3. Learning Objectives
• Understand the definition, scope, and role of
health policy in the United States.
• Recognize the principal features of U.S. health
policy
• Comprehend the process of legislative health
policy
4. Learning Objectives
• Be familiar with some of the critical health
policy issues in the United States
• Discuss the passage of the Patient Protection
and Affordable Care Act of 2010
5. Health Policy
• Public Policies
– are authoritative decisions made in the legislative,
executive, or judicial branches of government
• intended to direct or influence the actions,
behaviors, or decisions of others
• Health Policy
– the aggregate principles, stated or unstated
• that characterize the distribution of resources,
services, and political influences
• that impact on the health of the population
6. Different Forms of Health Policy
• Health policies
– a by-product of public social policies enacted by
– pertains to health care at all levels, including
policies affecting the production, provision, and
financing of health care services.
• Health policies can be made through the
private sector or the public policymaking
process
7. Different Forms of Health Policy
• Public Health policies include:
1. Reforms in medical education
2. 1965 enactment of Medicare and Medicaid
3. Federal funding for family planning clinics
4. A merger of two hospitals violates antitrust laws
5. Procedures for licensing physicians
6. Monitoring sanitation standards in restaurants
7. Banning smoking in public places
8. Regulatory Tools
• Health policies may be used as regulatory
tools
– they call on government to prescribe and control
the behavior of a particular target group by
monitoring the group and imposing sanctions if it
fails to comply
9. Allocative Tools
• Health policies may be used as allocative tools
– they involve the direct provision of income, services, or
goods to certain groups of individuals or institutions
• Distributive policies include:
– funding of medical research through the National Institute
of Health
– the development of medical personnel
– the construction of facilities
– initiation of new institutions
10. Allocative Tools
• Redistributive policies
–creates visible beneficiaries and payers
–takes money or power from one group and
gives it to another
11. The Principal Features of U.S. Health
Policy
• Features that characterize U.S. health policy:
– Fragmented
– Incremental
– Piecemeal reform
– Pluralistic (interest group)
– The decentralized role of the states
– The impact of presidential leadership
– Policy intervention begins with identifying what
markets fail or do not function well
12. The Principal Features of U.S. Health
Policy
• Government spending on health care fills the
private sector gaps
–Intervention includes:
• Environmental protection
• Preventative services
• Communicable disease control
• Care of special groups
• Institutional care of mentally and chronically ill
• Medical care to the indigent
• Support for research and training
13. Government as Subsidiary to the
Private Sector
• Most cited problems associated with government
involvement in health care:
– Bureaucratic inflexibility
– Excessive regulation
– Red tape
– Irrational paperwork
– Arbitrary and conflicting public directives
– Inconsistent enforcement of rules and regulations
– Escalating costs
14. Most cited problems associated with
government involvement in health care:
– Fraud and abuse
– Inadequate reimbursement schedules
– Arbitrary denial of claims
– Insensitivity to local needs
– Consumer and provider dissatisfaction
– Government programs tend to promote welfare
dependence rather than desire for employment
15. Fragmented, Incremental, and
Piecemeal Reform
• The subsidiary role of government with both private
and public approaches to healthcare result in a
complex and fragmented financing structure,
therefore:
– The employed are predominantly covered by
voluntary insurance that they and their employers
make
– The aged are insured through a combination of
coverage financed out of Medicare Part A and
Medicare Part B
16. Fragmented, Incremental, and
Piecemeal Reform
• The subsidiary role of government with both
private and public approaches to healthcare
result in a complex and fragmented financing
structure, therefore:
– The poor are covered through Medicaid via federal,
state, and local revenues
– Special population groups have coverage that the
federal government provides directly
17. Pluralistic and Interest Group Politics
• U.S. health policy outcomes result from
compromises to satisfy demands
• The policy community has included:
– Legislative committees
– Executive branch
– Private interest groups
• The first two communities supply policies
demanded by the third.
