HSA 4150 Florida International University Global Healthcare Systems and Policy Paper

Find two proper APA Style references for two (2)“External Authoritative Sources” (defined below), discussing healthcare policymaking at the nationallevel (US or other country) and provide a brief paragraph narrative (one paragraph for each of therequired two (2) “external authoritative sources”) incorporating proper APA in-text citations andreference for each source, as well as, a link for each source which leads to the full article referenced isrequired immediately following each reference. “External Authoritative Sources” for purposes of this course shall mean: books, peer reviewed journalarticles, education and government sites as well as non-partisan national or international organizations(such as WHO, UNICEF, UNAIDS etc) provided, the foregoing source/material selected has in textcitations and references to support statements made therein. Under no circumstances are newspapers including the Wall Street Journal, blogs (regardless of source), editorials, panel discussions and dot comsites be used. The foregoing are not considered authoritative for this course.

Attached you will find the book. please make sure each paragraph has 6-8 sentences.

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LEIYU SHI
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HAP/AUPHA Editorial Board for Undergraduate Studies
Philip Wessel, Chairman
University of Central Florida
John Cantiello, PhD
George Mason University
Nailya DeLellis, PhD
Central Michigan University
Karen Dielmann, EdD
Pennsylvania College of Health Sciences
Cathleen O. Erwin, PhD
Auburn University
Thomas Gariepy, PhD
Stonehill College
Jennifer B. Groebner, EdD
Governors State University
David A. Rosenthal, PhD
Baptist College of Health Sciences
MaryMargaret Sharp-Pucci, PhD
Loyola University Chicago
Aaron C. Spaulding, PhD
Mayo Clinic
M. Scott Stegall, PhD
Clayton State University
Michael K. Stowe, PhD
University of St. Francis
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LEIYU SHI
Health Administration Press, Chicago, Illinois
Association of University Programs in Health Administration, Washington, DC
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Your board, staff, or clients may also benefit from this book’s insight. For information on quantity discounts,
contact the Health Administration Press Marketing Manager at (312) 424-9450.
This publication is intended to provide accurate and authoritative information in regard to the subject matter
covered. It is sold, or otherwise provided, with the understanding that the publisher is not engaged in rendering
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The statements and opinions contained in this book are strictly those of the author and do not represent the
official positions of the American College of Healthcare Executives, the Foundation of the American College of
Healthcare Executives, or the Association of University Programs in Health Administration.
Copyright © 2019 by the Foundation of the American College of Healthcare Executives. Printed in the United
States of America. All rights reserved. This book or parts thereof may not be reproduced in any form without
written permission of the publisher.
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Library of Congress Cataloging-in-Publication Data
Names: Shi, Leiyu, author.
Title: Introduction to health policy / Leiyu Shi, Gateway to Healthcare Management.
Description: Second edition. | Chicago, Illinois : Health Administration Press, HAP ; Washington, D.C. :
Association of University Programs in Health Administration, AUPHA, [2019] | Includes bibliographical
references and index.
Identifiers: LCCN 2018040567 (print) | LCCN 2018041419 (ebook) | ISBN 9781640550261 (ebook) |
ISBN 9781640550278 (xml) | ISBN 9781640550285 (epub) | ISBN 9781640550292 (mobi) | ISBN
9781640550254 (print : alk. paper)
Subjects: LCSH: Medical policy—History. | Health care reform. | Public health—International cooperation.
Classification: LCC RA393 (ebook) | LCC RA393 .S473 2019 (print) | DDC 362.1—dc23
LC record available at https://lccn.loc.gov/2018040567
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A division of the Foundation of the
American College of Healthcare Executives
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Chicago, IL 60606-6698
(312) 424-2800
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Association of University Programs
in Health Administration
1730 M Street, NW
Suite 407
Washington, DC 20036
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11/21/18 10:55 AM
I dedicate this book to my wife, Ruoxian,
and my children, Sylvia, Jennifer, and Victor Shi.
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BR I E F CON T E N TS
Preface………………………………………………………………………………………………………..xiii
PART I Introduction
Chapter 1 Overview of Health Policy……………………………………………………………….3
PART II Health Policymaking
Chapter 2 Federal Health Policymaking………………………………………………………….37
Chapter 3 Health Policymaking at the State and Local Levels
and in the Private Sector…………………………………………………………70
Chapter 4 International Health Policymaking………………………………………………..102
PART III Health Policy Issues
Chapter 5 Health Policy Related to Financing and Delivery……………………………..131
Chapter 6 Health Policy for Diverse Populations……………………………………………155
Chapter 7 International Health Policy Issues………………………………………………….202
PART IV Health Policy Research
Chapter 8 Overview of Health Policy Research………………………………………………255
Chapter 9 Health Policy Research Methods…………………………………………………..292
Chapter 10 An Example of Health Policy Research…………………………………………..339
vii
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viii
Brief Contents
Glossary……………………………………………………………………………………………………..375
Index…………………………………………………………………………………………………………..383
About the Author………………………………………………………………………………………407
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D ETA I L E D C O N TE N TS
Preface………………………………………………………………………………………………………..xiii
PART I Introduction
Chapter 1 Overview of Health Policy……………………………………………………………….3
Learning Objectives………………………………………………………………………..3
Case Study 1: Healthcare Reform: Hillary Clinton
and Barack Obama………………………………………………………………….4
Case Study 2: Healthcare Reform After the ACA…………………………………5
Health Defined……………………………………………………………………………..6
Public Health Defined…………………………………………………………………….9
What Are the Determinants of Health?……………………………………………10
Policy Defined……………………………………………………………………………..18
Health Policy Defined…………………………………………………………………..19
What Are the Determinants of Health Policy?…………………………………..21
Stakeholders of Health Policy…………………………………………………………25
Why Is It Important to Study Health Policy?…………………………………….27
Key Points…………………………………………………………………………………..28
Case Study Questions……………………………………………………………………29
For Discussion……………………………………………………………………………..29
References…………………………………………………………………………………..30
PART II Health Policymaking
Chapter 2 Federal Health Policymaking………………………………………………………….37
Learning Objectives………………………………………………………………………37
ix
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x
Detailed Contents
Case Study 1: The Development of Medicare and Medicaid………………..38
Case Study 2: The Health Insurance Portability and Accountability
Act of 1996………………………………………………………………………….39
The US Political System………………………………………………………………..40
Policymaking Process at the Federal Level…………………………………………42
Attributes of Health Policymaking in the United States………………………54
Role of Interest Groups in US Health Policymaking…………………………..58
Key Points…………………………………………………………………………………..62
Case Study Questions……………………………………………………………………62
For Discussion……………………………………………………………………………..63
References…………………………………………………………………………………..63
Additional Resources…………………………………………………………………….68
Chapter 3 Health Policymaking at the State and Local Levels
and in the Private Sector…………………………………………………………70
Learning Objectives………………………………………………………………………70
Case Study 1: Massachusetts Healthcare Reform……………………………….71
Case Study 2: Connecticut Opioid Response Initiative……………………….71
State Government Structure…………………………………………………………..73
Local Government Structure………………………………………………………….79
Private Health Research Institutes…………………………………………………..81
Private Health Foundations……………………………………………………………82
Private Industry……………………………………………………………………………84
Attributes of Health Policy Development in Nonfederal Sectors…………..89
Key Points…………………………………………………………………………………..91
Case Study Questions……………………………………………………………………92
For Discussion……………………………………………………………………………..92
References…………………………………………………………………………………..93
Chapter 4 International Health Policymaking………………………………………………..102
Learning Objectives…………………………………………………………………….102
Case Study 1: WHO Healthy Cities Initiative…………………………………103
Case Study 2: Primary Care Workforce Around the World………………..104
The World Health Organization……………………………………………………105
Health Policymaking in Selected Countries…………………………………….109
Key Points…………………………………………………………………………………121
Case Study Questions………………………………………………………………….121
For Discussion……………………………………………………………………………122
References…………………………………………………………………………………122
Additional Resources…………………………………………………………………..128
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Detailed Contents
xi
PART III Health Policy Issues
Chapter 5 Health Policy Related to Financing and Delivery……………………………..131
Learning Objectives…………………………………………………………………….131
Case Study 1: The Federally Funded Health Center Program:
Providing Access, Overcoming Disparities……………………………….132
Case Study 2: Precision Medicine………………………………………………….133
Financing US Healthcare……………………………………………………………..134
US Healthcare Delivery……………………………………………………………….139
Policy Issues in Healthcare Financing and Delivery………………………….145
Key Points…………………………………………………………………………………149
Case Study Questions………………………………………………………………….150
For Discussion……………………………………………………………………………150
References…………………………………………………………………………………151
Chapter 6 Health Policy for Diverse Populations……………………………………………155
Learning Objectives…………………………………………………………………….155
Case Study 1: The Health Center Program……………………………………..156
Case Study 2: My Health GPS Program for Patients
with Multiple Chronic Conditions…………………………………………157
Defining Vulnerability…………………………………………………………………158
Health Policy Issues for Diverse Populations……………………………………159
Health Policy Issues for Vulnerable Subpopulations………………………….168
Key Points…………………………………………………………………………………184
Case Study Questions………………………………………………………………….184
For Discussion……………………………………………………………………………185
References…………………………………………………………………………………185
Chapter 7 International Health Policy Issues………………………………………………….202
Learning Objectives…………………………………………………………………….202
Case Study 1: Climate Change and Public Health……………………………203
Case Study 2: Primary Care Around the World……………………………….204
Health Policy Issues in Developed Countries…………………………………..207
Health Policy Issues in Developing Countries………………………………….217
Key Points…………………………………………………………………………………236
Case Study Questions………………………………………………………………….237
For Discussion……………………………………………………………………………237
References…………………………………………………………………………………237
Additional Resources…………………………………………………………………..250
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xii
Detailed Contents
PART IV Health Policy Research
Chapter 8 Overview of Health Policy Research………………………………………………255
Learning Objectives…………………………………………………………………….255
Case Study 1: The RAND Health Insurance Experiment…………………..256
Case Study 2: Idaho’s Preventive Health Assistance Program………………257
Defining Health Policy Research…………………………………………………..258
The Process of Health Policy Research……………………………………………265
Communicating Health Policy Research…………………………………………276
Implementing Health Policy Research……………………………………………279
Key Points…………………………………………………………………………………285
Case Study Questions………………………………………………………………….286
For Discussion……………………………………………………………………………286
References…………………………………………………………………………………287
Chapter 9 Health Policy Research Methods…………………………………………………..292
Learning Objectives…………………………………………………………………….292
Case Study 1: Health Centers and the Fight
Against Health Disparities in the United States………………………..293
Case Study 2: Vermont’s Accountable Communities
for Health Learning Lab……………………………………………………….294
Quantitative Methods…………………………………………………………………295
Qualitative Methods……………………………………………………………………314
Key Points…………………………………………………………………………………326
Case Study Questions………………………………………………………………….326
Case Study Assignment……………………………………………………………….327
For Discussion……………………………………………………………………………327
References…………………………………………………………………………………327
Additional Resources…………………………………………………………………..338
Chapter 10 An Example of Health Policy Research…………………………………………..339
by Sarika Rane Parasuraman
Learning Objectives…………………………………………………………………….339
Questions for Policy Analysis………………………………………………………..340
Policy Analysis: Responses to Exam Questions………………………………..341
