With the November elections looming, many organizations that we wouldn’t normally think of as hubs for engaging voters are playing an important role in ensuring eligible citizens are able to register. Community health centers, trusted spaces for obtaining health care, are among those entering the realm of voter registration. And their work in this area makes perfect sense. Low-income individuals are some of the most frequent clients of community health centers, all too often having been ostracized by other health care providers in their communities because they are uninsured. These health care clinics are well positioned to empower many of their current clientele who come in seeking medical care. Additionally, low-income individuals are disproportionately less likely to  be registered to vote, similarly disempowered from civic engagement because of the belief that the systems in place fail to support their families’ and communities’ needs.

Given this overlap, Nonprofit VOTE has long focused on advising community health centers as they integrate voter registration into their primary goals and responsibilities. With many health centers focused on greater community engagement, Nonprofit VOTE aims to help them recognize voter registration as a tool for empowering low-income consumers. By increasing the number of registered voters, communities can better advocate for their elected officials to respond to their needs—be it changes at the statewide or local level. With local health clinics facilitating the completion of a voter registration form, consumers are empowered to walk out of a health center with their health issues attended to, as well as the tools to participate in the next election.

Community health centers can incorporate voter registration into all aspects of their work, beginning with training and educating staff on the importance of registration. Nonprofit VOTE found that when staff members are informed regarding the direct positive impacts of voter registration on community health, they’re more invested in sharing these benefits among clients, as well as their own family and friends. Getting people registered to vote, and consequently starting a dialogue on the health disparities entrenched by social determinants of health, is a huge step forward in raising awareness on community health needs. These conversations are important in trying to understand complex health issues that aren’t limited to a single household, but are common health problems in the community. Becoming a registered voter can transform an individual’s perception of what she can do to impact her own community, which can, in turn, lead to people taking better care of themselves and their neighbors.

Rather than remaining on the sidelines, community health centers can actively integrate consumers into a valuable set of data on registered voters that will elicit the attention of their policymakers. A recent Nonprofit Vote webinar reiterated that high visibility—such as posters and distribution of  “I Pledge to Vote” buttons or stickers—and enthusiasm were both important to engaging consumers in voter registration opportunities.  Nonprofit Vote emphasized that a great opportunity to synthesize voter registration in health centers exists by tying it into outreach, education and enrollment efforts for health insurance coverage into Medicaid and Marketplaces. Simply by making “the ask,” staff members could inquire, just as they do about health insurance status, whether patients were interested in registering to vote, and subsequently provide the materials to do so. Through reimagining the different ways that health centers can connect consumers to their communities, Nonprofit Vote shares their tips on how these centers can help create a stronger safety net for vulnerable populations.

For more information on how to register voters in your area or work in collaboration with your community health centers, please feel free to read through the slideshow from the webinar or visit http://communityhealthvote.net/blog/.

-- Jessica Liao, Health Equity Intern

Almost two decades ago, the National Association of Insurance Commissioners (NAIC) adopted a model state law to regulate the adequacy of health plan provider networks. The model law contained a general standard that services be accessible without “unreasonable delay.” Seventeen years later, the federal government adopted this as the standard for qualified health plans (QHPs) in the new health insurance Marketplaces created under the Affordable Care Act (ACA).

Why update the model law now?

The NAIC’s model law – as reflected in federal and most state rules for Marketplace QHPs – did little to curb insurers’ rush to narrow their provider networks in the plans they sold for 2014. Fully 48 percent of QHPs came into the Marketplaces with narrow networks. The media published stories about consumers who were upset that physicians and hospitals they were used to seeing were no longer in their plan networks. Politicians weighed in, asking for more robust oversight of networks. The truth is, leading up to 2014, very few states had adopted the NAIC’s model law and fewer still did any proactive regulation to ensure networks were adequate.

Into this regulatory vacuum stepped the federal government, which indicated in March that it will conduct a review of network adequacy for 2015 QHPs, and signaled a future rulemaking in which they would adopt a tougher standard, perhaps modeled on the regulation of Medicare Advantage plans. This got the attention of state regulators, who immediately fired off a letter to HHS, asserting that the regulation of network adequacy was best handled by the states. Yet they also acknowledged that the NAIC model law needs to be updated to reflect changes in health plans and in the health marketplace, which has evolved since the 1990s to include an alphabet soup of plan network designs.

What is the process and timing for updating the model law?

