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CHAPTER 1
OVERVIEW OF HEALTH POLICY
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.
Case Study 1
Healthcare Reform: Hillary Clinton and Barack Obama
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.
Case Study 2
Healthcare Reform After 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.
At 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.
Health Defined
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, 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.
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.
Physical Health
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.
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)
Mental Health
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.
Social Well-Being
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 wellbeing, 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.
Public Health Defined
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 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."
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Excerpted from "Introduction to Health Policy"
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Copyright © 2019 Foundation of the American College of Healthcare Executives.
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