Dr. Mia talks with Dr. Debbie Freeland, geriatrician and Health & Aging Policy Fellow 2021-2022, about policies and advocacy for older adults.
We discussed big "P" Policy vs little "p" policy:
"P"olicy: Congress and/or State level legislation: SNL parody on "How a Bill does NOT become a law"
"p"olicy: agencies that carry out laws such as Health & Human Services, CDC, FDA, CMS, local health departments,
Senate Special Committee on Aging in DC contact
Congressional Committees- another way to influence policy
How to write an Op Ed
Master Plan on Aging
Transcripts on www.miayangmd.com.
Opinions expressed are exclusive of Dr. Mia Yang and not reflective of her or guest speaker's employers or funders.
Ask Dr. Mia: Conversations on Aging Well Transcript Ep.4
Welcome to ask dr. Mia Podcast conversations on Aging Well, this podcast is for educational and informational purposes only and solely as an educational tool for your own use. Dr. Mia is not providing medical, psychological, or nutritional advice. You should not use this information to diagnose or treat any health problems or illnesses without consulting your own medical practitioner. For more information, including transcription, please go to mia Youngmd.com. That's Miayangmd.com. And now our host, Dr. Mia.
Dr. Mia 00:46
And welcome back to Ask Dr. Mia Podcast. Today I have a special guest, Dr. Debbie Freeland with me. Debbie, if you can tell us about yourself.
Dr. Debbie Freeland 01:13
I'm so thankful to be here. Thank you for having me on. I am currently an assistant professor of internal medicine in the division of geriatric medicine at the University of Texas southwestern Medical Center in Dallas, Texas. My clinical focus is on home based primary care for older adults, and I was recently a 2021-2022 health and Aging Policy fellow. It's been a fun journey into geriatrics. That's great.
Dr. Mia 01:28
I think both of us have bit the house call bug because we both trained at Johns Hopkins bayview internal Medicine program. And that's where I don't know if you were a primary care resident.
Dr. Debbie Freeland 01:27
I was. Yeah
Dr. Mia 01:39
Me too. So our second year residency, we were given a panel of patients to take care of at home, and that's kind of how I fell in love with geriatrics as well.
Dr. Debbie Feeland 02:58
It was amazing. My journey with geriatrics actually started in college. I realized I wanted to do medicine of some kind, but didn't know what that meant. Figured I would get more experience. But most of the volunteer opportunities required you to be in the back doing kind of administrative things. And so I became a certified nurse assistant and thinking that I would work in a hospital. But all the hospitals in the area were like, no brand new CNA’s. Work at nursing homes first, get back to us in a year. And so I did that, worked at a nursing home five minutes from campus every weekend, fell in love with older adults, realized that there was so much that they could teach me, realized that there's quite a danger of dignity lost as we age, potentially, and that there was some vulnerability that I could try to help protect and help with. And so then came to medical school and realized that geriatric medicine was some of the most complex medicine people with ten diseases on 25 different medications. You get to stop medicines no one else is thinking about, stopping medicines that people love you for it. And then you get to actually talk about what matters and work so closely with the family. So that was nice. And then bayview. Yeah, the house called panel was fabulous.
Dr. Debbie Freeland 03:18
You get to carry around your orange tackle box full of phlebotomy supplies, and I was lucky enough to live next to the hospital, and so my panel was in my neighborhood. So I would just walk from my row home to the next row home, a few down, and it was a very special experience.
Dr. Mia 03:35
That's great. Yeah. You were much more early in your journey and your medical training when you got interested in Geriatrics. I think I was a much later differentiator, and I didn't really quite decide until second year residency. As late as possible.
Dr. Debbie Freeland 03:48
That is okay. I mean, I think later is even possible, right? Yeah, you can go off practice. Actually, a few of our fellows have already done that and are now realizing the benefits of Geriatric fellowship.
Dr. Mia 04:25
Yeah, absolutely. Not many people know that part of Geriatrics that makes Geriatrics really interesting is our understanding of the entire healthcare system, all of the different settings that our patients go through. It's not just the binary clinic versus hospital, but there is a lot in between, all the way from home to rehab, acute rehab, subacute rehab, palliative care. So I think I'm very proud to have trained in all of those different settings and be able to understand what our patients and their families go through. I'm curious, how did you get interested in health care policy?
