HLTH 556 Health Condition of Physical Mental & Social Well Being Discussion

An Interdisciplinary Approach
THIRD EDITION
Curtis P. McLaughlin, DBA
Professor Emeritus
Kenan-Flagler Business School and School of Public Health
University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
Craig D. McLaughlin, MJ
Health Policy Speaker and Consultant
Berkeley, California
World Headquarters
Jones & Bartlett Learning
5 Wall Street
Burlington, MA 01803
978-443-5000
[email protected]
www.jblearning.com
Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact
Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com.
Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations,
professional associations, and other qualified organizations. For details and specific discount information,
contact the special sales department at Jones & Bartlett Learning via the above contact information or send
an email to [email protected].
Copyright ? 2019 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form,
electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system,
without written permission from the copyright owner.
The content, statements, views, and opinions herein are the sole expression of the respective authors and
not that of Jones & Bartlett Learning, LLC. Reference herein to any specific commercial product, process, or
service by trade name, trademark, manufacturer, or otherwise does not constitute or imply its endorsement or
recommendation by Jones & Bartlett Learning, LLC and such reference shall not be used for advertising or product
endorsement purposes. All trademarks displayed are the trademarks of the parties noted herein. Health Policy
Analysis: An Interdisciplinary Approach, Third Edition is an independent publication and has not been authorized,
sponsored, or otherwise approved by the owners of the trademarks or service marks referenced in this product.
There may be images in this book that feature models; these models do not necessarily endorse, represent, or
participate in the activities represented in the images. Any screenshots in this product are for educational and
instructive purposes only. Any individuals and scenarios featured in the case studies throughout this product may
be real or fictitious, but are used for instructional purposes only.
This publication is designed to provide accurate and authoritative information in regard to the Subject Matter
covered. It is sold with the understanding that the publisher is not engaged in rendering legal, accounting, or other
professional service. If legal advice or other expert assistance is required, the service of a competent professional
person should be sought.
Production Credits
VP, Product Management: David D. Cella
Director of Product Management: Michael Brown
Product Specialist: Danielle Bessette
Production Manager: Carolyn Rogers Pershouse
Vendor Manager: Molly Hogue
Senior Marketing Manager:
Sophie Fleck Teague
Manufacturing and Inventory
Control Supervisor: Amy Bacus
Composition: codeMantra U.S. LLC
Project Management: codeMantra U.S. LLC
Cover Design: Kristin E. Parker
Rights & Media Specialist: Merideth Tumasz
Media Development Editor: Shannon Sheehan
Cover Image (Title Page, Part Opener, Chapter
Opener): ? uschools/Getty Images
Printing and Binding: Edwards Brothers Malloy
Cover Printing: Edwards Brothers Malloy
Library of Congress Cataloging-in-Publication Data
Names: McLaughlin, Curtis P., author. | McLaughlin, Craig, author.
Title: Health policy analysis: an interdisciplinary approach / Curtis P. McLaughlin,
Craig D. McLaughlin.
Description: Third edition. | Burlington, Massachusetts: Jones & Bartlett Learning, [2019] |
Includes bibliographical references and index.
Identifiers: LCCN 2018000271 | ISBN 9781284120240 (pbk.: alk. paper)
Subjects: | MESH: Health Policy | Health Planning | United States
Classification: LCC RA395.A3 | NLM WA 540 AA1 | DDC 362.1?dc23
LC record available at https://lccn.loc.gov/2018000271
6048
Printed in the United States of America
22 21 20 19 18
10 9 8 7 6 5 4 3 2 1
In memory of Barbara Nettles-Carlson,
RN, FNP, MPH?wife, mother, stepmother,
trailblazer, educator, and
dedicated health professional.
? uschools/Getty Images
Contents
Preface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Acknowledgments. . . . . . . . . . . . . . . . . . . . xi
About the Authors . . . . . . . . . . . . . . . . . . . xii
PART I The Context
1
Chapter 3 American
Exceptionalism?
