Budget Office - Home Page. 13 Apr.
2009 <http://www.cbo.gov/doc.cfm?index=8357&type=0>.
Facts and Figures 03 2008. MA Health Connector. 13 Apr. 2009 <http://www.mahealthconnector.org/portal/binary/com.epicentric.contentmanage
ment.servlet.ContentDeliveryServlet/About%2520Us/News%2520and%2520Updates/Current/Week%2520Beginning%2520March%25209%25
2C%25202008/Facts%2520and%2520Figures%25203%252008.doc>.
“Fewer low-income parents are being offered health insurance on the job, or are able to afford it privately.” Robert Wood Johnson Foundation. 22
May 2009 <http://covertheuninsured.org/content/fewer-low-income-parents-are-being-offered-health-insurance-job-or-are-able-afford-it-privat>
“Health Care in Crisis: 14,000 Losing Coverage Each Day.” Center for American Progress Action Fund. 13 Apr. 2009 <http://www.americanprogres
saction.org/issues/2009/02/health_in_crisis.html>.
“Health Spending per Capita.” Kaiser State Health Facts. 22 May 2009 <http://www.statehealthfacts.org/comparetable.jsp?ind=596&cat=5>
The Henry J. Kaiser Family Foundation - Health Policy, Media Resources, Public Health Education & South Africa - Kaiser Family Foundation. 13
Apr. 2009 <http://www.kff.org/medicaid/upload/Key%20Medicare%20and%20Medicaid%20Statistics.pdf>.
“HINC-06—Part 1”. U.S. Census Bureau. 23 May 2009 <http://pubdb3.census.gov/macro/032007/hhinc/new06_000.htm>
“Medicaid Payments per Enrollee, FY2006 -.” Kaiser State Health Facts. 13 Apr. 2009 <http://www.statehealthfacts.org/comparetablejsp?ind=183&
cat=4>.
“NCHC | Facts About Healthcare - Health Insurance Costs.” NCHC | Home. 13 Apr. 2009 <http://www.nchc.org/facts/cost.shtml>. NESARA-
National Economic Stabilization and Recovery Act. 13 Apr. 2009 <http://www.nesara.org/files/tax_compare.xls>.
Report from Massachusetts Secretary of Health and Human Services Timothy Murphy, to the Massachusetts General Court, “Chapter 58 Imple
mentation Update. June 12, 2006.
“Total Medicaid Enrollment, FY2006 -.” Kaiser State Health Facts. 13 Apr. 2009 <http://www.statehealthfacts.org/comparemaptable.
jsp?ind=198&cat=4>.

11
Beneficiary-Centered Assignment
For Medicare Part D
Tammie Chau, University of California - San Diego

By matching beneficiaries’ current medication regimen with the right prescription

drug plan, the states’ Department of Health Services can improve beneficiaries’
access to necessary drugs while lowering the cost to the beneficiary, states, and
the federal government.

Beneficiary-Centered Assignment, a method of matching individuals’ drug needs to a for-

mulary plan, is a cost effective strategy to better serve Medicare-Medicaid dual eligibles.
Over 6.2 million low-income seniors and disabled citizens qualify for both Medicare and
Medicaid coverage. These dual eligibles are randomly assigned to prescription drug
plans (PDPs). These privately-administered PDPs can vary depending on covered drug
benefits, premiums, co-payments, and the low-income federal subsidy. As consumers,
enrollees have the option of changing their drug coverage using Medicare’s Web-based
Plan Finder. However, the majority of dual eligibles do not explore available online op-
tions and remain enrolled in randomly assigned PDPs.

Using Maine as an example,

states should assist in enrolling Key Facts
and reassigning dual eligibles to • “Dual eligibles” are those who qualify for both
low-cost drug plans that fit bene- Medicare and Medicaid. They disproportion-
ficiaries’ needs. The process be- ately have multiple chronic conditions requir-
gins by reviewing the last three ing an average of ten (10) or more prescriptions
months of an individual’s drug per month.
regimen and comparing the po- • An estimated total of $47 billion and $53 billion
tential out-of-pocket expenses. will be spent in 2009 and 2010, respectively,
States should collaborate with on Part D drug benefits.
their pharmacist associations • Random assignment of common pharmaceu-
including pharmacy students to ticals can cost a monthly difference of $242
use Medicare’s Plan Finder. In more than the least expensive drug plan.
Maine, if an enrollee’s plan does
not cover 85 percent of the
medications they currently take,
then the state can switch drug plans on behalf of the beneficiary. Each participant is then
notified by letter about the switch and can opt- out if they prefer not to have their plan
changed.

On January 1, 2006, dual eligibles transitioned from Medicaid’s comprehensive drug

coverage to automatic enrollment in Medicare Part D’s PDP. This random assignment
ensured that each drug plan had equal amounts of enrollees instead of tailoring a plan
to beneficiaries. Random assignment of eligible enrollees not only complicated benefi-
ciaries’ access to prescription drugs, but also resulted in higher costs for the federal
government and states.
Random assignment of PDPs to dual eligibles makes it more difficult for enrollees to ob-
tain necessary drugs. For example, if a drug is not included on the approved list, then the
beneficiary must pay out-of-pocket or forego the drug entirely. Allowing states to better
accommodate dual eligibles with Beneficiary-Centered Assignment provides coverage
for current medication regimens without causing discrepancy in access to prescription
drugs. The potential savings for states and the federal government is substantial in main-
taining this coverage.

Widespread use of Beneficiary-Centered Assignment could streamline enrollees into

just several of the available PDPs. In turn, this could influence private plans to compete
for enrollment based on
adding common drugs to
Talking Points formularies.
• Current assignment of dual eligibles is random and
based upon equalizing the number of enrollees in Next Steps
each private drug plan. There is an ongoing chal-
• Beneficiary-Centered Assignment or intelligent as- lenge to better serve dual
signment assigns dual eligibles to a prescription drug eligibles with their special
plan that meets the individual’s needs. health needs. Decreasing
• Maine is the only state with authority granted from the widespread confusion
the Centers for Medicare and Medicaid Services for dual eligibles, Medi-
(CMS) to reassign dual eligibles to plans that cover care Part D should find an
60 percent to 95 percent of their drugs by evaluating alternative method of en-
beneficiaries’ drug regimens and plan options. rolling beneficiaries into
a prescription drug plan.
State legislators can enact
Beneficiary-Centered Assignment by taking steps to obtain authority granted from CMS
to give state pharmacist associations authorization to automatically enroll dual eligibles
into cost saving plans that match the beneficiaries’ current drug regimen.

