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Health Policy
exam 2
Health Care
Undergraduate 4

Additional Health Care Flashcards




Policy Formation Overview
-goal is to make new laws or improve old ones
-New laws can be seen or read in a number of places
-Constitution prohibits enactment of laws not specifically and directly made known to all citizens
Slip Law
enacted law is first printed in pamphlet form
-later published in U.S Statutes At Large (compilations of laws enacted in a particularly year)
- laws are eventually published in the US Code
Steps in the Legislative Process
1. Origination of ideas for proposed legislation
2. formal drafting of legislative proposals
3. Member of congress introduces bill to congress
4. Referred to committee for a hearing (committee can pass, reject or take no action)
5. Committee report on the passed bill is read in open session of the House or Senate and bill is referred to Rules Committee and subject for debate
6. After passing in one house, bill goes through the same procedure in the other house
7. If amendments are made, other house must approve changes
8. If bill is accepted by both houses, presidential action takes place
Origins of ideas for public policy
- Members of Congress
- Individuals
- Health-related organizations
- Interest groups
- Executive Communication from members of the executive branch to members of the legislative branch
---> executive influence is constitutionally sanctioned. Obligation to the president to report to Congress on the State of the Union and recommend policies
-Think tanks with proposals
-Opinion leaders and celebrities
Who drafts legislative proposals?
-Any member of Congress
- Initial draft done by congressional office staffers
-Official draft by the Office of Legislative Council (30 ghost writers)
-When drafted in the executive branch, trained legislative counsels write
***common to have multiple writers and sponsors on one bill
Process of introducing legislation to committees?
Members of Congress who have chosen to sponsor legislation introduce their proposal in the form of a bill.
- Bill is assigned a number
- Bill is physically taken to a clerk of the House or Senate
- Referred to appropriate standing committee for further study
**usually there is an overlap of jurisdiction with health related responsibilities
Facts About Legislative Standing Committees/Subcommittees
-20 committees in the House and Senate all with jurisdiction over certain area of legislation
-Committees divided into sub to faciliate work
-Membership on the committees is divided between the political parties (proportion is determined by majority party)
-Several joint committees
- Majority party controls the appointment of committee chairpersons, who exert great influence over development of legislation
Congressional Committees with Health Policy Jurisdiction
- no one comm. devoted to health policy
- overlap in jurisdiction of committees with health policy related responsibilities
-In the House, most health bills are referred to the House Committee on Energy and Commerce and Committee on Ways and Means
- In the Senate, Committee on Health, Education, Labor, and Pensions (HELP) and Committee on Finance
Senate Committee On Finance jurisdiction
Health care programs under the Social Security Act and health programs financed by a specific tax
-- Medicare and Medicaid
Senate Committee on HELP Jurisdiction
- Subcomittee on Children and Families, Employment and Workplace Safety, and Retirement and Aging
- Power over programs/agencies of the Department of Health and Human Services (FDA, CDC, NIH, AOA, Mental Health Services Admin and AHRQ)
- Also oversees public health and health insurance policy
House Committee on Ways and Means Jurisdiction with Subcommittee on Health
oversees bills and matters pertaining to providing payments from any source for healthcare, health delivery systems or health research
- healthcare programs of the SS Act
- tax credit and deductions dealing with health insurance premiums and healthcare costs
House Committee on Energy and Commerce jurisdiction
subcommittee on Health, Energy, and Environment
- all bills related to Medicaid and national health insurance
- public health and quarantine
-hospital reconstruction
- mental health and research
- biomedical research
- food and drugs
- clean air act and environmental protection
Committee Process of Legislation
- Bill introduced
- Assigned to appropriate committee/sub
- Committee reviews bills
- Committee can hold a hearing (members of the executive branch and reps of health-related orgs/interest groups present their views/recommendations)
- Mark up (going through the bill line by line making changes)
- Committee approves the bill and reports out for a vote to the floor
- Input is issued through a Statement of Administration Policy
- If a committee votes to report a bill favorably, a member writes a report, describing the purpose of the bill and reasons to support it.
- Bill and report are discharged from the committee
- Floor Action (amendments to the proposed bill require a lot of support b/c faith is in the committees to review the bill)
- Once passed, sent to other chamber
- Steps of assigning to a committee are repeated.