Historical and
Political. . . . . . . . . . . . 28
A Chronology . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
The Current ?Era? Emerges. . . . . . . . . . . . . . . . 36
Chapter 1 Introduction. . . . . . . . . 3
Employers Want Out: Backing
Consumer-Driven Health Care. . . . . . . . . 39
The Many Actors. . . . . . . . . . . . . . . . . . . . . . . . . . . 3
The Law of the Land: The ACA
(Temporarily?) . . . . . . . . . . . . . . . . . . . . . . . . 40
Health Care: What Is It? . . . . . . . . . . . . . . . . . . . . 5
Health Policy: What Is It?. . . . . . . . . . . . . . . . . . . 7
The Policy Analysis Process . . . . . . . . . . . . . . . . 7
Professionals and the Policy
Process. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
National Systems Differ but
Parallels Exist. . . . . . . . . . . . . . . . . . . . . . . . . . 10
Key Policy Categories. . . . . . . . . . . . . . . . . . . . 11
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Case 3: International Comparisons:
Where Else Might We Go?. . . . . . . . . . . . . 44
Discussion Questions. . . . . . . . . . . . . . . . . . . . 51
Chapter 4 Where Do We Want
to Be? . . . . . . . . . . . . . . 53
Overarching Medico-Social Issues. . . . . . . . 11
Where Are We? . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Impact of Societal Values on
Policy Decisions. . . . . . . . . . . . . . . . . . . . . . . 14
Alignment with the Rest of Society . . . . . . 56
What Do Governments Want? . . . . . . . . . . . 60
Politicization of Science and Limiting
Role of Expertise. . . . . . . . . . . . . . . . . . . . . . 15
Where in the World?. . . . . . . . . . . . . . . . . . . . . 64
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Case 4: National Standards on
Culturally and Linguistically
Appropriate Services in Health and
Health Care (CLAS). . . . . . . . . . . . . . . . . . . . 65
Chapter 2 American
Exceptionalism?
Structural and
Conceptual. . . . . . . . . . 16
Key Structural Issues. . . . . . . . . . . . . . . . . . . . . 17
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Discussion Questions. . . . . . . . . . . . . . . . . . . . 66
Chapter 5 Representative
Policy Options . . . . . . . 68
Key Conceptual Issues. . . . . . . . . . . . . . . . . . . 19
Access to Care. . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Industrialization and
Corporate Lite . . . . . . . . . . . . . . . . . . . . . . . . 25
Quality of Care. . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Costs of Health . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Enhance Patient Experience . . . . . . . . . . . . . 80
v
vi
Contents
Relationships with the External
Environment. . . . . . . . . . . . . . . . . . . . . . . . . . 92
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Case 5: Global Medical Coverage. . . . . . . . . 94
Chapter 8 The Policy Analysis
Process: EvidenceBased Medicine. . . . . 132
Discussion Questions. . . . . . . . . . . . . . . . . . . . 96
Reducing Variation and Saving
Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
PART II The Policy
Analysis Process
Crosscurrents Involved. . . . . . . . . . . . . . . . . . 134
99
Chapter 6 The Policy
Analysis Process:
Identification and
Definition. . . . . . . . . . 101
Early Sources of Misunderstanding. . . . . . 102
Getting the Scenario Right. . . . . . . . . . . . . . 102
Hidden Assumptions. . . . . . . . . . . . . . . . . . . 107
Where in the World?. . . . . . . . . . . . . . . . . . . . 110
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Case 6: Small Area Variations. . . . . . . . . . . . 111
Discussion Questions. . . . . . . . . . . . . . . . . . . 112
Chapter 7 The Policy Analysis
Process: Health
Technology
Assessment . . . . . . . . 113
Terminology. . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Technological Forecasting. . . . . . . . . . . . . . 114
Levels of Technological Forecasting. . . . . 115
Forecasting Methods. . . . . . . . . . . . . . . . . . . 119
Organizations Devoted to
Healthcare Technology
Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . 123
Where in the World?. . . . . . . . . . . . . . . . . . . . 124
The Process of Evidence-Based
Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Constraints on Variables Used in
Analysis of Evidence . . . . . . . . . . . . . . . . . 140
The Example of NICE. . . . . . . . . . . . . . . . . . . . 140
Decision Aids. . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Determining Value. . . . . . . . . . . . . . . . . . . . . . 143
Where in the World?. . . . . . . . . . . . . . . . . . . . 146
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Case 8: Comparative Effectiveness:
Avastin Versus Lucentis. . . . . . . . . . . . . . .146
Discussion Questions. . . . . . . . . . . . . . . . . . . 150
Chapter 9 The Policy Analysis
Process: Evaluation
of Political
Feasibility. . . . . . . . . . 151
Terminology. . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Overview. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Authorizing Environments. . . . . . . . . . . . . . 153
Key Government Actors . . . . . . . . . . . . . . . . 155
Political Inputs. . . . . . . . . . . . . . . . . . . . . . . . . . 161
Nongovernmental Actors. . . . . . . . . . . . . . . 164
Methods for Analyzing Political
Feasibility. . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Critiques of Political Feasibility
Analysis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Where in the World?. . . . . . . . . . . . . . . . . . . . 175
Case 7: Oregon?s Health Evidence
Review Commission. . . . . . . . . . . . . . . . . 125
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175
Case 9: Green Mountain Care . . . . . . . . . . . 176
Discussion Questions. . . . . . . . . . . . . . . . . . . 131
Discussion Questions. . . . . . . . . . . . . . . . . . . 179
Contents
vii
Chapter 10 The Policy Analysis
Process?
Evaluation of
Economic Viability . . . 180
Influence on Society: A Broader
Question. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Defining the Healthcare Process
Involved. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180
Scenarios. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 226
Selecting the Analytical Approach. . . . . . 183
Where in the World?. . . . . . . . . . . . . . . . . . . . 229
Basic Tools. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 184
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 229
Agreeing on the Resources
Required. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189
Case 11: The Folic Acid Fortification
Decision: Before and After. . . . . . . . . . . . 231
Determining Relevant Costs. . . . . . . . . . . . 190
Discussion Questions. . . . . . . . . . . . . . . . . . . 240
Valuing the Outcomes Produced. . . . . . . . 192
Dealing with Important
Uncertainties . . . . . . . . . . . . . . . . . . . . . . . . 199
Financial Feasibility. . . . . . . . . . . . . . . . . . . . . 201
Identifying Financing Methods. . . . . . . . . .202
Considering Distributional Effects. . . . . . . 202
Where in the World?. . . . . . . . . . . . . . . . . . . . 204
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
Case 10: Increasing the Federal
Cigarette Excise Tax. . . . . . . . . . . . . . . . . . 205
Discussion Questions. . . . . . . . . . . . . . . . . . . 210
Chapter 11 The Policy Analysis
Process: Analysis
of Values and
Social Context . . . . . 211
Double Checking for Interacting
Policies and Contextual Change. . . . . . 223
Trade-Offs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225
Working Out Your Own Scenarios . . . . . . 226
Chapter 12 Implementation
Strategy and
Planning. . . . . . . . . . 241
Levels of Implementation Failure. . . . . . . . 241
Implementation Planning. . . . . . . . . . . . . . .242
Setting Up to Succeed. . . . . . . . . . . . . . . . . . 247
That All-Important Start. . . . . . . . . . . . . . . . . 250
Providing for Periodic Reviews. . . . . . . . . . 250
Implementing Policies That Affect
Clinical Operations. . . . . . . . . . . . . . . . . . . 251
The Postmortem. . . . . . . . . . . . . . . . . . . . . . . . 251
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Case 12 : The Troubled Launch of
HealthCare.gov . . . . . . . . . . . . . . . . . . . . . . 253
Discussion Questions. . . . . . . . . . . . . . . . . . . 259
Equitable Access. . . . . . . . . . . . . . . . . . . . . . . . 212