Early in 2014, the NAIC created the Network Adequacy Model Review Subgroup, composed of state insurance regulators, to revise the model law. The subgroup’s first step was to invite various stakeholders to provide oral testimony. On separate conference calls the subgroup heard from provider groups, consumer advocates, insurance companies and accreditation organizations. The subgroup then asked these groups to provide written suggestions for updates to the model, which staff compiled into a master chart. The NAIC consumer representatives submitted comments that focused on (1) a more robust, quantifiable standard for network adequacy, (2) better oversight of plan compliance, (3) an end to balance billing by out-of-network providers working in in-network facilities, and (4) greater transparency of provider networks.

The subgroup is now engaged in a painstaking series of weekly conference calls, going line-by-line through the model law and attempting to achieve consensus on revisions. NAIC staff estimate that, so far, an average of 100 people have participated on each call, including consumer advocates, provider groups and insurers, as well as state officials. Although progress is slow (on the first call it took 20 minutes to revise the law’s title), the subgroup hopes to complete its revisions before the next NAIC national meeting, scheduled for mid-November in Washington, DC.

Why is this important and how can consumer advocates play a role?

NAIC’s model laws frequently serve as the template for state regulation of insurance products, and many insurance departments and legislatures will look first to NAIC’s language before drafting any network adequacy rules in their state. But it may be difficult to achieve consensus, with many stakeholders resisting stricter standards, more proactive oversight and transparency of plan networks. Ultimately, sometime this fall, insurance commissioners will need to vote on changes to the model, and advocates will need to weigh in to encourage them to include the NAIC consumer representatives’ key recommendations.

21st Century Snake Oil

 ·  PostScript

A pink advertising insert appeared in my local newspaper recently proclaiming that "We can help you Stay Stroke Free for only $149!” The ad by Life Line Screening urges readers to undergo ultrasound examination of their carotid arteries because "80% of stroke victims have no apparent warning signs or symptoms." The ad further asserts that "when detected early, 4 out of 5 strokes can be prevented."

Based on this ad, readers would seem to be well advised to call immediately for an appointment. But if they did so, they would be unnecessarily putting their lives at risk.

What the ad doesn't say is that stokes caused by a blockage of the carotid artery comprise a relatively small proportion of all strokes and that even if severe blockage of the carotid artery is found, surgery to clear that blockage is more likely to cause a stroke or kill you than not doing surgery. That was the conclusion reached by the American Academic of Family Physicians (AAFP) which, as part of the Choosing Wisely campaign, is urging doctors not to screen for carotid artery blockage. The AAFP wrote, "There is good evidence that for adult patients with no symptoms of carotid artery stenosis, the harms of screening outweigh the benefits. Screening could lead to non-indicated surgeries that result in serious harms, including death, stroke and myocardial infarction." Furthermore, the screening test is far from perfect, sometimes indicating that a severe blockage is present when it really isn't.  

The United States Preventive Services Task Force (USPSTF) also recommends against screening   in adults who show no other symptoms of carotid artery stenosis.  And even if a patient has another symptom or risk factor for stroke and other cardiovascular diseases, the recommended response is to practice good health habits like regular exercise, control high blood pressure or diabetes if they are present, and eat healthy—and, if you are older, take a daily aspirin.  So knowing if there was a blockage in the carotid artery would not lead to doing anything different. 

So what motivates Life Line Screening to scare readers into getting the test? I think money has a lot to do with it. Their ad boasts that nearly 8 million people have already been screened. At $149 per person, that's over a billion dollars.

Another screening company, Health Fairs, has been doing a similar form of cardiac screening, which evidence shows is equally unnecessary. This led Public Citizen to write a letter to 20 hospitals and other medical institutions urging them to sever ties with  Health Fairs. Public Citizen writes, "the company’s heavily promoted, community-wide cardiovascular health screening programs are unethical and are much more likely to do harm than good."

In response to Public Citizen’s letters, the American College of Cardiology blogged that “[o]ther than assessing blood pressure and serum cholesterol, being attentive to diabetes and promoting a healthy weight with regular exercise, we do not recommend broad and untargeted screening.”  And an op ed in JAMA supported Public Citizen’s call for hospitals to sever ties to these screening companies if they cannot justify the relationship transparently, and to fully disclose to patients the risks and benefits of the screenings offered.