Conference Committees
Establish a committee to resolve differences in a bill that both chambers of Congress have passed
- members are usually those that reported out the bill in each chamber
- if differences are resolved, a conference report is written and both houses vote on it
- bill dies when conference comm can't agree
Types of Presidential Action on Proposed Legislation
- Sign the bill
- Veto the bill- returns to Congress with an explanation (but 2/3 vote can override this)
- Niether sign nor veto and bill becomes law in 10 days
- Pocket veto- president does nothing until the Congress is adjourned and bill dies
Congressional Budget and Impoundment Control Act of 1974
Provides Congress with the process through which it establishes target levels for revenues, spending, and overall deficit for the coming year
--prior to this, no formal process for establishing a coherent budget
-- Created the Congressional Budget Office, directing more control of the budget to Congress and away from the President
-- decisions about budget affect health policy
The Federal Budget Legislation Process
1. President submits budget proposal (with the help of the OMB)
2. House and Senate Budget Committees have hearings, markups and reports
3. House and Senate consider amendments and individual budget resolutions
4. House and Senate conference committees agree to identical budget numbers and each chamber passes an identical conference report
5a. 13 separate appropriates subcomms hold hearings and markups to fund federal programs and report appropriation bills to House and Senate
5b. House and Senate Authorizing Committees have hearings and markups to change existing law to meet reconciliation instructions for hte purpose of decreasing spending/increasing revenue
6a. Full House/Senate consider amendments and votes to adopt individual appropriation bills
6b. House and Senate Budget Comms package reconciliation language fro the authorizing comms into one bill and report Reconciliation Bill to House and Senate
7a. Appropriations Bill Conference Reports- the House and Senate adopt identical conference reports but Failure to pass all appropriation bills requires a continuing resolution to continue funding government programs, otherwise government will shut down
7b. House and Senate consider amendments and pass individual reconciliation bills and send to House/Senate conferences
8a. President signs or vetoes the individual bills
8b. President signs or vetoes the Reconciliation bill
Differences between process of legislation for federal budget and all other legislation
- Constitution requires bill raising revenue must start at the House, so House leads the budget process
- President's role in developing budget legislation is more formalized and establishes the starting point for the process
- federal budget making has 3 distinct stages
Policy Implementation begins with this- establishment of the formal rules necessary to full effect the intent embedded in the law
- authoritative decisions made within the executive branch
- laws are seldom explicit enough to convey steps to guide implementation
What does the implementation phase of public policymaking involve?
- Management Undertaking
- Involves managing human resources, financial resources, and other resources that facilitate achievement of goals and objectives in the enacted legislation
Relationship between rule making and operation
Policy Implementation includes both these sets of activties
- rulemaking and operational activities are always cyclical
- rulemaking precedes operation but operation feeds back into rulemaking
- rules are modified based on experiences that come with operationalization
Who is responsible for Policy Implementation?
shifts from the legislative branch to executive
- legislative still oversees
- judicial plays a role
Executive Agencies' Implementation Responsibilities
Many agencies such as EPA, DHHS, CMS, and FDA exist to implement the laws
Legislative oversight of implementation is intended to accomplish the following
- ensure implementing organizations adhere to congressional intent
- improve efficiency and effectiveness of government operations
- assess the ability of orgs to manage and accomplish implementation
- ensure implementation of policies reflect public interest
Ways for Legislatives to oversee implementation
- funding appropriations that Congress must make to continue implementation of law (H and S appropriations comms review performance of orgs in carrying out implementation responsiblities)
- direct contact between members of Congress and executive branch personnel involved in implementing policies
- Each standing committee of H and S has certain oversight responsibilities
Judicial Role in Implementation
Rules for implementation can be challenged in courts
--admin law judges in the agencies hear the appeals of people dissatisfied with how implementation of a policy affects them
Federal Rulemaking Process
1. Congress takes action (enactment of new law) that requires executive agency to write and issue rules ---shift of authority from legislative to executive branch is not total. Congress is still involved 2. Agency develops draft and proposed rule 3. Agency reviews  draft proposed 4. OMB/OIRA review draft 5. publication of notice of proposed rulemaking 6. public comments 7. response to comments/development of draft final rule ---changes in proposed rules result from interactions and are among the most active points of involvement in policymaking for individuals 8. Review/approval of Draft Final Rule within Agency 9. OMB/OIRA reivew of draft final rule 10. Publication of Final Rule
Role of Interest Groups in Rulemaking
-routinely seek to influence rulemaking
-use lobbying and other forms of influence to guide rules for law
-high potential for conflicting interests
Strategies used to support rulemaking
- when rule development seems difficult because of competing interests, can organize a series of task forces to produce acceptable rules
- create advisory comissions
What is the Operation Stage of Policy Implementation?