Efficiency and Value . . . . . . . . . . . . . . . . . . . . 212
Patient Privacy and Confidentiality. . . . . . 213
Informed Consent. . . . . . . . . . . . . . . . . . . . . . 213
Personal Responsibility . . . . . . . . . . . . . . . . . 215
PART III The Professional
261
as Participant
Consumer Sovereignty . . . . . . . . . . . . . . . . . 216
Chapter 13 Health Professional
Leadership. . . . . . . . . . 263
Social Welfare. . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Disinterestedness. . . . . . . . . . . . . . . . . . . . . . . 263
Rationing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218
Informational Credibility. . . . . . . . . . . . . . . . 263
Process Equity. . . . . . . . . . . . . . . . . . . . . . . . . . 222
To Influence Globally, Start Locally . . . . . . 264
Professional Ethics. . . . . . . . . . . . . . . . . . . . . . 215
viii
Contents
Process Innovation . . . . . . . . . . . . . . . . . . . . . 265
Health Policy Analysis: A Relevant
School for Leadership. . . . . . . . . . . . . . . . 265
Governance. . . . . . . . . . . . . . . . . . . . . . . . . . . . 266
Communities. . . . . . . . . . . . . . . . . . . . . . . . . . . 266
Enhancing the Professional?s Role. . . . . . . 266
Where in the World?. . . . . . . . . . . . . . . . . . . . 268
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
Case 13: The Data Sharing Proposal. . . . . 269
Discussion Questions. . . . . . . . . . . . . . . . . . . 275
Chapter 14 Conclusion: All
Those Levers and
Still No Fulcrum. . . . 276
Where to Stand. . . . . . . . . . . . . . . . . . . . . . . . . 276
The Physician?s Dilemma. . . . . . . . . . . . . . . . 278
The ERISA Problem . . . . . . . . . . . . . . . . . . . . . 279
Many ACA Provisions Stay in Place, But
Uncertainty Continues. . . . . . . . . . . . . . . 279
Why Not an Unraveling?. . . . . . . . . . . . . . . . 280
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
References. . . . . . . . . . . . . . . . . . . . . . . . . 283
Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 299
Preface
??
? uschools/Getty Images
The Policy Analysis Process and Health
Professionals
T
his text is about the process of developing health policy relevant to the United
States. We have included the perspectives of a number of disciplines and professions. Because our country has many actors but no coherent, integrated,
systematic health policy at the federal level, even after the passage of the Patient
Protection and Affordable Care Act (ACA), we have drawn heavily on our personal
experiences and backgrounds, which include economics, political science, management, communications, and public health. We have also drawn on the experiences
of other countries. Although the federal government has taken on a greater role with
the passage of the ACA, states and even smaller jurisdictions will continue to play a
major role in health planning. Values, economics, and health risks may vary among
them, which suggests a need for independence in planning and execution. Canada?s
experience with a broad policy and specific health systems for each province has
seemed to work as well, or better than, a centralized bureaucracy might have. Even
the health services of a number of European countries have tended toward more
decentralization as time has passed.
This text is organized into three parts: ?The Context,? ?The Policy Analysis
Process,? and ?The Professional as a Participant.? We have anticipated that this text
will be used to review health system issues and policy planning for health in a variety
of graduate professional programs. We have not assumed zero knowledge of the
U.S. health system, but we have not anticipated that the reader will have a great
deal of background about how and why the U.S. health system developed as it did,
nor about the efforts that took place in the past to reform it. Therefore, Part I, ?The
Context,? explores current issues with the system (Chapters 1 and 2) and the history
of how that system has evolved (Chapter 3). Chapter 4 challenges readers to ask
about where we want to be, and Chapter 5 reviews policy alternatives that seem to
have strong support for getting from where we are to where we might want to be.