Key Points…………………………………………………………………………………366
For Discussion……………………………………………………………………………366
References…………………………………………………………………………………367
Glossary……………………………………………………………………………………………………..375
Index…………………………………………………………………………………………………………..383
About the Author………………………………………………………………………………………407
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P RE FA C E
U
S policymakers have been struggling for years to find solutions to our healthcare
challenges. Thus, healthcare reform is among the top priorities of almost every
administration. This introductory textbook on US health policy covers the related
areas of health policymaking, critical health policy issues, health policy research, and an
international perspective on health policy and policymaking. The book offers the following
features:
◆◆ Real-world cases to exemplify the theories and concepts presented from a
variety of perspectives, including the hospital setting, public health, managed
care, ambulatory care, and extended care
◆◆ Exhibits and extra feature boxes (Learning Points, For Your Consideration,
Key Legislation, Research from the Field, International Policymaking, Global
Health Impact, and others) that present background information on concepts,
examples, and up-to-date information
◆◆ Learning objectives and key points
◆◆ Discussion questions
O r g a ni z at i on
of the
B oo k
This book is organized in four parts: an introduction, an overview of health policymaking, a
health policy issues section, and a discussion of health policy research and analysis. Chapter 1,
the sole chapter in part I, introduces key terms related to, and the determinants of, health
xiii
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xiv
 Preface
and health policy. It lists the key stakeholders in health policymaking and presents important
reasons for studying health policy. The chapter lays the foundation for the rest of the book.
Part II—containing chapters 2, 3, and 4—examines the policymaking process at the
federal, state, and local levels; in the private sector; and in international settings. Chapter 2
focuses on the policymaking process at the federal level of the US government. Important
activities within the three policymaking stages—policy formulation, policy implementation,
and policy modification—are described. The key characteristics of health policymaking in
the United States are analyzed, and the role of interest groups in making policy is discussed.
Chapter 3 focuses on the US policymaking process at the state and local levels and in
the private sector, which includes the research community, foundations, and private industry.
Examples of policy-related research by private research institutes and foundations are described.
The impact of the private sector’s services and products on health and policy is illustrated
using the fast-food industry as well as tobacco and pharmaceutical companies as examples.
Chapter 4 discusses international health policymaking. The World Health Organization (WHO) is presented as an example of an international agency involved in policymaking related to health and major health initiatives. Three countries—Canada, Sweden, and
China—are highlighted to illustrate diverse policymaking processes in distinct geographic
regions. The experiences of these countries show that different political systems and policymaking processes lead to diverse approaches to population health and healthcare delivery.
Part III—encompassing chapters 5, 6, and 7—examines the policy issues related to
social, behavioral, and medical care health determinants; to people from diverse or medically or socially vulnerable populations; and to international health. Chapter 5 describes
how US healthcare is financed and delivered. Private and public health insurance programs
are summarized, and the subsystems of healthcare delivery—managed care plans, safety net
providers, public health programs, long-term care services, and military-operated healthcare—are introduced. After summarizing the major characteristics of US healthcare delivery,
the chapter provides examples of health policy issues related to financing (cost containment)
and delivery (healthcare workforce, professional accreditation, antitrust regulations, patient
access to care, and patient rights).
Chapter 6 defines medically and socially vulnerable populations and discusses the
dominant healthcare policy issues related to those populations. People from diverse populations include members of racial or ethnic minorities, the uninsured, people with low
socioeconomic status, the elderly, people with chronic illness, people with mental illness,
women and children, people with disabilities, the homeless, and people with HIV/AIDS.
In each segment, the magnitude of the problem is summarized and a detailed discussion of
the policies and strategies meant to address the problem is presented.
In chapter 7, dominant health policy issues in the international community are
discussed, with examples given for select countries, to help students understand not only
international health policy applications but also the field of global health. The chapter begins
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 Preface
xv
by examining issues shared by developed countries, such as modifying health systems to
better serve aging and diverse populations while maintaining high-quality care at a low cost.
It then discusses challenges faced by developing nations, such as controlling the spread of
disease, creating and maintaining high-functioning health systems with limited resources,
and dealing with the burdens of morbidity and mortality associated with poverty. Several
emerging issues are also illustrated that could affect global health in the future.
Part IV—comprising chapters 8, 9, and 10—presents an overview of policy analysis,
focusing on examples of commonly used quantitative and qualitative methods. Chapter 8
introduces health policy research (HPR) and highlights the discipline’s defining characteristics,
including applied, policy-relevant, ethical, multidisciplinary, scientific, and population-based
studies. The HPR process is summarized, and the chapter concludes with a discussion of
ways to communicate findings and the challenges in implementing those findings in practice.
Chapter 9 illustrates commonly used methods in HPR. Quantitative methods include
experimental research, survey research, evaluation research, cost–benefit analysis, and costeffectiveness analysis. Because evaluation research is closely tied to policy research, the process
involved in this type of research is described in greater detail. Qualitative methods include
participant observations, in-depth interviews (including focus groups), and case studies.
Examples of published studies using these methods are provided.
Chapter 10 provides an example that illustrates the key steps in health policy analysis: assessing the determinants of a health problem, identifying a policy intervention to
address the problem, critically evaluating the policy intervention, and proposing next steps
in addressing the problem.
New
to
T h i s E d i t i on
This second edition has retained most of the features of the first edition. In addition, significant updates have been made in the following key areas.
C ase S tudies
Each of the chapter-opening case studies from the first edition has been revised or replaced,
and a new, second case study has been added to chapters 1–9.
H ealthc are R ef orm
The latest developments in healthcare reform and legislation have been incorporated into the
book, especially in chapters 2 and 3 and in the many additions to the chapters in part III.
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xvi
 Preface
I nternati onal H ealth P olicy
The international health policy chapters (chapters 4 and 7) have broadened in scope with
more examples from the array of countries discussed in the book. New WHO initiatives
have also been added.
U pdated C ontent T hroughout
Content, references, and data (including in relevant exhibits) have been updated throughout. New and revised content includes coverage of the impact of the Affordable Care Act,
new healthcare reform directions, the patient-centered medical home, accountable care
organizations, precision medicine and big data, state and local healthcare reform activities,
private-sector initiatives, and the pharmaceutical industry. More examples of applications
in research have been added.
A c k n o w l e d gm e n t s
My PhD advisee Sarika Rane Parasuraman contributed chapter 10 (an applied example) and
is hereby acknowledged. The editorial staff of Health Administration Press have provided
hands-on assistance in editing the manuscript. Of course, all errors and omissions remain
my responsibility.
Leiyu Shi
i n str u CtOr r esOu r Ces
This book’s Instructor Resources include a test bank, PowerPoint slides for each
chapter, and answer guides for the book’s discussion questions.
For the most up-to-date information about this book and its Instructor Resources,
go to ache.org/HAP and search for the book’s order code (2374).
This book’s Instructor Resources are available to instructors who adopt this book for
use in their course. For access information, please e-mail hapbooks@ache.org.
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PA R T I
I N T R O D UCTION
T
he introduction, which consists of chapter 1, provides an overview of health policy. It defines
key terms related to health policy, reviews the framework of health determinants, and outlines
the concept of health policy formulation. In addition, the chapter introduces topics related to
health policy, including stakeholders, major types of health policies, and the importance of studying
health policy. The introduction provides readers with a foundation for examining how health policy
is established in the United States and elsewhere.
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CHAPTER 1
OV E R V I E W O F HE ALTH P OLICY
I have never had a policy. I have simply tried to do what seemed best each day, as
each day came.
—Abraham Lincoln
The health and vitality of our people are at least as well worth conserving as their
forests, waters, lands, and minerals, and in this great work the national government
must bear a most important part.
—Theodore Roosevelt
Learning Objectives
After completing this chapter, you should be able to
➤➤
define key terms related to health policy,
➤➤
appreciate the influence of health determinants,
➤➤
understand the framework of health policy formulation,
➤➤
identify the stakeholders in health policy,
➤➤
describe the major types of health policies, and
➤➤
discuss the importance of studying health policy.
3
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4
Introduction to Health Policy
Case Study 1
H e a lt h c a r e R e f o rm : H illary C lint on
and
B ara ck O b ama
Two major healthcare reform initiatives have played out on the US political landscape since
the late twentieth century: the Health Security Act, developed by the Clinton administration
in the 1990s and spearheaded by First Lady Hillary Clinton, which failed to pass into law, and
the Affordable Care Act (ACA), drafted by the Obama administration, which became federal law
in March 2010.
The hallmark of the Clinton plan was its universal coverage mandate, which required all
employers to contribute to a pool of funds to cover the costs of insurance premiums for their
workers, with caps on total employer costs and subsidies for small businesses. Competition
among private health plans and a cap on the growth of insurance premiums were to have held
costs in check, and additional financing was to have been provided through savings from cuts
in projected Medicare and Medicaid spending and increased taxes on tobacco (Oberlander
2007; Pesko and Robarts 2017).
The Obama plan focused on reforming the private health insurance market, extending
insurance coverage to the uninsured, providing better coverage for those with preexisting conditions, improving prescription drug coverage in Medicare, and extending the life of Medicare
trust fund accounts. The ACA was expected to be financed through taxes, such as a 40 percent
tax on “Cadillac” insurance policies (policies that offer the richest benefits) and taxes on
pharmaceuticals, medical devices, and indoor tanning services (KFF 2013), and through other
offsets or provisions of the law that reduce the overall cost of enacting legislation, such as
penalties on uninsured individuals.
The political landscape in 2009, as President Barack Obama’s healthcare reform initiative was being debated, was similar to that in the early 1990s: Both the Clinton and Obama
administrations were affiliated with the Democratic Party, both chambers of the US Congress
were controlled by Democrats, and national opinion strongly favored healthcare reform (Sack
and Connelly 2009).
