The Real World of Health Policy

Governor Establishes Office of Health Care Reform COMMONWEALTH OF PENNSYLVANIA GOVERNOR'S OFFICE EXECUTIVE ORDER Commonwealth's Health Care Reform Agenda WHEREAS, the citizens of the Commonwealth are entitled to an accessible and affordable health care system of the highest quality and WHEREAS, the Commonwealth agencies responsible for administering and delivering health care services have over time been delegated overlapping responsibilities and WHEREAS, due to redundant responsibilities, the...

The Budget Reconciliation Process

From time to time, Congress has chosen to make use of a special procedure outlined in the Congressional Budget Act known as reconciliation.2 This procedure was originally designed to facilitate the passage of deficit-reduction legislation and was created because procedural points of order could not compel Congress to pass spending cuts or tax increases called for in the budget resolution. While the reconciliation process was intended as a deficit-reduction mechanism, it has been used twice...

Health Policy and Health Determinants

As was discussed briefly in Chapter 1, health policies affect health through their effects on health determinants. These effects and the impact of health policies on individuals, organizations, and interest groups are explored in more detail in this chapter. It is important to understand the effects of health policies both on health determinants and, ultimately, on individuals, organizations and systems, and interest groups to fully appreciate the important role health policy plays in the...

Info

P.L. 85-544, Grants-in-Aid to Schools of Public Health, established a program of formula grants to the nation's schools of public health. P.L. 85-929, the Food Additive Amendment, amended the Food, Drug, and Cosmetic Act (see the 1938 P.L. 75-717) to require premarketing clearance from FDA for new food additives. The so-called Delaney clause, after Representative James Delaney, who sponsored the provision, stated that no additive shall be deemed to be safe ifit is found to induce cancer when...

Health Policy in Recent State of the Union Addresses by George W Bush

January 28,2003 State of the Union Following his opening remarks, the President noted, Our first goal is clear We must have an economy that grows fast enough to employ every man and woman who seeks a job. (Applause.) This goal was briefly discussed, then the president moved to the second goal as follows. Our second goal is high quality, affordable healthcare for all Americans. (Applause.) The American system of medicine is a model of skill and innovation, with a pace of discovery that is adding...

From Formulation to Implementation

Congress or a state legislature, approves proposed legislation, and the chief executive, whether the president or a governor, then signs it, the policymaking process crosses an important threshold. The point at which proposed legislation is formally enacted into law is the point of transition from policy formulation to policy implementation. As shown in Figure 6.1, the formal enactment of legislation serves to bridge the formulation and implementation phases...

House or Senate Floor Action on Proposed Legislation

Following approval of a bill by the full committee with jurisdiction, the bill is discharged from the committee along with its bill report. The House or the Senate, depending on where the bill is being considered, receives it from the relevant committee and places it on the legislative calendar for floor action. Bills can be further amended in debate on the floor of the House or the Senate. However, because such great reliance is placed on the committee process in both chambers, amendments to...

Problems

The breadth of this initiating variable in agenda setting can be seen in the range ofpossible public policies that have the potential to affect the pursuit of health. Chapters 1 and 2 discussed health as a function of several determinants the physical environments in which people live and work their behaviors and biology social factors and the type, quality, and timing ofhealth services that they receive. Beyond these determinants, as shown overarching Figure 5.1, the preferences ofindividuals,...

List Of Web Sites

Agency for Healthcare Research and Quality Alliance of Independent Academic Medical Centers American Academy of Family Physicians American Association of Homes and Services for the Aging American Association of Retired Persons American College of Healthcare Executives American Medical Women's Association Americans for Nonsmokers' Rights Foundation Association of American Medical Colleges Association of University Programs in Health Administration Biotechnology Industry Organization Blue Cross...

Acknowledgments

I wish to acknowledge the contributions made by several people to this revised book and to thank them for their help. Denise Warfield provided secretarial support. Linda Kalcevic provided superb editorial assistance throughout the revision. Mark Nordenberg, Arthur Levine, Bernard Goldstein, and Judith Lave provided a professional environment conducive to and supportive of scholarship. I thank Janet Davis, Amanda Karvelaitis, and Joyce Sherman at Health Administration Press for their...

Summary

The implementation phase of the policymaking process includes rulemaking in support ofimplementation, which is the focus ofthis chapter, as well as the actual operation of policies, which is the focus of Chapter 8. Rulemaking is a necessary part of policymaking because enacted laws seldom contain enough explicit and directive language concerning the steps necessary to guide their implementation adequately. Implementing organizations routinely promulgate rules to help guide the operation of...

Data Summary

The Medicare program covers 95 percent of our nation's aged population, as well as many people who are on Social Security because of disability. In 2003, Part A covered about 41 million enrollees with benefit payments of 152.1 billion, and Part B covered about 38 million enrollees with benefit payments of 123.8 billion. Administrative costs for both Parts A and B were under 2 percent of disbursements in 2003. Total disbursements for Medicare in 2003 were 280.8 billion. SOURCE Reprinted from a...