18. Pluralistic and Interest Group Politics
• Well-organized interest groups are the most effective
“demanders” of policies
• Examples include:
– American Medical Association
– American Association of Retired Persons
– American Hospital Association
– Pharmaceutical Research and Manufacturers of America
– Businesses are a newcomer to interest groups (See Exhibit
13-1)
19. Pluralistic and Interest Group Politics
• To overcome pluralistic interests and maximize
policy outcomes, diverse interest groups form
alliances with legislators
20. Decentralized Role of the States
• The role of the individual states has taken several
forms:
1. Financial support for the care and treatment of the poor
and chronically disabled
2. Quality assurance and oversight of health care
practitioners and facilities
3. Regulation of health care costs and insurance carriers
4. Health personnel training
5. Authorization of local government health services
21. Decentralized Role of the States
• 24 state governments created an “Insurance
risk pool”, which is a program that helps
people acquire private insurance (see exhibit
12-2)
22. Impact of Presidential Leadership
• Lyndon B. Johnson passed Medicare and Medicaid
• Harry Truman passed the Hill-Burton Hospital
Construction Act
• Richard Nixon passed:
– Federal support of health maintenance
organizations in 1973
– The enactment of the National Health Planning
and Resources Development Act of 1974 (con
legislation)
• Obama passed the ACA
23. The Development of Legislative Health
Policy
The making of U.S. health policy is a complex process
that involves private and public sectors, and reflects:
1. The relationship of the government to the private
sector
2. The distribution of authority and responsibility
within a federal system of government
3. The relationship between policy formulation and
implementation
4. A pluralistic ideology as the basis of politics
5. Incrementalism as the strategy for reform
24. The Policy Cycle
The formation and implementation of health policy
occurs in a policy cycle comprising five components:
1. Issue raising
2. Policy design
3. Public support building
4. Legislative decision making and policy support
building
5. Legislative decision making and policy
implementation
25. Legislative Committees and
Subcommittees
• Congress has three important powers that
make it extremely influential in the health
policy process:
1. The power to “make all laws which shall be
necessary and proper for carrying into
execution”
2. The power to tax
3. The power to spend
26. House Committees
• Ways and Means Committee
– has sole jurisdiction over Medicare Part A, Social
Security, unemployment compensation, public
welfare, and health care reform
• Energy and Commerce
– has jurisdiction over Medicaid, Medicare Part B,
matters of public health, mental health, health
personnel, HMO’s, foods and drugs, air pollution,
consumer products safety, health planning,
biomedical research, and heath protection
• Committee on Appropriations
– responsible for funding substantive legislature
provisions
27. Senate Committees
• Committee on Labor and Human Resources
–has jurisdiction over most health bills
• Committee on Finance
–has jurisdiction over taxes and revenues,
matters related to Social Security, Medicare,
Medicaid, and Maternal and Child Health
28. Access to Care
Two arguments for all American citizens have a
right to be guaranteed access to health care
1. All citizens have a right to the same level of care
2. All citizens have a right to the same minimum
level of care
29. Public Financing
• Policies have been enacted to provide access to
health care for specific groups otherwise unable to
pay for and receive care, including these groups:
– Elderly (Medicare),
– Poor children (Medicaid and SCHIP),
– Poor adults (Medicaid and local or state general
assistance),
– Persons with disabilities,
– Veterans (Department of Veterans Affairs),
– Native Americans (Indian Health Service),
– and patients with end-stage renal disease (Social
Security) including benefits for kidney dialysis and
transplants
30. Access and the Elderly
Two main concerns dominate the debate about
Medicare policy:
1. Spending should be restrained to keep the
program viable
2. The program needs to be truly comprehensive by
adding services not currently covered
31. Access and Minorities
• In some instances, the combination of low
income and minority status creates
difficulties; in others, the interaction of special
cultural habits and minority status causes
problems.
• With the exception of Native Americans
– no other minority population has programs
specifically designed to serve its needs.
32. Access in Rural Areas
In the Omnibus Budget Reconciliation Act of 1986,
Congress provided rural hospitals three important
provisions:
1. Separated urban and rural pools of funds used to
pay for outliers, or cases in which excessive
expenditures above the prospective payment system
allotment are incurred
2. Provided early payments to those with less than 100
beds
3. Changed criteria for rural referral centers to allow
more hospitals to qualify for funds.