However, whereas the Obama reform initiative became law, the earlier Clinton healthcare
reform package was defeated in Congress. Although Americans supported healthcare reform
in theory, the Clinton plan was derailed by the heavy opposition of the medical and insurance
industries and by antitax rhetoric. The disenchantment of the electorate following that failed
effort helped Republicans gain control of the House of Representatives and Senate in the
1994 election (Trafford 2010), which all but guaranteed that any further Democratic-designed
proposal would fail due to increasing political polarization in Congress.
After Republican president Donald Trump took office in January 2017, the Trump administration and the Republican-controlled Congress put forth many efforts to “repeal and replace”
the ACA. However, as of mid-2018, none of these attempts had succeeded.
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Chapter 1: Overview of Health Policy
5
Case Study 2
H e a lt hc a r e R e f o r m A f t e r
the
ACA
Healthcare reform continues to be a deeply partisan issue in US politics, and political gridlock
in Congress has made efforts at reform challenging. Since 2010, Republicans in Congress have
unsuccessfully attempted to repeal the ACA, voting more than 60 times to repeal or alter the
law (Cowen and Cornwall 2017). In January 2016, the Republican-controlled House and Senate
passed a bill that would have repealed the ACA, but President Obama, a Democrat, promptly
vetoed it. The Congressional Budget Office (CBO) review of the proposal concluded that the bill
would have canceled health insurance for 22 million people by 2018 (Cubanski and Neuman
2018). In the 2016 presidential election campaign, every Republican candidate vowed to “repeal
and replace” the ACA (Jost 2015). In January 2017, within hours of taking office, President Trump
issued his first executive order, moving to dismantle parts of the ACA (Davis and Pear 2017).
On March 7, 2017, Republicans introduced the two bills that constitute the original
American Health Care Act (AHCA) of 2017, H.R. 1628, to partially repeal the ACA. The Trump
administration announced its support for AHCA. On March 12, 2017, the CBO released its budget
analysis, projecting that 52 million Americans would be left uninsured under the AHCA and those
with insurance would have to pay higher premiums through 2020. On May 4, 2017, the House
narrowly passed the AHCA, by a vote of 217–213, and sent the bill to the Senate for deliberation. On June 22, 2017, the Senate released a discussion draft for an amendment to the bill,
which would rename it the Better Care Reconciliation Act of 2017. On July 28, 2017, the bill was
returned to the calendar after the Senate rejected several amendments, including the Health
Care Freedom Act, or the “skinny bill,” that would have repealed the ACA’s individual mandate
retroactive to 2016 and the employer mandate through 2025.
Does this legislation point to a new phase of healthcare reform whose success hinges
on support from both major political parties? As Wilensky (2017) suggested, Republicans and
Democrats might need to find a way to work together to enact comprehensive healthcare
reform beyond the ACA.
Or, does it signal a new approach toward dismantling the ACA through the administrative
process, such as policy implementation? In reaction to Congress’s repeated failure to repeal
the ACA, on October 12, 2017, President Trump issued Executive Order 13813, directing federal
agencies to expand the use of association health groups—groups of small businesses that pool
together to buy health insurance (Trump 2017).
The Tax Cuts and Jobs Act of 2017, passed and signed into law in December 2017, effectively repealed the mandate in the ACA that required all Americans to have health insurance.
Although the ACA was still the law of the land during the first year of the Trump administration,
many of its components were being modified in Trump’s second year.
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6
gross domestic product
The value of all goods
and services produced
within a country for
a given period; a
key indicator of the
country’s economic
activity and financial
well-being.
Introduction to Health Policy
A
t 16.9 percent of the nation’s total economic activity—also known as the gross
domestic product—healthcare spending in the United States leads all countries
in overall and per capita measures (OECD 2018). Yet the US healthcare system
does not perform well compared with those of other industrialized countries. A 2010 World
Health Organization (WHO) report ranked the US health system thirty-seventh among 191
countries (Tandon et al. 2018). In addition, a Commonwealth Fund study on healthcare
performance ranked the United States behind ten other industrialized countries—Australia,
Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland,
and the United Kingdom—on the basis of quality, efficiency, access, equity, and health
outcome measures (Davis, Schoen, and Stremikis 2014). The US healthcare system also
ranked last in a recent survey of eleven nations (Commonwealth Fund 2017).
Why have health policies tended to fail in the United States while they appear to succeed in other countries? The answer might be found in the context—the United States—and
the determinants of health and health policy in the country.
The main purpose of this chapter is to present a framework of health policy determinants and discuss their impact in the United States. Understanding this framework will help
the reader appreciate factors that contribute to health policy development in general and in
the United States in particular. The chapter first defines key concepts related to health policy
and later discusses the importance of studying health policy, including an awareness of its
international perspective. The stakeholders of health policy are also presented and analyzed
as key parts of the policy context.
H e a lt h D e f i ne d
WHO (1946) defines health as “not merely the absence of disease or infirmity but a state
of complete physical, mental and social well-being.” This broad definition recognizes that
health encompasses biological and social elements in addition to individual and community
well-being. Health may be seen as an indicator of personal and collective advancement. It
can signal the level of an individual’s well-being as well as the degree of success achieved
by a society and its government in promoting that well-being (Shi and Stevens 2010). This
definition of health implies that issues such as poverty, lack of education, discrimination,
and other social, cultural, and political conditions found around the world are essentially
public health issues.
However, health is also the result of personal characteristics and choices. This concept is the source of the fundamental tension in public health and has been a major topic
of discussion in the United States in the twenty-first century. Major debates continue over
whether people can be forced to take actions to ensure their own health, such as buying
health insurance (e.g., the “individual mandate” in the ACA), or be prohibited from performing actions that are unhealthy, such as limiting soft drinks in schools. Health policy in the
United States must attempt to balance the good of the public health with personal liberty,
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Chapter 1: Overview of Health Policy
7
KEY LEGISLATION
What Is the Status of Healthcare Reform in the United States?
In the United States, healthcare reform typically denotes a government-sponsored program
that strives to make health insurance available to the uninsured. Heretofore, healthcare reform
has not quite addressed how healthcare should be delivered, such as in resource allocations
across preventive, primary, and tertiary care settings. Although universal health insurance is
a difficult goal to realize, incremental reforms have been successful when political and economic environments were favorable. The first such program came in the form of the Old Age
Assistance program, which was enacted as part of the 1935 Social Security Act and provided
direct financial assistance to needy elderly persons.
Full health insurance for the elderly became available under the Medicare program, as did
health insurance for the indigent under the Medicaid program. Both programs were created in
1965 under the Great Society reforms of President Lyndon Johnson in an era when civil rights
and social justice had taken central stage in the United States. Later, authorized under the
Balanced Budget Act of 1997, the State Children’s Health Insurance Program—later renamed
the Children’s Health Insurance Program—was developed, whereby states can use federal
funds to cover children up to age 19 through their existing Medicaid programs.
One of the most significant healthcare reform efforts resulted in the Affordable Care Act
of 2010, designed to bring about major changes to the delivery of US healthcare. The key
objective of the ACA was to provide most, if not all, Americans with health insurance coverage.
life expectancy
Anticipated number of
years of life remaining at
a given age.
mortality
Number of deaths in a
given population within
a specified period.
morbidity
Incidence or prevalence
of diseases in a given
often a difficult compromise to make. Indeed, the conflict between the WHO definition of
health and many of the social, cultural, and political issues surrounding the US healthcare
system is one of the most important areas of debate for health policymakers.
population within a
specified period.
disability
A physical or mental
condition that limits
P hysical H ealth
The most common measure of physical health is life expectancy—the anticipated number
of remaining years of life at any stage. Exhibit 1.1 shows the ten countries ranking highest
in their population’s life expectancy as of 2015 and includes the US ranking for comparison.
Although good or positive health status is commonly associated with the definition
of health, the most frequently used indicators measure, instead, lack of health or incidence
of poor health—for example, mortality, morbidity, disability, and various indexes that
combine these factors. One such measure is quality-adjusted life years, which combines
mortality and morbidity in a single index. The Learning Point box titled “Measures of
Mortality, Morbidity, and Disability” lists categories by which each indicator is measured.
00_Shi (2374) Book.indb 7
an individual’s ability
to perform functions
considered normal.
quality-adjusted life
years
A combined mortality–
morbidity index that
reflects years of life
free of disability and
symptoms of illness.
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Introduction to Health Policy
Exhibit 1.1
Top Ten Countries
with the Longest
Life Expectancy,
with the United
States as
Comparison
Life expectancy at birth (years)
Rank Country (state/territory)
Overall
Male
Female
1
Japan
83.9
80.8
87.1
2
Switzerland
83.0
80.8
85.1
3
Spain
83.0
80.1
85.8
4
Italy
82.6
80.3
84.9
5
Australia
82.5
80.4
84.5
6
Iceland
82.5
81.2
83.8
7
Norway
82.4
80.5
84.2
8
France
82.4
79.2
85.5
9
Sweden
82.3
80.4
84.1
10
Korea
82.1
79.0
85.2
26
United States
78.8
76.3
81.2
Source: Data from OECD (2018).
M ental H ealth
In contrast to physical health, measures of mental health are limited. The major categories of mental health measures are mental conditions (e.g., depression, disorder, distress),
behaviors (e.g., suicide, drug or alcohol abuse), perceptions (e.g., perceived mental health
status), satisfaction (e.g., with life, work, relationships), and services received (e.g., counseling, drug treatment).
Mental illness ranks second, after ischemic heart disease, as a nationwide burden
on health and productivity (SAMHSA 2016). An estimated 17.9 percent of the US adult
population in 2014 had at least one diagnosable mental disorder, only 41 percent of whom
received any treatment (SAMHSA 2016). Serious mental illness costs the United States
$193.2 billion in lost earnings per year (SAMHSA 2016). Mental illness is a risk factor for
death from suicide, cardiovascular disease, and cancer. Mental health problems are frequently
associated with social problems. For example, with easy access to guns, mental health often
contributes to gun violence in both public and private settings.
S ocial W ell -B eing
The most commonly used measure of relative social well-being is socioeconomic status (SES).
An SES index typically considers such factors as education level, income, and occupation.
Quality of life is another common measure and may include the ability to perform various
roles (e.g., self-care, family care, social functioning), perceptions (e.g., emotional well-being,
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9
LEARNING POINT
Measures of Morbidity, Mortality, and Disability
Morbidity measures

