What is Health Policy?

1. What is Health Policy? HSA 6152 Spring 2007 Robert G. Frank

2. What is Policy Analysis? • Multi-element process of assess and analyzing components of a plan of action • Not an exact science, more of an art • Reviews the component parts of an issue or problems • Considers new options.

3. What is Policy Analysis? • Multi-element process of assess and analyzing components of a plan of action • Not an exact science, more of an art • Reviews the component parts of an issue or problems • Considers new options.

4. Policy Analysis • New discipline • Dates to early 1960s • Policy analysis should • Improve decision making • Consideration of broad sets of alternatives • Use of more systematic tools

5. Policy Analysis • Neutral analysts • Consider all options • Advocates for best options serving “national interest”

6. 1970s Amendments to the Legislative Reorganization Act • “Congressional declaration of analytic independence from the administrative branch” • Created CBO, CRS, and OTA

7. Evolution of Policy Analysis • Clients not only decision makers • Individuals stewarding institutional governance • Planning • Budgeting • Regulation

8. Office of Assistant Secretary for Planning and Evaluation (ASPE) • ASPE • Principal policy advisor to the secretary • Policy coordination, legislation development, strategic planning, policy research and evaluation and economic analysis

9. Office of Assistant Secretary for Planning and Evaluation (ASPE) • Use of office has varied with Administrations • Staff vary, initially Ph.D. economists…many from DoD • Over time staff has varied • Staff now serves entire department • Also, other units have policy analysts, so ASPE is only one voice to Secretary

10. Office of Assistant Secretary for Planning and Evaluation (ASPE) Early methodology and analytic techniques relied on economic models Evolution to reliance upon policy expertise of office vs. policy analysis

11. Needed skills for ASPE • Program knowledge • Statistics • Microeconomics • Cost-benefit analysis

12. Congressional Research ServiceCRS • Part of the Library of Congress • Most recent incarnation dates to 1970 Legislative Reorganization Act • Act allowed CRS to triple staff • Now @ 700 individuals • New staff teamed with experienced individuals

13. CRS • What is the legislative hook? • High volume, quick turnaround • “a reference factory” • Emphasis on legislative consultation, interdisciplinary work, & anticipatory work

14. CRS • Provision of background papers to the committee • Assistance in design of congressional hearings • Suggestions of witnesses for hearings • Possible questions for Members to ask witnesses • Attend hearings to supplement questions

15. CRS • Consultation at mark-ups • Hearing testimony • Consultation on the floor as requested • Prepare conference agendas • Consultation at conferences

16. CRS • Most important role may be participation in creation of new legislation • Work not available to the public • Unless released by a Member

17. CRS • Varied products • Electronic briefing books • Background reports on topics • CRS staff also interacts with Members and staff

18. CRS • In-house capacity • Modeling • Create microsimulation models • Fiscal analyses • Culture emphasizes qualitative approaches and oral tradition

19. Think Tanks • Originally, U.S. • Now world-wide • Have blended policy outside of political environment • Established by interest groups • Interest groups can adapt models developed by official sources

20. Heritage Foundation • Founded in 1973 • Formulate and promote conservative policies based on principles of free enterprise, limited government, individual freedom, traditional Americans values and strong national defense • Seeks to differentiate itself from other conservative think tanks by focusing on influencing decisions very early in the process

21. Heritage Foundation • Established in 1973 with 9 staff • 1997 staff of 180 • Added research staff in 1980 • Funding from individual sponsors

22. Heritage Foundation • Has pushed boundary of tax exempt organizations • Replaced the Kennedy School orienting new conservative congressman • Focus on Congress --- members and staff

24. Health Policy • Peters (1999) • Pubic policy • “sum of government activities, whether acting directly or through agents as it has influence on the life of citizens” • Birkland (2001) • “ a statement by government of what it intends to do or not do, such as laws regulation, ruling, decision, or order as a combination of these”

25. Health Policy • Cochran and Malone (1995) • “policitical decisions for implementing programs to achieve societal goals • Longest 2002 • “authoritative decisions made in the legislative, executive, or judicial branches of government that are intended to direct or influence the actions, behaviors, or decisions of others.

