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,...

References

The Formative Years of Social Security. Madison, WI University of Wisconsin Press. Anderson, G. F. 1992. The Courts and Health Policy Strengths and Limitations. Health Affairs 11 (4) 95-110. Centers for Medicare & Medicaid Services (CMS). 2004. A Chronology of Significant Events Leading to the Enactment of Medicare. Online information retrieved 6 6 05. Cook, T. P., and D. T. Campbell. 1979. Quasi-Experimentation Design and Analysis Issues for Field Settings. Chicago...

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

The Real World of Health Policy

The mission of the Environmental Protection Agency (EPA) (www.epa.gov) is to protect human health and the environment. Established in 1970, EPA develops and enforces regulations that implement environmental laws enacted by Congress. EPA's FY 2005 Annual Plan and Budget includes a budget of 7.8 billion and almost 18,000 employees. The major pieces of legislation that EPA implements or partially implements include the following. National Environmental Policy Act (NEPA) (1969) NEPA is the basic...

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.,...

Info

P.L. 95-292, the Medicare End-Stage Renal Disease Amendments, further amended the legislation governing the Medicare program (see the 1965 P.L. 89-97) in an attempt to help control the program's costs. Since the addition of coverage for ESRD under the Social Security Amendments of 1972 (P.L. 92-603), the costs to the Medicare program had risen steadily and quickly. This legislation added incentives to encourage the use of home dialysis and renal transplantation in ESRD. The legislation also...

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

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...

The Mechanics of the Modification Phase

The policymaking process provides abundant opportunities for the consequences that result from the formulation and implementation of public laws to influence the reformulation of future iterations as well as to change the rules and operational practices that guide their implementation. As the feedback arrows in Figure 9.1 illustrate, policies can be modified at four points in the policymaking process in both the agenda setting and legislation development that occur in the formulation phase and...

Regulatory Policies

Policies designed to influence the actions, behaviors, and decisions of others by directive are regulatory policies. In a variety of ways, all levels of government establish regulatory policies. As with allocative policies, government establishes such policies to ensure that public objectives are met. The five basic categories of regulatory health policies are 2. rate- or price-setting controls on health services providers 3. quality controls on the provision of health services 4....

Legislative Oversight of Implementation

Although organizations in the executive branch bear most of the responsibility for implementing policies, the legislative branch maintains a very important oversight responsibility in the implementation phase. Oversight of the executive branch's implementation of the policies enacted by the legislative branch is actually mandated in the Legislative Reorganization Act of 1946. Generally, legislative oversight is intended to accomplish the following ensure that implementing organizations adhere...

Health Policy in the States

In their role as payers, states assume significant responsibility for funding their Medicaid programs. Although the costs of these programs are shared with the federal government, this program typically consumes 21 percent or more of state budgets National Association of State Budget Officers 2004 . Medicaid is among the highest policy priorities let alone health policy priorities for the states. In addition to their funding roles in the Medicaid program, the states also typically pay the costs...

The Impact of Implementing Organizations and Their Managers on Implementation

The essence of the implementation phase of policymaking is that one or more organizations or agencies undertake to operationalize enacted legislation, ideally in a manner that permits realization of the legislative intent behind the legislation. This involves promulgating the rules under which implementation will proceed as well as actually putting the laws into operation. As noted earlier, one important constant in the dynamic circumstances involved in rulemaking and in operationalizing public...

Lobbying CMS to Make Administrative Changes to the Sustainable Growth Rate SGR Formula for Updating the Medicare

The Honorable Mark McClellan, M.D., Ph.D. Administrator Centers for Medicare amp Medicaid Services 200 Independence Avenue, SW Room 314-G Washington, DC 20201 All of the undersigned organizations believe that Medicare's formula for paying physicians and other health professionals is broken. Beginning in 2006, the Sustainable Growth Rate SGR , which is part of this formula, will cut reimbursements by five percent a year for seven consecutive years, with additional cuts for several years...

The Medicaid Medicare Relationship

Medicare beneficiaries who have low incomes and limited resources may also receive help from the Medicaid program. For such persons who are eligible for full Medicaid coverage, the Medicare healthcare coverage is supplemented by services that are available under their State's Medicaid program, according to eligibility category. These additional services may include, for example, nursing facility care beyond the 100-day limit covered by Medicare, prescription drugs, eyeglasses, and hearing aids....

Interest Groups in the Political Marketplace

Interest groups arise in democratic societies because many people realize that the opportunities to achieve particular benefits or other desired outcomes are enhanced through collective action within the political marketplace, specifically through influencing the public policymaking process. An excellent background resource on interest groups is found at http texaspolitics.laits .utexas.edu html ig index.html. They are ubiquitous in the United States as much in the health domain as in any...

Rules of Rulemaking

The promulgation of rules, as a formal part of the implementation phase of policymaking, is itself guided by certain rules and protocols, primarily contained in the Federal Register Act of 1935 and the Administrative Procedure Act of 1946. Key among these is the requirement that implementing agencies publish proposed rules. The purpose of publishing proposed rules is to give those with interests in the issue an opportunity to participate in the rulemaking prior to the adoption of a final rule....