Incidence of specific diseases: number of new cases in a defined population within a
specified period

Prevalence of specific diseases: number of instances in a defined population within a
specified period
Mortality measures

Crude (unadjusted for any other factors) death rate

Age-specific death rate

Condition-specific death rate

Infant death rate

Maternal death rate
Disability measures

Restricted activity days (e.g., bed days, work-loss days)

Limitations in performing activities of daily living (i.e., bathing, dressing, toileting, getting into or out of a bed or a chair, continence, eating)

Limitations in performing instrumental activities of daily living (i.e., doing housework
and chores, grocery shopping, preparing food, using the phone, traveling locally,
taking medicine)
social contacts
The frequency of social
activities a person
undertakes within a
pain tolerance, energy level), and living environment (e.g., pollution levels, crime prevalence). A third set of social well-being measures, often used by sociologists, is composed of
social contacts and social resources. Examples of social contacts include visits with family
members, friends, and relatives and participation in social events, such as membership
activities, professional conferences, and church gatherings. The social contacts factor can be
used as an indicator of social resources by determining whether an individual can rely on
social contacts for needed support and company and whether the people involved in these
contacts meet the individual’s needs for care and love.
specified period.
social resources
Interpersonal
relationships with social
contacts and the extent
to which the individual
can rely on the people
involved in these
contacts for support.
P u b l ic H e a lt h D e f i ne d
In the early twentieth century, Winslow (1920) defined public health as “the science and
the art of preventing disease, prolonging life, and promoting physical health and efficiency
through organized community efforts for the sanitation of the environment, the control of
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Introduction to Health Policy
community infections, the education of the individual in principles of personal hygiene, the
organization of medical and nursing service for the early diagnosis and preventive treatment
of disease, and the development of social machinery which will ensure to every individual in
the community a standard of living adequate for the maintenance of health.” It focuses on
prevention and involves the efforts of society as a whole. Public health is intended to protect
lives and improve the health of populations around the globe. Today, the Johns Hopkins
Bloomberg School of Public Health emphasizes the continued importance of public health
in its school motto, “Protecting Health, Saving Lives—Millions at a Time.”
Whereas healthcare is intended to treat, influence, and care for individuals, public
health operates on a larger scale. The field is described by the American Public Health
Association (APHA 2018) as one that “promotes and protects the health of people in the
communities where they live, learn, work and play.”
Public health has broad implications for a population. Successful public health activities
and initiatives can save money by promoting healthy living and prevention, thus reducing
healthcare costs and disease burden. In addition, these activities can improve quality of life, help
children thrive, and reduce the suffering caused by ill health in a population (APHA 2018).
The practice of public health leads to both direct benefits (e.g., healthier children, less chronic
disease, less need for acute care) and indirect benefits (e.g., fewer days missed from school
and work; increased funding available for other initiatives, such as education) for a society.
It is important to remember that public health, healthcare, and health policy are
interconnected areas of study and practice. All three have great influence on health.
W h at A r e
determinants of health
Factors that influence
health status.
Typically, they include
socioeconomic status,
environment, behaviors,
heredity, and access to
medical care.
00_Shi (2374) Book.indb 10
the
D e terminants
of
H ealth ?
Numerous theories on the determinants of health have been proposed since the midtwentieth century. Blum (1974) offered a framework called Force Field and Well-Being
Paradigms of Health, which suggests four major influences—the force fields—on health:
environment, lifestyle, heredity, and medical care. According to Blum, the most important
force field is the environment, followed by lifestyle and heredity. Medical care has the least
impact on health and well-being.
Twenty-first-century models focus on socioeconomic context and health behaviors.
For example, the Dahlgren and Whitehead (2006) model divides factors that influence health
into two categories. Fixed factors, the first category, are unchangeable, such as age, sex, and
genetic makeup. The second category is composed of modifiable factors, such as individual
lifestyle choices; social networks and community conditions; the environment in which one
lives and works; and access to important goods and services, such as education, sanitation,
food, and healthcare. The factors in the second category form layers of influence around the
population, and modifying them positively can improve population health.
Ansari and colleagues (2003) proposed a public health model of the determinants of
health in which these factors are categorized into four major groups: social determinants,
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Chapter 1: Overview of Health Policy
11
healthcare system attributes, disease-inducing behaviors (see the Learning Point box titled
“Prominent Theories on the Causes of Disease”), and health outcomes.
A conceptual framework developed by the WHO Commission on Social Determinants
of Health (2008) focuses on socioeconomic and political context; structural determinants and
socioeconomic position; intermediary determinants, such as material circumstances, socioenvironmental circumstances, behavioral and biological factors, social cohesion, and the healthcare
system; and the impact on health equity and well-being measured as health outcomes.
LEARNING POINT
Prominent Theories on the Causes of Disease
Many of the historically dominant theories related to health focus on disease rather than
well-being. The three most prominent theories of disease causality are germ theory, lifestyle
theory, and environmental theory.
Germ theory gained prominence in the nineteenth century with the rise of bacteriology
(Metchnikoff, Pasteur, and Koch 1939). Essentially, the theory holds that every disease has a
specific cause, which should be identifiable. Knowledge of the cause allows for the discovery
of a cure. Microorganisms, the general causal agent identified by germ theory, are thought to
act independently of the environment. Furthermore, the individual who serves as the host
of the microorganism is the source of the disease, which may then be transmitted from one
person to another—a process known as contagion. Strategies to address the disease focus
on identifying people with symptoms and providing follow-up medical treatment. Much
of biomedical research is still based on germ theory. The traditional concept of the agent,
host, and environment as the epidemiological triangle—epidemiology is the study of factors
controlling the presence or absence of a disease—is also based on the single-cause, singleeffect framework of germ theory.
Lifestyle theory tries to isolate specific behaviors (e.g., exercise, diet, smoking, drinking)
as causes of a disease and identifies solutions on the basis of improving or changing these
behaviors. As with germ theory, lifestyle theory defines problems as they relate to individuals
and focuses solutions on individually tailored interventions.
Environmental theory considers the general health and well-being of individuals more
than it does disease. It maintains that health is best understood by examining the larger
context of community. Traditional environmental approaches focused on poor sanitation,
which was connected to certain infectious diseases. With industrialization and its by-products
of overcrowding and filth, contemporary environmental approaches examine the impact of
production and consumption on emerging health problems. Environmental theory considers disease to be influenced by environmental and social factors. It contends that solutions
should be developed through policy and regulation and focused on systems rather than on
individuals and medical treatment.
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Introduction to Health Policy
Similarly, the US Department of Health and Human Services (HHS) publication
Healthy People 2020 embraced a holistic approach by considering the range of personal,
social, economic, and environmental factors that determine the health status of individuals
or populations (HHS 2010). Planning is now under way for the HHS Healthy People 2030
initiative and includes establishing a framework for the initiative (including the vision, mission, foundational principles, plan of action, and overarching goals) and identifying new
objectives (HHS 2018). In the first phase of the process, an expert advisory committee will
develop recommendations for the HHS secretary on the framework and implementation
of Healthy People 2030. Input from members of the public and relevant stakeholders will
guide the development of recommendations. During the second phase, a federal interagency
workgroup will use the advisory committee’s recommendations to establish objectives for
Healthy People 2030 (Haskins 2017). Exhibit 1.2 delineates the evolution of the Healthy
People initiatives and their respective overarching goals.
Exhibit 1.3 provides an overview of health determinants—environment, individual
characteristics, and medical care (discussed in greater detail in the sections that follow)—as
Exhibit 1.2
Evolution of
Healthy People
Initiatives
Target year
1990
Overarching
goals