Sources
Laura Sumner et al, “Improving the Medicare Part D Program for the Most Vulnerable Beneficiaries.” Com-
monwealth Fund, May 2007.
Jack Hoadley et al, “The Role of Beneficiary-Centered Assignment for Medicare Part D” MedPAC, June 2007.
“The Medicare Prescription Drug Benefit- An Updated Fact Sheet.” Henry J. Kaiser Family Foundation, March
2009.
Vernon Smith et al, “The Transition of Dual Eligibles to Medicare Part D Prescription Drug Coverage: State
Actions during Implementation” Henry J. Kaiser Family Foundation, February 2006.

13
Patient-Centered Reimbursement
For Chronic Diseases
Jamie Cohen and Andreas Shepard, Amherst College

Health care reimbursement methods that follow the patient can help support
health care providers who are preventing and controlling chronic diseases.

Seventy percent (70%) of health care costs in America are spent on people with chronic
diseases. As a result, proper preventative care and chronic disease management could
result in huge cost savings and quality of life improvements. For example, the Center for
Disease Control estimates that every $1 invested in outpatient training that helps indi-
viduals with diabetes manage their disease saves $8.76 in reduced health care costs. They
further estimate that foot-care programs that include regular examination and patient
education could prevent 85% percent of the amputations caused by diabetes.

While the importance of prevention is broadly accepted, creating incentives to encour-

age prevention has been difficult. Traditional private health insurance has little incentive
to cover preventive services, since patients are likely to change insurers before the sav-
ings are realized. Merely mandat-
ing coverage of certain preventive
health benefits, however, is often
Key Facts
insufficient. There must be a way • Nationwide, spending on patients with
to evaluate whether and how ef- chronic diseases accounts for 70% of health
fectively the care is being used. care expenditures.
New advances in health informa- • The Center for Disease Control estimates
tion technology can help address that every $1 invested in outpatient training
this need by creating ways to moni- that helps individuals with diabetes manage
tor whether patients are getting their disease saves $8.76 in reduced health
the preventive care they need and care costs.
ensuring that doctors are compen- • One-third of kidney failure complications
sated for keeping patients healthy from diabetes are preventable.
in the long term.

Analysis
Investing in chronic disease management programs, preventative care, and education
can help lower health care costs and improve quality of life. Although not all preventive
services programs are the same, the federal government should require private insur-
ance companies to reimburse providers for chronic disease management and prevention
services, according to standards governed by the CDC Preventive Services Taskforce.
Improved reimbursement methods are also needed to financially reward those doctors
who provide the best care, who under the current system are rewarded with more rev-
enue if they let their patient’ conditions worsen to the point where costly interventions
are necessary.

In order to track whether patients are achieving their health goals, the organization of
medical records will need improvement. The most promising avenues are electronic forms
of health tracking, such as fully electronic personal medical records and self-reporting
through social networking applications. The current administration has a head start on
this process, since the economic stimulus package included a provision establishing the
Office of the National Coordinator for Health Information Technology, but any system
that office creates must enable the key feature of matching of patients’ achievement of
health goals with their providers’ reimbursement.

The challenges of controlling the

Talking Points costs of chronic diseases are be-
• Fee-for-service reimbursement systems, ing felt across the country, and
like Medicare, reward providers who allow will likely be amplified if health
patients’ conditions to worsen to the point reforms increasing access to
where they need expensive interventions. those without health insurance
• Providers who prevent their patients from are passed. In order for any such
developing chronic diseases or help their health reform to have a sustain-
patients keep their chronic diseases in check able cost in the long term, pay-
receive very little financial reward. ment reforms will be needed. The
• Controlling the costs of chronic diseases will short-term costs – establishing
be important to controlling overall health care a more robust electronic health
costs. tracking system and of making
the first additional payments to
providers that are helping their
patients meet health goals – will be outweighed in the long run with fewer and better
managed chronic diseases. Regardless of whether reforms increasing access are passed,
the existing health care system, which already consumes 1/7th of GDP and continues to
grow, should be reshaped along similar lines.

Next Steps
A starting point for this new reimbursement model is state or federal health insurance
programs, including Medicare, Medicaid, or state health insurance options, like Com-
monwealth Care in Massachusetts. Medicare especially may benefit from the improved
management of chronic diseases, since the greatest costs of chronic diseases are found
in older patients.

Sources
Halvorsen, George. 2007. Health Care Reform Now!. San Francisco: John Wiley & Sons, Inc.
Centers for Disease Control and Prevention. “Preventing Diabetes and It’s Complications.” Revised Septem
ber 5, 2008. http://cdc.gov/nccdphp/publications/factsheets/Prevention/diabetes.htm
“Medicine Online”. Steve Coll. Think Tank blog post: June 9, 2009. <http://www.newyorker.com/online/blogs/
stevecoll/2009/06/medicine-online.html>

15
Nutrition Information
at Point of Purchase
Kelsey Jones, University of Georgia

Congress should take immediate action to require that restaurants provide basic
nutrition information at point-of-purchase and use innovative technology to dis-
seminate this information, engaging consumers in the process of actively improv-
ing their health.

This policy uses a two-pronged approach to achieve its goals of improved American
health. First, Congress should take immediate action requiring that restaurants provide
basic nutrition information at point-of-purchase. Second, the U.S. Department of Health
and Human Services (DHHS) should capitalize on the availability of this nutrition informa-
tion to encourage individual-based, personalized health promotion strategies via online
and mobile phone-centered healthy eating programs.