26. Health Policy • Authoritative • refers to decisions made in any part of government • all three branches

27. Policy and Health • When public policies or authoritative decisions refer to health it is health policy • Includes federal, state, and local government • Health policy affects classes of citizens • physicians, providers, consumers, the poor, the elderly

28. Health Policy • Laws • Rules • Regulations • Judicial Decisions

29. Health Policy • In the US: Consists of many decisions, rather than one large decision • Other countries have integrated, coordinated health systems (Great Britain, Canada)

30. Health Policy • PL 89-97 1965 law establishing Medicare • Executive order establishing federally funded health centers • Court ruling that an integrated delivery system’s acquisition of another hospital violates federal anti-trust • County health department’s procedure for inspecting restaurants • City government’s ordinance banning smoking in public places

31. Laws • Laws enacted at any level of government create policies • Laws passed at federal and state levels • federal laws: 1983 Amendments to the Social Security Act (P.L. 98-21) • state laws govern professional practice

32. Health Policy and Markets • Capitalist countries such as the USA assume • markets are critical to production • consumption of health services

33. Health Policy Interventions • intervention needed when markets fail • party models have differing tolerance for market imperfection

34. Conditions for the Market • True markets require: • buyers and sellers have adequate information to make informed decisions • large numbers of buyers and sellers • easy entry to the market • competitive products that can replace each other • adequate quantity of products

35. Health Policy Categories • Allocative Policies • provide net benefits to some at the expense of others • subsidies for medical education • rural hospital support • Medicare and Medicaid

36. Health Policy Categories • Regulatory Policies • policies designed to influence actions, behaviors, and decisions of others • market-entry restrictions • rate or price setting controls • quality controls • market preserving controls • social controls

37. Health Policy Categories • Regulatory Policies • market entry, rate controls, quality controls, market preserving controls are all economic regulation • social controls seek socially desired outcomes: smoke free workplace, nondiscriminatory hiring practices

38. Market-Entry Restrictions • State licensing laws • Planning programs • CON

39. Price Setting • Out of vogue • Electric and gas utility control • PPS

40. Quality • Food safety and quality standards • Medical Devices Amendments (P.L. 94-295) to the Food, Drug and Cosmetic Act (P.L. 75-717) • placed medical devices under FDA

41. Market Preserving • Health markets are not true markets; this class of regulatory action addresses market imperfections • Sherman Anti-trust laws

42. State Health Policy • Dynamic balance between state and federal policy • Recent ascendance of state policy • failed national reform in 1994-1995 • Medicaid growth

43. State Health Policy Roles • Lipson (1997) • financing or paying for several categories of people • public health • regulating health professions licensing and practice.

44. State Health Policy Roles • Financing • Medicaid • about 15% of most state budgets • State employee health benefits (large group when you consider teachers, employees, etc) • uninsured

45. State Health Policy Roles • Public Health • oldest most fundamental state health responsibility • States granted constitutional authority to establish laws to protect public’s health and welfare • engages states in environmental protection • Federal government delegates to states responsibility for monitoring the environment • monitoring workplace and food safety

46. State Health Policy Roles • Professional Regulation • license various professionals • write practice acts • license and monitor compliance

47. State Health Policy Roles • States regulate the content, pricing and marketing of insurance plans • Under the McCarran-Ferguson Act (P.L. 79-15)

48. ERISA 1974 • ERISA preempts state’s regulation of pensions and self-insured plans • COBRA 1985 – allows employees to purchase health coverage for 18 months post employment • 1996 HIPPA (P.L. 104-191) • allows employees guaranteed access to health coverage • company must provide benefits • premiums can be renewed assuming payment

49. ERISA • Enacted to remedy fraud mismanagement in private-sector employer pension plans • Includes broad preemptive language providing for federal law to supercede all state law • “relate to employee benefit plans sponsored by private-sector employers or unions

50. ERISA • ERISA has exemptions to preemptions • Self-insured plans cannot be regulated • Insured plans can be regulated by states • ERISA has led to 25 years of court interpretations • Courts have noted ERISA is “conspicuous in its breadth”