This fear mongering isn't confined to shady operations conducted from buses or rented VFW halls. Television ads from large commercial clinical laboratories urge viewers to get tested for celiac disease if they have any of a long list of common symptoms that just about everyone has experienced at one time or another like bloating, gas, indigestion, constipation, diarrhea, nausea, vomiting, or decreased appetite.

Pharmaceutical companies are in the "selling sickness" business in a big way as well. TV ads alert men to the symptoms of "Low T" (low testosterone) including fatigue or decreased energy. A recent patient came to me insisting on a prescription for the transdermal testosterone patch based on vague symptoms, while arguing that he didn't need any blood test to confirm the diagnosis. In a January article, AARP warned that new research has linked such testosterone hormone therapy with a significantly higher risk of heart attack, leading FDA to review the safety of this treatment. A physician  AARP interviewed advises men to see a physician that is qualified to make a proper diagnosis, but to avoid medical centers that “seem too promotional”.

America has a long history of hucksterism. "Snake-oil salesmen" sold their patent medicines to gullible consumers throughout the 19th century. The progressive movement in the early 20th century curtailed some of the most outlandish practices through pure food and drug laws and tighter regulation of untruthful advertising. But it seems as if we're now turning back the clock to the days of the Wild West with increasing clamor for less government regulation and an unfettered free market.

Free markets work well when consumers can be armed with the all the information they need to make rational choices.  But in health care, reliable information is complex and hard to come by, and consumers are also patients, who feel personally vulnerable.  Patients should have a voice in treatment choices, but they can also be misled into buying services and products they can’t fully assess, and don't really need.

What we need is more stringent government regulation of advertising of health products and services, not less. Ads should be prohibited not only when they are blatantly false, but also when they are so unbalanced, or incomplete as to become misleading. For instance, if an ad contradicts a recommendation of the USPSTF, then the ad should be required to include the task force's recommendation verbatim.

We also need to do a much better job letting the public know about trustworthy sources of health information, such as Choosing Wisely and Consumer Reports Best Buy Drugs. In this day of iPads and instant information, no one should get snookered into buying 21st century snake oil.

Stephen R. Smith, M.D., M.P.H., Community Catalyst physician consult

Many times the social and economic determinants of health are proxies for health inequalities within a community. Factors such as income, education, physical environment (where you live), social isolation, and the concentration of poverty often have more to do with the health of an individual or a community than availability or access to medical care. Because many people struggle with these larger structural issues on a daily basis, individual well-being or personal health can become impossible to achieve without addressing these broader issues. While it may seem that these factors only burden individuals, in truth hospitals and health systems bear some of these costs as well, through increased asthma visits to the emergency room, for instance, when their housing is in need of environmental interventions. It is in the best interests of both consumers and providers that providers address not only a patient’s specific health ailment, but also the root causes that lie in these social and economic determinants of health.  

 To help improve community health the Affordable Care Act (ACA) now requires that non-profit hospitals assess and attempt to address the unmet needs of the communities they serve through a Community Health Needs Assessment (CHNA) every three years. Under proposed IRS rules, non-profit hospitals must consult public health experts including local health departments, as well as “leaders, representatives, or members of medically underserved, low-income, and minority populations, and populations with chronic disease needs” for assessment guidance. Other providers, consumer advocates and non-profits, academics, and businesses should be engaged in the process.

 Hospitals must then use the CHNA to develop and adopt implementation strategies in a formal and transparent Implementation Plan that addresses the identified unmet community health needs. These strategies can include coalitions that reduce youth violence or substance use disorders, safe communal spaces like parks, safe and affordable neighborhood housing, food banks or farmers markets, training for community health workers, or even workforce development programs that insure a culturally competent workforce.

 By using the CHNA to conduct culturally competent discussions on community health concerns, hospitals can get both useful information about the community’s needs and simultaneously increase awareness and access to prevention and treatment options that address population health. When conducting the CHNA process, hospitals should be mindful of the fact that consumers unfamiliar with hospital settings and etiquette are often intimidated by long, technical surveys, or by surveys with forced choices that may not be in their native language. Consequently, to encourage participation in the CHNA process, hospitals should be careful to be inclusive in constructing their data collection methods. Surveys  should be available in the various languages spoken in the community along with translators who can provide assistance in clarifying concepts. Focus groups, stakeholder interviews, or community meetings should partner with organizations trusted by community participants. Culturally competent measures such as these are central to enhancing the ability of individuals to speak freely about personal or community health issues.