Budget Revisions

According to the Michigan Constitution, no appropriation is a mandate to spend. The Governor, by Executive Order and with the approval of the appropriations committees, can reduce expenditures whenever it appears that actual revenues for a fiscal period will fall below the revenue estimates on which the appropriations for that period are based. By statute, any recommendation for the reduction of expenditures must be approved or disapproved by both of the Appropriations Committees within ten...

Subcommittee on Social Security

The Subcommittee intends to hold hearings to examine the degree to which Social Security programs are meeting the needs of today's and tomorrow's beneficiaries, along with the financial challenges facing the program and proposals to strengthen Social Security. Use of the Social Security Number. The Subcommittee will continue their examination of the integrity of Social Security numbers (SSNs) and Social Security cards as identifiers, including their role in...

Use of this illustration is restricted

One aspect of the courts' role that most complicates policy modification arises from the fact that the court system in the United States is highly decentralized. Although court autonomy is an important element in the ability of courts to play their roles in the American system of government, one consequence of this autonomy is the possibility of inconsistency in the treatment of policy-relevant issues. As has been noted, The structure of the judicial system has made it difficult for the courts...

Closing the Books

The fiscal year runs from October 1 to September 30 of the following year. The following January, the State Budget Office releases its initial estimates of the actual year-end balances in the General Fund and School Aid Fund. These estimates are contained in a report referred to as the Preliminary Book Closing Report. Final book closing occurs in March. The State Budget Office releases the final accounting for the previous fiscal year revenues, expenditures, and year-end balances. These data...

Subcommittee on Human Resources

Reauthorizing the Temporary Assistance for Needy Families (TANF) and related programs to amend and improve the 1996 welfare reform law continues to be a priority for the Subcommittee. Issues of particular interest to the Subcommittee include how TANF block grant funds and other HHS efforts to communicate with the public are used to develop strong families and encourage healthy marriage and how welfare reform policies can be strengthened to better promote increased work, reduced...

The Federal Budget Process

The way in which Congress develops tax and spending legislation is guided by a set of specific procedures laid out in the Congressional Budget Act of 1974. The centerpiece of the Budget Act is the requirement that Congress each year develop a budget resolution setting overarching limits on spending and on tax cuts. These limits apply to legislation developed by individual congressional committees as well as to any amendments offered to such legislation on the House or Senate floor. The...

Step Two The Congressional Budget Resolution

After receivingthe President's budget request, Congress generally holds hearings to question Administration officials about the budget and then develops its own budget resolution. This work is done by the House and Senate Budget Committees, whose sole function is to draft the budget resolution. Once the committees are done, their budget resolution goes to the House and Senate floor, where it can be amended (by a majority vote).1 It then goes to a House-Senate conference to resolve any...

Committee and Subcommittee Operations

Depending on whether the chairperson of a committee has assigned a bill to a subcommittee, either the full committee or the subcommittee can, if it chooses, hold hearings on bills. At these public hearings, members of the executive branch, representatives ofhealth-related organizations and interest groups, and other individuals are permitted to present their views and recommendations on the legislation under consideration. The Real World of Health Policy Testimony on the Anabolic Steroid...

Amount and Duration of Medicaid Services

Within broad Federal guidelines and certain limitations, States determine the amount and duration of services offered under their Medicaid programs. States may limit, for example, the number of days of hospital care or the number of physician visits covered. Two restrictions apply (1) limits must result in a sufficient level of services to reasonably achieve the purpose of the benefits and (2) limits on benefits may not discriminate among beneficiaries based on medical diagnosis or condition....

Detailed Contents

List of Acronyms and List of Web Preface 1 Health and Health Health Health Policy Defined Forms of Health Policies Categories of Health The Connection Between Health Policy and Health 24 Health Policy in the The Role and Importance of Policy Competency in the Pursuit of Discussion 2 Impact of Health Policy 33 Health Policy and Health Health Policy and Individuals, Organizations, and Interest Groups 54 Discussion 3 Context and Process of Health Policymaking 75 The Context of Health Policymaking...

Possible Solutions to the High Cost of Health Care

Consumer-driven healthcare, the major private-sector strategy for addressing rising costs, is unlikely to address the fundamental causes of rising healthcare costs. In fact, it is likely to have adverse consequences for patients. Consumer-driven healthcare contributes to excessive financial burdens on patients, particularly lower-income and sicker patients. If all Americans had a 1,000 deductible plan, one-third would spend more than 10 percent oftheir income on healthcare if they were...

Categories of Health Policies

In capitalist economies, such as that of the United States, the presumption is that private markets best determine the production and consumption of goods and services, including health services. In such economies, government generally intrudes with policies only when private markets fail to achieve desired public objectives. The most credible arguments for policy intervention in the nation's domestic activities begin with the identification of situations in which markets are not functioning...

Administration on Aging

The Older Americans Act of 1965 (P.L. 89-73) (OAA) created AoA as the agency with primary responsibility to implement the law. In addition, OAA authorized grants to states for community planning and services programs, as well as for research, demonstrations, and training projects in the field of aging. Subsequent amendments to OAA added grants to area agencies on aging for local needs identification, planning, and funding ofservices, including but not limited to nutrition programs in the...