involves the actual conduct or running of the programs and processes embedded in enacted public laws
- the domain of the civil servants who staff the government
--requires extensive management of resources to make laws operate smoothly
2 variables that determine the success of any policy's operational stage
1. how the policy is designed/constructed
2. certain characteristics of the organization charged with implementation, including the capability of the managers.
Impact of a policy's design or construction on operation
The way laws are written affect its implementation. Specifically...
1.objectives of the policy
--well-written laws have clear objectives
--when those responsible for implementation understand the law's intentions, it is easier to operate the programs and procedures
--multiple objectives may conflict or make operation difficult
2. hypothesis of the policy
--theory of what the policy can do- if its wrong, the operational stage will not solve the problem the policy intended to address of flexibility in operating the policy
--the nature/extent of any decisions left to the implementing orgs
--vague words can create problems but so can being too specific.
--often laws say what is to be accomplished but don't say how
What determines fit between implementing organizations and policy objectives?
1. The organization is sympathetic to the policy's goals/objectives
--this depends on attitudes of leaders/managers of the org (degree to which they are hostile or sympathetic)
2. The organization has the necessary resources to implement policy effectively
3. Technology
--Regulatory policies require implementation technologies that control behaviors of who is being regulated (i.e ability to impose sanctions)
--Allocative policies require technologies through which implementing orgs deliver income, goods or services
Core Activities in Managing during implementation
Their ability to...
1. Strategize
2. Design
3. Lead
Managerial Strategizing
-establish suitable organizational missions, goals, and objectives
-develop and carry out plans to accomplish the orgs purposes.
-must consider how to adapt their domain to their challenges/opportunities in their environment (economic, social, governmental, technological factors)
-have expertise in discerning important information in one's environment
Steps involved in conducting situational analyses for managers
1. Scanning the environment to identify strategic issues (i.e trends, threats)
2. Monitoring strategic issues identified
3. forecasting the future directions of strategic issues
4. assessing the implications of these issues
**must also consider assessment of internal strengths and weaknesses
Managerial Designing
managers design the org's structure
- designate individual positions
- create teams, departments, and divisions
- challenging because environment is volatile so this task is ongoing
Reasons for a manager to change the organization's design
1. significant change occurs in the environment that directly impacts operations (i.e new law)
2. Org adopts new technologies or is given new implementation responsibilities
3. Change in management (admin change)
4. Change in a larger scale program
Managerial Leadership
-A manager must determine, initiate, integrate, and oversee the work of others
-mold internal and external agreement on the org's purposes/priorities
-build support for the organization among stakeholders
-strike a balance among the economic and professional interests of the org's members
-negotiate and maintain effective relationships with people and organizations
Transformational v Transactional Leadership
Transformational: accomplished through decisions about organizational mission and structure, resources, priorities, quality and other performance standards
--ability to instill a common vision of what the org is to accomplish and how
Transactional: leaders help meet certain needs of the followers if they perform to the leader's expectations
Basic Management Skills that facilitate organizational leadership
-communication so everyone is on the same page
-conflict resolution and mobilize widespread commitment
Managerial Competencies Necessary for Operation
1. Policy- ability to successfully analyze the public policymaking process, accurately assess its impact on the org's responsbility, and successfully influence the process
2. Conceptual- ability to envision the org's roles in the larger context in which it exists. Allows managers to ID, understand, and interact with external and internal stakeholders. Also enhances manager's ability to visualize future of their org
3. Technical- knowing how to effectively strategize, lead, and design, and actual work of the org
4. Interpersonal- cluster of knowledge related to the human interactions. Must be able to develop and instill a common vision and stimulate motivation. Not only interpersonal relationships within the org but among or b/t other orgs.
