HSA 4150 Florida International University Global Healthcare Systems and Policy Paper

Find two proper APA Style references for two (2) “External Authoritative Sources” (defined below), discussing healthcare policymaking at the national level (US or other country) and provide a brief paragraph narrative (one paragraph for each of the required two (2) “external authoritative sources”) incorporating proper APA in-text citations and reference for each source, as well as, a link for each source which leads to the full article referenced is required immediately following each reference.

“External Authoritative Sources” for purposes of this course shall mean: books, peer reviewed journal articles, education and government sites as well as non-partisan national or international organizations (such as WHO, UNICEF, UNAIDS etc) provided, the foregoing source/material selected has in text citations and references to support statements made therein. Under no circumstances are newspapers including the Wall Street Journal, blogs (regardless of source), editorials, panel discussions and dot com sites be used. The foregoing are not considered authoritative for this course.

Attached you will find the book. please make sure each paragraph has 6-8 sentences.

LEIYU SHI 00_Shi (2374) Book.indb 1 11/21/18 10:55 AM HAP/AUPHA Editorial Board for Undergraduate Studies Philip Wessel, Chairman University of Central Florida John Cantiello, PhD George Mason University Nailya DeLellis, PhD Central Michigan University Karen Dielmann, EdD Pennsylvania College of Health Sciences Cathleen O. Erwin, PhD Auburn University Thomas Gariepy, PhD Stonehill College Jennifer B. Groebner, EdD Governors State University David A. Rosenthal, PhD Baptist College of Health Sciences MaryMargaret Sharp-Pucci, PhD Loyola University Chicago Aaron C. Spaulding, PhD Mayo Clinic M. Scott Stegall, PhD Clayton State University Michael K. Stowe, PhD University of St. Francis 00_Shi (2374) Book.indb 2 11/21/18 10:55 AM LEIYU SHI Health Administration Press, Chicago, Illinois Association of University Programs in Health Administration, Washington, DC 00_Shi (2374) Book.indb 3 11/21/18 10:55 AM Your board, staff, or clients may also benefit from this book’s insight. For information on quantity discounts, contact the Health Administration Press Marketing Manager at (312) 424-9450. This publication is intended to provide accurate and authoritative information in regard to the subject matter covered. It is sold, or otherwise provided, with the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. The statements and opinions contained in this book are strictly those of the author and do not represent the official positions of the American College of Healthcare Executives, the Foundation of the American College of Healthcare Executives, or the Association of University Programs in Health Administration. Copyright © 2019 by the Foundation of the American College of Healthcare Executives. Printed in the United States of America. All rights reserved. This book or parts thereof may not be reproduced in any form without written permission of the publisher. 23  22  21  20  19  5  4  3  2  1 Library of Congress Cataloging-in-Publication Data Names: Shi, Leiyu, author. Title: Introduction to health policy / Leiyu Shi, Gateway to Healthcare Management. Description: Second edition. | Chicago, Illinois : Health Administration Press, HAP ; Washington, D.C. : Association of University Programs in Health Administration, AUPHA, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2018040567 (print) | LCCN 2018041419 (ebook) | ISBN 9781640550261 (ebook) | ISBN 9781640550278 (xml) | ISBN 9781640550285 (epub) | ISBN 9781640550292 (mobi) | ISBN 9781640550254 (print : alk. paper) Subjects: LCSH: Medical policy—History. | Health care reform. | Public health—International cooperation. Classification: LCC RA393 (ebook) | LCC RA393 .S473 2019 (print) | DDC 362.1—dc23 LC record available at https://lccn.loc.gov/2018040567 The paper used in this publication meets the minimum requirements of American National Standard for Information Sciences—Permanence of Paper for Printed Library Materials, ANSI Z39.48-1984. ∞TM Acquisitions editor: Jennette McClain; Manuscript editor: Lori Meek Schuldt; Project manager: Andrew Baumann; Cover designer: James Slate; Layout: Cepheus Edmondson Found an error or a typo? We want to know! Please e-mail it to hapbooks@ache.org, mentioning the book’s title and putting “Book Error” in the subject line. For photocopying and copyright information, please contact Copyright Clearance Center at www.copyright. com or at (978) 750-8400. Health Administration Press A division of the Foundation of the American College of Healthcare Executives 300 S. Riverside Plaza, Suite 1900 Chicago, IL 60606-6698 (312) 424-2800 00_Shi (2374) Book.indb 4 Association of University Programs in Health Administration 1730 M Street, NW Suite 407 Washington, DC 20036 (202) 763-7283 11/21/18 10:55 AM I dedicate this book to my wife, Ruoxian, and my children, Sylvia, Jennifer, and Victor Shi. 00_Shi (2374) Book.indb 5 11/21/18 10:55 AM 00_Shi (2374) Book.indb 6 11/21/18 10:55 AM BR I E F CON T E N TS Preface………………………………………………………………………………………………………..xiii PART I Introduction Chapter 1 Overview of Health Policy……………………………………………………………….3 PART II Health Policymaking Chapter 2 Federal Health Policymaking………………………………………………………….37 Chapter 3 Health Policymaking at the State and Local Levels and in the Private Sector…………………………………………………………70 Chapter 4 International Health Policymaking………………………………………………..102 PART III Health Policy Issues Chapter 5 Health Policy Related to Financing and Delivery……………………………..131 Chapter 6 Health Policy for Diverse Populations……………………………………………155 Chapter 7 International Health Policy Issues………………………………………………….202 PART IV Health Policy Research Chapter 8 Overview of Health Policy Research………………………………………………255 Chapter 9 Health Policy Research Methods…………………………………………………..292 Chapter 10 An Example of Health Policy Research…………………………………………..339 vii 00_Shi (2374) Book.indb 7 11/21/18 10:55 AM viii Brief Contents Glossary……………………………………………………………………………………………………..375 Index…………………………………………………………………………………………………………..383 About the Author………………………………………………………………………………………407 00_Shi (2374) Book.indb 8 11/21/18 10:55 AM D ETA I L E D C O N TE N TS Preface………………………………………………………………………………………………………..xiii PART I Introduction Chapter 1 Overview of Health Policy……………………………………………………………….3 Learning Objectives………………………………………………………………………..3 Case Study 1: Healthcare Reform: Hillary Clinton and Barack Obama………………………………………………………………….4 Case Study 2: Healthcare Reform After the ACA…………………………………5 Health Defined……………………………………………………………………………..6 Public Health Defined…………………………………………………………………….9 What Are the Determinants of Health?……………………………………………10 Policy Defined……………………………………………………………………………..18 Health Policy Defined…………………………………………………………………..19 What Are the Determinants of Health Policy?…………………………………..21 Stakeholders of Health Policy…………………………………………………………25 Why Is It Important to Study Health Policy?…………………………………….27 Key Points…………………………………………………………………………………..28 Case Study Questions……………………………………………………………………29 For Discussion……………………………………………………………………………..29 References…………………………………………………………………………………..30 PART II Health Policymaking Chapter 2 Federal Health Policymaking………………………………………………………….37 Learning Objectives………………………………………………………………………37 ix 00_Shi (2374) Book.indb 9 11/21/18 10:55 AM x Detailed Contents Case Study 1: The Development of Medicare and Medicaid………………..38 Case Study 2: The Health Insurance Portability and Accountability Act of 1996………………………………………………………………………….39 The US Political System………………………………………………………………..40 Policymaking Process at the Federal Level…………………………………………42 Attributes of Health Policymaking in the United States………………………54 Role of Interest Groups in US Health Policymaking…………………………..58 Key Points…………………………………………………………………………………..62 Case Study Questions……………………………………………………………………62 For Discussion……………………………………………………………………………..63 References…………………………………………………………………………………..63 Additional Resources…………………………………………………………………….68 Chapter 3 Health Policymaking at the State and Local Levels and in the Private Sector…………………………………………………………70 Learning Objectives………………………………………………………………………70 Case Study 1: Massachusetts Healthcare Reform……………………………….71 Case Study 2: Connecticut Opioid Response Initiative……………………….71 State Government Structure…………………………………………………………..73 Local Government Structure………………………………………………………….79 Private Health Research Institutes…………………………………………………..81 Private Health Foundations……………………………………………………………82 Private Industry……………………………………………………………………………84 Attributes of Health Policy Development in Nonfederal Sectors…………..89 Key Points…………………………………………………………………………………..91 Case Study Questions……………………………………………………………………92 For Discussion……………………………………………………………………………..92 References…………………………………………………………………………………..93 Chapter 4 International Health Policymaking………………………………………………..102 Learning Objectives…………………………………………………………………….102 Case Study 1: WHO Healthy Cities Initiative…………………………………103 Case Study 2: Primary Care Workforce Around the World………………..104 The World Health Organization……………………………………………………105 Health Policymaking in Selected Countries…………………………………….109 Key Points…………………………………………………………………………………121 Case Study Questions………………………………………………………………….121 For Discussion……………………………………………………………………………122 References…………………………………………………………………………………122 Additional Resources…………………………………………………………………..128 00_Shi (2374) Book.indb 10 11/21/18 10:55 AM Detailed Contents xi PART III Health Policy Issues Chapter 5 Health Policy Related to Financing and Delivery……………………………..131 Learning Objectives…………………………………………………………………….131 Case Study 1: The Federally Funded Health Center Program: Providing Access, Overcoming Disparities……………………………….132 Case Study 2: Precision Medicine………………………………………………….133 Financing US Healthcare……………………………………………………………..134 US Healthcare Delivery……………………………………………………………….139 Policy Issues in Healthcare Financing and Delivery………………………….145 Key Points…………………………………………………………………………………149 Case Study Questions………………………………………………………………….150 For Discussion……………………………………………………………………………150 References…………………………………………………………………………………151 Chapter 6 Health Policy for Diverse Populations……………………………………………155 Learning Objectives…………………………………………………………………….155 Case Study 1: The Health Center Program……………………………………..156 Case Study 2: My Health GPS Program for Patients with Multiple Chronic Conditions…………………………………………157 Defining Vulnerability…………………………………………………………………158 Health Policy Issues for Diverse Populations……………………………………159 Health Policy Issues for Vulnerable Subpopulations………………………….168 Key Points…………………………………………………………………………………184 Case Study Questions………………………………………………………………….184 For Discussion……………………………………………………………………………185 References…………………………………………………………………………………185 Chapter 7 International Health Policy Issues………………………………………………….202 Learning Objectives…………………………………………………………………….202 Case Study 1: Climate Change and Public Health……………………………203 Case Study 2: Primary Care Around the World……………………………….204 Health Policy Issues in Developed Countries…………………………………..207 Health Policy Issues in Developing Countries………………………………….217 Key Points…………………………………………………………………………………236 Case Study Questions………………………………………………………………….237 For Discussion……………………………………………………………………………237 References…………………………………………………………………………………237 Additional Resources…………………………………………………………………..250 00_Shi (2374) Book.indb 11 11/21/18 10:55 AM xii Detailed Contents PART IV Health Policy Research Chapter 8 Overview