Decrease
mortality:
infants to
adults
Increase
independence
among older
adults
2000



Increase span •
of healthy life
Reduce health
disparities
Achieve access •
to preventive
services for all
2010
Increase
quality and
years of
healthy life
Eliminate
health
disparities
2020




Attain high-quality,
longer lives free of
preventable disease,
disability, injury, and
premature death
Achieve health equity;
eliminate disparities
Create social and
physical environments
that promote good
health
Promote quality of life,
healthy development,
and healthy behaviors
across life stages
No. of topic
areas
15
22
28
42
No. of
objectives/
measures
226
312
1,000
approximately 1,200
Source: Healthy People Initiatives of 1990, 2000, 2010, and 2020 (HHS 2010).
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Chapter 1: Overview of Health Policy
Exhibit 1.3
Conceptual
Framework
of Health
Determinants
Environment
– Physical
– Social
Individual
characteristics
– Demographic
– Behavioral
– Socioeconomic
13
Health status
– Physical
– Mental
– Social
Medical care
– Organizing
– Financing
– Delivering
they interact to influence health status. For example, although individual characteristics
and medical care affect health on their own, they also interact to become another type of
factor influencing health.
E nvironment
The environment in this context is composed of the physical and social dimensions of an
individual’s existence over which the individual has little or no control. These dimensions
exert influence at the family, community, and policy levels of society. Environmental determinants have a greater impact on health than the medical care system does.
Physical Dimension
The use of energy sources (e.g., oil, coal) by a population creates certain health hazards in
the physical environment. Those hazards can present themselves in the form of air, noise, or
water pollution, resulting in hearing loss, infectious disease, gastroenteritis, cancer, emphysema, and bronchitis. To address the impact of climate change, WHO has launched the
Climate and Health Country Profile Project (see the For Your Consideration box titled
“WHO Climate and Health Country Profile Project”).
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Introduction to Health Policy
FOR YOUR CONSIDERATION
WHO Climate and Health Country Profile Project
According to WHO (2018), the Climate and Health Country Profile Project “aims to raise awareness of the health impacts of climate change, support evidence-based decision making to
strengthen the climate resilience of health systems, and promote actions that improve health
while reducing carbon emissions. The profiles provide country-specific estimates of current
and future climate hazards and the expected burden of climate change on human health,
identify opportunities for health co-benefits from climate mitigation actions, and track current policy responses at national level.”
The project has been expected to track national progress on climate action in the health
sector through a WHO climate and health country survey conducted every two years and
designed to provide updated information on such aspects as adaptation and resilience
measures, climate and health finance, disease surveillance, emergency preparedness, leadership and governance, mitigation action in the health sector, and national vulnerability and
adaptation assessments (WHO 2018).
The first set of Climate and Health Country Profiles was released in late 2015 and included
more than 40 countries (WHO 2018). Based on the evidence presented in these profiles, WHO
(2015) contended that “placing a price on polluting fuels that reflected their health impacts
would be expected to cut outdoor air pollution deaths by approximately half, reduce carbon
dioxide emissions by over 20 percent, and raise approximately $3 trillion per year in revenue—
over half the total value of health spending by all of the world’s governments.” Collection
of data for a second set of profiles was expected to be completed in late 2017, the results of
which would be compiled and presented in 2019 (WHO 2018).
Social Dimension
The social environment is reflected in a nation’s political, economic, and cultural preferences, which exert significant influence on the health of the population. Characteristics
of an environment’s social dimension include behavioral health factors and demographic
trends. In the United States, for example, rates of psychological stress, homicide, suicide,
and other behavioral health indicators can be attributed in part to crowding, isolation, and
other social environmental factors. In terms of population trends, the increase in the number
of elderly—those aged 65 years or older—as a proportion of the total population will place
increasing pressure on healthcare systems around the world.
I ndividual C harac teristi c s R elated
to
H ealth
Demographic, behavioral, and socioeconomic conditions shape individual characteristics,
which explain much of the variation in health status within populations. As discussed in
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Chapter 1: Overview of Health Policy
15
the following paragraphs, these factors interact with and are influenced by the environment,
thereby affecting individuals’ health.
Demographics
Age, gender, and race or ethnicity are strongly associated with health. Advancing age, for
example, contributes to arthritis, diabetes, atherosclerosis, and cancer. Gender health is
influenced in part by the social construct of gender characteristics, such as the association
between masculine identity and risk-taking.
People also experience significant differences in health status depending on their race
or ethnic origin. Explanations for these differences include SES, behaviors, social circumstances, level of access to healthcare services (CDC 2005a; Filice and Joynt 2017; Gupta et
al. 2018; James et al. 2017; Shi 1999; Shi, Lee, Chung, et al. 2017; Shi, Lee, Haile, et al.
2017; Shi and Stevens 2010), and factors that are associated with particular racial or ethnic
groups (CDC 2012b).
Behaviors
The leading causes of death in the United States have shifted since the beginning of the
twentieth century. In 1900, infectious diseases such as diphtheria, tuberculosis, measles,
and pneumonia caused 797 per 100,000 deaths in the United States; by the end of the
twentieth century, infectious diseases caused fewer than 100 per 100,000 deaths while
chronic diseases such as heart disease and cancer caused significantly higher mortality
(Armstrong, Conn, and Pinner 1999). This “epidemiologic transition” supports the idea
that behavioral risk factors—including poor dietary habits, cigarette smoking, alcohol
abuse, lack of exercise, and unsafe driving—tend to predict higher risk for certain chronic
diseases and mortality. See exhibit 1.4 for examples of the association between risk factors
and leading causes of death.
The level of behavioral risk factors exhibited by a population is related to SES. For
example, the prevalence of smoking is greater among those with less education; in 2011,
45.3 percent of Americans who had obtained a GED (General Educational Development)
certificate reported being a current cigarette smoker, compared with only 5 percent of those
who held graduate degrees (CDC 2012a). Behavioral risk factors are divided into three
categories: leisure activity risks, consumption risks, and employment participation and
occupational risks (Dever 2006). These categories are determined in part by the collective
decisions made by individuals in a particular group that affect their health. The degree of
control they have in these decisions varies by category: Individuals have the least control
over employment and occupational factors, more control over consumption factors, and
the greatest control over leisure activity–related factors.
Destructive behaviors related to employment and occupational risks are usually difficult for individuals to control. To offset such risks, the federal government created regulatory
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Introduction to Health Policy
Exhibit 1.4
The Association
Between Health
Behaviors and
Leading Causes of
Death
Cause of death
Heart
disease
Cancers
Smoking
X
X
High blood pressure
X
High cholesterol
X
Poor diet
X
Obesity
X
Lack of exercise
X
Stress
X
Health behavior
Alcohol abuse
Drug misuse
Unsafe driving
Diabetes Cirrhosis Homicide
X
X
X
X
X
X
X
Stroke
X
X
X
X
agencies, such as the Occupational Safety and Health Administration, that require employers
to maintain safe workplaces and practices.
Individuals have more control over consumption than over occupation-related behaviors; however, environmental factors, such as availability of affordable, healthy foods, play a
significant role in the extent of their control. Consumption risks include overeating (resulting in obesity), high cholesterol intake (heart disease), alcohol consumption (motor vehicle
accidents), alcohol addiction (liver cirrhosis), cigarette smoking (chronic bronchitis and
emphysema, lung cancer, aggravating heart disease), drug dependency (suicide, homicide,
malnutrition, accidents, social withdrawal, acute anxiety), and excessive glucose or sugar
intake (dental caries, obesity, hyperglycemia, diabetes).
Unlike the risks related to employment and occupation, those that accompany leisure
and consumption activities are relatively unregulated, with the exception of efforts to control
the use of illegal drugs and the purchase of tobacco and alcohol products by underage youth.
Leisure-related destructive behaviors include sexual promiscuity and unprotected sex (which can
result in sexually transmitted diseases, including AIDS, syphilis, and gonorrhea) and limited or
no exercise (which may lead to overweight and obesity and aggravate other health conditions).
Socioeconomic Status
The major components of SES are income, education, and occupational status. SES is a strong
and consistent predictor of health status. Individuals with low SES suffer disproportionately
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Chapter 1: Overview of Health Policy
17
from most diseases and experience higher rates of mortality than those with midlevel or
high-level SES. For example, after controlling for access to medical care, studies show that
countries providing universal health insurance, such as England, report the same SES–health
relationships as those found in the United States, which does not yet offer universal health
insurance (Acheson 1998; Cormman et al. 2015).
SES influences health to the extent to which individuals and populations are exposed
to physical and social threats; have knowledge of health conditions; encounter adverse environmental conditions, such as pathogens and carcinogens; and are exposed to undesirable