5. Collaborative- ability to partner with other entities, negotiate, and produce mutually beneficial outcomes
Interagency Collaboration
The ability to develop shared cultures and minimize the differences that exist between collaborating entities
--often times policy initiatives require coordinated action among many agencies.
--successful implementation depends on how smooth interactions among agencies are
3 problem Health Care Reform is addressing
Healthcare Reform
Changing public policies affecting the delivery of healthcare in the country by expanding access to coverage, increasing quality and affordability
Process by which groups of people ake collective decisions
---relationships are a key component
History of Healthcare Reform
Teddy Roosevelt- AMA opposed to any health care reform and used socialist rhetoric to influence policy
FDR- social security but health care reform not on agenda because it was not feasible
2 Truman- AMA still a stumbling bloack but passed hospital construction act, which financed buildings of hospitals, labs and research
Eisenhower- no push for reofrm but created the health education welfare department now known as HHS
----health was becoming an issue for people after coming back from war
Johnson- Medicare/Medicaid
Nixon- economy so bad, universal health care no feasible
Reagan- Prospective payment system where prices are fixed in advance
Clinton- fail to pass his health reform
Obama - Affordable Care Act
US Health System Facts from speaker
-50 million people (8.7 million children) have no insurance
-more than 1/3 of people with insurance fear they will lose it
-US spends $1.4 trillion on health care
-Well insured believe insurance companies are compromising their health
-yearly avg premium increases of 12-16% are forcing organizations to drop employee coverage
Objectives of Obama Reform
-Plan that covers everyone
-If you have insurance, keep it, but spend less on premiums
-Nobody turned away from preexisting condition
-everyone able to buy a plan similar to federal employees'
-all medical services covered
-high standards for quality and efficiency
-if you can't afford insurance, there are subsidies available
Basics of Pre-existing Condtion Law
-create temporary pre-existing condition insurance plans for people who are not insured
-to qualify, must be uninsured for 6 months
-federally funded
-available in each state until 2014
Basics of Affordable Care Act
-children remain on parents' insurance until 26
-may be married, but spouses and children not eligible
Other components of the reform act
-expand Medicaid to people under 65 with incomes up to 133% of the poverty level
-create new health insurance exhcanges where individuals and small employers purchase coverage (market place)
-provide premium subsidies to eligible families with incomes up to 400% the poverty level
Obama's approach to passing health care reform
1. Meet with AMA to diffuse opposition
--need to build relationships to make reform politically feasible
2. Let congress write the bill
3. Do not emphasize problem of the uninsured-
--uninsured = poor people that don't vote
--focus on lowering premiums for middle class
4. Move FAST
--big campaign process, need to show results
--Scott Brown won, changing numbers of Democrats to support bill in Congress
Population Health
comprehensive framework for understanding and improving the health and well being of a defined population
Public Health
tal actions to improve health; its core functions relate to assessment, assurance, and policy setting; the domain of government agencies or their agents
Medical Care
health care services provided to individual patients, generally in response to acute or chronic illness
Health Policy
the planning, development and implementation of interventions designed to maintain and improve the health of a group of individuals
--attempts to maximize use of research, evaluation, and analysis
Evidence based public health policy
attempts to rely on scientific empiricism and analysis to accomplish the assessment, development, and assurance functions
applies scientific empiricism to help guide clinical decisions of providers and delivery systems
Goal of Health Policy
1. decrease health status inequalities
2. improve health of the population
Ways to achieve health policy goals
1. Use stronger evidence/develop knowledge
--measure health status of population
--analyze determinants of health
2. Base decisions on evidence- health status, determinants, interventions
--analysis of health issue priority setting
--taking action and evaluating results
3. Use multiple strategies to address issues
--increase investment in public health
--accountability for outcomes
--intersectional colloboration
Reasons for problems in our health system
1. little infrastructure to provide coordinated population-oriented care
2. evidence-based medicine not widespread
3. procedurally focused
--fee for service
--specialized care dominates PCP and preventive care
Policy modification v initiation
initiation: the establishment of an orginial public law (resulting from initial development of legislation in the formulation phase)
Modification- results when the consequences of existing policies feed back into the agenda-setting and legislation development stages to stimulate changes
Incrementalism in regards to US policymaking
The U.S public policymaking process consists of continual modification of policies and these changes are modest
--we like this approach because building on existing policies via modification in small steps allows our economic and social systems to adjust without being threatened by change
--effects of policy play out slowly and sometimes predictably
--increases likelihood of reaching compromises among diverse interests
When can modification of policies take place?