Dr. Debbie Freeland 05:13
Yeah, great question. So I was seeing how policy affected residents in the nursing home, even when I was a college student. So my colleagues in college would work jobs at Whole Foods and make $16 an hour checking groceries, bagging groceries, and I would work with my colleagues at the nursing home. And this would be their second, potentially third job. They'd have health problems from all the lifting and the backbreaking work that we’re doing, and we're making just barely above minimum wage, which is $7.25 in Texas, and it's still that way now in 2023, which is frightening. So I started to see these things but was not really aware of them. Oh, really? Policy is at play here.
Dr. Debbie Freeland 06:01
But then doing my residency in Baltimore, especially at the time that it happened, realizing some of the structural issues facing health care and actually facing all of our systems. George Floyd was murdered during my residency. Seeing the disparities in Baltimore, which is a majority black city in a way that I had not seen in Dallas whenever I had done my undergraduate medical education. So that was very striking. And had a wonderful mentor, Dr. Bruce Leff, who had done the Health and Aging Policy Fellowship. And he recommended this as one of the next steps because I think other ways could be getting a master's in public health. But this was very helpful for me in terms of I was just starting my career.
Dr. Debbie Freeland 06:10
So I applied after my Geriatric fellowship and was able to negotiate kind of a starting faculty 20% time to do this fellowship.
Dr. Mia 06:16
Oh, got you. So the fellowship was part of your first attending job when you got back to Texas?
Dr. Debbie Freeland 06:34
Yes. So when I went back to Texas, actually, for my one year fellowship, for Geriatrics and then stayed on. And since I knew the chief of Geriatrics, he realized that my interest was in policy and trying to explore and see how this fit into my career further. So then I did the Health and Aging Policy Fellowship as part of my work.
Dr. Mia 07:19
That's great. Yeah. I'm curious. I think so much of policy influences what kind of things are implemented in real life, both from a financial peace but also from an organizational regulatory perspective and I think with everything that was happening in 2016 and all of the kind of racial disparity awareness that non black people are suddenly aware of, I'm just curious to whether you noticed any racial differences in terms of the people who work with you in college at CNA’s versus the people who were working and getting paid almost twice as much as Whole Foods.
Dr. Debbie Freeland 08:03
Yeah, absolutely. So I went to a liberal art school in Texas. It was mostly white. And my colleagues, the other CNA’s, and even the RN’s and laundry staff and everyone at the nursing home tended to be people of color. There were fewer white people as support staff at the nursing home. And I think that is a common thing across our nation. And so that is another piece of policy at play. And it's been interesting to see how policy truly affects how our patients live their lives, but also how we are able to practice medicine and what sort of access people have to things and how we're having to fight to the mail for access for patients.
Dr. Mia 08:09
Yeah. What's an example that comes to your mind in terms of a recent policy fight?
Dr. Debbie Freeland 09:03
It's interesting because policies happening both at the federal level, state level, and then again, it would be a mistake to think only of legislation as policy. It's also happening, like you mentioned, at the regulatory level, at agencies. So there's a number of fights happening. I think last year we were really hoping that Build Back Better would contain some legislation for older adults around supporting and access for hearing AIDS, for dental, for vision. And we've secured some progress in terms of potentially over the counter hearing aid access. But dental and vision have really fallen off. It's interesting what's going on right now with Medicare Advantage programs and how they are able to offer supplemental benefits and how traditional Medicare you're not able to access those unless you have like a medigap policy.
Dr. Debbie Freeland 09:50
So there are some changes, I think, going on with Medicare Advantage that the federal government is becoming a lot more focused on and thinking about how can we help make sure Medicare is sustainable, whether it's Medicare Advantage, the private sector or traditional Medicare from the government. And then in Texas there's a big fight going on in terms of advanced care planning. So it has always been fairly controversial in Texas and I think it's become a little more controversial nationally, both in our field and discussions and palliative care, and there's a lot of semantics around that. So I don't necessarily want to get into that. But talking about what matters to people, planning ahead for the future, for medical care, as well as naming a surrogate or medical power of attorney.