of Health Policy Research………………………………………………255 Learning Objectives…………………………………………………………………….255 Case Study 1: The RAND Health Insurance Experiment…………………..256 Case Study 2: Idaho’s Preventive Health Assistance Program………………257 Defining Health Policy Research…………………………………………………..258 The Process of Health Policy Research……………………………………………265 Communicating Health Policy Research…………………………………………276 Implementing Health Policy Research……………………………………………279 Key Points…………………………………………………………………………………285 Case Study Questions………………………………………………………………….286 For Discussion……………………………………………………………………………286 References…………………………………………………………………………………287 Chapter 9 Health Policy Research Methods…………………………………………………..292 Learning Objectives…………………………………………………………………….292 Case Study 1: Health Centers and the Fight Against Health Disparities in the United States………………………..293 Case Study 2: Vermont’s Accountable Communities for Health Learning Lab……………………………………………………….294 Quantitative Methods…………………………………………………………………295 Qualitative Methods……………………………………………………………………314 Key Points…………………………………………………………………………………326 Case Study Questions………………………………………………………………….326 Case Study Assignment……………………………………………………………….327 For Discussion……………………………………………………………………………327 References…………………………………………………………………………………327 Additional Resources…………………………………………………………………..338 Chapter 10 An Example of Health Policy Research…………………………………………..339 by Sarika Rane Parasuraman Learning Objectives…………………………………………………………………….339 Questions for Policy Analysis………………………………………………………..340 Policy Analysis: Responses to Exam Questions………………………………..341 Key Points…………………………………………………………………………………366 For Discussion……………………………………………………………………………366 References…………………………………………………………………………………367 Glossary……………………………………………………………………………………………………..375 Index…………………………………………………………………………………………………………..383 About the Author………………………………………………………………………………………407 00_Shi (2374) Book.indb 12 11/21/18 10:55 AM P RE FA C E U S policymakers have been struggling for years to find solutions to our healthcare challenges. Thus, healthcare reform is among the top priorities of almost every administration. This introductory textbook on US health policy covers the related areas of health policymaking, critical health policy issues, health policy research, and an international perspective on health policy and policymaking. The book offers the following features: ◆◆ Real-world cases to exemplify the theories and concepts presented from a variety of perspectives, including the hospital setting, public health, managed care, ambulatory care, and extended care ◆◆ Exhibits and extra feature boxes (Learning Points, For Your Consideration, Key Legislation, Research from the Field, International Policymaking, Global Health Impact, and others) that present background information on concepts, examples, and up-to-date information ◆◆ Learning objectives and key points ◆◆ Discussion questions O r g a ni z at i on of the B oo k This book is organized in four parts: an introduction, an overview of health policymaking, a health policy issues section, and a discussion of health policy research and analysis. Chapter 1, the sole chapter in part I, introduces key terms related to, and the determinants of, health xiii 00_Shi (2374) Book.indb 13 11/21/18 10:55 AM xiv Preface and health policy. It lists the key stakeholders in health policymaking and presents important reasons for studying health policy. The chapter lays the foundation for the rest of the book. Part II—containing chapters 2, 3, and 4—examines the policymaking process at the federal, state, and local levels; in the private sector; and in international settings. Chapter 2 focuses on the policymaking process at the federal level of the US government. Important activities within the three policymaking stages—policy formulation, policy implementation, and policy modification—are described. The key characteristics of health policymaking in the United States are analyzed, and the role of interest groups in making policy is discussed. Chapter 3 focuses on the US policymaking process at the state and local levels and in the private sector, which includes the research community, foundations, and private industry. Examples of policy-related research by private research institutes and foundations are described. The impact of the private sector’s services and products on health and policy is illustrated using the fast-food industry as well as tobacco and pharmaceutical companies as examples. Chapter 4 discusses international health policymaking. The World Health Organization (WHO) is presented as an example of an international agency involved in policymaking related to health and major health initiatives. Three countries—Canada, Sweden, and China—are highlighted to illustrate diverse policymaking processes in distinct geographic regions. The experiences of these countries show that different political systems and policymaking processes lead to diverse approaches to population health and healthcare delivery. Part III—encompassing chapters 5, 6, and 7—examines the policy issues related to social, behavioral, and medical care health determinants; to people from diverse or medically or socially vulnerable populations; and to international health. Chapter 5 describes how US healthcare is financed and delivered. Private and public health insurance programs are summarized, and the subsystems of healthcare delivery—managed care plans, safety net providers, public health programs, long-term care services, and military-operated healthcare—are introduced. After summarizing the major characteristics of US healthcare delivery, the chapter provides examples of health policy issues related to financing (cost containment) and delivery (healthcare workforce, professional accreditation, antitrust regulations, patient access to care, and patient rights). Chapter 6 defines medically and socially vulnerable populations and discusses the dominant healthcare policy issues related to those populations. People from diverse populations include members of racial or ethnic minorities, the uninsured, people with low socioeconomic status, the elderly, people with chronic illness, people with mental illness, women and children, people with disabilities, the homeless, and people with HIV/AIDS. In each segment, the magnitude of the problem is summarized and a detailed discussion of the policies and strategies meant to address the problem is presented. In chapter 7, dominant health policy issues in the international community are discussed, with examples given for select countries, to help students understand not only international health policy applications but also the field of global health. The chapter begins 00_Shi (2374) Book.indb 14 11/21/18 10:55 AM Preface xv by examining issues shared by developed countries, such as modifying health systems to better serve aging and diverse populations while maintaining high-quality care at a low cost. It then discusses challenges faced by developing nations, such as controlling the spread of disease, creating and maintaining high-functioning health systems with limited resources, and dealing with the burdens of morbidity and mortality associated with poverty. Several emerging issues are also illustrated that could affect global health in the future. Part IV—comprising chapters 8, 9, and 10—presents an overview of policy analysis, focusing on examples of commonly used quantitative and qualitative methods. Chapter 8 introduces health policy research (HPR) and highlights the discipline’s defining characteristics, including applied, policy-relevant, ethical, multidisciplinary, scientific, and population-based studies. The HPR process is summarized, and the chapter concludes with a discussion of ways to communicate findings and the challenges in implementing those findings in practice. Chapter 9 illustrates commonly used methods in HPR. Quantitative methods include experimental research, survey research, evaluation research, cost–benefit analysis, and costeffectiveness analysis. Because evaluation research is closely tied to policy research, the process involved in this type of research is described in greater detail. Qualitative methods include participant observations, in-depth interviews (including focus groups), and case studies. Examples of published studies using these methods are provided. Chapter 10 provides an example that illustrates the key steps in health policy analysis: assessing the determinants of a health problem, identifying a policy intervention to address the problem, critically evaluating the policy intervention, and proposing next steps in addressing the problem. New to T h i s E d i t i on This second edition has retained most of the features of the first edition. In addition, significant updates have been made in the following key areas. C ase S tudies Each of the chapter-opening case studies from the first edition has been revised or replaced, and a new, second case study has been added to chapters 1–9. H ealthc are R ef orm The latest developments in healthcare reform and legislation have been incorporated into the book, especially in chapters 2 and 3 and in the many additions to the chapters in part III. 00_Shi (2374) Book.indb 15 11/21/18 10:55 AM xvi Preface I nternati onal H ealth P olicy The international health policy chapters (chapters 4 and 7) have broadened in scope with more examples from the array of countries discussed in the book. New WHO initiatives have also been added. U pdated C ontent T hroughout Content, references, and data (including in relevant exhibits) have been updated throughout. New and revised content includes coverage of the impact of the Affordable Care Act, new healthcare reform directions, the patient-centered medical home, accountable care organizations, precision medicine and big data, state and local healthcare reform activities, private-sector initiatives, and the pharmaceutical industry. More examples of applications in research have been added. A c k n o w l e d gm e n t s My PhD advisee Sarika Rane Parasuraman contributed chapter 10 (an applied example) and is hereby acknowledged. The editorial staff of Health Administration Press have provided hands-on assistance in editing the manuscript. Of course, all errors and omissions remain my responsibility. Leiyu Shi i n str u CtOr r esOu r Ces This book’s Instructor Resources include a test bank, PowerPoint slides for each chapter, and answer guides for the book’s discussion questions. For the most up-to-date information about this book and its Instructor Resources, go to ache.org/HAP and search for the book’s order code (2374). This book’s Instructor Resources are available to instructors who adopt this book for use in their course. For access information, please e-mail hapbooks@ache.org. 00_Shi (2374) Book.indb 16 11/21/18 10:55 AM PA R T I I N T R O D UCTION T he introduction, which consists of chapter 1, provides an overview of health policy. It defines key terms related to health policy, reviews the framework of health determinants, and outlines the concept of health policy formulation. In addition, the chapter introduces topics related to health policy, including stakeholders, major types of health policies, and the importance of studying health policy. The introduction provides readers with a foundation for examining how health policy is established in the United States and elsewhere. 