Scope of Medicaid Services

Title XIX of the Social Security Act allows considerable flexibility within the States' Medicaid plans. However, some Federal requirements are mandatory if Federal matching funds are to be received. A State's Medicaid program must offer medical assistance for certain basic services to most categorically needy populations. These services generally include the following Inpatient hospital services. Outpatient hospital services. Nursing facility services for persons aged 21 or older. Family...

Influencing Public Policy Environments

Leaders of health-related organizations and interest groups typically develop strong operational commitments to devising ways to exert influence in their public policy environments. There is nothing innately wrong with a leader establishing an operational objective of being influential in the entity's public policy environment. However, it almost goes without saying that activities directed to this objective can easily be tainted by overzealous attempts to influence the policymaking process for...

Full Committee

The full Committee intends to hold hearings to examine proposals to reform Federal taxation. Fiscal Year 2006 and 2007 Budget Initiatives Regarding Taxes. The full Committee intends to hold hearings to receive information regarding tax legislation proposed in the President's 2006 and 2007 budgets. Strengthening Social Security. The full Committee intends to hold hearings to examine various issues affecting the well-being of individual recipients, the financial challenges facing...

Legislative Action

By custom, all the appropriation bills are introduced in both houses of the Legislature and are divided between the houses for consideration. The bills usually receive more detailed hearings in the house of origin. Generally, all the appropriation bills are introduced by each appropriations committee chair or the ranking member of the Governor's party. Traditionally, only half of the bills are considered in each house initially. Currently, the practice is to alternate the house of origin each...

References

The Politics of Health Legislation An Economic Perspective, 2nd ed., rev. Chicago Health Administration Press. Iglehart, J. K. 1992. The American Health Care System Medicare. New England Journal of Medicine 327 (20) 1467-72. Medicare Learning Network. 2005. The Federal Rulemaking Process. Online information retrieved2 21 05. http www.cms.hhs.gov medlearn qrgrule .asp . Moon, M. 1993. Medicare Now and in the Future. Washington, DC Urban Institute. Nadel, M. 1995....

Development of the Governors Executive Budget

The development of each new fiscal year budget begins in August approximately thirteen to fourteen months prior to the beginning of the new fiscal year. The process starts with the State Budget Office issuing program policy guidelines to the departments. The guidelines and directions include assumptions regarding revenue changes, federal funds information, and economic adjustments. The guidelines also include instructions for the preparation of different levels of expenditures for each...

The Impact of a Policys Design or Construction on Its Own Operation

As with any writing intended to influence the actions, behaviors, or decisions of others (e.g., legal contracts, procedure manuals), the language and construction of a policy especially a policy in the form of a public law play a crucial role in the course and success of its operationalization. The impact of the design of a public law can be felt both in the rulemaking associated with its 269 implementation and in its operation. The design or construction of a policy includes its goals and...

Overview Of Medicare

Title XVIII of the Social Security Act, designated Health Insurance for the Aged and Disabled, is commonly known as Medicare. As part of the Social Security Amendments of 1965, the Medicare legislation established a health insurance program for aged persons to complement the retirement, survivors, and disability insurance benefits under Title II of the Social Security Act. When first implemented in 1966, Medicare covered most persons age 65 or over. In 1973, the following groups also became...

Coverage

Part A is generally provided automatically, and free of premiums, to persons age 65 or over who are eligible for Social Security or Railroad Retirement benefits, whether they have claimed these monthly cash benefits or not. Also, workers and their spouses with a sufficient period of Medicare-only coverage in Federal, State, or local government employment are eligible beginning at age 65. Similarly, individuals who have been entitled to Social Security or Railroad Retirement disability benefits...

Program Financing Beneficiary Liabilities and Provider Payments

All financial operations for Medicare are handled through two trust funds, one for HI (Part A) and one for SMI (Parts B and D). These trust funds, which are special accounts in the U.S. Treasury, are credited with all receipts and charged with all expenditures for benefits and administrative costs. The trust funds cannot be used for any other purpose. Assets not needed for the payment of costs are invested in special Treasury securities. The following sections describe Medicare's financing...

Health Policies and Human Behavior and Biology

As Rene Dubos (1959, 110) observed decades ago, To ward off disease or recover health, men as well as women and children as a rule find it easier to depend on the healers than to attempt the more difficult task of living wisely. The price of this attitude is partially reflected in the causes of death in the United States. Ranked from highest to lowest by the Centers for Disease Control and Prevention (CDC 2005), the ten leading causes are heart disease, cancer, stroke, chronic lower respiratory...

Health Policies and the Physical Environment

When people are exposed to harmful agents such as asbestos, dioxin, excessive noise, ionizing radiation, or toxic chemical and biological agents, their health is directly affected. Dangerous exposure possibilities pervade the physical environments of many people. Some of the exposure is through such agents as synthetic compounds that are introduced into the environment as by-products of technological growth and development. Some exposure is through wastes that result from the manufacture, use,...