Managed by the DHHS, the primary

aspect of this policy would require
food producers to display calorie,
fat, cholesterol, sodium, carbohy-
drates, and protein content along-
side or below each product to offer
visible, easy access to such infor-
mation. Additionally, the Food and
Drug Administration’s Recommend-
ed Daily Nutrition Values would
appear elsewhere on the menu, al-
lowing consumers to use this infor-
mation as a point-of-reference when
evaluating the health quality of meal
purchases.
Key Facts
• The United States faces an “obesity epi-
demic,” with the prevalence of obesity dou-
bling in the last twenty years and the nation
reflecting a rate of 66 percent of Americans
that are overweight or obese.
• Much of this obesity crisis stems from
Americans’ consumption of unhealthy res-
taurant meals. Studies show that if restau-
rants provide nutrition information to con-
sumers, preferences shift toward healthier
meal fares.

To maximize the program’s effectiveness, DHHS should complement the program with
a technology-based educational campaign to encourage healthy eating habits and per-
sonalized wellness plans. This policy’s dissemination will build upon current government-
sponsored internet resources, such as the U.S. Department of Agriculture’s “My Pyramid”
website. Incorporating restaurant nutrition information into the website’s food database,
promoting these web-based personalized health and weight loss plans through public
educational campaigns, and adapting wellness programs to new technology such as
smart phone applications will allow consumers to apply these resources to their needs.
Moreover, such technology resources use will allow consumers to create individualized
health profiles such that the applications recognize and respond to health concerns such
as allergies, low-sodium diets, limited calorie intakes, cholesterol needs, and so forth,
when a consumer chooses to dine at a restaurant.
The number of overweight Americans has risen dramatically in recent decades, prompt-
ing the U.S. Surgeon General to deem obesity an epidemic. Significantly, obesity ac-
counts for over 300,000 deaths per year and the present generation of youth may not
outlive their parents. In aggregate economic terms, obesity costs the United States over
$117 billion annually. Coinciding with growing obesity rates, studies show a significant
increase in the consumption of restaurant food, which is typically more dense in calories,
fats, sodium and sugars than at-home alternatives. Studies show that providing restau-
rant patrons with nutrition information results in a shift in consumer preferences, allowing
for a more efficient market. Health professionals suggest that as consumers move away
from high-calorie, high-fat dishes, restaurants will follow suit by replacing those foods
with healthier options.

This policy arms consumers with

Talking Points the ability to make informed choic-
• A policy mandating nutrition information on es while avoiding potential ineffi-
menus will equip consumers with the skills ciencies of alternative government
needed to make healthier dining choices programs, such as outlawing trans
while requiring minimal government inter- fats or taxing restaurants with less
vention and regulation. healthy fares. It minimizes admin-
• While beneficial, menu labeling cannot istrative costs associated with im-
provide all the information that individual posing and enforcing government
consumers may desire or need; Congress standards within the private sector.
should use nutrition information from res- Finally, by using new technology
taurants to provide consumers with more portals such as cell phone applica-
comprehensive, low-cost health resources tions, individuals will have virtually
and plans through new technology portals unlimited access to these resources
(such as the web and mobile phones). which they can personalize to their
own health needs.

Sources
U.S. Department of Health and Human Services (DHHS), The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity
(Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General, 2001), XI.
David B. Allison, PhD, Kevin R. Fontaine, PhD, JoAnn E. Manson, MD, DrPH, June Stevens, PhD, and Theodore B. VanItallie, MD, “Annual Deaths
Attributable to Obesity in the United States,” Journal of the American Medical Association 282, no. 16 (1999): 1535.
S. Jay Olshansky, PhD, Douglas J. Passaro, MD, Ronald C. Hershow, MD, Jennifer Layden, MPH, Bruce A Carnes, PhD, Jacob Brody, MD, Leonard
Hayflick, PhD, Robert N. Butler, MD, David B. Allison, PhD, and David S. Ludwig, MD, PhD, “A Potential Decline in Life Expectancy in the United
States in the 21st Century,” New England Journal of Medicine 352, no. 11, 1143.
U.S. Department of Health and Human Services, “Preventing Obesity and Chronic Diseases through Good Nutrition and Physical Activity,”
Centers for Disease Control and Prevention, http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/obesity.htm (accessed October
8, 2007).
Shanthy A. Bowman, PhD and Bryan T. Vinyard, PhD, “Fast Food Consumption of U.S. Adults: Impact on Energy and Nutrient Intakes and Over
weight Status” Journal of the American College of Nutrition 3, no. 2 (2003): 167.
National Restaurant Association, “Frequently Asked Questions,” National Restaurant Association, http://www.restaurant.org/aboutus/faqs.cfm
(accessed October 12, 2007).
Burton et al., 1673.
Burton, 1674.
Fred Kuchler, Elise Golan, Jayachandran N. Variyam, and Stephen R. Crutchfield, “Obesity Policy and the Law of Unintended Consequences” U.S.
Department of Agriculture Economic Research Service, http://www.ers.usda.gov/AmberWaves/June05/Features/ObesityPolicy.htm (accessed
October 7, 2007).
John C. Kozup, Elizabeth H. Creyer, and Scot Burton, “Making Healthful Food Choices: The Influence on Health Claims and Nutrition Information
on Consumers’ Evaluations of Packaged Food Products and Restaurant Menu Items,” Journal of Marketing 67, (April 2003): 32.
Jayachandran N. Variyam, “Nutrition Labeling in the Food-Away-from-Home Sector: An Economic Assessment,” U.S. Department of Agriculture
Economic Research Service, Economic Research Report Number 4, http://www.ers.usda.gov/publications/err4/err4.pdf (accessed October 12,
2007).

17
Extending Prescribing Privileges
to Clinical Psychologists
Jeremy Ford, University of North Carolina - Chapel Hill

Extend prescribing privileges to clinical psychologists and prepare them through

training programs in drug therapy in order to lower costs and mitigate disparities
in access to mental health treatment for youth and patients in rural areas.