Dr. Debbie Freeland 10:50
And in Texas, it has progressively become harder to have a do not resuscitate order or to die without aggressive measures if you don't want that. And so recently, in the last few years, 2017, 2018, there was a law that came out making an additional form required at hospitals if you want to be, do not resuscitate. And it didn't matter if you had your directive to physicians filled out, you still had to fill out a hospital specific form. And so if you go to ut southwestern, you fill it out. If you go to Baylor cross the street, you have to fill it out again. It's got all the same restrictive witnessing requirements as general advanced directives. And then not to mention we have an out of hospital dnr form that is also required, can't be signed by physicians assistants or nurse practitioners.
Dr. Debbie Freeland 11:34
And anytime someone opens this legislation, there's concern that it might be amended to become more restrictive. There are a few groups that are lobbying to try to remove the ability for medical futility in cases where two doctors, or typically its doctors as well as ethics team and everyone, decide that continued treatment is not in the benefit of the patient. And so no one wants to touch anything because there's concern, at least legislatively, there's concern that things could be worse for the most vulnerable. These are some of the things I started to learn in my classroom. Interesting.
Dr. Mia 12:21
Yeah, I think I'm not familiar with the Health and Aging Policy Fellowship, but I see that on the website, and I'll put the website in the show notes. Fellows are placed with different agencies and different levels of government. For example, there's the Senate Special Committee on Aging, and then there's state representatives like you're with the state of Texas. How do aging related policies work? And that may be too big of a question. How do these policies get eventually passed into law? I'm sure that differs whether it's a state specific policy versus a national policy. I'm just curious if you can kind of help me and the audience learn a little bit more about that.
Dr. Debbie Freeland 13:19
Yeah, absolutely. So just a little bit more about the policy fellowship. So it is one year, it's competitive, it is nonpartisan. You can either have a residential placement, which would be in DC or a non residential placement if you have a day job like I did. Fellows are selected based on their commitment to health and aging issues and leadership potential, as well as their interest in impacting policy. It's interdisciplinary, so it's wonderful working with physiotherapists, with entrepreneurs. There's been physicians, nurses, social workers, psychologists, dietitians in the past, healthcare administrators, economists, lawyers. So it's been very cool to bring all of these groups of people together to think about how we can affect aging policy. And it's also been kind of late stage career people. So Dr. Sharon Inouye, a delirium guru, has done it, and then people who were just starting off like me.
Dr. Debbie Freeland 14:11
So very cool. Fellowship, and part of the fellowship is six weeks spent in DC. So even if you're non residential, you do go to DC and do some orientation and kind of 101 102 government basics. And that was very helpful in my understanding of how policy works. And so again, there's policy at the federal level, the state level, the agency, even community, and then I think we talk about advocacy and policies that are affecting patients at the patient level. And so it's important to realize that on Capitol Hill, there's the Senate and the House of Representatives, and they work closely with the President in terms of creating legislation. And that is one form of policy. There is kind of a big “P” policy and a little “p” policy.
Dr. Debbie Freeland 16:06
And so when you're thinking about national or state policy change, that's legislation or executive actions done by the President, essentially, big P policy requires action by elected officials. Little P policy, you can think of it as policies happening at the agency level, whether that's Health and Human Services at the federal level or in Texas, it's the Health and Human Services Commission. It could be little P policy happening at the health system level, or even the health Department. And so that's kind of the way I like to think about different types of policy. Once legislation is created, it may not, even if it gets passed, which is not really going to get into the back and forth between the House and the Senate and the schoolhouse Rock. There's a fun video from there and I think an snl of an updated schoolhouse Rock. We can maybe include those links for fun. Just do a good job of explaining how things used to be, how things are in terms of Congress. But once you've passed legislation, it may not actually go anywhere or do anything if Congress has not appropriated fund to it. And so not just the legislation, but the appropriations process, you may have heard of in the news that's really assigning budget to some of the legislation that has been passed. And so legislation is important. Promoting appropriations for that legislation is important. And then you can make laws all day, legislation all day, and nothing may happen even after that until the agency actually implements the legislation by agencies, I'm thinking Health and Human Services. You've heard of CMS: Center for Medicare and Medicaid Services. You've heard of the Department of Veterans Affairs.
