05 May Health policies must undergo policy processes of analysis prior to implementation. Pre-process, intra-process, and post-process all have major imp
in Social Science
Health policies must undergo policy processes of analysis prior to implementation. Pre-process, intra-process, and post-process all have major impacts on healthcare organizations and consumers. Based on the policy many people may face economical or social change, which could either be just/unjust.
- Evaluate the ACA’s impact on healthcare quality and cost.
- How does the ACA impact society as a whole?
- Highlight the relevance of the Federal Medicaid Assistance Percentage (FMAP), as it relates to the ACA.
If everyone is in charge, then no one is in charge. Health policy is problematic throughout the world, but it is particularly challenging in the United States, where there is no consensus about which government agency or social institution, if any, has an accepted, legitimate role of developing or implementing national health policy. The U.S. Constitution is silent on the subject of health and health care. Although its preamble promises “to promote the general Welfare,” the Tenth Amendment states, “The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people.” Neither education nor health care powers are specifically allotted to the federal government in the Constitution. The omission of health, however, cannot be attributed solely to the framers’ intent, despite the presence of three physicians at the Constitutional Convention. They lived in a world of “evil humours” where one visited “barbers and churgeons.”
Constitutional issues almost derailed the Patient Protection and Affordable Care Act (ACA) of 2010 before the Supreme Court. In 2012, the Court, by a 5–4 vote, upheld the constitutionality of the “individual mandate” provisions that require most individuals to carry basic health insurance or pay a penalty on their income tax return. At the same time, it overturned a provision requiring states to expand Medicaid access, ruling that it was unconstitutional because it did not provide states enough latitude.
President after president has pushed for an overhaul to our health care system and remedies to the access problems it creates. Only Lyndon Johnson and Barack Obama have succeeded. Attempts by Truman, Eisenhower, Nixon, and Clinton were less successful. In the more recent past, the rapid growth of health care costs has expanded the policy debate, as has growing recognition of medical errors and other quality problems. In the meantime, policy analysts struggle to make progress with a highly fragmented system and a divided body politic.
1.1 THE MANY ACTORS
Policy decisions are made at multiple levels of U.S. society:
• National government
• State and local governments
• Health care institutions
• Provider professionals
• Payer organizations (employers and insurers)
• Employers (meeting the mandate)
• Individuals (consumers)
Tables 1-2 through 1-7 , which are distributed throughout this chapter, provide samples of major health policy questions faced in each of these domains. Like most tables and lists in this text, they are meant to be illustrative, not exhaustive.
In such a decentralized environment, government may take a hands-on approach, treating health care as a public good, as it does transportation and education, or a hands-off approach, favoring market-driven outcomes. Therefore, government’s stance and specific policies may swing dramatically as political power shifts. For example, during the 2012 presidential campaign, one side vowed to repeal the ACA if it gained complete control of the political process, undoing a major accomplishment of the Obama administration. Sharp changes in public attitudes are not unknown. The 1988 Medicare Catastrophic Coverage Act had a favorable rating with the public when passed, but was repealed in November 1989 as the public, especially the wealthier elderly, learned more about it.
This chapter describes what health care policy is, how the policy analysis process works, and the different roles health professionals can play in setting and implementing health policy over time. The role of a policy analyst is described quite completely in the excerpt from the U.S. Office of Personnel Management Operating Manual displayed in Table 1-1 . As you proceed through the text, you will likely note many parallels between that role description and the organization of this text, even though this text is meant to outline health policy analysis for health care professionals rather than cover the full training needs for a career in policy analysis. We then provide an overview of some of the major policy issues facing health care in this country. Finally, we address how certain potentially confusing terms are employed throughout this text and suggest ways to integrate the material that you will be learning with your knowledge from other disciplines.
Table 1-1 Excerpts from the Office of Personnel Management Qualification Standards for General Schedule Positions—Policy Analysis Positions
• Knowledge of a pertinent professional subject-matter field(s). Typically there is a direct, even critical, relationship between the possession of subject-matter expertise and successful performance of analytical assignments.
• Knowledge of economic theories including micro-economics and the effect of proposed policies on production costs and prices, wages, resource allocations, or consumer behavior; and/or macro-economics and the effect of proposed policies on income and employment, investment, interest rates, and price level.
• Knowledge of public policy issues related to a subject-matter field.