 CHNA-related conversations are an opportunity for hospitals to highlight the fact that health is not limited to surgeries or prescriptions. Health improvement interventions can address factors such education, employment or poverty in a culturally sensitive and competent manner. By shedding light on how social and economic factors impact an individual’s health, the CHNA can be a powerful tool to benefit both hospitals and community members, and to address health inequities. 


Jessica Liao, Health Equity Intern

Guest Blog

In Arizona, the month of August is usually associated with 100+ degree weather, swimming pools, sunscreen, and the occasional summer monsoon or dust storm. It also marks the end of summer break for students from preschool to university. For those working to educate consumers about their new health care options and enroll them in health coverage, several factors converge during the back-to-school season, creating an opportune moment to engage families. 

Across the country, many local departments, organizations, cities, and school districts are busy organizing back-to-school events for families. At the Arizona Children’s Action Alliance, we view this as a prime opportunity to work with other outreach and enrollment groups to maximize their participation at back-to-school events and help link families to health coverage.

Prioritizing Health Coverage at Community-Based Back-to-School Events

Often, we are so focused on families that we overlook the need to inform and include back-to-school event organizers, whether they are city officials or school administrators, about the importance of health coverage for kids. We’ve found that building relationships with event organizers greatly increases the tools and resources at our disposal during back-to-school events. Advocates should work with event organizers to maximize attendee exposure to and resources for health coverage. Most event organizers are extremely receptive to the idea; after all, there is a growing body of evidence showing that kids perform better in school when they have access to affordable health care. 

Leading up to the new school year in Arizona, we partnered with the Latino Institute to identify creative ways to capture the attention of parents and promote health coverage enrollment during back-to-school events organized by the City of Phoenix. This resulted in a series of actions that elevated the message of enrollment including:

  • health enrollment flyers in the free backpacks handed out to all children attending the events
  • a televised back-to-school panel where our job was to talk about health coverage
  • broadcasts about where parents can get help with enrollment
  • a condition that attendees must learn about health coverage from health assisters or Navigators present at events in order to enter raffles for prizes

These strategies greatly enhanced our participation and impact. The assister and Navigator organizations we worked with increased enrollment appointments four to five-fold compared to the prior year, when their participation was limited to manning display booths. The increased opportunity to promote the message of health coverage was made possible through proactive and robust collaboration with event organizers. 

Strategies for Increasing Enrollment During Back to School Events

There are many barriers—including multiple, competing priorities—which prevent families from successfully enrolling, even if they make the commitment to do so.  Back-to-school events provide a convenient opportunity for families to enroll in health coverage because it is folded into other back-to-school preparations. Working with event organizers to provide families with the tools they need to apply for coverage efficiently and effectively can help improve the chance of enrolling families who attend the event.

To help make sure that families are prepared to enroll, advocates should work with event organizers to distribute reminders, checklists, and other information to families prior to the events. One significant obstacle to signing up families for coverage is that parents rarely bring all of the documents and information they need to apply for Medicaid or Marketplace plans for their families. Therefore, our team found an application checklist envelope to be a useful resource. The envelope is printed in English and Spanish with a checklist of documents needed to successfully apply in one sitting. Parents then have a guide and an easy-to-use envelope to collect their documents, check corresponding boxes, and show up prepared. 

To reach parents before events, we worked to ensure that pertinent health coverage information, flyers, and the checklist envelope were available through events’ promotional websites and other media. For example, at one back-to-school event held at the Metrocenter Mall in Phoenix, we worked with event organizers to place information about how families could access flyers and the checklist envelope, as well as other health coverage information, at the food court in advance of the event. 

Not all back-to-school events include an enrollment site for families, even if families are ready to apply and assisters and Navigators are available. To ensure families who are ready to enroll are able to do so when they arrive at back-to-school events, advocates can work with event organizers to make sure there is private space set aside for assisters and Navigators to help families enroll on the spot. It’s important to have computers, scanners, printers, and internet available on hand to immediately help people who are ready to apply.

There is no secret formula to successful enrollment, and everyone working to link families to health coverage knows that persistence and a positive attitude are critical, despite the challenges. We encourage advocates to continue sharing with their counterparts and to regularly review best practices taking place across the country with the goal of improving efforts to cover more families.  

Joe Fu, Health Policy Director, Children’s Action Alliance Arizona