Proposed Rule

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Medicare Program Medicare Prescription Drug Benefit AGENCY Centers for Medicare & Medicaid Services (CMS), HHS. ACTION Proposed rule. SUMMARY This proposed rule would implement the new Medicare Prescription Drug Benefit. This new voluntary prescription drug benefit program was enacted into law on December 8, 2003, in section 101 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003...

Health And Health Policy

Health and its pursuit are tightly interwoven into the social and economic fabric of all industrialized nations. Health plays a direct and important role not only in the physical and mental well-being of people but in nations' economies as well. The United States is expected to spend more than 2 trillion in pursuit of health in 2006, representing 16 percent of the nation's gross domestic product (GDP), and to spend about 3.6 trillion, or 18.7 percent of GDP, by 2014 (Heffler et al. 2005). Thus,...

Analyzing Public Policy Environments

Implicit in policy competency of the leaders of organizations or groups is the capability to accurately analyze the public policy environment of their entity. Such analyses include understanding the strategic consequences of events and forces in an entity's public policy environment. Policy-competent leaders are able to assess the impacts, both in terms ofopportunities and threats, ofpublic policies on their domains and, because they can do this in advance of the impact, are able to position...

Contents In Brief

List of Acronyms and List of Web Preface 1 Health and Health 2 Impact of Health Policy 33 3 Context and Process of Health Policymaking 75 4 Policy Competency 125 5 Policy Formulation Agenda Setting 161 6 Policy Formulation Development of Legislation 203 7 Policy Implementation 8 Policy Implementation Appendix A Overview of Medicare 355 Appendix B Overview of Medicaid 367 Appendix C Briefly Annotated Chronological List of Selected U.S. Federal Laws Pertaining to About the

Perspectives on the Medicare Program

Medicare has from its inception been the focus of contentious infighting among policymakers, including legislators responsible for laws pertaining to the Medicare program, and executive branch members, including staff at CMS, which is responsible for implementing the program (Longest 2003). Constant and sometimes intense pressure from groups with vested interests in the program especially advocates for the program's beneficiaries and for hospitals and physicians fuel the policy battles over the...

Inside a Congressional Committee

For 208 years, the Committee on Energy and Commerce, the oldest legislative standing committee in the U.S. House of Representatives, has served as the principal guide for the House in matters relating to the promotion of commerce and to the public's health and marketplace interests. In performing this historic function, the Committee has developed what is arguably the broadest (non-tax-oriented) jurisdiction of any Congressional committee. Today, it maintains principal responsibility for...

Health Policy and Health Related Organizations

The existence and accomplishments of many organizations are affected by health policies. Certainly, the missions, objectives, and internal structures and resources, including the quality of their leadership, greatly influence the accomplishments of these organizations. However, the performance levels achieved by these organizations whether measured in terms of contribution to health outcomes for customers, financial strength, reputation, growth, competitive position, scope of services provided,...

Legislation Development for State Budgets

The states also develop budget legislation, although the process varies considerably from state to state. In all states, however, the budget is among the most if not the most important mechanisms for establishing policy priorities. Pennsylvania uses a process that includes three key steps (IssuesPA 2005) * The Governor is clearly in control of the first phase of building a budget. Preparing for the next year's budget begins in the Governor's Office a full year in advance. The Governor...

Testimony on the Anabolic Steroid Control Act of 2004

Chairman of the Board, United States Anti-Doping Agency Before the House Subcommittee on Crime, Terrorism and Homeland Security of Legislative Hearing on H.R. 3866, the Anabolic Steroid Control Act of 2004. Mr. Chairman, members of the committee, good morning. My name is Dr. Ralph Hale. Thank you for the opportunity to testify regarding this important health issue. Today, I am here as the Chairman of the Board of Directors of the United States Anti-Doping Agency. I am also a physician who has...

Services Funded By the OAA

There are six core services funded by the OAA including Supportive services, which enable communities to provide rides to medical appointments, and grocery and drug stores. Supportive services provide handyman, chore and personal care services so that older persons can stay in their homes. These services extend to community services such as adult day care and information and assistance as well. Nutrition services, which include more than a meal. Since its creation, the Older Americans Act...

Introducing and Referring Proposed Legislation to Committees

Members of the Senate or the House of Representatives who have chosen to sponsor or cosponsor legislation introduce their proposals in the form of bills. On occasion, identical bills are introduced in both the Senate and the House for simultaneous consideration. When bills are introduced in either chamber of Congress, they are assigned a sequential number (e.g., H.R. 1, H.R. 2, H.R. 3, etc. S. 1, S. 2, S. 3, etc.) based on the order of introduction by the presiding officer, and are referred to...

The Human Element in Analyzing and Influencing Public Policy Environments

A significant challenge even for those with a high level ofpolicy competency in successfully analyzing or influencing public policy environments lies in the fact that these environments are largely controlled by humans. The diverse preferences, objectives, priorities, levels of understanding of issues, and other foibles of the people in an entity's public policy environment make accurate analysis or successful influence difficult. The widely divergent positions ofpol-icymakers in regard to...