social conditions, such as crime.
M edi cal C are
Most items that we buy and sell are commodities—goods and services whose worth can
be calculated as a monetary value, that serve a specific (rather than an intrinsic or esoteric)
purpose, and that can be exchanged with other similar products (Doty 2008). Medical
care differs from traditional commodities in four important ways. First, the demand for
medical care is derived; that is, it stems from the demand for a more fundamental commodity—health itself.
The second difference is the presence of the agency relationship. Because patients
generally lack the technical knowledge to make health-related decisions, they delegate this
authority to their physicians with the expectation that physicians will act for patients as
patients would for themselves if they had the appropriate expertise.
If physicians were to act solely in the interests of patients, the agency relationship
would be virtually indistinguishable from normal consumer behavior. However, physicians’
decisions typically reflect the physicians’ self-interests as well as the interests of their patients.
Those self-interests may arise from pressures imposed by professional colleagues and institutions, adherence to medical ethics, or a desire to make good use of available resources.
One implication of the agency relationship is that medical care may or may not be
provided, depending on the payer of services for the patient. For example, physicians who
treat members of a health maintenance organization (HMO) may have an incentive to
restrict the number of hospital admissions they order because HMO patients’ care is prepaid; that is, the physician will not be paid more to provide more services. Acting on this
incentive means that the physician is acting as an imperfect agent.
The third difference between medical care provision and the provision of other products
and services is that healthcare pricing varies according to who pays the fees. Because most patients
are covered by insurance, the amount paid by patients out-of-pocket at the point of care for
most medical services is often significantly lower than the total payment made to the provider.
The fourth difference is that medical care service provision is influenced by its environment, whereas other commodities are not. In other words, the social, economic, demographic,
00_Shi (2374) Book.indb 17
agency relationship
In healthcare, delegation
by the patient of some
authority to make
decisions and perform
actions on the patient’s
behalf to an expert such
as a physician or other
healthcare provider.
health maintenance
organization (HMO)
A managed care
organization that
integrates medical
care with payment and
typically requires the
use of a specified panel
of providers.
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Introduction to Health Policy
technological, political, and cultural contexts dictate how, when, where, and to whom
healthcare services are offered, which is not true of other products and services. For example,
of the forces currently reshaping the healthcare industry, the number of uninsured people
(social context) is a major factor driving health insurance reform debates.
P o l i c y D e f i ne d
A policy is a decision made by an authority about an action—either one to be taken or one
to be prohibited—to promote or limit the occurrence of a particular circumstance in a
population. In the United States, the authority charged with making policy is a legislative,
executive, or judicial body operating under the purview of a federal, state, or local public
administration. Public policy—decision making that affects the general population or significant segments thereof—is meant to improve the conditions and general welfare of the
population or subpopulations under its jurisdiction. Other countries, however, may have
different mechanisms of developing policies (see the For Your Consideration box titled
“Dominant Political Systems of the World”).
Although public policies are intended to serve the interests of the public at large,
the term public has different interpretations according to the political context in which it is
applied. For example, policymakers tend to be most responsive to the views and wishes of
constituents who are politically active and communicate directly with their representatives.
FOR YOUR CONSIDERATION
Dominant Political Systems of the World
Democracy—political system that allows for each individual to participate either directly or
through elected representatives (United States, Canada)
Republic—political system in which the government remains mostly subject to the people,
and leaders can be recalled (France, Egypt, India)
Monarchy—political system in which the inherited ruler (monarch) is head of state, the constitution limits the monarch’s power, and others make laws (United Kingdom, Denmark,
Kuwait, Spain, Sweden)
Communism/Socialism—political system based on the ideology of communism as taught by
Karl Marx, Vladimir Lenin, or Mao Zedong, often dominated by a single party or an elite group
of people (China, Russia, Cuba)
Dictatorship—political system in which a single person (dictator) is the main individual ruling
the country, not restricted by constitutions or parliaments (Zimbabwe, Uzbekistan, North Korea)
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In the private sector, authority is conferred to the executive or board of directors of
an organization. Private policy—policy that affects the private organization only—is meant
to improve the conditions and general welfare of the employees of that organization. Because
private organizations function in the larger social (public) environment, private policies
must take into account the spirit of public policies.
H e a lt h P o l i c y D e f i ne d
Miller (1987, 15) defined health policy as “the aggregate of principles, stated or unstated,
that . . . characterize the distribution of resources, services, and political influences that
impact on the health of the population.” This definition and others focus on US federal or
public-level health policy and do not reflect non-US political systems nor account for the
fact that private-sector policy also influences health.
Therefore, in this book we define health policy as policy that pertains to or influences
the attainment of health. In terms of the determinants-of-health framework, health policy refers
to legislation that may influence—directly or indirectly—social and physical environments,
behaviors, SES, and availability of and accessibility to medical care services. Health policies
affect groups or classes of individuals, such as physicians, the poor, the elderly, and children.
They can also affect types of organizations, such as medical schools, HMOs, nursing homes,
medical technology producers, and employers. On the basis of this broad definition, health
consequences may result from virtually all major policies, such as Social Security mandates,
national defense–related guidelines, labor policies, and immigration policies.
Furthermore, in the United States, each branch and level of government can influence health policy. For example, both the executive and legislative branches at the federal,
state, and local levels can establish health policies, and the judicial branch at each level can
uphold, strike down, or modify existing laws affecting health and healthcare. Examples of
public, or government, health policy include legislative and regulatory efforts to ensure air
and water quality and support for cancer research.
Health policies can also be made through the private sector. Examples of private-sector
health policies are the decisions made by insurance companies regarding their product lines,
pricing, and marketing and by employers regarding health benefits, such as leave policies,
work site health promotion, and insurance coverage.
Health policy must be distinguished from healthcare policy, which refers to that
part of health policy pertaining to the financing, organization, and delivery of care. Healthcare policy may cover the training of health professionals; licensing of health professionals
and facilities; administration of public health insurance programs, such as Medicare and
Medicaid; deployment of electronic health records; efforts to control healthcare costs; and
regulation of private health insurance. Whereas the predominant goal of health policy is to
improve population health, the goals of healthcare policy are typically to provide equitable
and efficient access to high-quality healthcare services.
00_Shi (2374) Book.indb 19
health policy
Legislation over
individuals,
organizations, or
society whose goal is to
improve health for the
general population or
subpopulations.
healthcare policy
The part of health policy
specifically related to
the financing, delivery,
and governance of
health services for the
general population or
subpopulations within a
jurisdiction.
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20
Introduction to Health Policy
FOR YOUR CONSIDERATION
The United States as an Individualist Culture?
T ypes
of
H ealth P olicy
The scope of health policy is determined by the
political and economic system of a country. In
the United States, where pro-individual and proThe American political culture is characterized by some observmarket sentiments tend to dominate (see the For
ers as being rooted in a distrust of power—particularly governYour Consideration box titled “The United States
ment power—and a preference for volunteerism and self-rule in
as an Individualist Culture?”), health policies are
small, homogeneous groups with limited purposes. How would
likely to be fragmented, incremental, and nonyou describe the political culture of average Americans? Do you
comprehensive. National policies and programs
agree or disagree with the characterization posed here? Provide
are typically crafted to reflect the notion that local
examples to support your answer.
communities are in the best position to identify
strategies to address their unique needs. However,
the types of changes that can be enacted at the
community level are clearly limited. Next, we summarize the two major types of health
policies: regulatory and allocative.
regulatory policies
Regulations or rules that
impose restrictions and
are intended to control
the behavior of a target
group by monitoring
the group and imposing
sanctions if it fails to
comply.
distributive policies
Regulations that provide
Regulatory Health Policies
Health policies may be used as regulatory tools that call on the government to prescribe and
control the behavior of a particular target group by monitoring the group and imposing
sanctions if it fails to comply. Examples of regulatory policies include prohibition of smoking in public places, licensure requirements for medical professions, and processes related to