00_Shi (2374) Book.indb 1 11/21/18 10:55 AM 00_Shi (2374) Book.indb 2 11/21/18 10:55 AM CHAPTER 1 OV E R V I E W O F HE ALTH P OLICY I have never had a policy. I have simply tried to do what seemed best each day, as each day came. —Abraham Lincoln The health and vitality of our people are at least as well worth conserving as their forests, waters, lands, and minerals, and in this great work the national government must bear a most important part. —Theodore Roosevelt Learning Objectives After completing this chapter, you should be able to ➤➤ define key terms related to health policy, ➤➤ appreciate the influence of health determinants, ➤➤ understand the framework of health policy formulation, ➤➤ identify the stakeholders in health policy, ➤➤ describe the major types of health policies, and ➤➤ discuss the importance of studying health policy. 3 00_Shi (2374) Book.indb 3 11/21/18 10:55 AM 4 Introduction to Health Policy Case Study 1 H e a lt h c a r e R e f o rm : H illary C lint on and B ara ck O b ama Two major healthcare reform initiatives have played out on the US political landscape since the late twentieth century: the Health Security Act, developed by the Clinton administration in the 1990s and spearheaded by First Lady Hillary Clinton, which failed to pass into law, and the Affordable Care Act (ACA), drafted by the Obama administration, which became federal law in March 2010. The hallmark of the Clinton plan was its universal coverage mandate, which required all employers to contribute to a pool of funds to cover the costs of insurance premiums for their workers, with caps on total employer costs and subsidies for small businesses. Competition among private health plans and a cap on the growth of insurance premiums were to have held costs in check, and additional financing was to have been provided through savings from cuts in projected Medicare and Medicaid spending and increased taxes on tobacco (Oberlander 2007; Pesko and Robarts 2017). The Obama plan focused on reforming the private health insurance market, extending insurance coverage to the uninsured, providing better coverage for those with preexisting conditions, improving prescription drug coverage in Medicare, and extending the life of Medicare trust fund accounts. The ACA was expected to be financed through taxes, such as a 40 percent tax on “Cadillac” insurance policies (policies that offer the richest benefits) and taxes on pharmaceuticals, medical devices, and indoor tanning services (KFF 2013), and through other offsets or provisions of the law that reduce the overall cost of enacting legislation, such as penalties on uninsured individuals. The political landscape in 2009, as President Barack Obama’s healthcare reform initiative was being debated, was similar to that in the early 1990s: Both the Clinton and Obama administrations were affiliated with the Democratic Party, both chambers of the US Congress were controlled by Democrats, and national opinion strongly favored healthcare reform (Sack and Connelly 2009). However, whereas the Obama reform initiative became law, the earlier Clinton healthcare reform package was defeated in Congress. Although Americans supported healthcare reform in theory, the Clinton plan was derailed by the heavy opposition of the medical and insurance industries and by antitax rhetoric. The disenchantment of the electorate following that failed effort helped Republicans gain control of the House of Representatives and Senate in the 1994 election (Trafford 2010), which all but guaranteed that any further Democratic-designed proposal would fail due to increasing political polarization in Congress. After Republican president Donald Trump took office in January 2017, the Trump administration and the Republican-controlled Congress put forth many efforts to “repeal and replace” the ACA. However, as of mid-2018, none of these attempts had succeeded. 00_Shi (2374) Book.indb 4 11/21/18 10:55 AM Chapter 1: Overview of Health Policy 5 Case Study 2 H e a lt hc a r e R e f o r m A f t e r the ACA Healthcare reform continues to be a deeply partisan issue in US politics, and political gridlock in Congress has made efforts at reform challenging. Since 2010, Republicans in Congress have unsuccessfully attempted to repeal the ACA, voting more than 60 times to repeal or alter the law (Cowen and Cornwall 2017). In January 2016, the Republican-controlled House and Senate passed a bill that would have repealed the ACA, but President Obama, a Democrat, promptly vetoed it. The Congressional Budget Office (CBO) review of the proposal concluded that the bill would have canceled health insurance for 22 million people by 2018 (Cubanski and Neuman 2018). In the 2016 presidential election campaign, every Republican candidate vowed to “repeal and replace” the ACA (Jost 2015). In January 2017, within hours of taking office, President Trump issued his first executive order, moving to dismantle parts of the ACA (Davis and Pear 2017). On March 7, 2017, Republicans introduced the two bills that constitute the original American Health Care Act (AHCA) of 2017, H.R. 1628, to partially repeal the ACA. The Trump administration announced its support for AHCA. On March 12, 2017, the CBO released its budget analysis, projecting that 52 million Americans would be left uninsured under the AHCA and those with insurance would have to pay higher premiums through 2020. On May 4, 2017, the House narrowly passed the AHCA, by a vote of 217–213, and sent the bill to the Senate for deliberation. On June 22, 2017, the Senate released a discussion draft for an amendment to the bill, which would rename it the Better Care Reconciliation Act of 2017. On July 28, 2017, the bill was returned to the calendar after the Senate rejected several amendments, including the Health Care Freedom Act, or the “skinny bill,” that would have repealed the ACA’s individual mandate retroactive to 2016 and the employer mandate through 2025. Does this legislation point to a new phase of healthcare reform whose success hinges on support from both major political parties? As Wilensky (2017) suggested, Republicans and Democrats might need to find a way to work together to enact comprehensive healthcare reform beyond the ACA. Or, does it signal a new approach toward dismantling the ACA through the administrative process, such as policy implementation? In reaction to Congress’s repeated failure to repeal the ACA, on October 12, 2017, President Trump issued Executive Order 13813, directing federal agencies to expand the use of association health groups—groups of small businesses that pool together to buy health insurance (Trump 2017). The Tax Cuts and Jobs Act of 2017, passed and signed into law in December 2017, effectively repealed the mandate in the ACA that required all Americans to have health insurance. Although the ACA was still the law of the land during the first year of the Trump administration, many of its components were being modified in Trump’s second year. 00_Shi (2374) Book.indb 5 11/21/18 10:55 AM 6 gross domestic product The value of all goods and services produced within a country for a given period; a key indicator of the country’s economic activity and financial well-being. Introduction to Health Policy A t 16.9 percent of the nation’s total economic activity—also known as the gross domestic product—healthcare spending in the United States leads all countries in overall and per capita measures (OECD 2018). Yet the US healthcare system does not perform well compared with those of other industrialized countries. A 2010 World Health Organization (WHO) report ranked the US health system thirty-seventh among 191 countries (Tandon et al. 2018). In addition, a Commonwealth Fund study on healthcare performance ranked the United States behind ten other industrialized countries—Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom—on the basis of quality, efficiency, access, equity, and health outcome measures (Davis, Schoen, and Stremikis 2014). The US healthcare system also ranked last in a recent survey of eleven nations (Commonwealth Fund 2017). Why have health policies tended to fail in the United States while they appear to succeed in other countries? The answer might be found in the context—the United States—and the determinants of health and health policy in the country. The main purpose of this chapter is to present a framework of health policy determinants and discuss their impact in the United States. Understanding this framework will help the reader appreciate factors that contribute to health policy development in general and in the United States in particular. The chapter first defines key concepts related to health policy and later discusses the importance of studying health policy, including an awareness of its international perspective. The stakeholders of health policy are also presented and analyzed as key parts of the policy context. H e a lt h D e f i ne d WHO (1946) defines health as “not merely the absence of disease or infirmity but a state of complete physical, mental and social well-being.” This broad definition recognizes that health encompasses biological and social elements in addition to individual and community well-being. Health may be seen as an indicator of personal and collective advancement. It can signal the level of an individual’s well-being as well as the degree of success achieved by a society and its government in promoting that well-being (Shi and Stevens 2010). This definition of health implies that issues such as poverty, lack of education, discrimination, and other social, cultural, and political conditions found around the world are essentially public health issues. However, health is also the result of personal characteristics and choices. This concept is the source of the fundamental tension in public health and has been a major topic of discussion in the United States in the twenty-first century. Major debates continue over whether people can be forced to take actions to ensure their own health, such as buying health insurance (e.g., the “individual mandate” in the ACA), or be prohibited from performing actions that are unhealthy, such as limiting soft drinks in schools. Health policy in the United States must attempt to balance the good of the public health with personal liberty, 00_Shi (2374) Book.indb 6 11/21/18 10:55 AM Chapter 1: Overview of Health Policy 7 KEY LEGISLATION What Is the Status of Healthcare Reform in the United States? In the United States, healthcare reform typically denotes a government-sponsored program that strives to make health insurance available to the uninsured. Heretofore, healthcare reform has not quite addressed how healthcare should be delivered, such as in resource allocations across preventive, primary, and tertiary care settings. Although universal health insurance is a difficult goal to realize, incremental reforms have been successful when political and economic environments were favorable. The first such program came in the form of the Old Age Assistance program, which was enacted as part of the 1935 Social Security Act and provided direct financial assistance to needy elderly persons. Full health insurance for the elderly became available under the Medicare program, as did health insurance for the indigent under the Medicaid program. Both programs were created in 1965 under the Great Society reforms of President Lyndon Johnson in an era when civil rights and social justice had taken central stage in the United States. Later, authorized under the Balanced Budget Act of 1997, the State Children’s Health Insurance Program—later renamed the Children’s Health Insurance Program—was developed, whereby states can use federal funds to cover children up to age 19 through their existing Medicaid programs. One of the most significant healthcare reform efforts resulted in the Affordable Care Act of 2010, designed to bring about major changes to the delivery of US healthcare. The key objective of the ACA was to provide most, if not all, Americans with health insurance coverage. life expectancy Anticipated number of years of life remaining at a given age. mortality Number of deaths in a given population within a specified period. morbidity Incidence or prevalence of diseases in a given often a difficult compromise to make. Indeed, the conflict between the WHO definition of health and many of the social, cultural, and political issues surrounding the US healthcare system is one of the most important areas of debate for health policymakers. population within a specified period. disability A physical or mental condition that limits P hysical H ealth The most common measure of physical health is life expectancy—the anticipated number of remaining years of life at any stage. Exhibit 1.1 shows the ten countries ranking highest in their population’s life expectancy as of 2015 and includes the US ranking for comparison. Although good or positive health status is commonly associated with the definition of health, the most frequently used indicators measure, instead, lack of health or incidence of poor health—for example, mortality, morbidity, disability, and various indexes that combine these factors. One such measure is quality-adjusted life years, which combines mortality and morbidity in a single index. The Learning Point box titled “Measures of Mortality, Morbidity, and Disability” lists categories by which each indicator is measured. 