Some of these are reflected in the ACA, while others are not. These chapters do not
purport to be ?value free,? but this text is different from most books on health policy
because it does not attempt to push a single solution set. Studying the present is
important for research and understanding, but the educational purpose of this text,
and presumably of any course in which it is assigned, is to prepare students to meet
whatever new, and perhaps unforeseen, challenges that develop in the future.
Part II, ?The Policy Analysis Process,? develops a set of tools for future use.
Chapter 6 deals with identification and definition of the issues to be studied.
Chapter 7 introduces some of the concepts of technology assessment applicable
ix
x
Preface
to health care. Chapter 8 adds more concepts of technology assessment related to
evidence-based clinical innovation and management. Chapter 9 reviews the political processes that influence planning in various settings, especially the public-sector
health arena. Chapter 10 presents the accepted methods of economic and financial analysis that determine the economic viability of healthcare plans. Chapter 11
addresses the ethical and other value considerations that must enter into the health
policy process. In our deeply divided country, value issues are important. They crop
up in just about every context and influence the outcome of most analyses. We have
put this chapter after the other three process chapters to try to offset the tendency
of many less sophisticated students to start with the qualitative and never get to the
rewarding, but demanding, work of including the quantitative. Part II ends with
Chapter 12, which focuses on implementation. Policies and plans must take into
account the capacities of organizations and societies to implement them. At the
same time, how the policy-making process proceeds becomes a part of the context
within which the implementation will take place. Yes, there is a problem of circularity here, but that is real life.
Part III, ?The Professional as Participant,? deals with the roles, skills, and leadership that health professionals can bring to the policy-making process in their local
and national communities. It also acknowledges that one has to act out of a personal
set of values and point of view, while at the same time preserving one?s flexibility to
make incremental progress if that is all that can be achieved. Chapter 13 suggests
that there are important roles for healthcare professionals in the change process. It
also discusses the skills that health professionals need to acquire if they are going to
be accepted into the process and work effectively on its tasks, either from the inside
or the outside. Chapter 14 provides summary material and concluding material for
the text.
Acknowledgments
? uschools/Getty Images
Curtis McLaughlin would like to recognize a number of individuals who helped
steer him in the direction of health policy and administration and supported him
to continue in it for more than 40 years. They include Roy Penchansky and the late
John Dunlop while at Harvard, and Sagar Jain, Arnold Kaluzny, and the late Maurice
Lee at University of North Carolina at Chapel Hill.
Craig McLaughlin would like to extend his appreciation to the members and
staff of the Washington State Board of Health during his tenure there, as well as the
many other talented leaders in state and local public health in Washington State for
their tutelage. In particular, he would like to recognize the board?s former executive
director, Don Sloma, and the former board chairs?Linda Lake, Dr. Thomas Locke,
Dr. Kim Marie Thorburn, and Treuman Katz?for their patient mentoring.
xi
About the Authors
? uschools/Getty Images
Curtis P. McLaughlin, DBA, is professor emeritus at the Kenan-Flagler Business
School of the University of North Carolina at Chapel Hill and Senior Research
?Fellow Emeritus at the Cecil B. Sheps Center for Health Services Research. He was
also professor of Health Policy and Administration in the School of Public Health.
Prior to coming to North Carolina, he was assistant professor at the Harvard Business School and also taught in the Harvard School of Public Health. He is the ?author
or coauthor of several hundred publications, including the first three editions of
Continuous Quality Improvement in Health Care with A. D. Kaluzny and Implementing Continuous Quality Improvement in Health Care: A Global Casebook with
J.K. J? ohnson and W.A. Sollecito for Jones & Bartlett Learning.