There has been a persisting shortage of psychiatrists in the United States. Due to poor
funding and inadequate recruitment from medical schools, child and adolescent psychia-
trists will continue to be in short supply, as will psychiatrists practicing in rural parts of the
country. Some lawmakers have addressed this shortage by allowing clinical psychologists
to prescribe psychotropic medications – drugs for mental illness.

Analysis
Although some psychiatrists have
expressed concern that prescrib-
ing psychologists would provide in-
adequate care and could increase
the risk of fatal drug interactions
for children, psychologists have
proven to be effective prescribers
in various settings after training in
pharmacotherapy. The Department
of Defense launched a project in
1989 to train military psychologists
in prescribing psychotropic medi-
cations. After two years of training,
supervising psychiatrists rated the
prescribing skills of graduates as
“good to excellent.”
Key Facts
• One in four adults suffers from a diagnos-
able mental disorder, and 6% suffer from
serious mental illness.
• There were 6,300 practicing child psychia-
trists as of 2003, whereas an estimated
30,000 were needed.
• In 2000, large metropolitan areas had 6.9
child psychiatrists per 100,000 youth, but
in rural areas, there were 0.3 psychiatrists
per 100,000 youth.
• The average hourly cost of an appointment
is $62.64 with a psychiatrist and $39.44 with
a psychologist.

Prescribing psychologists could generate savings for the mental health system and pa-
tient. Psychiatrists undergo four years of expensive and broad-based medical training
of which only six weeks is dedicated to clinical psychiatric medicine. Psychiatrists also
complete an additional four years of residency. Students incur debt that is usually paid
off by relatively high salaries following residency – a cost absorbed by patients and the
health care system.

Doctoral training for psychologists is far less expensive and more specific to mental ill-
ness than the medical education of psychiatrists. Given their relatively inexpensive train-
ing, psychologists do not accrue as much debt as medical students and usually command
lower salaries than psychiatrists.
Stakeholders
Americans of all ages with mental disorders, especially those living in rural areas, could
benefit from this policy. They would have increased access to necessary psychotropic
medications and a greater abundance of prescribers. They would also experience great-
er savings due to lower transportation and provider costs. Psychologists could benefit
economically and professionally from expanded career choices. Psychiatrists would con-
tinue to offer a competing approach that focuses on pharmacological intervention rather
than psychotherapy.

Next Steps
Talking Points Lawmakers should address the
• After training in drug therapy, psychologists shortage of psychiatric services
are proficient prescribers of psychotropic through federal legislation mod-
medications. eled after recent state legislation
• An increased supply of prescribing mental in New Mexico and Louisiana.
health professionals could address short- Following bill passage and pro-
ages in rural and child mental health care. gram development at academic
• Training prescribing psychologists would be institutions, the United States
significantly less costly than training new could have its first generation of
psychiatrists, generating savings for mental prescribing psychologists to treat
health systems and patients. underserved populations in one
to two years.

Sources
Kim, W.J. “Child and Adolescent Psychiatry Workforce: A Critical Shortage and National Challenge.” Aca
demic Psychiatry 27(4):277-292.
Kessler, R.C., Chiu, W.T., Demler, O.,Walters E.E. “Prevalence, severity, and comorbidity of twelve-month
DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R)”. Archives of General Psychiatry
62:617-627 (2005).
Bates, B. “Child Psychiatrists in Huge Demand: Shortage Deemed a ‘Dire Problem’” Clinical Psychiatry News
31:1-5 (2003).
Levin, A. “Rural Counties Suffer From Child Psychiatry Shortage” Psychiatr News 41:4 (2006).
Pingitore, D.P., et al. “Comparison of Psychologists and Psychiatrists in Clinical Practice.” Psychiatric Services
53:977-983 (2002).
National Alliance on Mental Illness. “Prescribing Privileges for Psychologists: An Overview” 2002. http://
www.nami.org/Template.cfm?Section=Issue_Spotlights&template=/ContentManagement/ContentDisplay.
cfm&ContentID=8375.
American Academy of Child and Adolescent Psychiatry. “AACAP State Psychologist Prescribing Update.”
(2005).
National Alliance on Mental Illness. “Prescribing Privileges for Psychologists: An Overview” (2002). http://
www.nami.org/Template.cfm?Section=Issue_Spotlights&template=/ContentManagement/ContentDisplay.
cfm&ContentID=8375.
Galka, S.W., et al. “Medical Students’ Attitudes Toward Mental Disorders Before and After a Psychiatric Rota
tion.” Academic Psychiatry 29:4 (2005).
Salary of Benefits of Psychiatric Residency Program for the University of Washington. http://depts.washington.
edu/psychres/salary.shtml.
American Psychological Association. Singleton, D., Tate A, and Randall, G. “Report of the 2001 APA Salary
Survey” (2003). http://research.apa.org/01salary/index.html.
Psychiatrist Salaries (2009). http://swz.salary.com/salarywizard/layouthtmls/swzl_compresult_national_
HC07000027.html

19
Strengthening Community-Based
Mental Health Care for Veterans
Taylor Johnson, University of Michigan

Comprehensive peer support programs that allow returning veterans to connect

with support networks in their communities and through social networking sites
can provide important supplementary mental health services for young veterans
returning from Iraq and Afghanistan.

Many gaps in the veterans mental health system are creating significant barriers to rein-
tegration for returning veterans. Despite new legislation to expand access to traditional
mental health services for veterans, little support is provided to overcome the stigma of
receiving mental health services and to ensure continued support between therapy ses-
sions. Peer support specialists fill both of these roles and perform a wide range of tasks
to assist consumers in regaining control over their own lives and over their own recovery
process, which include:
Key Facts
• Serving as models by demon-
• The Army’s Mental Health Advisory Team has
strating good communication
estimated that 30 percent of high combat
skills, effective coping skills,
marines and soldiers returning from Iraq de-
recovery-oriented living skills,
velop post-traumatic stress disorder (PTSD),
and self-help strategies.
anxiety, or depression.
• Helping veterans develop
• A Vet4Vet survey of veterans demonstrated
and implement treatment
increasing overall improvement and progress
plans.
in the recovery process based on number of
• Assisting veterans in attend-
peer support sessions attended.
ing their activities and ap-
• Only 42 percent of soldiers and 38 percent of
pointments.
marines who screened positive for a mental
Peer support specialists have health problem in Iraq sought treatment.
been identified as an important
supplement to relieve the already
strained veteran mental health system. Minimal national funding has been appropriated
to develop these programs, which has resulted in states implementing veteran peer sup-
port programs on a small scale.