Dr. Debbie Freeland 17:03
You've heard a lot from the CDC: Center for Disease Control. During the pandemic, the FDA so Food and Drug Agency. So all of these different agencies then take the legislation that's in their purview and have to implement and set regulations. So that's another way that policy happens and a way that we can play a role. And then there is something called rulemaking, which I think is a little more in depth than the lay public typically gets involved. But I think it's an important area for physicians and clinicians to think about how agencies kind of maintain and update those regulations. And so every year cms thinks about how they're going to reimburse physicians for the care that they give, and that's called the physician fee schedule. The way that they update payment is they are able to do rulemaking every year.
Dr. Debbie Freeland 17:39
It's a public process. Anyone can comment. So technically the lay public can. It's helpful to learn how to be most effective in making those comments, like I'm learning that and would not even pretend to be an expert in that. So the agency then has to review every comment. They then think about whether they might change the proposed rule and they change it accordingly based on testimony that they've heard, hearings that they've held, the public comments from everywhere, and they may or may not make changes depending on what they've heard.
Dr. Mia 17:51
Yeah, it sounds like there's a very parallel process of the scientific discovery and then the actual implementation of that discovery. I wonder if it's also a very significant time lag.
Dr. Debbie Freeland 18:46
Absolutely. So there's been a lot of research looking into that time lag. The most quoted number is 17 years from going from kind of bench research to then policy change for the entire public. And there's reasons why you would not want it to move too quickly. Right? We don't want to be making giant changes for the country too fast, but also you don't want to be delaying important things. So for drug research, there is a process in terms of getting approval, making sure we're not misusing inappropriately studying subjects. We want to make sure we're doing it safely. So there are some reasons for that delay. But of course, 17 years is quite a long time. And so it's important that we actually work closely between researchers, clinicians and the government thinking about what are the questions we need to be asking.
Dr. Debbie Freeland 19:06
Does the government come to the researcher and say, hey, we want to know the answer to this question. If there's dialogue there, the researcher can be like, well really, maybe the question should be slightly different and there could really be some positive changes made from that. There's good communication between all of these different groups.
Dr. Mia 19:52
It's just so interesting that I am not, except for one recent example where some part of the largest dementia care clinical trial going on right now called DCare or Dementia Care. It's a pragmatic study comparing two different models of dementia care management and that is one rare exception where the study investigators are in very close communication with center for Medicare and medicaid because they're interested in potentially doing a demonstration project on this particular model of care to see if it's worth government money to pay for it. Obviously I'm biased. I'm part of the study investigators, but we're not going to talk about that during this call.
Dr. Mia 20:23
But I do think of how rare it is that research actually can directly inform policy and vice versa because I think the most common research we think about that's funded by the government is really more basic science research on the part of nih and nia. But there's not a whole lot of implementation or non drug type of system change research that I think we're tremendously lacking to the detriment of patients and the public too.
Dr. Debbie Freeland 20:38
It does seem like implementation science is on the rise and I think kind of help with that translational nature that is needed to kind of move policy and move clinical care together and faster. I agree.
Yeah. So kind of getting back to this advocacy piece, what are some probably effective ways besides calling our local representatives and writing them letters? What are some other ways that the public can potentially influence policy?
Dr. Debbie Freeland 21:41
Sure. Well, big P and little P policy and to be clear, big P versus little P. Just because it's big P doesn't mean it's actually more important. It's actually usually harder to change, slower to change. And so a lot can be done at the little P policy. So I don't mean to diminish little P policies. Anyway, I do want to talk a little bit about in answering this question. So one other thing that I was kind of surprised to learn in the fellowship is it's not just like who your representative is, but actually what committees they are on. And so there are committees in both the Senate and the House of Representatives, both at the federal level but also the state levels. And there is a lot of power in that committee and so one representative may be on the Finance Committee.