Policy Implementation Rulemaking

Implemation And Feedback

Policy formulation, as a phase of the overall public policymaking process, is described in Chapters 5 and 6 as two sets of interrelated activities agenda setting and the development of legislation. Sometimes, these formulation activities lead to policies in the form of new or amended public laws, such as the enactment of P.L. 108-173 the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 which amends Title XVIII of the Social Security Act to provide for a voluntary program...

The Capability of Managers to Contribute to Implementation

The performance of the managers of implementing organizations, especially those at senior levels, directly affects the performance levels achieved by implementing organizations White and Newcomer 2005 . The type, quality, and extent of the contributions made by managers depend on their managerial capability that is, how adeptly they carry out a trio of interrelated activities strategizing, designing, and leading Zuckerman and Dowling 1997 Longest 2005 . These managerial activities are discussed...

The Role of Oversight Actors in Policy Modification

Oversight actors in the public policymaking process include participants from each branch of government. Their roles are played differently, but each has important implications for policy modification. In the legislative branch, oversight responsibilities are assigned to committees and subcommittees, which can stimulate modification in policy formulation and implementation. Chief executives presidents, governors, or mayors, depending on the level of government and their top appointees monitor...

Policymaking Is Influenced by External Factors

Another important feature of the public policymaking process shown in Figure 3.2 is that the entire process is influenced by factors external to the process itself. This makes the policymaking process an open system, one in which the process interacts with and is affected by events and circumstances in its external environment. This important phenomenon is shown in the model by the impact ofthe preferences ofthe individuals, organizations, and interest groups that are affected by policies along...

Origins of Ideas for Public Policy

Ideas for public policy in the form of law, which are expressed in bills, originate in many places. They obviously come from the members of Congress, whether from the House of Representatives or the Senate. In fact, many legislators are elected to Congress, at least in part, on the basis of the legislative ideas they expressed in their election campaigns. Promises to introduce certain legislative proposals, made during campaigns specifically to the constituents whom candidates seek to...

Policymaking Is a Highly Political Process

One feature of the public policymaking process that the model presented in Figure 3.2 cannot adequately show but one that is crucial to understanding the policymaking process is the political nature of the process in operation. While there is a belief among many people and a naive hope among still others that public policymaking is a predominantly rational decision-making process, this is not the case. The process would no doubt be simpler and better if it were driven exclusively by fully...

Use of this table isrestricted

Began an enduring history of uncertainty about and ambiguity toward the role ofinterest groups in public policymaking in the United States. One point about which there is neither uncertainty nor ambiguity, however, is that interest groups play an active role in the public policymaking process. Reflecting widely divergent views on the manner in which interest groups play their role in this process, two distinct perspectives on ways in which groups influence policymaking have emerged the...

Interest Groups in the Judicial Process

Although interest groups are probably better known for their attempts to influence legislative and executive branch decisions, they also pursue their policy goals in the courts. Some groups have found the judicial branch to be more receptive to their efforts than either of the other two branches of government. Interest groups that do not have the economic resources to mount an intensive lobbying effort in Congress or a state legislature may find it much easier to hire a lawyer and find some...

The Medicare Program A Long History of Policy Modification in Practice

As described in the foregoing sections, modification of previous decisions is possible at many points in the policymaking process. In fact, modification of previous decisions characterizes the process. The role of policy modification can be seen vividly, for example, in the legislative history of the Medicare program. Imbedded in the chronology of Medicare-related legislation are many examples of how the modification phase of public policymaking plays out. The chronology of Medicare begins with...

Managerial Competencies Underpin Performance

Successfully carrying out the strategizing, designing, and leading activities necessary to manage implementation organizations requires that managers possess certain competencies. In Chapter 4, a competency was defined as a cluster of related knowledge, skills, and ability sometimes referred to by the acronym SKA that 1 affect a major part of one's job a role or responsibility , 2 correlate with performance on the job, 3 can be measured against well accepted standards, and 4 can be improved by...

The Fit Between Implementing Organizations and the Goals and Objectives of Policies

No characteristic of an implementing organization is more basic to success than a close fit between the organization and the goals and objectives of the policies it must implement. The keys to such a fit include whether 1 the organization is sympathetic to the policy's goals and objectives and 2 the organization has the necessary resources, in the form of authority, money, personnel, status or prestige, information and expertise, technology, and physical facilities and equipment, to implement...

Interest Group Involvement in Agenda Setting

To appreciate fully the role of interest groups in helping to set the policy agenda, it is useful to first consider the role of individual members of American society in health policy agenda setting. In a representative form of government, such as that of the United States, individual members of society, unless they are among the elected representatives, usually do not have the opportunity to vote directly on policies. They do, however, have opportunities to vote on policymakers. Thus,...

Publics Agenda Differs from Presidents

Bush begins his second term with considerably less popular support than other recent incumbent presidents after their reelection. He also is proposing a second-term policy agenda that differs in several key respects from the public's. Healthcare, aid for the poor, and the growing budget deficit are all increasingly important public priorities, while limiting lawsuit awards, making recent tax cuts permanent and tax simplification rank near the bottom of the public's agenda. Social...