A grant program to develop training and implement veteran peer support programs
throughout the nation can help ensure that veterans have the necessary resources to
successfully reintegrate into society upon returning home. In addition to promoting
healthy veterans, this legislation creates unique job opportunities that are specifically
designed for veterans. Because peer support’s effectiveness relies on the connection
of shared experience, these jobs will be filled by veterans who have recovered from ill-
nesses brought about by their experiences in the military.
Analysis
The stigma associated with mental illness in the military is one of the many challenges
veterans must overcome when accessing mental health services. Because soldiers fear
the professional consequences of being diagnosed with a mental illness, they often avoid
treatment and instead serve multiple combat tours while suffering from a mental illness,
impairing their service. The social stigma associated with mental illness has also led many
veterans to abuse alcohol or drugs in order to ‘treat’ their illness, creating a large popula-
tion of veterans with co-occurring mental illnesses. Peer support specialists provide a
unique support network for returning veterans and can also serve as a non-threatening
entry point into the mental health system. The opportunity to access peer services will
lead to greater awareness and recognition of mental illness in the military, combating the
stigma associated with it.

Mental health services are most of-

Talking Points ten accessed by veterans at Veter-
• Veteran peer support programs create ans Administration Hospitals which,
paid professional opportunities for veter- due to distance or unstable trans-
ans and develop important resources for portation options, can make utiliz-
returning veterans. ing those services frequently or in
• Peer support specialists serve as an im- an emergency difficult. By training
portant supplement to traditional mental veteran peer support specialists
health services, easing the strain on the located in communities throughout
current veteran mental health system. each state, veterans will be able to
• Mental health resources are not a benefit access services on a local level. In
that should be given to veterans, rather addition, the use of social network-
they are an entitlement that veterans have ing sites will allow for easy access
earned through their service to America. to peer services. Through targeted
use of these online resources, the
peer support program will be able
to reach the many young returning veterans who communicate more reliably through
online services.

Sources
Armstrong, Moe. “What is Peer Support?.” Veteran Recovery. http://www.veteranrecovery.med.va.gov/peer_
support/What_is_peer_support.pdf (accessed June 11, 2009).
“Veteran Recovery - Job Description PEER SUPPORT SPECIALIST, GS5 - Mental Health Service.” Welcome
to Veteran Recovery. http://www.veteranrecovery.med.va.gov/announce/positions/Peer_Support_Speciaist_
Position_Description.htm (accessed June 11, 2009).
Armstrong, Moe. “What is Peer Support?.” Veteran Recovery. http://www.veteranrecovery.med.va.gov/peer
support/What_is_peer_support.pdf (accessed June 11, 2009).
“America’s Wounded Warriers.” Veterans for America. www.veteransforamerica.org/wp-content/up
loads/2007/12/trends-in-treatment-r2.pdf (accessed June 11, 2009).
Center for Community Support & Research, Wichita State University. “Vets4Vets Program Evaluation.” Vets 4
Vets - Peer Support For Iraq And Afghanistan-Era Vets. http://www.vets4vets.us/ (accessed June 11, 2009).
Ibid
Alvarez, Lizette. “After the Battle, Fighting the Bottle at Home - Series - NYTimes.com.” The New York
Times - Breaking News, World News & Multimedia. http://www.nytimes.com/2008/07/08/
us/08vetshtml?pagewanted=1&_r=1 (accessed June 11, 2009).

21
Expanding Personal Control
of Electronic Health Records
Eva Galvan, Yale University

Health information technology efforts should be expanded to include the cre-

ation of an online, integrated personally-controllable health record (PCHR),
which would monitor the advancement of certain long-term illnesses by suggest-
ing tailored action plans according to the patient’s specific condition.

The 2009 stimulus package has dedicated funding for health care providers to adopt
health information technology (HIT). To offset the cost and difficulties encountered in
adopting HIT, the stimulus package includes a provision for electronic health records
(EHRs) with various features such as “patient demographic and clinical health informa-
tion.”

The United States Depart- Key Facts

ment of Veterans Affairs has • The 2009 stimulus package provides grants
already registered hundreds around $19 billion to health care providers to
of thousands of veterans to support the adoption or upgrading of health in-
use MyHealtheVet, a PCHR formation technologies.
website, to find caregivers, ap- • Over two-thirds of hospitals had at least partial-
ply for prescription refill, track ly implemented EHR programs in 2006, and 10
labs, and keep food and activ- percent of hospitals were using computerized
ity journals, among many other physician order-entry.
services. • Health administration costs in 1999 totaled at
least $294.3 billion in the U.S., or $1,059 per capi-
While the stimulus package has ta, while Canada spends $307 per capita.
already outlined terms of EHR
development and HIT imple-
mentation, an easily understandable, patient-accessible system such as PCHRs incorpo-
rated into new HIT programs is a logical and critical next step. The federal government
could provide overall coordination for this initiative through a new online portal, My-
Health.gov, modeled after MyHealtheVet.

Analysis
Upgrading and standardizing EHRs to allow for patient access online will improve the
quality of care that patients receive and ensure that patients can better manage their
own treatment. The benefits of creating a simple PCHR system far exceed any cost of
creating and distributing it alongside the upgraded HIT that hospitals will be receiving
through the stimulus package. Close monitoring of chronic illnesses such as diabetes will
lessen their overall impact on and cost to American society.

To be successful, PCHRs would have to be not only fast and simple for the doctor to
use during appointments but also easy for the patient to understand. The MyHealtheVet
website has achieved this goal with its “Frequently Asked Questions” section and clear
explanations of the resources it offers. “Wellness Reminders” such as the ones used by
the MyHealtheVet PCHR website can remind patients of appointments or to adhere to
lifestyles consistent with maintaining health.