the approval of new drugs. State insurance departments across the country regulate health
insurance companies in an effort to protect customers from default on coverage in the case
of a company’s financial failure, excessive premiums, or deceptive practices.
Private health policies can also be regulatory. For example, physicians set standards of
medical practice and hospitals undergo assessments from accreditation service organizations,
such as The Joint Commission, to ensure compliance with all standards.
benefits or services to
targeted populations
or subpopulations,
typically as entitlements.
redistributive policies
Deliberate efforts to
alter the distribution
of benefits by taking
money or property from
one group and giving it
to another.
00_Shi (2374) Book.indb 20
Allocative Health Policies
Allocative health policies involve the direct provision of income, services, or goods to certain
groups of individuals or institutions. They can be distributive or redistributive. Distributive
policies spread benefits across society. Examples include the funding of medical research
through the National Institutes of Health, provision of public health and health promotion
services, training of medical personnel, and construction of healthcare facilities. Redistributive policies take money or power from one group and give it to another. This approach
typically creates visible beneficiaries and payers. Examples include means-tested social insurance programs such as Medicaid, which uses tax revenue from the more affluent population
to provide free or low-cost health insurance to the poor, to subsidize the welfare program,
11/21/18 10:55 AM
Chapter 1: Overview of Health Policy
21
and to fund public housing. It should be pointed out that Medicare and Social Security are
not redistributive policies nor “entitlements” because they are supported by funds collected
through deductions from the income of working people before their retirement and then
distributed later to members of that same population after their retirement.
W h at A r e
the
D e t e rm i n a n ts
of
H ealth P oli cy ?
As noted earlier, the framework for health determinants includes four major categories:
environment, health status, medical care, and individual characteristics (shown earlier
in exhibit 1.3). The framework for health policy determinants is presented in exhibit 1.5.
Broad determinants include the nature of the health problem, the sociocultural norms that
influence the perception of the problem, and the political system within which the health
policy is formulated. The inner circle of the framework shows the narrower determinants:
◆◆ Potential solutions to the identified health problem
◆◆ Views and efforts of the stakeholders
◆◆ Demonstrated leadership of the policymakers
◆◆ Available resources needed to implement the health policy
This general framework may be applied to health policies at the national, state, or
local level; to public and private policies; and to health policies in the United States and
Exhibit 1.5
A Conceptual
Framework of
Health Policy
Determinants
Political system
Leadership
Health
problem
Solutions
Resources
Health
policy
Stakeholders
Sociocultural norms
00_Shi (2374) Book.indb 21
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22
Introduction to Health Policy
elsewhere. The remainder of this section describes these components in greater detail, and
chapters 2 through 4 illustrate the application of this framework in various settings.
B road D eterminants
of
H ealth P olicy
Among the broad determinants of health policy are the nature of the health problem,
sociocultural norms, and the political system of the country, each of which is discussed in
this section.
Health Problem
The nature of the health problem is typically the first consideration of policy, the significance
of which is determined by its magnitude and severity. Magnitude indicates the reach of the
problem. If the health problem affects a large segment of the population (e.g., heart disease,
diabetes), it is considered widespread. Severity denotes the extent to which the problem
is urgent. See the Learning Point box titled “Infectious Disease Epidemics: Severe Acute
Respiratory Syndrome and Influenza” for examples.
LEARNING POINT
Infectious Disease Epidemics: Severe Acute Respiratory Syndrome and
Influenza
Severe acute respiratory syndrome (SARS) is a serious form of viral pneumonia that can result
in acute respiratory distress and, sometimes, death. It first came to the attention of Asian
health officials in February 2003. In just a few months, it had spread throughout North America,
South America, Europe, and Asia, affecting 8,098 individuals in more than 25 countries. Of
those infected, 774 died. The 2003 SARS epidemic demonstrated how quickly an infectious
respiratory disease could spread across the world and registered among the most severe
health problems in the twenty-first century.
Influenza (flu) is a contagious respiratory illness caused by influenza viruses, which can
cause mild to severe illness. Serious outcomes of flu infection can result in hospitalization or
even death. More than 130 million doses of flu vaccine were distributed in the 2017–2018 winter
season. Although the impact of flu varies, it places a substantial burden on the health of people
in the United States each year. The Centers for Disease Control and Prevention (CDC) estimates
that influenza resulted in between 9.2 million and 35.6 million illnesses, between 140,000 and
710,000 hospitalizations, and between 12,000 and 56,000 deaths annually from 2010 to 2017.
Source: CDC (2005b, 2017).
00_Shi (2374) Book.indb 22
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Chapter 1: Overview of Health Policy
23
Sociocultural Norms
Sociocultural norms reflect the accepted values, beliefs, attitudes, and behaviors of a society
or group. These norms play a significant role in the public’s perception of the nature of a
health problem, the role of the government versus individuals in addressing that problem,
and the type of solution or policy implemented to manage it. For example, mental illness
carries a social stigma in many cultures. Although poor mental health has long been a pervasive problem in the United States and elsewhere, relatively little public action has been
taken to promote improvements in mental health status, care, and treatment.
Political System
Although a democratically governed country is more likely to develop health policies that reflect
the public’s interests (officials are publicly elected and presumably represent the electorate’s interests), the process of policy development is typically more difficult in democratic systems than
in single-rule governments, not only because the development of legislation in a democracy is
arduous but also because the public’s interests are rarely coherent. In authoritarian (single-party)
countries, policies can be developed more quickly but may not truly reflect the public’s interests.
N arro w D eterminants
of
H ealth P olicy
The narrow determinants of health policy include solutions, stakeholders, leadership, and
resources, each of which is discussed in this section.
Solutions
Potential solutions to a health problem facilitate policy development. If solutions do not emerge,
policymakers may direct their efforts away from full-fledged policy consideration and toward
finding a solution, likely by initiating a research study. If a health problem has more than one
potential solution, policy research and analysis is conducted to identify the optimal solution
given the political climate, available resources, and expectations of prominent stakeholders.
Stakeholders
Entities or individuals who have a direct or indirect role in the development of policy are
considered stakeholders. The influence of stakeholders is particularly strong in a democracy,
as elected officials often cater to the interests of their constituency—either to fulfill a campaign promise or to gain reelection. Policy is more likely to be enacted when the positions
of the various stakeholders converge. The next major section in this chapter describes the
key stakeholders in US health policy.
00_Shi (2374) Book.indb 23
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24
Introduction to Health Policy
Leadership
No matter how significant the problem or how determined the stakeholders, health policy
addressing a particular problem will not appear on the policy agenda without the approval of
the governing body’s leader. The first case study at the beginning of this chapter demonstrates
the contrasting leadership styles of President Barack Obama and former First Lady Hillary
Clinton. The For Your Consideration box titled “Quotes from Selected US Presidents”
reflects the leadership styles of a number of US presidents throughout the nation’s history
and provides clues as to how they governed.
FOR YOUR CONSIDERATION
Quotes from Selected US Presidents
Associate yourself with men of good quality if you esteem your own reputation; for
’tis better to be alone than in bad company.
—George Washington
To be good, and to do good, is all we have to do.
—John Adams
It is by a thorough knowledge of the whole subject that [people] are enabled to
judge correctly of the past and to give a proper direction to the future.
—James Monroe
If your actions inspire others to dream more, learn more, do more, and become
more, you are a leader.
—John Quincy Adams
Any man worth his salt will stick up for what he believes right, but it takes a slightly
better man to acknowledge instantly and without reservation that he is in error.
—Andrew Jackson
While men inhabiting different parts of this vast continent cannot be expected to
hold the same opinions, they can unite in a common objective and sustain common
principles.
—Franklin Pierce
The test of leadership is not to put greatness into humanity, but to elicit it, for the
greatness is already there.
—James Buchanan
I don’t like that man. I must get to know him better.
—Abraham Lincoln
00_Shi (2374) Book.indb 24
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Chapter 1: Overview of Health Policy
25
FOR YOUR CONSIDERATION
Quotes from Selected US Presidents (continued)
If you always support the correct principles then you will never get the wrong
results!
—Andrew Johnson
The object of love is to serve, not to win.
—Woodrow Wilson
[People] are not prisoners of fate, but only prisoners of their own minds.
—Franklin D. Roosevelt
It is amazing what you can accomplish if you do not care who gets the credit.
—Harry S. Truman
Efforts and courage are not enough without purpose and direction.
—John F. Kennedy
A leadership is someone who brings people together.
—George W. Bush
Change will not come if we wait for some other person or some other time. We are
