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 intervening set ofvariables, or health determinants. The health determinants, in turn, directly affect health. Thus, when examining the ways in which health policy can affect health, consider the role of health policy in the following health determinants:
• the physical environments in which people live and work;
• the behavioral choices that people make and the role that biology plays in their health;
- Physical environment
- Behavior and biology
- Social factors
The Impact of Policy
Health on Health
Determinants and on Health
- Health services
• the social factors that affect people's health, including their economic circumstances; their socioeconomic position in society; the income distribution within the society; discrimination based on factors such as race/ethnicity, gender, or sexual orientation; and the availability of social networks or social support; and
• the health services available to people and their access to these services.
Health policies have effects on each of these determinants of health, and thus on health itself, as shown in Figure 1.2. The nature of these effects is explored more fully in Chapter 2. First, however, it will be useful to comment briefly on the increasingly important roles of states in health policy and on the concept of policy competency.
An unsettled debate over the appropriate distribution between a strong central federal government and the states regarding health policy responsibilities dates from the nation's founding. Over the years, the balance has shifted from time to time, with the federal government playing an especially dominant role in health policy for most of the period since the mid-1960s. In recent years, however, stimulated by changes in states' responsibilities for operating the Medicaid program and the failure in the early 1990s of federally led attempts at comprehensive health reform, the traditional health policy roles of the states have been reinforced and, in some states, new, broader roles in health policy have been undertaken.
Traditionally, the states have played substantial roles in several areas of health policy. Lipson (1997) identifies three in particular: (1) financing or paying for health services for several categories of people; (2) ensuring the public's health; and (3) regulating health-related professionals and organizations, including health insurance organizations and plans. In recent years, a fourth role has been added in some states: experimenting with comprehensive health reform strategies.
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