Stakeholders
Everyone benefits from the implementation of integrated PCHRs; however, patients at
risk of or suffering from chronic illnesses and multiple co-morbidities will be most af-
fected because the most significant gains can be made through personalized disease
management. The burden of using this program to its full potential will rest with medical
professionals and facility administrators, who will have to make sure the patient under-
stands how to access the useful information, and with patients, who have to make the
commitment to access the information.

Next Steps
Talking Points The first step to imple-
• Although the stimulus package has provided funding menting an integrated,
for EHRs, it failed to provide for a comprehensive pa- patient-accessible PHR
tient-accessible system. program is to find fund-
• Upgrading and standardizing EHRs to allow for patient ing, either from Con-
access will improve the quality of care that patients re- gress or through exist-
ceive and ensure that patients can better manage their ing funding directed to
own treatment. the Office of the Na-
• Creating a patient-accessible system is currently fea- tional Coordinator for
sible because of ongoing initiatives for large-scale up- HIT. The National Co-
grades in HIT; the collaboration to develop a baseline ordinator should then
EHR system should additionally be required to inte- oversee the design of
grate patient access. a flexible, uniform pro-
gram, compatible with
the EHR programs al-
ready funded by the stimulus package. The program must be written through close col-
laboration between public health experts, medical professionals, program designers, and
any existing private programs. The last phase will involve implementation and expansion
measures similar to those being envisioned for the baseline EHR programs.

Sources
“Continued Progress: Hospital Use of Information Technology.” American Hospital Association. 2007. <http://
www-03.ibm.com/industries/global/files/continuedprogress.pdf> (accessed April 5, 2009).
“My HealtheVet – The Gateway to Veteran Health and Wellness.” The United States Department of Veteran
Affairs. 30 April 2009. <http://www.myhealth.va.gov> (accessed May 5, 2009).
“Speaker Nancy Pelosi: American Recovery and Reinvestment Act.” <http://www.speaker.gov/newsroom/
legislation?id=0273> (accessed April 5, 2009).
“The American Recovery and Reinvestment Act of 2009.”<http://frwebgate.access.gpo.gov/cgi-bin/getdoc.
cgi?dbname=111_cong_bills&docid=f:h1enr.pdf> (accessed April 5, 2009).
Woolhandler, Steffie, Campbell, Terry, Himmelstein, David U. “Costs of Health Care Administration in the
United States and Canada.” N Engl J Med, 349 (2003) 768-775.

23
Using Municipal Identification Cards
as Gateways to Health Services
Lauren Hunter, Greg Mittl, Jessica Becker, and Eva Galvan, Yale University

Municipal ID cards can increase access to free and low-cost health services,
especially for immigrants and the uninsured.

Cities across the country have recently implemented municipal identification cards, rec-
ognizing the potential for such cards to incorporate immigrants and other underrepre-
sented groups into the city community. Like driver’s licenses, municipal ID cards con-
tain the bearer’s photograph, address, and date of birth, as well as a unique identifying
number and an expiration date. Unlike driver’s licenses, all city residents – regardless of
immigration status – may obtain municipal ID cards.1 The first such card was New Haven’s
“Elm City Resident Card” (ECRC), which has inspired programs in other cities, notably
San Francisco.2

In addition to acting as a form of

identification, some municipal ID
cards offer services, such as debit or
library capabilities. In March 2009,
the Elm City Resident Card was
linked to a program that offers a 20
percent discount on all prescription
drugs at CVS pharmacies, making
this discount available to uninsured
New Haven residents with an ECRC.3
The incorporation of a prescription
drug discount into a municipal ID
card was a first step toward utilizing
these cards as gateways for health
services.
Key Facts
• As of 2005, there were 46.6 million un-
insured Americans (15.9 percent of the
population).4
• Immigrants use about half as many health
services as U.S.-born individuals.5
• About 10 percent of all ambulatory health
care expenditures are for emergency
room services.6
• 7370 New Haven residents have applied
for the Elm City Resident Card.7

Analysis
There are several ways in which a municipal ID card can increase resident access to
free and low-cost health services. One possible approach is to embed personal health
information on the card itself – an especially compelling option since health providers
regularly struggle to locate the medical histories of immigrants and the uninsured. The
card could simply display basic health information, such as the bearer’s allergies and
organ donor status. A more complex version of the card would be an electronic health
record offering a comprehensive medical history.

Several options require greater involvement on the part of the municipal government. A
city can compile information on low-cost health care and include a box on the ID card
application form that residents can “check” in order to receive the compilation when
they receive the ID card. This approach responds to the disjointed and confusing nature
of American health care by providing straightforward instructions for access. Another
option for city governments is to market the card as a “safe space” icon to the immigrant
community. For example, a city could create a program for familiarizing providers with
immigrant health and financial needs. When providers complete the program, they are
“certified” by the city and can, perhaps, display the ID card icon in their office.

The costs of implementing and maintaining the ID cards are minimal. New Haven’s card
is actually funded by supportive organizations outside of the city government.8 The costs
of the health components are also small and consist primarily of administrative time in-
vested in communicating with providers, advocacy groups, etc.

Stakeholders
Reassuring immigrants that providers are familiar with their needs and presenting the
uninsured with financially-feasible health care options will encourage both groups to visit
physicians earlier, contributing to their well-being. In addition, significant financial ben-
efits flow to the taxpayer. When the uninsured and impoverished are financially able to
access preventative services, their costly use of emergency rooms decreases. Lastly, the
entire city is strengthened when its members feel safe, healthy, and valued.