Mr. McLaughlin received his BA with honors in chemistry from Wesleyan
?University and his MBA with distinction and his DBA from Harvard Business School.
While there, he studied and then taught in the Harvard interdisciplinary program in
healthcare economics and management. At the Business School in Chapel Hill, he
developed management programs for health professionals and directed the Operations Management Area and the Doctoral Program. He has served as a consultant to
the World Health Organization and a number of businesses and organizations.
Craig D. McLaughlin, MJ, retired as the executive director of the Washington State
Board of Health, a position he held when he coauthored the first edition of this text.
He joined the board as senior health policy manager in 2001 and served as executive
director from 2004 through 2011. Immediately prior, he served as director of college relations and adjunct faculty for The Evergreen State College. As a newspaper
editor and freelance journalist for more than a decade, Mr. McLaughlin wrote and
edited articles on a broad range of health issues. He has served as a communications
consultant to foundations and as a management consultant to media organizations.
He continues to serve as a public health policy consultant as well as a freelance journalist and motivational speaker.
Mr. McLaughlin earned his BA in biology from Wesleyan University and his
masters in journalism from the University of California at Berkeley. He also completed all coursework toward an MPA with a concentration in health administration
at the University of New Mexico.
xii
PART I
The Context
The Policy Analysis
Process and Health
Professionals
The
Context
Health
Professions
and
Professionals
? uschools/Getty Images
Policy
Analysis
Although this book is designed to be valuable to anyone engaged in
health policy development, its primary purpose is to enable current
and future health professionals to understand and then participate
in the health policy process. The figure above shows policy analysis
and the work of the health professions taking place within the context
of the healthcare system. The first section of this book develops that
context. It begins with an explanation of what health policy analysts
think about and do (Chapter 1). This is followed by a discussion of the
current status of the U.S. healthcare system (Chapter 2) and a review of
factors that influenced its development as the decentralized system we
have today (Chapter 3). The case accompanying Chapter 3 provides a
chance to look at the experiences of other countries and develop some
hypotheses about how these countries achieved their current status.
Chapter 4 reviews the many and varied objectives for the U.S. healthcare system being expressed by various policy participants. Chapter 5
presents many of the policy choices being suggested. One educational
outcome you should try to achieve is to understand these positions,
their underlying assumptions, and their strengths and weaknesses.
These chapters provide both the context and vocabulary for
moving on to the second part of this book, which outlines available
tools for rational policy analysis?one of the circles within a circle
in the diagram. The third part of this book looks at the role of the
health professions and professionals and, in particular, how they can
and should participate in policy analysis.
1
? uschools/Getty Images
CHAPTER 1
Introduction
P
resident after president has pushed for an overhaul to our healthcare system and remedies for its access problems. Only Lyndon Johnson and Barack
Obama shepherded through dramatic changes. Attempts by Truman, Eisenhower, Nixon, and Clinton were less successful. In the more recent past, the rapid
growth of healthcare costs has expanded the policy debate. So has growing recognition of medical errors and other quality problems. In the meantime, policy makers
struggle with a highly fragmented system and a divided body politic. At the same
time, the rest of the developed world has advanced, used, and institutionalized
increasingly sophisticated approaches to policy analysis. Such efforts have supported these countries in doing a better job delivering quality care at less cost.
More recently, the United States has faced continuous near-miss attempts to
replace the Affordable Care Act (ACA), as well as tax proposals, executive orders,
and administrative policy revisions that undermined the act. Uncertainty has dominated the industry and added to costs. This ongoing debate centered on contending definitions of affordability, adequate coverage, consumer choice, and acceptable
wealth transfer mechanisms.
??
The Many Actors
Policy decisions are made at multiple levels of U.S. society:
??
??
??
??
??
??
??
National government
State and local governments
Healthcare institutions
Provider professionals
Payer organizations (employers and insurers)
Employers (meeting the mandate)
Individuals (consumers)
BOX 1-2 through BOX 1-7 distributed throughout this chapter provide samples of
health policy questions faced in each of these domains. Like most tables and lists in
this text, they are meant to be illustrative, not exhaustive.