Judicial Dimension of Implementation

Legislation, as well as the rules made by those responsible for its implementation, can be challenged in the courts. Administrative law judges in the implementing agencies hear the appeals of people or organizations who are dissatisfied with the way the implementation of a policy affects them. For example, the Office of Administrative Law Judges OALJ www.epa.gov oalj is an independent office in the Office of the Administrator of EPA. These administrative law judges conduct hearings and render...

Rulemaking The Beginning of Implementation

Enacted laws seldom contain enough explicit language to guide their implementation completely. Rather, they are often vague on implementation details, leaving it to the implementing organizations to specify, publish, and circulate the rules or regulations remember, these terms have the same meaning in the policy context subsequently used to guide the law's actual operation. For this reason, implementation typically begins with rulemaking. Figure 7.4 contrasts laws and rules. Publish in Slip Law...

Drafting Legislative Proposals

The drafting of legislative proposals is something of an art in itself, one requiring considerable skill, knowledge, and experience. Any member of the Senate or House of Representatives can draft bills, and these legislators' staffs are usually instrumental in drafting legislation, often with assistance from the Legislative Counsel's Office in the Senate or House of Representatives. Information about how the Legislative Counsel's Office for the House and the Senate works can be seen at http...

The Context of Health Policymaking The Political Marketplace

A useful conceptualization of the political marketplace for health policies can be based on the operation of traditional economic markets because economic markets and political markets share a number of characteristics. Many different kinds of products and services, including those used in the pursuit of health, are bought and sold in the context of economic markets. In these markets, willing buyers and sellers enter into economic exchanges involving something ofvalue to both parties. One party...

The Role and Importance of Policy Competency in the Pursuit of Health

Policy Formulation And Implementation

Because there is a powerful connection between health policy and health, anyone professionally involved in the pursuit of health through any of the determinants shown in Figure 1.2 has a vested interest in understanding the health policymaking process at both state and federal levels. An understanding of this process is important to developing a higher degree of policy competency. Much more is said about policy competency in Chapter 4, and in many ways this book is about enhancing the policy...

Health Policy Defined

Three Branches Government

There are many definitions of public policy, and no universal agreement has been reached on which is best. For example, Peters 2003 defines public policy as the sum of government activities, whether acting directly or through agents, as it has an influence on the life of citizens. Birkland 2001, 132 defines public policy as a statement by government of what it intends to do or not to do, such as a law, regulation, ruling, decision, or order, or a combination of these. Cochran and Malone 1999...

The Choreography of Legislation Development

Development of legislation is the point in policy formulation where specific legislative proposals, which are characterized in the previous chapter as hypothetical or unproved potential solutions to the problems they are intended to address, advance through a series of steps that can end in new or amended public laws. These steps, not unlike those of a dance, are specified or choreographed. Only when all of the steps in the legislation development process are completed recall that this happens...

Policy Implementation Operation

This chapter continues our focus on the implementation phase of public policymaking a phase that involves two interrelated sets of activities. The shaded portion of Figure 7.1 shows that policy implementation begins with rulemaking, which was the focus of Chapter 7. The second stage in policy implementation, also shown in the shaded portion of Figure 7.1, is the operation of public laws, and that stage is the focus of this chapter. If a policy in the form of a public law is intended to protect...

The Components of the Policymaking Process Are Interactive and Interdependent

A third important feature of the policymaking model is that while it emphasizes the various distinct component parts or phases of the policymaking process, it also shows that they are highly interactive and interdependent. The conceptualization of the public policymaking process as a set of interrelated phases has been used by a number of authors, although there is considerable variation in labeling the phases of activities in these models as well as in their comprehensiveness. Paul-Shaheen...

Hypothesis of the Policy

Vague or conflicting goals and objectives are not the only potentially serious problems with the construction of policies problems that can make their operational stage very difficult, if not impossible. The procedural paradigm set forth in a public law can also be flawed. Embedded in every policy is a theory, or hypothesis, about the effect of operationalizing the policy if someone does A, then B will result. As Thompson 1997 has noted, however, only in a perfect world would policymakers...

Policy Competency

The impact of health policies that is, the authoritative decisions made within government was discussed extensively in Chapter 2. Individuals, communities, and populations, as well as health-related organizations and groups, feel the effects ofhealth policies. To varying degrees depending on the relative importance of the impact of policies on them, all share two related areas of concern about policies and the process that produces them. 1. They want to know how policies will affect them and...

Interest Group Resources and Success in Influencing the Policy Agenda

Using lobbying, electioneering, litigation, and efforts to shape public opinion as tactics, interest groups seek to influence the policy agenda and the larger public policymaking process to the strategic advantage of their members. The degree of success they achieve is highly dependent on the resources at their disposal. Ornstein and Elder 1978 categorize the resources of interest groups into the following categories physical resources, especially money and the number of members organizational...