Next Steps
Talking Points With more than 7,000 people
• Municipal ID cards can become navigation signed up for the ECRC in New
tools for fragmented and confusing health sys- Haven, and other cities imple-
tems, providing residents – immigrants and the menting or proposing similar
uninsured, in particular – increased access to cards, the future of the munici-
needed health services. pal ID card as a health service
• Connecting municipal ID cards to low-cost gateway may be at a turning
health services saves taxpayers’ money by re- point. City government – both
ducing the burden of immigrants and the unin- the executive and legislative
sured on our emergency rooms. branches – must support the
• Municipal ID cards, especially when they in- creation of municipal ID cards.
clude a public health component, encourage Incorporating health compo-
immigrants to become stakeholders in the nents into existing cards can
community, improving resident relationships involve collaboration between
and decreasing crime. city government and community
health centers, hospitals, and
myriad advocacy groups.

Sources
1. Matos, Kica. “The Elm City Resident Card: New Haven Reaches Out to Immigrants.” New England Community Developments 4 (2008): 1-7.
2. “SF City ID Card.” City and County of San Francisco, Office of the County Clerk. 2 Apr. 2009 <http://www.sfgov.org/site/countyclerk_index.
asp?id=78261>.
3. “New Haven Prescription Discount Card.” City of New Haven. 2 Apr. 2009 <http://www.cityofnewhaven.com/Mayor/PrescriptionCard.asp>.
4. “The Number Of Uninsured Americans Is At An All-Time High.” 29 Aug. 2006. Center on Budget and Policy Priorities. 2 Apr. 2009 <http://www.
cbpp.org/cms/?fa=view&id=628>.
5. Mohanty, Sarita A., et al. “Health Care Expenditures of Immigrants in the United States: A Nationally Representative Analysis.” American Journal
of Public Health 8 (2005): 1431-1438. <http://www.ajph.org/cgi/content/abstract/95/8/1431?ijkey=8c08cb8559640f816a8266203327208226734af7&ke
ytype2=tf_ipsecsha>.
6. Machlin, Steven R. “Expenses for a Hospital Emergency Room Visit, 2003.” Medical Expenditure Panel Survey. Jan. 2006. Agency for Healthcare
Research and Quality. 2 Apr. 2009 <http://www.meps.ahcpr.gov/mepsweb//data_files/publications/st111/stat111.pdf>.
7. Lu, Carmen. “ID card drive aims to draw Elis.” 1 Apr. 2009. Yale Daily News. 2 Apr. 2009 <http://www.yaledailynews.com/articles/view/28402>.
8. Matos, Kica. “The Elm City Resident Card: New Haven Reaches Out to Immigrants.” New England Community Developments 4 (2008): 1-7.

25
Using Biometrics To Coordinate
Health Care For Undocumented Patients
Yining “Tommy” Fu and Neil Parikh, Rice University

Coupling fingerprint and retinal scanners with already existing Electronic Medi-
cal Record (EMR) software will help medical institutions streamline information
access and avoid redundant treatments and expenses for undocumented pa-
tients.

Patient identification is a major barrier to care for the 3.5 million homeless people and 15
million undocumented immigrants currently living in the U.S. Illness among these popula-
tions is exacerbated by their lack of stable residence and safe storage for identification
documents such as driver’s licenses and insurance cards. These documents are the pri-
mary means of patient identification currently used by healthcare centers. In their ab-
sence, physicians and clinics pour substantial time and resources into identifying patients
in order to treat them.

New advances in biometric Key Facts

technology, like fingerprint and • In 2000, our nation’s hospitals spent close to
retinal scanners, can help re- $190 million on undocumented patients.
duce this disconnect by quickly • 20 percent of the uninsured (compared with 3
and conveniently measuring bi- percent of those with coverage) say their usual
ological data for the purpose of source of care is the emergency room.
identification. By syncing these • An estimated $60,000 in government appro-
mobile devices with existing priations would be required to equip every
EMR software, healthcare cen- Federally Qualified Health Center in the U.S.
ters could extend the advantag- with a Biometric-EMR system.
es of digitally organized health
information to a population that
previously could not be tracked within the system. Integrating EMR and biometric identi-
fication would allow doctors to obtain the health history of even the most undocumented
or incapacitated patient with just the swipe of a finger.

The specific use of fingerprint biometrics is a new approach that builds on a history of un-
successful efforts to address the challenge of patient identification. Biotracking devices
like USB bracelets and radio-frequency identification (RFID) cards were all vulnerable to
loss, malfunction, or misplacement. The use of fingerprint identification would circumvent
this persistent obstacle by eliminating the risk of identification loss altogether. In past
years, pilot programs combining these technologies have been implemented successfully
at the Mayo Clinic in Minneapolis, MN and Catholic Health Systems in Buffalo, NY. The
idea has yet to be applied to undocumented patients, the group that may, in fact, benefit
the most from it.

New advances in biometric technology make this approach inexpensive and easy to dis-
seminate. Feedback from health information companies suggests that with the attain-
ment of compatibility between different software systems and standards, this protocol
can be implemented readily with fingerprint scanners as inexpensive as $30. Meanwhile,
savings from the reduction of uncompensated care are projected to reach up to $74 mil-
lion in Houston alone.

Immigrant communities may be concerned that health data would be connected to im-
migration data in order to identified undocumented citizens, but with appropriate privacy
safeguards health data can be kept separate. In addition, if biometric data are used to
identify all patients who come to community health centers, then the ability to single out
non-citizens will also be diminished.

Stakeholders
This novel Biometric-EMR protocol would principally benefit undocumented patients
such as the homeless. They will no longer have to undergo the entire regimen of clinical
tests each time they visit a health center, enabling them to receive better care and open-
ing up time and diagnostic resources for additional cases. Physicians who treat these pa-
tients also stand to benefit.
Greater convenience and
Talking Points speed in obtaining medi-
• For medical personnel, the greater efficiency, reli- cal histories will allow them
ability, and speed of information access enabled by to treat more patients and
a Biometric-EMR system translates into better pro- provide more comprehen-
ductivity and continuity of care for patients. sive care. Lastly, hospitals
• It can also reduce obligatory expenses such as and clinics will benefit from
emergency room services by improving their effi- reduced congestion and
ciency and preventing waste. waste of resources.
• The quicker and more convenient check-in process
enabled by Biometric patient identification may in- Next Steps
crease patient satisfaction and make primary care a The authors have already
more attractive alternative to expensive emergency begun a pilot program at
and catastrophic care. the HOPE Clinic, a Feder-
ally Qualified Health Center
(FQHC) in Houston, TX, to
assess the cost-saving and efficiency benefits of this EMR-Biometric protocol over a six-
month trial period. If successful, the program will seek to introduce this Biometric-EMR
protocol to clinics in the Houston Metropolitan area, the state of Texas, and ultimately
around the U.S. Meanwhile, similar programs can be implemented nationwide in other
certified FQHC clinics. As evidenced by the successes in New York and Minnesota, it is
feasible to integrate these biometric tools with existing medical institutions.