Rules and Regulations

Another form of policies is the rules and regulations (the terms are used interchangeably in the policy context) established to guide the implementation of laws. Because such rules are authoritative decisions made in the executive branch of government by the organizations and agencies responsible for implementing laws, they fit the definition of public policies. The rules associated with the implementation of complex laws routinely fill hundreds and sometimes thousands ofpages. Rulemaking, the...

Basis of Eligibility and Maintenance Assistance Status

Medicaid does not provide medical assistance for all poor persons. Under the broadest provisions of the Federal statute, Medicaid does not provide healthcare services even for very poor persons unless they are in one of the groups designated below. Low income is only one test for Medicaid eligibility for those within these groups their resources also are tested against threshold levels (as determined by each State within Federal guidelines). States generally have broad discretion in determining...

Medicare Claims Processing

Medicare's Part A and Part B fee-for-service claims are processed by nongovernment organizations or agencies that contract to serve as the fiscal agent between providers and the Federal Government. These claims processors are known as intermediaries and carriers. They apply the Medicare coverage rules to determine the appropriateness of claims. Medicare intermediaries process Part A claims for institutional services, including inpatient hospital claims, SNFs, HHAs, and hospice services. They...

Health Policies and Health Services

Another important determinant of health is the availability of and access to health services, which are any of a host of specific activities undertaken to maintain or improve health or to prevent decrements of health (Longest, Rakich, and Darr 2000, 5). Health services can be preventive (e.g., behavior modification, blood pressure screening, mammography) acute (e.g., surgical procedures, antibiotics to fight infection) chronic (e.g., control of diabetes or hypertension) restorative (e.g.,...

Map Can Sharpen Focus

The model of the policymaking process shown in Figure 3.2 can serve as a map to direct influencing efforts where they can be most useful. Depending on the circumstances of a particular situation, the proper focus may be one or more of the various component phases, or stages within them, of the policymaking process as shown in Figure 4.1. By defining and documenting problems developing and evaluating solutions shaping political circumstances through lobbying and the courts At Legislation...

Policymaking Is a Cyclical Process

Careful consideration of the modification phase of policymaking is fundamentally important to understanding the process as a continual cycle of interrelated activity. Efforts to modify existing policies are routinely triggered when their consequences are negative. This is clearly seen in The Real World of Health Policy AMVETS Seek Higher Funding for VA, for example. In situations where the consequences of existing policies are positive for individuals, organizations, or groups, they may well...

The Nature of the Health Policy Agenda

The confluence of problems and potential solutions and political circumstances that surround them invariably shapes a health policy agenda. This agenda, however, is extraordinarily dynamic, changing literally on a day-today basis. In addition, the nation's health policy agenda does not exist in a vacuum. Instead, it coexists with policy agendas in other domains such as defense, welfare, education, and homeland securuity. This is further complicated by the fact that in a pluralistic society...

Notes In Health Policy

The Library of Congress maintains a web site (thomas.loc.gov), on which extensive information on federal legislation is provided. This is an excellent source of additional information on public laws that pertain to health. Information about public laws can also be accessed through www.firstgov.gov, the official United States government web site, or through www.access.gpo.gov, a site maintained by the Government Printing Office. 2. Reflecting the convention adopted by Congress, acts began to be...

How Are the Terms of the Budget Resolution Enforced

The main enforcement mechanism that prevents Congress from passing legislation that is not in keeping with the budget resolution is the ability of a single member of the House or the Senate to raise a point of order on the floor to block such legislation. In recent years, this point of order has not been particularly important in the House because it can be waived there by a simple majority vote on a resolution developed by the leadership-appointed Rules Committee, which sets the conditions...

Reducing Medical Errors

Between 44,000 and 98,000 Americans die each year in U.S. hospitals due to preventable medical errors, making hospital errors between the fifth and eighth leading cause of death, killing more Americans than breast cancer, traffic accidents or AIDS. Serious medication errors occur in the cases of five to 10 percent of patients admitted to hospitals. These numbers may understate the problem because they do not include preventable deaths due to medical treatments outside of hospitals. Public...

Final Rule

DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Parts 400, 403, 411, 417, and 423 Medicare Program Medicare Prescription Drug Benefit AGENCY Centers for Medicare & Medicaid Services (CMS), HHS. ACTION Final rule. SUMMARY This final rule implements the provisions of the Social Security Act (the Act) establishing and regulating the Medicare Prescription Drug Benefit. The new voluntary prescription drug benefit program was enacted into law on December...

Judicial Decisions

Judicial decisions are another form ofpolicies. An example is the U.S. Supreme Court's ruling in 2000 (by a 5-4 vote) that the FDA cannot regulate tobacco. Another example is the Supreme Court's decision on January 10,2005, not to hear an appeal filed by six health insurers in a bid to stop a class-action lawsuit brought by more than 600,000 doctors who claim the companies underpaid them for treating patients. This decision allowed a lower court's ruling to stand, meaning that a class-action...