Dr. Debbie Freeland 22:33
And that committee has its own set of staff different from the representatives themselves. They hold hearings, so for example, the Finance Committee held a hearing this past spring on mental health. They released a report based on what they had found. It was really looking at parity and access for those on Medicare and medicaid to mental health services. You mentioned again the Special Committee on Aging in the Senate, they don't actually have jurisdiction to make laws, but they do a lot of the research about aging policy that can then inform what other committees are doing around legislation. They write reports to really help encourage age friendly policies. So this past year they have a hearing on promoting healthy and affordable food for older adults. That was mid December. They've had a hearing on retirement security, healthcare and fiscal health. That was in November.
Dr. Debbie Freeland 23:11
And so all of this is actually public domain. You can see some of the reports that they've made from their hearings. But I want listeners to know that the power is not just in speaking to your representative, but also speaking to those committees. So if your representative is not on those committees, look who is and then reach out to them. And if you are someone experiencing issues around aging policy, your voice matters. So it is important to call and talk to them. And you may not actually reach them. You may just reach their staff. But speaking with even a legislative director actually holds a lot of weight, and they pass that information on.
Dr. Mia 23:25
So for the people who are on those committees, they don't have to be, say, a Texas representative. You can still contact them because of an aging related issue that may be experiencing or have knowledge about.
Dr. Debbie Freeland 24:24
Exactly. Yeah. And so that's helpful. I would also add that it's incredibly important, of course, to educate yourself about the issues. And so if there's something you're experiencing, that's an aging issue. So dementia care or social isolation caregiving is a big one. There are advocacy groups, lobbying groups, there's also foundations that learn more about this and try to keep their ear to the ground about what's going on. And so they may either know more about the topic to help your understanding, or you may be able to speak with them, and they can help further represent your concerns because they are talking to Congress all the time. So some examples AARP USA, Aging, National Council on Aging are some advocacy groups, foundations like the John A. Hartford foundation, they help fund a lot of research for aging and a lot of clinical care.
Dr. Debbie Freeland 25:36
The Scan Foundation, the Kaiser Family Foundation, they're really looking at a lot of policy issues around older adults. And then C-span is a nice, free way to be able to get a look into what's happening in terms of in the legislature, the federal level. But there may be issues that you want to learn more about that's important to at least educate yourself. And those are some resources to potentially do that. So not just speaking, though, to your Congress member, but also voting for that Congress member is a huge way of advocating both for yourself, for loved ones. It's interesting in the literature, they frame this as voting, as a form of preventive medicine. We talk to people about wearing seatbelts, about vaccines. But voting is actually also something that can really be a form of preventive medicine because it affects so much of what care people are able to access. And so it doesn't need to get political. It doesn't need to get partisan. It just needs to be, you know, what your rights are on the line. And so while it feels like a lot to do to learn about the candidates that are coming up, it's worth it, and it's important.
Dr. Mia 26:07
Yeah. And I also think in terms of local level politics, that's really important. The City Council makes a lot of the rules and budgets in terms of local or state level area agencies on Aging. And all of those things are probably, sometimes, I think, more impactful than say, writing a big name legislature like Build. Back Better or anything like that. Involves so many different parties and have such polarizing dynamics.
Dr. Debbie Freeland 26:49
Absolutely. Most fellas do a placement at the federal level and I was like, I am going to be in Texas for a very long time. I married a Texan and I realized I could work at the federal level on medicaid expansion all day and it would not affect my patients here in Texas. And so all politics is local and that can be a big way to kind of make changes at a faster, more incremental level. And then if you feel like you have a story to tell or you are an expert or you have data or you're doing research or you're learning about these issues, you have a parent that is aging and you are in it. Writing an op ed could be another way.