• Knowledge of the executive/legislative decision making process.
• Knowledge of pertinent research and analytical methodology and ability to apply such techniques to policy issues, such as:
• Qualitative techniques, such as performing extensive inquiry into a wide variety of significant issues, problems, or proposals; determining data sources and relevance of findings and synthesizing information; evaluating tentative study findings and drawing logical conclusions; and identifying omissions, questionable assumptions, or inadequate data in the analytical work of others.
• Quantitative methods, such as cost benefit analysis, design of computer simulation models and statistical analysis including survey methods and regression analysis.
• Knowledge of the programs or organizations and activities to assess the political and institutional environment in which decisions are made and implemented.
• Skill in dealing with decision makers and their immediate staffs. Skill in interacting with other specialists and experts in the same or related fields.
• Ability to exercise judgment in all phases of analysis, ranging from sorting out the most important problems when dealing with voluminous amounts of information to ensure that the many facets of a policy issue are explored, to sifting evidence and developing feasible options or alternative proposals and anticipating policy consequences.
• Skill in effectively communicating highly complex technical material or highly complex issues that may have controversial findings, or both, using language appropriate to specialists and/or nonspecialists, facilitating the formulation of a decision.
• Skill in written communication to organize ideas and present findings in a logical manner with supporting, as well as adverse, criteria for specific issues, and to prepare material complicated by short deadlines and limited information.
• Skill in effective oral communication techniques to explain, justify, or discuss a variety of public issues requiring a logical presentation of appropriate facts and information or analysis.
• Ability to work effectively under the pressure of tight time frames and rigid deadlines.
Source: Reproduced from: http://www.opm.gov/qualifications/standards/Specialty-Stds/gs-policy.asp; accessed 12/01/12. For more detail see Section IV-A (pp33-34) of the Operational Manual for Qualification Standards for General Schedule Positions.
Table 1-2 Illustrative Health Policy Issues at the U.S. Federal Level
• How should otherwise healthy people be motivated to participate in health insurance programs, thus lowering the average premium?
• What population groups should receive subsidized coverage from tax revenues?
• Because the Constitution does not include the topic of health care as a federal responsibility, how should the federal government participate in supporting health care for all?
• How should the federal government support quality improvement efforts if state boards are not effectively addressing medical error rates?
• The cost of malpractice insurance in some states threatens the supply of providers in some specialties and appears to raise the cost of care, so what is the role of the federal government in avoiding the negative effects of malpractice lawsuits?
• Progress in information technology implementation in health care has lagged behind most other information-intensive service sectors. Are the provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act sufficient to overcome this problem?
• What services should be covered under Medicare? Medicaid?
• How many health professionals in a subspecialty are sufficient? Armed with the right answer, what should we being doing about any shortages? About any surpluses?
1.2 Health Care: What Is It?
1.2 HEALTH CARE: WHAT IS IT?
The terms health and health care are used loosely in U.S. policy debates. Often what people mean by health is an absence of notable ailments. The World Health Organization (2005), however, defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
Similarly, when people utter the phrase the health care system, they often are talking about the system for financing and delivering personal medical services—what some refer to as illness care and we will refer to primarily as the medical care system. The entire system that promotes health and wellness is actually much more complex. Other health systems include public health, mental health, and oral health. Moreover, much of our health is the result of social determinants, such as housing, education, social capital, our natural environment, and the way we construct the built environment around us. These are shaped by policy decisions made outside the health care system.
Thinking about health in terms of population outcomes can dramatically shift the way problems are defined and addressed. One example is identifying the leading causes of death. Using a disease model, the leading killers are ailments such as heart disease, cancer, stroke, injury, and lung disease, but McGinnis and Foege (1993), using a population-based, prevention-oriented perspective, identified the “real causes of death” as behaviors such as tobacco use, improper diet, lack of physical activity, and alcohol misuse. They argued that 88% of what we spend on health nationally pays for access to medical care, but in terms of influence on health status, medical care accounts for a mere 10%. This view attributes 50% of our health status to our behaviors, 20% to genetics, and 20% to environmental factors. Yet only 4% of health spending has been going to promote healthy behaviors and 8% to all other nonmedical health-related activities (Robert Wood Johnson Foundation, 2000). Since the mid-1960s, public health spending as a percentage of overall spending on health care has fluctuated between 1% and 1.5% (Frist, 2002), and yet 25 years of the 30-year increase in life expectancy between 1900 and 1995 can be attributed to public health interventions.