1. Agenda Setting
2. Legislation development
3. Rulemaking
4. Operation
Modification in Policy Formulation Phase
routinely begins here because problems already receiving attention become better defined and understood
--possible solutions can be assessed better based on experience
--interactions among govt and interest groups affected become important components during reformulation of future policies
--policies already have developmental history and an implementation experience which influence its modification
Modification in Policy Implementation Phase
Occurs in the rulemaking or operation phases
--existing policies modified most frequently thorugh changes in the rules used to guide their implementation
--Managers responsible for operating a law have many opportunities to modify the policy in terms of its effect on those affected by the law
--stimulus for modification comes from internal and external influences
Structural features of Modification
1. Oversight actors
2. results of formal analyses/assessments of policy performance
Role of oversight actors in policy modification
3 branches of govt are the actors
--legislative: oversight goes to committees. Appropriation committees are most important by using budget review mechanism
--executive: monitor implmentation and initiate adjustments when needed. OMB especially helpful in analyzing effectiveness of organizations.
--courts determine when modification is needed based on how laws are interpreted and enforced. Its most direct modifying effect is on implmentation- ensuring appropriate application of laws and supporting its rules
Role of the OMB in Modification
1. helps forumlate president's spending plans
2. evaluates effectiveness of agency programs and procedures
3. assess competing funding demands among agencies
4. sets funding priorities
5. overall, improve the management of policy implementation
Effective policy analysis that leads to good modification entails...
a continuum of analytical activities that begin in agenda setting and support the entire policymaking process (not after the policy is implemented)
continuum of analytical activities is categorized as?
-ex-ante policy analysis
-policy maintenance
-policy monitoring
-ex-post policy analysis
Ex-ante policy analysis
"anticipatory" and influences agenda setting
--helps decision makers clarify the problems they face and ID potential solutions to the problem
--includes analysis of cost/benefits of alternatives
--any quantifying information that helps ID political consequences and implications of policy
Policy Maintenence
helps ensure policies are implemented as formulators designed them to be
--analysis that is part of legislative oversight and managerial control
--usually makes changes during implementation
Policy Monitoring
measuring and recording of the ongoing operation of a policy's implementation
Ex-post policy analysis
determine the real value of a policy
--assessment of the degree to which policy objectives are achieved through its implementation
Analyses based on Before-and-After Comparisons
compares conditions before a policy is implemented with conditions after it has an opportunity to affect society
--most widely used
Analyses based on With-or-Without Comparisons
assessing consequences of policy for individuals and comparing them to situations in which the policy does not exist
--prevail in health policy domain because of variation among states
Analyses based on Actual-vs-Planned Performance Comparisons
comparing policy objectives with actual post implementation improvements
experimental analytical designs
permits more meaningful conclusions
--individuals are randomly assigned to controls groups
--expensive and difficult to conduct
Cost-benefit analysis and Cost-effectiveness analysis
-important in the search of policies that provide value for public dollars
--CBA evaluation is based on relationships between benefits and costs of a policy. Analyses result in a measure of net benefits
--CEA- performance assmessment based on the desire to achieve objectives in the least costly way (find alternative solutions to a policy that are cost efficient)
Government Accountability Office
"Congressional Watchdog" - investigates how the goverment spends taxpayer $$.
--provides Congress with information that is objective, fact-based, nonpartisan
--pretty independent
--conducts wide range of policies so has a diverse staff
GAO supports congressional oversight by...
1. auditing agency operations to determine whether federal funds are being spent efficiently/effectively
2. investgating illegal/improper activities
3. reports on how well government programs are meeting their objectives
4. performing policy analyses and outlining options for consideration
5. issuing legal decisions and opinion
Congressional Budget Office (CBO)
provides congress with analyses needed for economic and budget decisions and information and estimates required for the budget process
--mission is narrow and focused
--helps Congress formulate budget plans and helps them stay within these plans
--helps assess impact of federal mandates
--helps consider impact of policies on the federal budget but no specific policy recommendations
Congressional Research Service
provide Congress with info that would allow it to make more informed decisions
--offers expert congressional testimonies, reports on current legislative issues, and briefings
--assists at every stage of the policy process
--staff is over 450
--organized by 5 categories clustered around American law
IOM report findings
1. uninsured individuals under 65 is large and increasing
2. uninsured children and adults do not receive the care they need and suffer from poorer health
3. one uninsured person in a family can put the family's financial stability at risk
4. high uninsured rate adversely affects overall health status of the population and its healthcare institions
What is the relationship between an organization's external environment and its performance?