00_Shi (2374) Book.indb 7 an individual’s ability to perform functions considered normal. quality-adjusted life years A combined mortality– morbidity index that reflects years of life free of disability and symptoms of illness. 11/21/18 10:55 AM 8 Introduction to Health Policy Exhibit 1.1 Top Ten Countries with the Longest Life Expectancy, with the United States as Comparison Life expectancy at birth (years) Rank Country (state/territory) Overall Male Female 1 Japan 83.9 80.8 87.1 2 Switzerland 83.0 80.8 85.1 3 Spain 83.0 80.1 85.8 4 Italy 82.6 80.3 84.9 5 Australia 82.5 80.4 84.5 6 Iceland 82.5 81.2 83.8 7 Norway 82.4 80.5 84.2 8 France 82.4 79.2 85.5 9 Sweden 82.3 80.4 84.1 10 Korea 82.1 79.0 85.2 26 United States 78.8 76.3 81.2 Source: Data from OECD (2018). M ental H ealth In contrast to physical health, measures of mental health are limited. The major categories of mental health measures are mental conditions (e.g., depression, disorder, distress), behaviors (e.g., suicide, drug or alcohol abuse), perceptions (e.g., perceived mental health status), satisfaction (e.g., with life, work, relationships), and services received (e.g., counseling, drug treatment). Mental illness ranks second, after ischemic heart disease, as a nationwide burden on health and productivity (SAMHSA 2016). An estimated 17.9 percent of the US adult population in 2014 had at least one diagnosable mental disorder, only 41 percent of whom received any treatment (SAMHSA 2016). Serious mental illness costs the United States $193.2 billion in lost earnings per year (SAMHSA 2016). Mental illness is a risk factor for death from suicide, cardiovascular disease, and cancer. Mental health problems are frequently associated with social problems. For example, with easy access to guns, mental health often contributes to gun violence in both public and private settings. S ocial W ell -B eing The most commonly used measure of relative social well-being is socioeconomic status (SES). An SES index typically considers such factors as education level, income, and occupation. Quality of life is another common measure and may include the ability to perform various roles (e.g., self-care, family care, social functioning), perceptions (e.g., emotional well-being, 00_Shi (2374) Book.indb 8 11/21/18 10:55 AM Chapter 1: Overview of Health Policy 9 LEARNING POINT Measures of Morbidity, Mortality, and Disability Morbidity measures • Incidence of specific diseases: number of new cases in a defined population within a specified period • Prevalence of specific diseases: number of instances in a defined population within a specified period Mortality measures • Crude (unadjusted for any other factors) death rate • Age-specific death rate • Condition-specific death rate • Infant death rate • Maternal death rate Disability measures • Restricted activity days (e.g., bed days, work-loss days) • Limitations in performing activities of daily living (i.e., bathing, dressing, toileting, getting into or out of a bed or a chair, continence, eating) • Limitations in performing instrumental activities of daily living (i.e., doing housework and chores, grocery shopping, preparing food, using the phone, traveling locally, taking medicine) social contacts The frequency of social activities a person undertakes within a pain tolerance, energy level), and living environment (e.g., pollution levels, crime prevalence). A third set of social well-being measures, often used by sociologists, is composed of social contacts and social resources. Examples of social contacts include visits with family members, friends, and relatives and participation in social events, such as membership activities, professional conferences, and church gatherings. The social contacts factor can be used as an indicator of social resources by determining whether an individual can rely on social contacts for needed support and company and whether the people involved in these contacts meet the individual’s needs for care and love. specified period. social resources Interpersonal relationships with social contacts and the extent to which the individual can rely on the people involved in these contacts for support. P u b l ic H e a lt h D e f i ne d In the early twentieth century, Winslow (1920) defined public health as “the science and the art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts for the sanitation of the environment, the control of 00_Shi (2374) Book.indb 9 11/21/18 10:55 AM 10 Introduction to Health Policy community infections, the education of the individual in principles of personal hygiene, the organization of medical and nursing service for the early diagnosis and preventive treatment of disease, and the development of social machinery which will ensure to every individual in the community a standard of living adequate for the maintenance of health.” It focuses on prevention and involves the efforts of society as a whole. Public health is intended to protect lives and improve the health of populations around the globe. Today, the Johns Hopkins Bloomberg School of Public Health emphasizes the continued importance of public health in its school motto, “Protecting Health, Saving Lives—Millions at a Time.” Whereas healthcare is intended to treat, influence, and care for individuals, public health operates on a larger scale. The field is described by the American Public Health Association (APHA 2018) as one that “promotes and protects the health of people in the communities where they live, learn, work and play.” Public health has broad implications for a population. Successful public health activities and initiatives can save money by promoting healthy living and prevention, thus reducing healthcare costs and disease burden. In addition, these activities can improve quality of life, help children thrive, and reduce the suffering caused by ill health in a population (APHA 2018). The practice of public health leads to both direct benefits (e.g., healthier children, less chronic disease, less need for acute care) and indirect benefits (e.g., fewer days missed from school and work; increased funding available for other initiatives, such as education) for a society. It is important to remember that public health, healthcare, and health policy are interconnected areas of study and practice. All three have great influence on health. W h at A r e determinants of health Factors that influence health status. Typically, they include socioeconomic status, environment, behaviors, heredity, and access to medical care. 00_Shi (2374) Book.indb 10 the D e terminants of H ealth ? Numerous theories on the determinants of health have been proposed since the midtwentieth century. Blum (1974) offered a framework called Force Field and Well-Being Paradigms of Health, which suggests four major influences—the force fields—on health: environment, lifestyle, heredity, and medical care. According to Blum, the most important force field is the environment, followed by lifestyle and heredity. Medical care has the least impact on health and well-being. Twenty-first-century models focus on socioeconomic context and health behaviors. For example, the Dahlgren and Whitehead (2006) model divides factors that influence health into two categories. Fixed factors, the first category, are unchangeable, such as age, sex, and genetic makeup. The second category is composed of modifiable factors, such as individual lifestyle choices; social networks and community conditions; the environment in which one lives and works; and access to important goods and services, such as education, sanitation, food, and healthcare. The factors in the second category form layers of influence around the population, and modifying them positively can improve population health. Ansari and colleagues (2003) proposed a public health model of the determinants of health in which these factors are categorized into four major groups: social determinants, 11/21/18 10:55 AM Chapter 1: Overview of Health Policy 11 healthcare system attributes, disease-inducing behaviors (see the Learning Point box titled “Prominent Theories on the Causes of Disease”), and health outcomes. A conceptual framework developed by the WHO Commission on Social Determinants of Health (2008) focuses on socioeconomic and political context; structural determinants and socioeconomic position; intermediary determinants, such as material circumstances, socioenvironmental circumstances, behavioral and biological factors, social cohesion, and the healthcare system; and the impact on health equity and well-being measured as health outcomes. LEARNING POINT Prominent Theories on the Causes of Disease Many of the historically dominant theories related to health focus on disease rather than well-being. The three most prominent theories of disease causality are germ theory, lifestyle theory, and environmental theory. Germ theory gained prominence in the nineteenth century with the rise of bacteriology (Metchnikoff, Pasteur, and Koch 1939). Essentially, the theory holds that every disease has a specific cause, which should be identifiable. Knowledge of the cause allows for the discovery of a cure. Microorganisms, the general causal agent identified by germ theory, are thought to act independently of the environment. Furthermore, the individual who serves as the host of the microorganism is the source of the disease, which may then be transmitted from one person to another—a process known as contagion. Strategies to address the disease focus on identifying people with symptoms and providing follow-up medical treatment. Much of biomedical research is still based on germ theory. The traditional concept of the agent, host, and environment as the epidemiological triangle—epidemiology is the study of factors controlling the presence or absence of a disease—is also based on the single-cause, singleeffect framework of germ theory. Lifestyle theory tries to isolate specific behaviors (e.g., exercise, diet, smoking, drinking) as causes of a disease and identifies solutions on the basis of improving or changing these behaviors. As with germ theory, lifestyle theory defines problems as they relate to individuals and focuses solutions on individually tailored interventions. Environmental theory considers the general health and well-being of individuals more than it does disease. It maintains that health is best understood by examining the larger context of community. Traditional environmental approaches focused on poor sanitation, which was connected to certain infectious diseases. With industrialization and its by-products of overcrowding and filth, contemporary environmental approaches examine the impact of production and consumption on emerging health problems. Environmental theory considers disease to be influenced by environmental and social factors. It contends that solutions should be developed through policy and regulation and focused on systems rather than on individuals and medical treatment. 