Some examples used to illustrate points throughout this text draw on material from outside the realm of medical care finance and delivery. One case study discusses folic acid fortification of foods, an example of a population-based public health intervention. This text, however, focuses mostly on access, cost, and quality issues related to personal medical services. That is because the primary intended audience is health care professionals (people who operate primarily from within the medical care system) and also the simple fact that the United States is currently wrestling with many critical issues related to health care access cost and quality. Readers are urged, however, to keep that intentional bias in mind and to think about how a big-picture view of health might change the way problems and solutions are identified. For instance, one reform proposal currently in vogue, and discussed in several places in this text, is pay for performance, also known as pay for quality. Pay-for-performance programs provide financial incentives for providers to meet certain process and outcome measures. Kindig (2006, p. 2611) has proposed a “pay-for-population health performance system” that “would go beyond medical care to include financial incentives for the equally essential nonmedical care determinants of population health.”
Table 1-3 Illustrative Health Policy Issues at State and Local Levels
• What services should be provided and to whom under Medicaid options and waivers?
• How should the professional licensure be conducted so as to encourage quality of care, adequate access, and appropriate competition?
• How should the public university system decide how many professionals to train to ensure adequate access to all sections of the state? To all target groups?
• How aggressive should our state be in implementing and supporting health insurance exchanges?
• What should be the roles of the state insurance regulations and oversight boards in ensuring access to care for the general public and for special populations?
• Should the curative health care system, the mental health system, and public health clinics be merged as health care access becomes universal?
• What are intended and unintended consequences of sex education policies on health and health services?
• How do we undertake health care emergency planning for responses to floods, earthquakes, pandemics, and terrorism? What is the relationship between the state systems (public health and military) and local first responders?
1.3 Health Policy: What Is It?
1.3 HEALTH POLICY: WHAT IS IT?
Beyond the scope issues just described, most of us are clear on what health policy is about in general terms. Simply stated, health policy addresses questions such as:
• Where are we with our health care?
• How did we get here?
• Where do we want to be?
• What other alternatives are available here and throughout the world?
• What is likely to work in the future given our political process?
• What roles should health professionals and ordinary citizens play in this process?
• How can we become better prepared for such roles?
We cannot expect any representative cross section of participants to agree on the answers to all of these questions because their interests often conflict. A goal of this text is to encourage development of an objective, managerial approach to decision making—one that uses precise definitions of terms and relationships and carefully considers the key issues (and walks in the shoes of key actors) before reaching individual conclusions. Readers should come away with a set of tools for interpreting and analyzing events, situations, and alternatives—tools that can add to the skills already developed through professional training and experience. No one need abandon what has worked, but we hope to empower analysts to do a better job using a broader array of methods that fit a greater variety of situations.
Table 1-4 Illustrative Health Policy Issues for Health Care Institutions
• How much charitable (uncompensated) care should we provide beyond that which is mandated?
• What should be our health information technology strategy?
• Should we undertake joint planning for future services with our local health department?
• How should we go about increasing the proportion of the local population who volunteer as local organ donors?
• Can we rationalize the services provided by local providers, reducing duplication and waste, and still avoid charges of anticompetitive practices?
• What should we be doing to become an effective learning organization?
1.4 The Policy Analysis Process
1.4 THE POLICY ANALYSIS PROCESS
The policy analysis process usually involves the following activities:
• Problem identification. Why do we think we need to evaluate and possibly change the way we do things? What kinds of actions are people asking for? What are the drivers that require that scarce resources be devoted to this policy area? What is the intended output? What is the expected result?
• Process definition. What is the current situation? What concerns are people citing? Why are current results unsatisfactory to some? What is being done about it? Who are the current actors, and what are their roles? Are people framing the issue effectively? What are reasonable expectations for results over a relevant time horizon?
• Process analysis. What is happening in practice? How are outputs and outcomes measured, and why? What are interested parties recommending? What are the resource inputs? Are they appropriate? Are the outputs distributed fairly? Policy analysis can be approached rationally using a consistent set of steps:
• Map out the existing processes that yield the outputs and outcomes of concern in as much detail as necessary to be operational.
• Generate a list of solution strategies and narrow it to viable alternatives.
• Map out the best processes for the more promising alternatives.
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