hether health policies take the form of laws, rules or regulations, operational decisions, or judicial decisions, as described in Chapter 1, they are all decisions, and they are made through a complex decision-making process. With certain variations, policies at the federal, state, and local levels of government are made through similar processes. Furthermore, the structure of the decision-making process is the same for all policy domains, whether the domain is health, education, defense, taxes, welfare, or other domains. Although health policy is the focus, all public policy is made through a decision-making process called policymaking.
The domain of health policy is very broad because health is a function of multiple determinants: the physical environment within which people live and work, their behaviors and biology, social factors, and the health services to which they have access. Not only is the health policy domain broad but also there are numerous overlaps and blurred lines between the health domain and other policy domains. For example, it is impossible, as a practical matter, to consider health policy aside from its relationship to tax policy. Health policy cannot be separated from the fact that government must finance, essentially through taxes, the services or programs established by health policy, whether in the form of health services for the beneficiaries of the Medicare program, research in biomedical laboratories, or other services. At a minimum, any dollars spent as a result of health policies always have alternative uses in other domains to which the money could be directed by policymakers.
Another example of how policy domains overlap is the 1996 Personal Responsibility and Work Opportunity Reconciliation Act (P.L. 104-193), also known as the Welfare Reform Act, which had significant health implications. In addition to the obvious impact of changes in the nation's welfare policy on such health determinants as the social and economic environments faced by affected people, this law affects eligibility for the Medicaid program in a fundamental way. Since the establishment of the Medicaid program in 1965, eligibility for a key welfare benefit, Aid to Families with Dependent Children (AFDC), and eligibility for Medicaid benefits have been linked. Families receiving AFDC have been automatically eligible for Medicaid and enrolled in the Medicaid program. The Welfare Reform Act, however, replaced AFDC with the Temporary Assistance to Needy Families (TANF) block grant. Under the provisions of the TANF block grant, states are given broad flexibility to 75
design income support and work programs for low-income families with children and are required to impose federally mandated restrictions, such as time limits, on federally funded assistance.
The Welfare Reform Act does provide that children and parents who would have qualified for Medicaid based on their eligibility for AFDC continue to be eligible for Medicaid, but, in the absence of AFDC, states find it necessary to use different mechanisms to identify and enroll former AFDC recipients in their Medicaid programs. This example of the overlap between the policy domains of health and welfare is typical of the ways in which policy in one domain relates to policy in other domains. The European Commissioner for Health and Consumer Protection states this relationship as follows: "To achieve good health, we need to look at the grass root problems—poverty, social exclusion, healthcare access. We need to understand how different socioeconomic and environmental factors affect health. And then we need to make all these factors work together for good health. Good health must become the driving force behind all policy-making" (Byrne 2004, 2).
The purpose of this chapter is to present both a model of the public policymaking process and a description of the political context within which the policymaking process takes place. The political context—or political marketplace, as it is often called—is discussed first.
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