In such a decentralized environment, government may take a hands-on
approach, treating health care as a public good, as it does transportation and education, or a hands-off approach, favoring market-driven outcomes. Therefore,
3
4
Chapter 1 Introduction
government?s stance and specific policies may swing dramatically as political power
shifts. For example, during the 2016 presidential campaign, one side vowed to repeal
the ACA if it gained complete control of the political process, undoing a major
accomplishment of the Obama administration. Wide swings in public attitudes are
not unknown. The 1988 Medicare Catastrophic Coverage Act had a favorable rating
with the public when passed, but was repealed in November 1989 as the public, especially the wealthier elderly, learned more about how they would have to pay for it.
This chapter describes what healthcare policy is, how the policy analysis
process works, and the different roles health professionals can play in setting and
implementing health policy over time. The role of a policy analyst is described quite
completely in the excerpt from the U.S. Office of Personnel Management Operating
Manual displayed in BOX 1-1.
BOX 1-1 Excerpts from the Office of Personnel Management Qualification
Standards for General Schedule Positions?Policy Analysis Positions
??
??
??
??
??
??
??
??
??
??
Knowledge of a pertinent professional subject-matter field(s). Typically there is a
direct, even critical, relationship between the possession of subject-matter expertise
and successful performance of analytical assignments.
Knowledge of economic theories including micro-economics and the effect of
proposed policies on production costs and prices, wages, resource allocations, or
consumer behavior; and/or macro-economics and the effect of proposed policies
on income and employment, investment, interest rates, and price level.
Knowledge of public policy issues related to a subject-matter field.
Knowledge of the executive/legislative decision-making process.
Knowledge of pertinent research and analytical methodology and ability to apply
such techniques to policy issues, such as:
?? Qualitative techniques, such as performing extensive inquiry into a wide
variety of significant issues, problems, or proposals; determining data sources
and relevance of findings and synthesizing information; evaluating tentative
study findings and drawing logical conclusions; and identifying omissions,
questionable assumptions, or inadequate data in the analytical work of others.
?? Quantitative methods, such as cost benefit analysis, design of computer
simulation models and statistical analysis including survey methods and
regression analysis.
Knowledge of the programs or organizations and activities to assess the political
and institutional environment in which decisions are made and implemented.
Skill in dealing with decision makers and their immediate staffs. Skill in interacting
with other specialists and experts in the same or related fields.
Ability to exercise judgment in all phases of analysis, ranging from sorting out the
most important problems when dealing with voluminous amounts of information
to ensure that the many facets of a policy issue are explored, to sifting evidence
and developing feasible options or alternative proposals and anticipating policy
consequences.
Skill in effectively communicating highly complex technical material or highly complex
issues that may have controversial findings, or both, using language appropriate to
specialists and/or nonspecialists, facilitating the formulation of a decision.
Skill in written communication to organize ideas and present findings in a logical
manner with supporting, as well as adverse, criteria for specific issues, and to
prepare material complicated by short deadlines and limited information.
Health Care: What Is It?
??
??
5
Skill in effective oral communication techniques to explain, justify, or discuss a
variety of public issues requiring a logical presentation of appropriate facts and
information or analysis.
Ability to work effectively under the pressure of tight time frames and rigid deadlines.
Reproduced from www.opm.gov/policy-data-oversight/classification-qualifications/general-schedule-qualification-standards
/specialty-areas/policy-analysis-positions/; accessed 10/13/17. For more detail see Section IV-A (pp. 33-34) of the Operational
Manual for Qualification Standards for General Schedule Positions.
BOX 1-2 Illustrative Health Policy Issues at the U.S. Federal Level
??
??
??
??
??
??
??
??
??
How should otherwise healthy people be motivated to participate in health
i