Legislation Development for the Federal Budget

Because enactment of legislation related to the federal government's annual budget is so crucial to the performance of government and to the well-being ofthe American people, special procedures have been developed to guide this process. The Congressional Budget and Impoundment Control Act of 1974 (P.L. 93-344) and its subsequent amendments provide Congress with the process through which it establishes target levels for revenues, expenditures, and the overall deficit for the coming fiscal year....

Modification Through the Cyclical Relationship Between Rulemaking and Operation

An important aspect of policy modification within the implementation phase of the process is represented by the feedback loop in Figure 9.1 between rulemaking and operation. As discussed in Chapters 7 and 8, there is a cyclical relationship between rulemaking and the operational activities involved with a public law's implementation. Although rulemaking precedes operation in the sequence of these activities, the experiences gained in operations feed back into rulemaking. This cyclical...

Policy Goals and Objectives

Well-written laws always include clearly articulated goals and objectives that the law is intended to achieve, although clear goals and objectives are only part of the makeup of a good policy. When those with implementation responsibility know what the law is really intended to accomplish what its goals and objectives are it is easier to operate the programs and procedures embedded within it. In contrast, when the goals and objectives of a policy are not clear or when they are multiple or...

Health Policies and Social Factors

In addition to their physical environments, behaviors, and genetics, a number of social factors, many of them interconnected, play roles in the health of people. Chronic unemployment, the absence of a supportive family structure, poverty, homelessness, and discrimination, among other social factors, affect the health of people as surely, and often as dramatically, as harmful viruses or carcinogens. People who live in poverty experience measurably worse health status more frequent and more...

Presidential Action on Proposed Legislation

The president has several options regarding proposed legislation that has been approved by both the House and the Senate. The bill can be signed, in which case it immediately becomes law. The president can veto the bill, in which case it must be returned to Congress along with an explanation of the basis for rejection. A two-thirds vote in both houses of the Congress can override a presidential veto. The president's third option is neither to veto the bill nor to sign it. In this case, the bill...

Health Determinants

Both for individuals and for a population of individuals, health determinants include the physical environments in which people live and work their behaviors their biology genetic makeup, family history, and physical and mental health problems acquired during life a host of social factors that include economic circumstances, socioeconomic position, and income distribution discrimination based on factors such as race ethnicity, gender, or sexual orientation and on the availability of social...

Discussion Questions

Discuss the formulation phase of policymaking in general terms. 2. Discuss agenda setting as the confluence of three streams of activities. Include the concept of a window of opportunity for legislation development in your answer. 3. Describe the nature of problems that drive policy formulation. 5. Discuss the role of research in health policy agenda setting. 5. Contrast decision making in the public and private sectors as it relates to selecting from among alternative solutions to problems....

Conference Committees

Ifthe Senate does not accept the House's position orthe House does not agree to the Senate's position , one ofthe chambers may propose creation of a conference committee to negotiate and resolve the matters in disagreement between the two chambers. Typically, the Senate gets to conference with the House by adopting this standard motion Mr. President, I move that the Senate insist on its amendments or disagree to the House amendments to the Senate-passed measure , request a conference with the...

The Influential Role of Chief Executives in Agenda Setting

A second especially influential participant in setting the policy agenda, including that for policy in the health domain, is the chief executive the president, governor, or mayor. In cases where these individuals enjoy popularity, they can easily play preeminent roles in agenda setting. Kingdon 1995 attributes the influential role in agenda setting of presidents and his point also applies to other chief executives to certain institutional resources inherent in the executive office. Political...

Organization Design to Support Policy Competency

One of the important responsibilities of senior-level managers is to establish the intentional patterns of relationships among human and other resources within their domains of responsibility. These patterns of relationships are called organization designs. Specifically, the patterns of relationships among human and other resources established by managers are formal organization designs. This distinction is important coexisting within formal organization designs are informal structures that...

Operational Decisions

When organizations or agencies in the executive branch of a government, regardless of level, implement laws, they invariably must make many operational decisions as implementation proceeds. These decisions, which are different from the formal rules that also influence implementation, are policies as well. For example, in implementing the Water Quality Improvement Act P.L. 91-224 , the several federal agencies with implementation responsibilities establish operational protocols and procedures...

Forms of Health Policies

Health policies, which were defined earlier as authoritative decisions, take one of several basic forms. Some policies are the decisions made by legislators that are codified in the statutory language of specific pieces of enacted legislation. These are laws. Other policies are the rules and regulations established to implement laws or to operate government and its various programs. Still others are the judicial branch's decisions related to health. Examples of health policies include the 1965...

Conceptual Model of the Public Policymaking Process

The most useful way to conceptualize a process as complex and intricate as the one through which public policies are made is through a schematic model of the process. Although such models, like the one presented here, tend Figure 3.2 A Model of the Public Policymaking Process in the United States Preferences of individuals, organizations, and interest groups, along with biological, cultural, demographic, ecological, economic, ethical, legal, psychological, social, and technological inputs The...