33. Access in Rural Areas
The OBRA of 1987 included provisions that :
– Provided greater increase in reimbursement to rural
hospitals than to urban hospitals
– Allowed rural hospitals located adjacent to metropolitan
statistical areas to be defined as urban hospitals
– Authorized a rural health care transition program to
provide assistance to hospitals and others wishing to adopt
new service delivery strategies
34. Access in Rural Areas
The OBRA of 1987 included provisions that :
– Required a report in the appropriateness of separate
urban and rural rates
– Authorized small rural hospitals to serve as residency
training cites for physicians
35. Cost of Care
• The National Health Planning and Resources
Development Act of 1974:
– became law in 1975.
– the transition from improvement of access to cost
containment
• the principal theme in federal health policy.
36. Quality of Care
• OBRA of 1989
– Congress created a new agency, now known as the
Agency for Healthcare Research and Quality (AHRQ)
– Mandated to conduct and support research
concerning outcomes, effectiveness, and
appropriateness of health care services and
procedures.
37. Quality of Care
The AHRQ established funding for patient outcomes
research teams (PORTs)
– focuses on particular medical conditions
– It’s the medical treatment effectiveness program that
consists of four elements:
• medical treatment effectiveness research,
• development of databases for such research,
• development of clinical guidelines and
• the dissemination of research findings and
clinical guidelines
38. Quality of Care
In March 2001, the Institute of Medicine (IOM)
issued:
– Crossing the Quality Chasm, which identified six
areas of quality improvement:
1. Safety
2. Effectiveness
3. Patient-Centeredness
4. Timelines
5. Efficiency
6. Equity
39. Research and Policy Development
The research community influences policymaking
through:
– Documentation
• Gathering, cataloging, correlating
– Analysis
• Feasibility, efficacy, practicality of an
intervention
– Prescription
• Research that shows a course of action
40. Health Insurance Reform
One common criticism of the U.S. health care
system:
– the U.S. is the only industrialized nation that fails
to assure universal access to basic health care.
– the passage of the Patient Protection and
Affordable Care Act of 2010
41. States as Leaders
• During the 1980’s, President Reagan ushered a
return of greater control and discretion over
the financing, delivery, and regulation of
health care to the states.
• Block grants
– consolidates funds from different categorical
programs into one lump sum
• distributed to the states on a formula basis
• became a key vehicle to achieve all three goals
42. States as Leaders
One of the oldest and most fundamental state
roles is in protecting the public’s health, which
includes:
– Protecting the environment, workplace, housing,
food and water
– Preventing injuries and promoting health
behaviors
– Responding to disasters and assisting in recovery
43. States as Leaders
One of the oldest and most fundamental state
roles is in protecting the public’s health, which
includes:
– Ensuring quality, accessibility and accountability of
medical care
– Providing basic health services when otherwise
unavailable
– Monitoring the population’s health status
– Developing policies and plans that support health
improvement
44. States as Leaders
The Institute of Medicine (1988) condensed
these activities into three basic functions:
1. Assessment of health status and systems
2. Policy development
3. Assurance of personal, educational, and
environmental health services
45. Medical Malpractice
• According to DHHS, the malpractice litigation
“crisis” threatens access to health care
• Malpractice insurance premiums increasing by
double digits
• A possible $250,000 cap for damages?
46. Mental Health Benefits
• 30 million Americans suffer from
schizophrenia, depression, etc.
• Employers offer lower treatment benefits
• Possible federal law requiring equal treatment
47. Steps to a Healthy U.S.
The DHHS launched The Steps to a Healthy U.S.
initiative:
– The initiative unites all relevant programs of the
Health and Human Services agencies such as:
• Centers for Disease Control
• Centers of Medicare and Medicaid Services
• Food and Drug Administration
• National Institute of Health
48. ACA Takeaway
• The DHHS and the IRS have been charged with the
responsibilities for regulating most of the ACA’s
provisions.
• The ACA became a reality only after reaching
compromises with the hospital industry, insurance
companies, and the pharmaceutical industry.
• Despite the early rollout of certain provisions, much
remains to be done in implementing the full law.
• In early July 2013, the US Department of the Treasury
reported that the employer mandate would be pushed
back until 2015. Consumer cost protection mandates
are also postponed until 2015.