Dr. Debbie Freeland 27:25
So you don't have to write to a congressperson directly, but writing an op-ed that gets published in the newspaper or on a blog, it's helpful to have kind of a succinct, catchy title, but having a compelling story that's placed in a larger context, you can give policy solutions. I mean, people are listening to op eds. And then it is also helpful if you're going to write an op ed that you can briefly address the other side of the issue because it gives your op ed a little bit more credibility. And so that's another way. It doesn't have to be necessarily to legislative staff.
Dr. Mia 27:41
Interesting. So the legislative staff and people who do research on aging related topics, they are also reading op eds that are going around just like the rest of us, who are maybe not thinking about policy day in and day out.
Dr. Debbie Freeland 28:02
Yes, exactly. Yeah. And people take titles and they take them seriously. I mean, legislative staff is also reading scientific journal articles and so when they see in a title that advanced Care planning is not worth doing, they take that message. So it is important to be nuanced in terms of our concerns.
Dr. Mia 28:15
Yeah, I think the title may be like how much of it is like gathering interest so more people will read versus a nuanced enough title to really, truly represent the issue. Those are very different things.
Dr. Debbie Freeland 28:28
That's right. But legislative staff have a finite amount of time, like all of us, and are often covering many different issues. It is important to have a title that draws people in.
Dr. Mia 29:01
Yeah, I'm just thinking sometimes it's always interesting what people will take away, especially from, I think, an opinion page where you're not necessarily presenting the scientific data, you're presenting your interpretation of the science. It can get rather tricky depending on who's interpreting that. But thank you so much. Anything else you wanted to add, debbie? I really appreciate all the work that you're doing and kind of the insights you've talked about already this morning. I've certainly learned things about how our government works and ways to make an impact. So anything else you want to add?
Dr. Debbie Freeland 29:49
Sure. I just wanted to say a few other things. When people think of policy affecting older adults, we may often kind of stop at Medicare. Medicare is huge. They make big decisions since they're the biggest insurer. They make decisions about what medications are covered, what services are covered, where people can and cannot live, and what kind of rehab you can get. So it is a big and important part, but not the only thing that affects older adults. So just a few other local things. A lot of funding for projects comes from the Older Americans Act at the federal level and that gets filtered into states, and then states choose what to do with that funding. And sometimes that's intergenerational programming, getting younger and older people together, which has been shown to be a benefit to both generations, both groups.
Dr. Debbie Freeland 30:34
Social isolation is a major issue and can be addressed in unique ways like that. And Area Agencies on Aging, like you mentioned, are a good spot for they get some of that funding and decide what to do with it. And then one other thing is several states have something called a Master Plan on Aging. This is starting to become more common. It is at the state level. Texas is one of five states that currently have one. Colorado, I think, has one. California, I think Oregon is in the works this year. The plan often has expectations on how to try to help aging in the state. It's not always enough. So in Texas, ours is mainly advisory, like we talked about. There's not appropriations behind it.
Dr. Debbie Freeland 31:00
They write policy briefs around important topics for aging, health policy, but not necessarily have too much proof behind them. But talking to a representative about a Master Plan on aging or asking them why doesn't our state have one? Or how can we get one? Are we thinking about aging? Is another kind of more local topic, at least at the state level and then last big policy thing, sorry.
Dr. Mia 31:02
We can go on forever.
Dr. Debbie Freeland 32:19
I do think we're seeing fewer and fewer people go into geriatric medicine as well as primary care. And it's a huge problem. We need preventive care. We need to focus on that. And historically, insurances and our payment systems have not supported that. And so I think another thing that is not maybe always connected in the public is that actually how the payment models occur is driving a ton of what is covered. And so we've been very fee for service. Insurance will pay for tests and things to be done to people historically. And yet really we want to try to move into value based care. And we've been trying to do that. But again, this takes us back to researchers trying to figure out, well, what does value look like for an older adult, which may look very different for a younger adult and based on their physiology, their needs, their comorbidities, their medical problems. So until our country changes, really our focus on how we pay for medical care, I'm not sure we'll have a solution to the primary care shortage and the total lack of geriatricians in this country.
Dr. Mia 32:35
All right, well, thank you again. And thank you all for joining us on this episode, talking about policies related to aging and hope you guys take away some really practical steps in terms of getting your voices heard. Thank you.
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