The myriad decisions that constitute health policy are increasingly important. Health is a personal, high-priority goal of most people, and the pursuit of health is of growing significance to the nation's economy and to its system of social justice. Thus, it should surprise no one that health policy receives a great deal of attention from government.

Health policy is defined in this textbook as the set of authoritative decisions made within government that pertain to health and to the pursuit of health. The phrase authoritative decisions is crucial in the definition and refers to decisions that are made anywhere within the three branches of government—at any level of government—and are within the legitimate purview (i.e., within the official roles, responsibilities, and authorities) of those making the decisions.

Through a long history of incremental and modest steps, an extensive array of authoritative decisions that comprise health policy has evolved in the United States. Although this history has been punctuated occasionally by dramatic developments in health policy, especially the emergence of Medicare and Medicaid in 1965, health policymaking is mostly a story of slow but persistent evolution and modification.

Health policy's role in the pursuit of health is played out across many fronts because health is determined by many variables: the physical environment in which people live and work, their biology and behavior, social factors, and access to health services. The effects of health policies are seen in each of these determinants of health.

Whether at the federal, state, or local level, governments formulate, implement, and constantly modify health policies within an intricately choreographed policymaking process. The central and unifying purpose of this book is to provide a comprehensive model of this process for those who have an interest in or a curiosity about health policy and the policymaking process. An understanding of this process is essential to policy competency. For typical health professionals, policy competency is at most a secondary interest. However, a degree of policy competency sufficient to permit one to effectively analyze the public policy environment that affects them and their work—and to exert influence in that environment—is an increasingly important attribute for those whose professional lives are devoted to the pursuit of better health for society.



The model of the health policymaking process presented in this book was first developed, and continues to be refined, for the benefit of my students. The fact that the model proved useful as a framework for their understanding of the extraordinarily complicated process of health policymaking stimulated me to present it to a broader audience, the result ofwhich was the first edition of this book. Through four editions, the book has been and will continue to be used in health policy courses as a means to provide students with an overview of the policymaking process. The model puts the various aspects of policymaking in perspective and serves as a foundation on which students can build their more detailed knowledge of the process—that is to say, they can build their policy competency.

The structure of this textbook largely reflects the model of the pol-icymaking process. Following definitions of health and of health policy in Chapter 1, Chapter 2 emphasizes the ways in which policy affects health determinants. An overview of the context (the political marketplace) and the process of policymaking are presented in Chapter 3. Chapter 4 contains extensive new (since the previous edition) material on policy competency, which is defined as the dual abilities to analyze the public policy environment of a health-related organization or interest group and to exert influence in this environment. This competency is increasingly important to everyone involved professionally in the pursuit of health. Information to strengthen both abilities is also presented. Chapters 5 through 9 describe specific aspects of the poli-cymaking process and follow the model of the process presented in Chapter 3. Chapters 5 and 6 address the agenda-setting and legislation-development aspects of policy formulation, respectively. Chapters 7 and 8 address the rule-making and operation aspects ofpolicy implementation, respectively. Chapter 9 addresses policy modification, reflecting the fact that all policies are subject to modification.

The book includes three appendixes, one of which lists chronologically the most important federal laws pertaining to health enacted in the United States. In addition to providing synopses of these laws, the chronology illustrates several important characteristics of the nation's health policy. The list clearly shows, for example, that the vast majority of health policies are but modifications of or amendments to previously enacted laws; incrementalism has indeed prevailed in the development of American health policy. The list also shows that health policy mirrors the various determinants of health. There are policies to address the environments in which people live, their lifestyle, and their genetics, as well as numerous policies related to the provision of and payment for health services. The other two appendixes are new to this edition and provide detailed information about Medicare and Medicaid.

In this edition, a popular feature called The Real World of Health Policy has been expanded. These highlighted boxes are placed throughout the text and present excerpts from congressional testimony; examples of rules or

Preface xxiii proposed rules issued by implementing agencies; and reprints of illustrative news stories, letters, executive orders, and other documents that illustrate important real-world aspects of the policymaking process. The intent is to enliven the text and to provide useful and illustrative examples.

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