Sources
“Biometric scanner used for hospital security. (01-JUN-05) Hospital Access Management.” AccessMyLibrary - News, Research, and Information
that Libraries Trust. 13 Apr. 2009. http://www.accessmylibrary.com/coms2/summary_0286-12207924_ITM.
“Can EMR save you money?” Medical Practice Management Trends. 13 Apr. 2009. http://www.medicalpracticetrends.com/technology/emr-save-
money/.
Lawrence, Stacey. “Biometrics Bring Fingerprint ID to Hospitals - Health Care.” Research, Best Practices and News for Information Technology
Executives - CIO Insight. 13 Apr. 2009. http://www.cioinsight.com/c/a/Health-Care/Biometrics-Bring-Fingerprint-ID-to-Hospitals/.
“NCHC | Facts About Healthcare - Health Insurance Coverage.” NCHC | Home. 13 April 2009. http://www.nchc.org/facts/coverage.shtml.
“Total FQHCs - United States -.” Kaiser State Health Facts. 13 April 2009 http://www.statehealthfacts.org/profileind.jsp?ind=424&cat=8&rgn=1.
Combs, Susan. “The Uninsured: A Hidden Burden on Texas Employers and Communities.” Texas Comptroller of Public Accounts. 13 April 2009.
http://www.window.state.tx.us/specialrpt/uninsured05/.

27
 Center for Health Care
Year in Review
Robert Nelb, Lead Strategist and Senior Fellow for Health Care

The articles in this journal are just the surface of the work that the Health Policy Center
has done this year. In this final section, I hope to highlight the some of the great work that
goes on behind the scenes and the lessons learned for other students who hope to turn
their ideas into policy.

Of course, the Roosevelt Institute Campus Network is not like most think tanks. We do
not sit around in rooms all day and write pages and pages of papers that are destined
for the recycle bin. We engage students from communities across the country and are
motivated by their fresh perspectives to try and make a tangible impact in the world. It is
a model that we have summed up in a simple phrase: Think Impact.

Think Impact is about so much more than publishing articles in a journal. It is the process
of how we come up with our ideas and way that we use the power of our ideas to make
real change. It is easy to dismiss the ideas of young people as naïve or inconsequential,
but in this past year alone, our fellows have already made a tangible difference. In the
years to come, I have no doubt that our ideas will be changing the world.

Think
Most of the ideas in this journal were developed in the spring of 2009 at our second
annual student health policy conference. Students from all across the country convened
in Washington, DC to hear from experts, advocates, and policymakers, including Lau-
ren Aronson, the policy director for
the White House Office of Health
Reform. From the very start we were Think
thinking of the audience for our pol-
• Think of your audience when choosing
icy ideas.
your topic.
• Value diversity and bring together many
A select group of Roosevelt fellows
different perspectives.
also participated in a special writing
• Meet with community members and
workshop to further their ideas. One
draw from your personal experiences in
of the best parts of this workshop
order to make policy that is relevant to
was hearing the various perspectives
real needs.
from our diverse group of students
from all across the country. Not only
did we hear from students of many
different backgrounds, but we were also able to share ideas with students from different
disciplines, such as engineering and business, in order to develop the kind of interdisci-
plinary ideas that are so important for health policy.

Although conferences in Washington are exciting, the real work of Roosevelt happens
outside the beltway. With a network of chapters at universities across the country, the
Roosevelt Institute Campus Network is especially equipped to investigate issues at the
local level. This year, three of our chapters -- the University of North Carolina, Amherst,
and Yale University -- organized site visits with their local community health centers in
order to learn first hand about problems in the health care system. By getting outside the
classroom, our fellows were able to develop new, innovative ideas, like the Yale health
policy center’s article in this journal about using municipal ID cards as a gateway to help
improve access to health services.

Impact
Once our students develop new ideas, communication is an important part of the policy
process. This journal is just one of our many policy venues to communicate new ideas.
This year we published Roosevelt Rx, our first journal of student health policy ideas; we
organized policy discussions on our blog, and published op-eds and letters to the editor
in major newspapers, including the New York Times.

Words alone are not enough, however, so we have also been active in organizing events
and projects to help turn our ideas into reality. In addition to organizing events in Con-
gress to promote our policies, some of our fellows have been taking action to imple-
ment their policy ideas at the local level. For example, Tommy Fu and Neil Parikh at Rice
University received funding to implement a pilot program of their biometrics policy in
Houston. Students who do not have the resources and connections of more established
organizations, but that does not mean we cannot make a difference.

Despite all these successes, we

Impact also know that change is not easy.
I have learned this lesson my-
• Communicate your idea in many different
self through a policy idea about
forms.
automatic enrollment in public
• Try out your idea on the local level, where you
health insurance programs that
may be able to have a more direct impact.
I published in one of Roosevelt’s
• Keey trying, no matter what.
first journals. Although the idea
seemed simple, change didn’t
happen overnight. However, after
publishing commentary about the idea in many different newspapers and working with
many different partner organizations, I am now pleased to say that the idea was recently
published by the Brookings Institution’s Hamilton project and became a part of the re-
cently passed Children’s Health Insurance Program Reauthorization Act. Change doesn’t
happen alone and it does not happen overnight, but it is possible.

29
your ideas.
your leadership.
your issues.

it’s the new

student activism.

rooseveltcampusnetwork.org
Rooseveltcampusnetwork.org