The Operation of Political Markets

Much about the operation of economic markets applies to the way political markets operate. Health policies indeed, all public policies are made within the context of political markets, which in many ways operate like traditional economic markets. There are, however, some notable differences between economic and political marketplaces. The most fundamental difference is that buyers or demanders in economic markets express their preferences by spending their own money. That is, buyers in economic...

Types of Groups Involved in Financing Political Campaigns

501 c groups Nonprofit, tax-exempt groups organized under section 501 c of the Internal Revenue Code that can engage in varying amounts of political activity, depending on the type of group. For example, 501 c 3 groups operate for religious, charitable, scientific or educational purposes. These groups are not supposed to engage in any political activities, though some voter registration activities are permitted. 501 c 4 groups are commonly called social welfare organizations that may engage in...

Political Circumstances

The existence of a problem that might be solved or lessened by a change in policy, even in combination with a possible solution to that problem, is not of itself sufficient to move the problem solution combination forward in the policymaking process. A political force, or what is sometimes called political will, is also necessary to advance a problem potential solution combination. Thus, the political circumstances surrounding each problem potential solution in the policymaking process form the...

The Role of Analysis in Policy Modification

A second key structural feature of policy modification is the role played by formal analysis also called assessments or evaluations of the performance of policies. The results of these efforts can trigger and guide modification in policies House 1993 . Good policy analysis increases the likelihood of appropriate modifications. The most efficacious modification of policies is generally based on solid information, including information obtained through policy analysis. To be of most value in...

Interplay Among Demanders and Suppliers in the Political Marketplace

Within the context of the political marketplace, many participants both demanders and suppliers ofpolicies seek to further their objectives. The various objectives can be self-interest objectives involving some health or economic advantage or public-interest objectives based on views about what is best for the public, or at least some specific subset of society such as the elderly, poor, or medically underserved. In both cases, the outcome depends greatly on the relative abilities of some...

Modification Occuring With Legislation

The modification phase of the public policymaking process involves the feeding back of the consequences of policies and the actions these consequences stimulate into the other phases of the process. As the feedback loop depicted in Figure 9.1 shows, policy modification occurs in both the agenda setting and legislation development inherent in policy formulation and in the rulemaking and operations that characterize policy implementation. The modification phase is an extremely important feature...

Legislative Committees and Subcommittees

Both the Senate and the House ofRepresentatives are organized into committees and subcommittees. The committee structure of Congress is a fundamental feature of the activities involved in the development of legislation and is crucial to the actual development oflegislation. Committee and subcommittee deliberations provide the settings for intensive and thorough consideration of legislative proposals. At present, there are 20 standing committees in the House and 17 in the Senate. Each of the...

Overview Of Medicaid

Title XIX of the Social Security Act is a Federal State entitlement program that pays for medical assistance for certain individuals and families with low incomes and resources. This program, known as Medicaid, became law in 1965 as a cooperative venture jointly funded by the Federal and State governments including the District of Columbia and the Territories to assist States in furnishing medical assistance to eligible needy persons. Medi-caid is the largest source of funding for medical and...

Modification in the Policy Formulation Phase

Modification of policies in the formulation phase the reformulation of existing policies occurs in both agenda setting and legislation development. Recall from the discussion in Chapters 5 and 6 that policy formulation making the decisions that result in public laws entails these two distinct and sequentially related sets of activities in which policymakers, and those who would influence their decisions and actions, engage. The result of the formulation phase of policymaking for initial...

Benefits of and Limitations to Effectively Analyzing Public Policy Environments

A number of concrete benefits derive from the effective analysis of any organization's or interest group's public policy environment by its leaders. Such analysis permits its leaders to classify and organize complex information about the public policymaking process and about forces and pressures that affect the process identify and assess current public policies that do or will affect their entity identify and assess the formulation of emerging public policies including new laws, amendments,...

Payment for Medicaid Services

Medicaid operates as a vendor payment program. States may pay healthcare providers directly on a fee-for-service basis, or States may pay for Medicaid services through various prepayment arrangements, such as health maintenance organizations HMOs . Within federally imposed upper limits and specific restrictions, each State for the most part has broad discretion in determining the payment methodology and payment rate for services. Generally, payment rates must be sufficient to enlist enough...

The Procedure of Analyzing Public Policy Environments

The analysis of the public policy environment of an entity such as a healthcare organization or an interest group is part of the larger external environmental analysis through which its leaders seek to determine the externally imposed opportunities and threats facing their organization or, in the case of interest groups, their members. The relevant variables in their external environments include, but are not limited to, the public policy environment. In fact, the external environments of...

Distinguishing Policy Modification from Policy Initiation

Implementation Feedback

Conceptually, policy modification can be differentiated from policy initiation, although in reality the two are closely intertwined. Policy initiation the establishment of an original public law results when the confluence of problems, possible solutions, and political circumstances leads to the initial development of legislation in the formulation phase as described in Chapters 5 and 6 and, when enacted into public law, then to subsequent first iterations of rulemaking and operation as the law...