00_Shi (2374) Book.indb 11 11/21/18 10:55 AM 12 Introduction to Health Policy Similarly, the US Department of Health and Human Services (HHS) publication Healthy People 2020 embraced a holistic approach by considering the range of personal, social, economic, and environmental factors that determine the health status of individuals or populations (HHS 2010). Planning is now under way for the HHS Healthy People 2030 initiative and includes establishing a framework for the initiative (including the vision, mission, foundational principles, plan of action, and overarching goals) and identifying new objectives (HHS 2018). In the first phase of the process, an expert advisory committee will develop recommendations for the HHS secretary on the framework and implementation of Healthy People 2030. Input from members of the public and relevant stakeholders will guide the development of recommendations. During the second phase, a federal interagency workgroup will use the advisory committee’s recommendations to establish objectives for Healthy People 2030 (Haskins 2017). Exhibit 1.2 delineates the evolution of the Healthy People initiatives and their respective overarching goals. Exhibit 1.3 provides an overview of health determinants—environment, individual characteristics, and medical care (discussed in greater detail in the sections that follow)—as Exhibit 1.2 Evolution of Healthy People Initiatives Target year 1990 Overarching goals • • Decrease mortality: infants to adults Increase independence among older adults 2000 • • • Increase span • of healthy life Reduce health disparities Achieve access • to preventive services for all 2010 Increase quality and years of healthy life Eliminate health disparities 2020 • • • • Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death Achieve health equity; eliminate disparities Create social and physical environments that promote good health Promote quality of life, healthy development, and healthy behaviors across life stages No. of topic areas 15 22 28 42 No. of objectives/ measures 226 312 1,000 approximately 1,200 Source: Healthy People Initiatives of 1990, 2000, 2010, and 2020 (HHS 2010). 00_Shi (2374) Book.indb 12 11/21/18 10:55 AM Chapter 1: Overview of Health Policy Exhibit 1.3 Conceptual Framework of Health Determinants Environment – Physical – Social Individual characteristics – Demographic – Behavioral – Socioeconomic 13 Health status – Physical – Mental – Social Medical care – Organizing – Financing – Delivering they interact to influence health status. For example, although individual characteristics and medical care affect health on their own, they also interact to become another type of factor influencing health. E nvironment The environment in this context is composed of the physical and social dimensions of an individual’s existence over which the individual has little or no control. These dimensions exert influence at the family, community, and policy levels of society. Environmental determinants have a greater impact on health than the medical care system does. Physical Dimension The use of energy sources (e.g., oil, coal) by a population creates certain health hazards in the physical environment. Those hazards can present themselves in the form of air, noise, or water pollution, resulting in hearing loss, infectious disease, gastroenteritis, cancer, emphysema, and bronchitis. To address the impact of climate change, WHO has launched the Climate and Health Country Profile Project (see the For Your Consideration box titled “WHO Climate and Health Country Profile Project”). 00_Shi (2374) Book.indb 13 11/21/18 10:55 AM 14 Introduction to Health Policy FOR YOUR CONSIDERATION WHO Climate and Health Country Profile Project According to WHO (2018), the Climate and Health Country Profile Project “aims to raise awareness of the health impacts of climate change, support evidence-based decision making to strengthen the climate resilience of health systems, and promote actions that improve health while reducing carbon emissions. The profiles provide country-specific estimates of current and future climate hazards and the expected burden of climate change on human health, identify opportunities for health co-benefits from climate mitigation actions, and track current policy responses at national level.” The project has been expected to track national progress on climate action in the health sector through a WHO climate and health country survey conducted every two years and designed to provide updated information on such aspects as adaptation and resilience measures, climate and health finance, disease surveillance, emergency preparedness, leadership and governance, mitigation action in the health sector, and national vulnerability and adaptation assessments (WHO 2018). The first set of Climate and Health Country Profiles was released in late 2015 and included more than 40 countries (WHO 2018). Based on the evidence presented in these profiles, WHO (2015) contended that “placing a price on polluting fuels that reflected their health impacts would be expected to cut outdoor air pollution deaths by approximately half, reduce carbon dioxide emissions by over 20 percent, and raise approximately $3 trillion per year in revenue— over half the total value of health spending by all of the world’s governments.” Collection of data for a second set of profiles was expected to be completed in late 2017, the results of which would be compiled and presented in 2019 (WHO 2018). Social Dimension The social environment is reflected in a nation’s political, economic, and cultural preferences, which exert significant influence on the health of the population. Characteristics of an environment’s social dimension include behavioral health factors and demographic trends. In the United States, for example, rates of psychological stress, homicide, suicide, and other behavioral health indicators can be attributed in part to crowding, isolation, and other social environmental factors. In terms of population trends, the increase in the number of elderly—those aged 65 years or older—as a proportion of the total population will place increasing pressure on healthcare systems around the world. I ndividual C harac teristi c s R elated to H ealth Demographic, behavioral, and socioeconomic conditions shape individual characteristics, which explain much of the variation in health status within populations. As discussed in 00_Shi (2374) Book.indb 14 11/21/18 10:55 AM Chapter 1: Overview of Health Policy 15 the following paragraphs, these factors interact with and are influenced by the environment, thereby affecting individuals’ health. Demographics Age, gender, and race or ethnicity are strongly associated with health. Advancing age, for example, contributes to arthritis, diabetes, atherosclerosis, and cancer. Gender health is influenced in part by the social construct of gender characteristics, such as the association between masculine identity and risk-taking. People also experience significant differences in health status depending on their race or ethnic origin. Explanations for these differences include SES, behaviors, social circumstances, level of access to healthcare services (CDC 2005a; Filice and Joynt 2017; Gupta et al. 2018; James et al. 2017; Shi 1999; Shi, Lee, Chung, et al. 2017; Shi, Lee, Haile, et al. 2017; Shi and Stevens 2010), and factors that are associated with particular racial or ethnic groups (CDC 2012b). Behaviors The leading causes of death in the United States have shifted since the beginning of the twentieth century. In 1900, infectious diseases such as diphtheria, tuberculosis, measles, and pneumonia caused 797 per 100,000 deaths in the United States; by the end of the twentieth century, infectious diseases caused fewer than 100 per 100,000 deaths while chronic diseases such as heart disease and cancer caused significantly higher mortality (Armstrong, Conn, and Pinner 1999). This “epidemiologic transition” supports the idea that behavioral risk factors—including poor dietary habits, cigarette smoking, alcohol abuse, lack of exercise, and unsafe driving—tend to predict higher risk for certain chronic diseases and mortality. See exhibit 1.4 for examples of the association between risk factors and leading causes of death. The level of behavioral risk factors exhibited by a population is related to SES. For example, the prevalence of smoking is greater among those with less education; in 2011, 45.3 percent of Americans who had obtained a GED (General Educational Development) certificate reported being a current cigarette smoker, compared with only 5 percent of those who held graduate degrees (CDC 2012a). Behavioral risk factors are divided into three categories: leisure activity risks, consumption risks, and employment participation and occupational risks (Dever 2006). These categories are determined in part by the collective decisions made by individuals in a particular group that affect their health. The degree of control they have in these decisions varies by category: Individuals have the least control over employment and occupational factors, more control over consumption factors, and the greatest control over leisure activity–related factors. Destructive behaviors related to employment and occupational risks are usually difficult for individuals to control. To offset such risks, the federal government created regulatory 00_Shi (2374) Book.indb 15 11/21/18 10:55 AM 16 Introduction to Health Policy Exhibit 1.4 The Association Between Health Behaviors and Leading Causes of Death Cause of death Heart disease Cancers Smoking X X High blood pressure X High cholesterol X Poor diet X Obesity X Lack of exercise X Stress X Health behavior Alcohol abuse Drug misuse Unsafe driving Diabetes Cirrhosis Homicide X X X X X X X Stroke X X X X agencies, such as the Occupational Safety and Health Administration, that require employers to maintain safe workplaces and practices. Individuals have more control over consumption than over occupation-related behaviors; however, environmental factors, such as availability of affordable, healthy foods, play a significant role in the extent of their control. Consumption risks include overeating (resulting in obesity), high cholesterol intake (heart disease), alcohol consumption (motor vehicle accidents), alcohol addiction (liver cirrhosis), cigarette smoking (chronic bronchitis and emphysema, lung cancer, aggravating heart disease), drug dependency (suicide, homicide, malnutrition, accidents, social withdrawal, acute anxiety), and excessive glucose or sugar intake (dental caries, obesity, hyperglycemia, diabetes). Unlike the risks related to employment and occupation, those that accompany leisure and consumption activities are relatively unregulated, with the exception of efforts