External environment = policy changes, biological, cultural, economic, social etc dimensions
--These factors yield opportunities and threats to which organizations must respond strategically
--Implementation of these strategies affect its structures and produce a degree of performance
3 main types of organizations in the healthcare system
1. Primary Health Service Providers
2. Secondary Provider Organizations (provide resources for primary orgs to use such as education systems, insurance companies, pharmaceutical companies)
3. Health related interest groups
Horizontal vs Vertical integration of health organizations
Horizontal: organizations relate to each other on a continuum to provide coordinated care to patients (mergers, acquitiions)
Vertical: multiple organizations unify in systems to provide continuum of care
Policy Competence
cluster of related knowledge skills and ability that permit one to successfully:
--analyze public policymaking process and its effect on one's domain of interest
--influence the process
--seeing the policy process as a decision-making process
Formal v. Informal Organization Designs
formal- intentional patterns of relationships established by managers
informal-- structures that exist because people working together within formal designs establish relationships that lie outside the boundaries of the formal structure

**organizations with policy interests can build formal structures to effectively analyze their public policy enivronment and influence it
Benefits of effective policy environment analysis
the organization can...
--classify and organize complex information about the policy process and the forces that affect it
--ID current policies that will affect the org
--ID formulation of emerging policies that will affect the org
--speculate about potential policeis
--link information about policies to the organization's objectives, strategies, and performance
Steps for an effective analysis of a public policy environment
1. Scanning (who or what?)
--ID relevant policy issues: the policy itself, solutions, and political circumstances
--one approach is ad hoc task force to render a collective opinion or consultants
2. Monitoring
--tracking the strategic policy issues IDed
--much narrower focus than scanning- usually track only a couple of issues that change slowly over time
3. Forecasting
--extending the issues beyond their current state- simply the future direction of policy issues, which gives leaders time to formulate a response
4. Assessing
--characterizing importance of the issues for the org usually through opportunities and threats
5. Diffusing
--spreading the results among those in the org who can help formulate and implement its response
Methods of forecasting changes in public policy issues
Trend Extrapolation
--tracking an issue and using the information to predict future changes
--must understand the history of the policy
--works best under stable conditions not when there are sudden changes
Scenario Development
--a plausible story given the many uncertainties in the health environment
--define several alternative scenarios and use to create a response
Ways for Leaders to Diffuse Information about the policy environment
1. use power to dictate diffusion
2. use reason to persuade all who are affected
3. use education of participants to emphasize and convince everyone
4 philosophical principles guiding policymaking
-Respect for Autonomy of others
---rights of individuals to independent self-determination
---fairness- much of health policy is in terms of fairness in the distribution of health-related benefits and burdens on society
--participants in the process seek to do good
--make decisions to minimze harm
3 views of Justice
1. Egalitarian Perspective
--everyone should have equal access to the benefits and burdens arising from the pursuit of health (Medicare)
2. Libertarian Perspective
--max of social and economic liberty for indivudals. Policies favoring unrestrained markets as a way to distribute benefits/burdens
3. Utilitarian Perspective
--public utility is maximized- greatest good for greatest number of people
places to influence policymaking
1. Policy formulation
- at agenda setting by defining problems, developing solutions, and shaping political circumstances through lobbying OR at legislation by participating in drafting or testifying at hearings
2. Policy Implementation
--At rulemaking by providing formal comments on draft rules or serving on rulemaking advisory comms OR at policy operation by interacting with policy implementers
3. Policy modification
--by documenting the case for modifications through experience and formal evaluations
Limitations of effective policy environment analysis
- nobody can predict the future- only can guess what will happen
- cannot be aware of every aspect of the policymaking process or details
- leaders may not be able to correctly interpret the effect of policies on the org
- leaders may find the org is unable to respond appropriately to emergent policies
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