Briefly Annotated Chronological List Of Selected Us Federal Laws Pertaining To Health1

An act of July 16, 1798, passed by the Fifth Congress of the United States, taxed the employers of merchant seamen to fund arrangements for their healthcare through the Marine Hospital Service. In the language of the act, the master or owner of every ship or vessel of the United States arriving from a foreign port into any port in the United States shall . . . render to the collector a true account ofthe number ofseamen that shall have been employed on board such vessel. . . and shall pay to...

Health Policy and Individuals Organizations and Interest Groups

In previous sections, we considered how health policy affects the determinants of health the physical environment, human behavior and biology, social factors, and health services. It is also useful to consider the impact of policies on individuals, organizations, and interest groups. At the level of individuals, it is important to remember that health is a state that exists in everyone and that health policy can affect the pursuit of this state by and for everyone. However, the impact of...

Degree of Flexibility in Implementing the Policy

Another aspect of the construction of policies that can have significant impact on their implementation is the nature and extent of decisions left to the implementing organizations. These decisions arise by virtue of the explicitly directive language in the law, by what is not said in the law, or by confusing or vague language in the law. For example, although a degree of flexibility in developing the rules to be used in policy implementation can be advantageous, vague policy directives can...

Executive Agencies Implementation Responsibilities

Medicare Organizational Chart

Agencies such as the Department of Health and Human Services DHHS www.dhhs.gov and the Department of Justice DOJ www.usdoj.gov as well as subdivisions of those departments and a number of independent federal agencies such as the Environmental Protection Agency EPA www.epa .gov , the Consumer Product Safety Commission CPSC www.cpsc.gov , and the Food and Drug Administration FDA fda.gov bear direct responsibility for implementing laws enacted by the legislative branch. These and many other...

Policy Modification

Policymaking is not a perfect process. Mistakes of omission and commission are routinely made in both the formulation and implemention phases ofpublic policymaking. The model ofthe policymaking process described throughout this book comes full cycle because of a third phase of the process, modification. This phase is a necessary part of policymaking because perfection eludes policymakers in the formulation and implementation phases. Even when decisions about policies are correct at the time...

Committees with Health Policy Jurisdiction

Although no congressional committee is devoted exclusively to the health policy domain, several committees and subcommittees have jurisdiction in health-related legislation development. The Real World of Health Policy Inside a Congressional Committee describes the history and structure of an important committee with extensive health jurisdiction, the Committee on Energy and Commerce of the House of Representatives. Similar information on the operation of committees in the Senate is contained in...

Health Policy and Health Related Interest Groups

Health services and secondary provider organizations, as discussed in the previous section, are not the only entities with health policy concerns and interests. A wide variety of health-related interest groups, including some that are consumer based or that are organized around individual health practitioner memberships, exist because of the collective interests of their individual or organizational members in health policymaking and the resulting health policies. As will be discussed more...

Influence A Matter of Power and Focus

The effective exercise of influence in the public policy environments of organizations and interest groups, either individually or in collaboration, depends on having a basis for their influence and on knowing where and when to focus their efforts. Power is the potential to exert influence. It is the basis of influence in a public policy environment. Much like the sources of interpersonal power discussed in Chapter 3, the power that entities use to exert influence in their public policy...

The Connection Between Health Policy and Health

From government's perspective, the central purpose of health policy is to enhance health or to facilitate its pursuit by the citizenry. Of course, it is possible for other purposes to be served through specific health policies, including providing economic advantages to certain individuals and organizations. But the defining purpose of health policy, so far as government is concerned, is to support the people in their quest for health. Health policies have their impact on health through an...

Incrementalism in Policymaking

Not only are most public policies in all domains, including health, modifications of previously established policies but also most of the modifications reflect only modest changes Hinckley 1983 . The combination of a process that is characterized by continual modification of previous decisions with the fact that these changes tend to be modest has led to the apt characterization of the public policymaking process in the United States as a process of incrementalism Lindblom 1969, 1992 . The...

Policy Formulation Agenda Setting

The three distinct phases of the health policymaking process modeled in Chapter 3 see Figure 3.2 are examined in greater detail in this chapter, as well as in Chapters 6, 7, and 8. This chapter focuses on the agenda setting that occurs in the policy formulation phase of the policymaking process. Chapter 6 focuses on the development of legislation that also occurs in that phase. Chapter 7 describes the policy implementation phase, and Chapter 8 discusses the policy modification phase. These four...

Modification in the Policy Implementation Phase

Modification ofpolicies in the implementation phase occurs in both rulemak-ing and in the operation of policies. Recall from the discussion in Chapters 7 and 8 that policy implementation entails these two distinct and sequentially related sets of activities in which policymakers, and those who would influence their decisions and actions, engage. Feedback from the consequences of formulated and implemented policies can also stimulate the modification of policies in the implementation phase, at...

Agenda Setting

Kingdon 1995 describes agenda setting in public policymaking as a function of the confluence of three streams of activity problems, possible solutions to the problems, and political circumstances. Some people prefer the term issue to Kingdon's choice of problem to refer to something that might trigger policymaking Gormley and Boccuti 2001 . It really does not matter which term is used we will use problem to be consistent with Kingdon's terminology. In his conceptualization, when problems...