to control the use of illegal drugs and the purchase of tobacco and alcohol products by underage youth. Leisure-related destructive behaviors include sexual promiscuity and unprotected sex (which can result in sexually transmitted diseases, including AIDS, syphilis, and gonorrhea) and limited or no exercise (which may lead to overweight and obesity and aggravate other health conditions). Socioeconomic Status The major components of SES are income, education, and occupational status. SES is a strong and consistent predictor of health status. Individuals with low SES suffer disproportionately 00_Shi (2374) Book.indb 16 11/21/18 10:55 AM Chapter 1: Overview of Health Policy 17 from most diseases and experience higher rates of mortality than those with midlevel or high-level SES. For example, after controlling for access to medical care, studies show that countries providing universal health insurance, such as England, report the same SES–health relationships as those found in the United States, which does not yet offer universal health insurance (Acheson 1998; Cormman et al. 2015). SES influences health to the extent to which individuals and populations are exposed to physical and social threats; have knowledge of health conditions; encounter adverse environmental conditions, such as pathogens and carcinogens; and are exposed to undesirable social conditions, such as crime. M edi cal C are Most items that we buy and sell are commodities—goods and services whose worth can be calculated as a monetary value, that serve a specific (rather than an intrinsic or esoteric) purpose, and that can be exchanged with other similar products (Doty 2008). Medical care differs from traditional commodities in four important ways. First, the demand for medical care is derived; that is, it stems from the demand for a more fundamental commodity—health itself. The second difference is the presence of the agency relationship. Because patients generally lack the technical knowledge to make health-related decisions, they delegate this authority to their physicians with the expectation that physicians will act for patients as patients would for themselves if they had the appropriate expertise. If physicians were to act solely in the interests of patients, the agency relationship would be virtually indistinguishable from normal consumer behavior. However, physicians’ decisions typically reflect the physicians’ self-interests as well as the interests of their patients. Those self-interests may arise from pressures imposed by professional colleagues and institutions, adherence to medical ethics, or a desire to make good use of available resources. One implication of the agency relationship is that medical care may or may not be provided, depending on the payer of services for the patient. For example, physicians who treat members of a health maintenance organization (HMO) may have an incentive to restrict the number of hospital admissions they order because HMO patients’ care is prepaid; that is, the physician will not be paid more to provide more services. Acting on this incentive means that the physician is acting as an imperfect agent. The third difference between medical care provision and the provision of other products and services is that healthcare pricing varies according to who pays the fees. Because most patients are covered by insurance, the amount paid by patients out-of-pocket at the point of care for most medical services is often significantly lower than the total payment made to the provider. The fourth difference is that medical care service provision is influenced by its environment, whereas other commodities are not. In other words, the social, economic, demographic, 00_Shi (2374) Book.indb 17 agency relationship In healthcare, delegation by the patient of some authority to make decisions and perform actions on the patient’s behalf to an expert such as a physician or other healthcare provider. health maintenance organization (HMO) A managed care organization that integrates medical care with payment and typically requires the use of a specified panel of providers. 11/21/18 10:55 AM 18 Introduction to Health Policy technological, political, and cultural contexts dictate how, when, where, and to whom healthcare services are offered, which is not true of other products and services. For example, of the forces currently reshaping the healthcare industry, the number of uninsured people (social context) is a major factor driving health insurance reform debates. P o l i c y D e f i ne d A policy is a decision made by an authority about an action—either one to be taken or one to be prohibited—to promote or limit the occurrence of a particular circumstance in a population. In the United States, the authority charged with making policy is a legislative, executive, or judicial body operating under the purview of a federal, state, or local public administration. Public policy—decision making that affects the general population or significant segments thereof—is meant to improve the conditions and general welfare of the population or subpopulations under its jurisdiction. Other countries, however, may have different mechanisms of developing policies (see the For Your Consideration box titled “Dominant Political Systems of the World”). Although public policies are intended to serve the interests of the public at large, the term public has different interpretations according to the political context in which it is applied. For example, policymakers tend to be most responsive to the views and wishes of constituents who are politically active and communicate directly with their representatives. FOR YOUR CONSIDERATION Dominant Political Systems of the World Democracy—political system that allows for each individual to participate either directly or through elected representatives (United States, Canada) Republic—political system in which the government remains mostly subject to the people, and leaders can be recalled (France, Egypt, India) Monarchy—political system in which the inherited ruler (monarch) is head of state, the constitution limits the monarch’s power, and others make laws (United Kingdom, Denmark, Kuwait, Spain, Sweden) Communism/Socialism—political system based on the ideology of communism as taught by Karl Marx, Vladimir Lenin, or Mao Zedong, often dominated by a single party or an elite group of people (China, Russia, Cuba) Dictatorship—political system in which a single person (dictator) is the main individual ruling the country, not restricted by constitutions or parliaments (Zimbabwe, Uzbekistan, North Korea) 00_Shi (2374) Book.indb 18 11/21/18 10:55 AM Chapter 1: Overview of Health Policy 19 In the private sector, authority is conferred to the executive or board of directors of an organization. Private policy—policy that affects the private organization only—is meant to improve the conditions and general welfare of the employees of that organization. Because private organizations function in the larger social (public) environment, private policies must take into account the spirit of public policies. H e a lt h P o l i c y D e f i ne d Miller (1987, 15) defined health policy as “the aggregate of principles, stated or unstated, that . . . characterize the distribution of resources, services, and political influences that impact on the health of the population.” This definition and others focus on US federal or public-level health policy and do not reflect non-US political systems nor account for the fact that private-sector policy also influences health. Therefore, in this book we define health policy as policy that pertains to or influences the attainment of health. In terms of the determinants-of-health framework, health policy refers to legislation that may influence—directly or indirectly—social and physical environments, behaviors, SES, and availability of and accessibility to medical care services. Health policies affect groups or classes of individuals, such as physicians, the poor, the elderly, and children. They can also affect types of organizations, such as medical schools, HMOs, nursing homes, medical technology producers, and employers. On the basis of this broad definition, health consequences may result from virtually all major policies, such as Social Security mandates, national defense–related guidelines, labor policies, and immigration policies. Furthermore, in the United States, each branch and level of government can influence health policy. For example, both the executive and legislative branches at the federal, state, and local levels can establish health policies, and the judicial branch at each level can uphold, strike down, or modify existing laws affecting health and healthcare. Examples of public, or government, health policy include legislative and regulatory efforts to ensure air and water quality and support for cancer research. Health policies can also be made through the private sector. Examples of private-sector health policies are the decisions made by insurance companies regarding their product lines, pricing, and marketing and by employers regarding health benefits, such as leave policies, work site health promotion, and insurance coverage. Health policy must be distinguished from healthcare policy, which refers to that part of health policy pertaining to the financing, organization, and delivery of care. Healthcare policy may cover the training of health professionals; licensing of health professionals and facilities; administration of public health insurance programs, such as Medicare and Medicaid; deployment of electronic health records; efforts to control healthcare costs; and regulation of private health insurance. Whereas the predominant goal of health policy is to improve population health, the goals of healthcare policy are typically to provide equitable and efficient access to high-quality healthcare services. 00_Shi (2374) Book.indb 19 health policy Legislation over individuals, organizations, or society whose goal is to improve health for the general population or subpopulations. healthcare policy The part of health policy specifically related to the financing, delivery, and governance of health services for the general population or subpopulations within a jurisdiction. 11/21/18 10:55 AM 20 Introduction to Health Policy FOR YOUR CONSIDERATION The United States as an Individualist Culture? T ypes of H ealth P olicy The scope of health policy is determined by the political and economic system of a country. In the United States, where pro-individual and proThe American political culture is characterized by some observmarket sentiments tend to dominate (see the For ers as being rooted in a distrust of power—particularly governYour Consideration box titled “The United States ment power—and a preference for volunteerism and self-rule in as an Individualist Culture?”), health policies are small, homogeneous groups with limited purposes. How would likely to be fragmented, incremental, and nonyou describe the political culture of average Americans? Do you comprehensive. National policies and programs agree or disagree with the characterization posed here? Provide are typically crafted to reflect the notion that local examples to support your answer. communities are in the best position to identify strategies to address their unique needs. However, the types of changes that can be enacted at the community level are clearly limited. Next, we summarize the two major types of health policies: regulatory and allocative. regulatory policies Regulations or rules that impose restrictions and are intended to control the behavior of a target group by monitoring the group and imposing sanctions if it fails to comply. distributive policies Regulations that provide Regulatory Health Policies Health policies may be used as regulatory tools that call on the government to prescribe and control the behavior of a particular target group by monitoring the group and imposing sanctions if it fails to comply. Examples of regulatory policies include prohibition of smoking in public places, licensure requirements for medical professions, and processes related to the approval of new drugs. State insurance departments across the country regulate health insurance companies in an effort to protect customers from default on coverage in the case of a company’s financial failure, excessive premiums, or deceptive practices. Private health policies can also be regulatory. For example, physicians set standards of medical practice and hospitals undergo assessments from accreditation service organizations, such as The Joint Commission, to ensure compliance with all standards. benefits or services to targeted populations or subpopulations, typically as entitlements. redistributive policies Deliberate efforts to alter the distribution of benefits by taking money or property from one group and giving it to another. 00_Shi (2374) Book.indb 20 Allocative Health Policies Allocative health policies involve the direct provision of income, services, or goods to certain groups of individuals or institutions. They can be distributive or redistributive. Distributive policies spread benefits across society. Examples include the funding of medical research through the National Institutes of Health, provision of public health and health promotion services, training of medical personnel, and construction of healthcare facilities. Redistributive policies take money or power from one group and give it to another. This approach typically creates visible beneficiaries and payers. Examples include means-tested social insurance programs such as Medicaid, which uses tax revenue from the more affluent population to provide free or low-cost health insurance to the poor, to subsidize the welfare program, 11/21/18 10:55 AM Chapter 1: Overview of Health Policy 21 and to fund public housing. It should be pointed out that Medicare and Social Security are not redistributive policies nor “entitlements” because they are supported by funds collected through deductions from the income of working people before their retirement and then distributed later to members of that same population after their retirement. W h at A r e the D e t e rm i n a n ts of H ealth P oli cy ? As noted earlier, the framework for health determinants includes four major categories: environment, health status, medical care, and individual characteristics (shown earlier in exhibit 1.3). The framework for health policy determinants is presented in exhibit 1.5. Broad determinants include the nature of the health problem, the sociocultural norms that influence the perception of the problem, and the political system within which the health policy is formulated. The inner circle of the framework shows the narrower determinants: ◆◆ Potential solutions to the identified health problem ◆◆ Views and efforts of the stakeholders ◆◆ Demonstrated leadership of the policymakers ◆◆ Available resources needed to implement the health policy This general framework may be applied to health policies at the national, state, or local level; to public and private policies; and to health policies in the United States and Exhibit 1.5 A Conceptual Framework of Health Policy Determinants Political system Leadership Health problem Solutions Resources Health policy Stakeholders Sociocultural norms 00_Shi (2374) Book.indb 21 11/21/18 10:55 AM 22 Introduction to Health Policy elsewhere. The remainder of this section describes these components in greater detail, and chapters 2 through 4 illustrate the application of this framework in various settings. B road D eterminants of H ealth P olicy Among the broad determinants of health policy are the nature of the health problem, sociocultural norms, and the political system of the country, each of which is discussed in this section. Health Problem The nature of the health problem is typically the first consideration of policy, the significance of which is determined by its magnitude and severity. Magnitude indicates the reach of the problem. If the health problem affects a large segment of the population (e.g., heart disease, diabetes), it is considered widespread. Severity denotes the extent to which the problem is urgent. See the Learning Point box titled “Infectious Disease Epidemics: Severe Acute Respiratory Syndrome and Influenza” for examples. LEARNING POINT Infectious Disease Epidemics: Severe Acute Respiratory Syndrome and Influenza Severe acute respiratory syndrome (SARS) is a serious form of viral pneumonia that can result in acute respiratory distress and, sometimes, death. It first came to the attention of Asian health officials in February 2003. In just a few months, it had spread throughout North America, South America, Europe, and Asia, affecting 8,098 individuals in more than 25 countries. Of those infected, 774 died. The 2003 SARS epidemic demonstrated how quickly an infectious respiratory disease could spread across the world and registered among the most severe health problems in the twenty-first century. Influenza (flu) is a contagious respiratory illness caused by influenza viruses, which can cause mild to severe illness. Serious outcomes of flu infection can result in hospitalization or even death. More than 130 million doses of flu vaccine were distributed in the 2017–2018 winter season. Although the impact of flu varies, it places a substantial burden on the health of people in the United States each year. The Centers for Disease Control and Prevention (CDC) estimates that influenza resulted in between 9.2 million and 35.6 million illnesses, between 140,000 and 710,000 hospitalizations, and between 12,000 and 56,000 deaths annually from 2010 to 2017. Source: CDC (2005b, 2017). 00_Shi (2374) Book.indb 22 11/21/18 10:55 AM Chapter 1: Overview of Health Policy 23 Sociocultural Norms Sociocultural norms reflect the accepted values, beliefs, attitudes, and behaviors of a society or group. These norms play a significant role in the public’s perception of the nature of a health problem, the role of the government versus individuals in addressing that problem, and the type of solution or policy implemented to manage it. For example, mental illness carries a social stigma in many cultures. Although poor mental health has long been a pervasive problem in the United States and elsewhere, relatively little public action has been taken to promote improvements in mental health status, care, and treatment. Political System Although a democratically governed country is more likely to develop health policies that reflect the public’s interests (officials are publicly elected and presumably represent the electorate’s interests), the process of policy development is typically more difficult in democratic systems than in single-rule governments, not only because the development of legislation in a democracy is arduous but also because the public’s interests are rarely coherent. In authoritarian (single-party) countries, policies can be developed more quickly but may not truly reflect the public’s interests. N arro w D eterminants of H ealth P olicy The narrow determinants of health policy include solutions, stakeholders, leadership, and resources, each of which is discussed in this section. Solutions Potential solutions to a health problem facilitate policy development. If solutions do not emerge, policymakers may direct their efforts away from full-fledged policy consideration and toward finding a solution, likely by initiating a research study. If a health problem has more than one potential solution, policy research and analysis is conducted to identify the optimal solution given the political climate, available resources, and expectations of prominent stakeholders. Stakeholders Entities or individuals who have a direct or indirect role in the development of policy are considered stakeholders. The influence of stakeholders is particularly strong in a democracy, as elected officials often cater to the interests of their constituency—either to fulfill a campaign promise or to gain reelection. Policy is more likely to be enacted when the positions of the various stakeholders converge. The next major section in this chapter describes the key stakeholders in US health policy. 00_Shi (2374) Book.indb 23 11/21/18 10:55 AM 24 Introduction to Health Policy Leadership No matter how significant the problem or how determined the stakeholders, health policy addressing a particular problem will not appear on the policy agenda without the approval of the governing body’s leader. The first case study at the beginning of this chapter demonstrates the contrasting leadership styles of President Barack Obama and former First Lady Hillary Clinton. The For Your Consideration box titled “Quotes from Selected US Presidents” reflects the leadership styles of a number of US presidents throughout the nation’s history and provides clues as to how they governed. FOR YOUR CONSIDERATION Quotes from Selected US Presidents Associate yourself with men of good quality if you esteem your own reputation; for ’tis better to be alone than in bad company. —George Washington To be good, and to do good, is all we have to do. —John Adams It is by a thorough knowledge of the whole subject that [people] are enabled to judge correctly of the past and to give a proper direction to the future. —James Monroe If your actions inspire others to dream more, learn more, do more, and become more, you are a leader. —John Quincy Adams Any man worth his salt will stick up for what he believes right, but it takes a slightly better man to acknowledge instantly and without reservation that he is in error. —Andrew Jackson While men inhabiting different parts of this vast continent cannot be expected to hold the same opinions, they can unite in a common objective and sustain common principles. —Franklin Pierce The test of leadership is not to put greatness into humanity, but to elicit it, for the greatness is already there. —James Buchanan I don’t like that man. I must get to know him better. —Abraham Lincoln 00_Shi (2374) Book.indb 24 11/21/18 10:55 AM Chapter 1: Overview of Health Policy 25 FOR YOUR CONSIDERATION Quotes from Selected US Presidents (continued) If you always support the correct principles then you will never get the wrong results! —Andrew Johnson The object of love is to serve, not to win. —Woodrow Wilson [People] are not prisoners of fate, but only prisoners of their own minds. —Franklin D. Roosevelt It is amazing what you can accomplish if you do not care who gets the credit. —Harry S. Truman Efforts and courage are not enough without purpose and direction. —John F. Kennedy A leadership is someone who brings people together. —George W. Bush Change will not come if we wait for some other person or some other time. We are the ones we’ve been waiting for. We are the change that we seek. —Barack Obama Resources Not even the most effective policy can be implemented without the available financial and administrative resources. Financial feasibility tests are conducted during the policy development process to ensure that adequate funds are available and to verify that the benefits will outweigh the costs. Administrative feasibility studies examine how policy can be translated into programs and carried out under an existing or new infrastructure. S ta k e h ol d e rs of H e a lt h P olic y As shown in the framework of health policy determinants (exhibit 1.5), stakeholders frequently exert a powerful influence on health policy development. Indeed, as shown in later chapters, stakeholders influence not only the formulation of health policy but also its implementation and modification. 00_Shi (2374) Book.indb 25 11/21/18 10:55 AM 26 Introduction to Health Policy One type of stakeholder is the interest group. Interest groups are composed of individuals or entities that at least nominally present a unified position on their preferences regarding a A collective of particular health problem or its solution. Lobbying by organized interest groups is a common individuals or entities that hold a common component of the political process in a democracy. Because stakeholders often differ in their posiset of preferences on tions and preferences, and coalition building is usually specific to an issue, interest groups are not a particular health always static, and their formations typically depend on the particular health problem under policy issue and often seek to consideration. The following paragraphs introduce the major stakeholders in US health policy. influence policymaking Consumers and patients. Consumers and patients are typically the intended benefior public opinion. ciaries of health policy, because they suffer the consequences of a health problem that could be the target of health policy. However, consumers have diverse health problems, and yet lobbying the prioritization of those problems is not always determined by consumers. Furthermore, Activities seeking to consumers with the same health problem may have diverse interests and different cultural influence an individual norms. Consumers’ views may also be influenced by their own economic status, such as or organization with whether they currently have health insurance coverage. For example, those without insurance decision-making are more likely to favor a government program or reform that expands insurance coverage. authority. Those with insurance coverage are more concerned with lowering the premiums or copayments for their insurance coverage. The more their interests converge and the more organized they become as a collective, the more likely consumers are to influence policy development. Healthcare providers. Healthcare providers—individuals who provide direct patient care— include physicians, nurses, dentists, pharmacists, and other health professionals. Traditionally, healthcare providers value autonomy and have an interest in preserving the prestige and expertise associated with their careers. The size and diversity of the US healthcare workforce often result in a less-than-unified voice in the healthcare provider community—for example, between physicians and nonphysicians, primary care doctors and specialists, and public health and medical care. Healthcare organizations. Healthcare organizations are the institutional settings in which healthcare providers work or provide care to patients. Traditional settings include hospitals FOR YOUR CONSIDERATION (inpatient and outpatient) and community-based Interests Common to Healthcare Administrators offices. Organizational settings now also include diagnostic imaging centers, occupational health centers, and psychiatric outpatient centers, among Healthcare administrators are responsible for overseeing a health others. Administrators of these institutions may facility or department. According to the Health Careers Center (2004), they “plan, coordinate, and supervise” all activities in their share an interest, for example, in serving their cusarea, including the work of staff members. Healthcare administomers and maintaining the financial well-being of trators also take responsibility for developing and implementtheir institutions at the same time (see the For Your ing standards, operating procedures, and organizational policies Consideration box titled “Interests Common to that help the facility operate at peak efficiency, and they can be Healthcare Administrators”). However, like healthinvolved in developing and expanding programs in new areas, such care providers, different healthcare institutions have as medical research and preventive care. different priorities and interests, often tied to consumers, services, and payments. interest group 00_Shi (2374) Book.indb 26 11/21/18 10:55 AM Chapter 1: Overview of Health Policy Payers and insurers. Payers and insurers can be private (commercial or other private enterprise) or public (government-operated entity). Private insurance is offered by commercial insurance companies (e.g., Aetna, Prudential); Blue Cross/Blue Shield; self-insured employers; and managed care organizations (MCOs), such as an HMO or a preferred provider organization (PPO). Public insurance includes federally funded programs such as Medicare, which provides insurance for the elderly and certain individuals with disabilities; Medicaid, for the indigent; TRICARE, for US Department of Defense active military service personnel and their families; and Veterans Affairs programs, for former armed forces personnel. One interest that private insurance companies and MCOs have in common is maintaining their share of the health insurance market; in contrast, a main interest of public payers is ensuring coverage for vulnerable populations at reasonable costs. Regulators. In addition to providing public insurance for the elderly and indigent, the government functions as a regulator, seeking to make sure that basic services are provided, their quality is maintained by the providers, and the overall cost of providing care in the community or sector is contained. Medical device and pharmaceutical manufacturers. Manufacturers of medical equipment and drugs have a vested interest in health policy, especially with regard to payments for the use of their products. With the rapid advancement of science and technology, numerous devices and types of equipment have been developed for medical use, such as fetal monitors, computerized electrocardiograph machines, and magnetic resonance imaging machines. Such equipment is useful in the diagnosis of diseases but is expensive. Educational and research institutions. Health policy affects the type and quantity of healthcare providers to be trained, making educational institutions another significant stakeholder. Similarly, research facilities are affected by health policy that directs the types of research to be conducted. Businesses and corporations. American businesses and corporations have a keen interest in health policy that, among other issues, mandates healthcare coverage levels. These stakeholders seek to minimize the cost they incur for providing health insurance as a benefit to their employees. W h y I s I t I mpo rta n t to 27 preferred provider organization (PPO) A managed care organization that offers unrestricted provider options to enrollees and discounted fee arrangements to providers. Medicare Federal government insurance plan for persons aged 65 years or older, individuals with disabilities who are entitled to Social Security benefits, and people who have endstage renal (kidney) disease. Medicaid Jointly administered federal and state insurance plan for the indigent. S t udy H ealth P oli cy ? Understanding how health policy is developed is the first step toward influencing policy. And only by knowing the health policy determinants and how they manifest in particular contexts can one appreciate the key features of policy development (see the For Your Consideration box titled “Why Is an International Perspective of Health Policy Useful?”). In addition, the study of health policy allows an individual or a group the ability to engage in efforts to improve it. For example, policy entrepreneurs—those who work from outside the government to introduce and implement innovative ideas into public-sector practice—are instrumental in bringing new ideas and fundamentally changing the usual way of practice. 00_Shi (2374) Book.indb 27 11/21/18 10:55 AM 28 Introduction to Health Policy FOR YOUR CONSIDERATION Why Is an International Perspective of Health Policy Useful? Countries vary in their demographics, population health needs, and social norms, but they share commonalities, such as population aging and leading causes of death. Learning from the best practices of other countries—compared with a country developing its own evidence-based approaches—can significantly shorten the time in which the country improves healthcare delivery. Incorporating global trends in health policymaking may also help exert influence on global health policy (Jones, Clavier, and Potvin 2017). Just as the US experience and lessons can benefit other countries as they consider healthcare delivery reform, so, too, can the United States learn from the experiences of other countries in expanding its health policy options. One result of this convergence of international health policies is the increase in similarity of global trends. Industrialized countries need not limit their examination to other developed countries; the experiences of developing countries can also be instructive (Dixon and Alakeson 2010; Modisenyane, Hendricks, and Fineberg 2017). Such countries tend to focus on basic and community-oriented public health and primary care, which may prove instructive for developed countries as they struggle to control costs and improve outcomes. Furthermore, the importance of health policy itself is another reason to study it. As shown in the framework of health determinants (exhibit 1.3), policy is an integral component of environmental health determinants. Improvements to policy development, such as ensuring that a policy truly addresses a critical health problem and that it is developed in an expeditious manner, can significantly improve a population’s overall health. In addition, policy influences other determinants of health and therefore must be thoroughly understood to enhance the country’s health system. Key Points ➤➤ Health determinants, such as environment and social structure, interact with biological factors and medical care to determine an individual’s health status. ➤➤ Health policy formulation is influenced by broad determinants (health problems, sociocultural norms, and political system) and narrow determinants (solutions, stakeholders, leadership, and resources). ➤➤ The major stakeholders in US health policy include consumers and patients, healthcare providers, healthcare organizations, payers and insurers, regulators, medical device and pharmaceutical manufacturers, educational and research institutions, and businesses and corporations. 00_Shi (2374) Book.indb 28 11/21/18 10:55 AM Chapter 1: Overview of Health Policy ➤➤ 29 US health policy has evolved over time and will continue to change in response to new health concerns and interests. Case Study Questions C ase S tudy 1 After researching the events surrounding the healthcare reform initiatives undertaken by the Clinton, Obama, and Trump administrations, answer the following questions: 1. What factors might explain why the Obama plan succeeded? What events may have caused the Clinton plan and Trump’s initial attempts to fail? 2. How do you think the failure of the Clinton healthcare reform effort influenced the outcome of the congressional election that followed? 3. Why does health reform continue to be controversial despite widespread opinion in favor of change? C ase S tudy 2 After researching the current developments in healthcare reform, answer the following questions: 1. What are the similarities and differences in the…