the ones we’ve been waiting for. We are the change that we seek.
—Barack Obama
Resources
Not even the most effective policy can be implemented without the available financial and
administrative resources. Financial feasibility tests are conducted during the policy development process to ensure that adequate funds are available and to verify that the benefits will
outweigh the costs. Administrative feasibility studies examine how policy can be translated
into programs and carried out under an existing or new infrastructure.
S ta k e h ol d e rs
of
H e a lt h P olic y
As shown in the framework of health policy determinants (exhibit 1.5), stakeholders frequently exert a powerful influence on health policy development. Indeed, as shown in
later chapters, stakeholders influence not only the formulation of health policy but also its
implementation and modification.
00_Shi (2374) Book.indb 25
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26
Introduction to Health Policy
One type of stakeholder is the interest group. Interest groups are composed of individuals or entities that at least nominally present a unified position on their preferences regarding a
A collective of
particular health problem or its solution. Lobbying by organized interest groups is a common
individuals or entities
that hold a common
component of the political process in a democracy. Because stakeholders often differ in their posiset of preferences on
tions and preferences, and coalition building is usually specific to an issue, interest groups are not
a particular health
always static, and their formations typically depend on the particular health problem under policy
issue and often seek to
consideration. The following paragraphs introduce the major stakeholders in US health policy.
influence policymaking
Consumers and patients. Consumers and patients are typically the intended benefior public opinion.
ciaries of health policy, because they suffer the consequences of a health problem that could
be the target of health policy. However, consumers have diverse health problems, and yet
lobbying
the prioritization of those problems is not always determined by consumers. Furthermore,
Activities seeking to
consumers with the same health problem may have diverse interests and different cultural
influence an individual
norms. Consumers’ views may also be influenced by their own economic status, such as
or organization with
whether they currently have health insurance coverage. For example, those without insurance
decision-making
are more likely to favor a government program or reform that expands insurance coverage.
authority.
Those with insurance coverage are more concerned with lowering the premiums or copayments for their insurance coverage. The more their interests converge and the more organized
they become as a collective, the more likely consumers are to influence policy development.
Healthcare providers. Healthcare providers—individuals who provide direct patient care—
include physicians, nurses, dentists, pharmacists, and other health professionals. Traditionally,
healthcare providers value autonomy and have an interest in preserving the prestige and expertise
associated with their careers. The size and diversity of the US healthcare workforce often result in
a less-than-unified voice in the healthcare provider community—for example, between physicians
and nonphysicians, primary care doctors and specialists, and public health and medical care.
Healthcare organizations. Healthcare organizations are the institutional settings in
which healthcare providers work or provide care
to patients. Traditional settings include hospitals
FOR YOUR CONSIDERATION
(inpatient and outpatient) and community-based
Interests Common to Healthcare Administrators
offices. Organizational settings now also include
diagnostic imaging centers, occupational health
centers, and psychiatric outpatient centers, among
Healthcare administrators are responsible for overseeing a health
others. Administrators of these institutions may
facility or department. According to the Health Careers Center
(2004), they “plan, coordinate, and supervise” all activities in their
share an interest, for example, in serving their cusarea, including the work of staff members. Healthcare administomers and maintaining the financial well-being of
trators also take responsibility for developing and implementtheir institutions at the same time (see the For Your
ing standards, operating procedures, and organizational policies
Consideration box titled “Interests Common to
that help the facility operate at peak efficiency, and they can be
Healthcare Administrators”). However, like healthinvolved in developing and expanding programs in new areas, such
care providers, different healthcare institutions have
as medical research and preventive care.
different priorities and interests, often tied to consumers, services, and payments.
interest group
00_Shi (2374) Book.indb 26
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Chapter 1: Overview of Health Policy
Payers and insurers. Payers and insurers can be private (commercial or other private
enterprise) or public (government-operated entity). Private insurance is offered by commercial insurance companies (e.g., Aetna, Prudential); Blue Cross/Blue Shield; self-insured
employers; and managed care organizations (MCOs), such as an HMO or a preferred
provider organization (PPO). Public insurance includes federally funded programs such
as Medicare, which provides insurance for the elderly and certain individuals with disabilities; Medicaid, for the indigent; TRICARE, for US Department of Defense active military
service personnel and their families; and Veterans Affairs programs, for former armed forces
personnel. One interest that private insurance companies and MCOs have in common is
maintaining their share of the health insurance market; in contrast, a main interest of public
payers is ensuring coverage for vulnerable populations at reasonable costs.
Regulators. In addition to providing public insurance for the elderly and indigent, the
government functions as a regulator, seeking to make sure that basic services are provided,
their quality is maintained by the providers, and the overall cost of providing care in the
community or sector is contained.
Medical device and pharmaceutical manufacturers. Manufacturers of medical equipment
and drugs have a vested interest in health policy, especially with regard to payments for the
use of their products. With the rapid advancement of science and technology, numerous
devices and types of equipment have been developed for medical use, such as fetal monitors,
computerized electrocardiograph machines, and magnetic resonance imaging machines.
Such equipment is useful in the diagnosis of diseases but is expensive.
Educational and research institutions. Health policy affects the type and quantity
of healthcare providers to be trained, making educational institutions another significant
stakeholder. Similarly, research facilities are affected by health policy that directs the types
of research to be conducted.
Businesses and corporations. American businesses and corporations have a keen interest in health policy that, among other issues, mandates healthcare coverage levels. These
stakeholders seek to minimize the cost they incur for providing health insurance as a benefit
to their employees.
W h y I s I t I mpo rta n t
to
27
preferred provider
organization (PPO)
A managed care
organization that offers
unrestricted provider
options to enrollees
and discounted fee
arrangements to
providers.
Medicare
Federal government
insurance plan for
persons aged 65 years
or older, individuals
with disabilities who
are entitled to Social
Security benefits, and
people who have endstage renal (kidney)
disease.
Medicaid
Jointly administered
federal and state
insurance plan for the
indigent.
S t udy H ealth P oli cy ?
Understanding how health policy is developed is the first step toward influencing policy. And
only by knowing the health policy determinants and how they manifest in particular contexts
can one appreciate the key features of policy development (see the For Your Consideration
box titled “Why Is an International Perspective of Health Policy Useful?”).
In addition, the study of health policy allows an individual or a group the ability to
engage in efforts to improve it. For example, policy entrepreneurs—those who work from outside
the government to introduce and implement innovative ideas into public-sector practice—are
instrumental in bringing new ideas and fundamentally changing the usual way of practice.
00_Shi (2374) Book.indb 27
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28
Introduction to Health Policy
FOR YOUR CONSIDERATION
Why Is an International Perspective of Health Policy Useful?
Countries vary in their demographics, population health needs, and social norms, but they
share commonalities, such as population aging and leading causes of death. Learning from the
best practices of other countries—compared with a country developing its own evidence-based
approaches—can significantly shorten the time in which the country improves healthcare delivery. Incorporating global trends in health policymaking may also help exert influence on global
health policy (Jones, Clavier, and Potvin 2017). Just as the US experience and lessons can benefit
other countries as they consider healthcare delivery reform, so, too, can the United States learn
from the experiences of other countries in expanding its health policy options. One result of
this convergence of international health policies is the increase in similarity of global trends.
Industrialized countries need not limit their examination to other developed countries;
the experiences of developing countries can also be instructive (Dixon and Alakeson 2010;
Modisenyane, Hendricks, and Fineberg 2017). Such countries tend to focus on basic and
community-oriented public health and primary care, which may prove instructive for developed countries as they struggle to control costs and improve outcomes.
Furthermore, the importance of health policy itself is another reason to study it. As
shown in the framework of health determinants (exhibit 1.3), policy is an integral component of environmental health determinants. Improvements to policy development, such as
ensuring that a policy truly addresses a critical health problem and that it is developed in
an expeditious manner, can significantly improve a population’s overall health. In addition,
policy influences other determinants of health and therefore must be thoroughly understood
to enhance the country’s health system.
Key Points
➤➤
Health determinants, such as environment and social structure, interact with biological
factors and medical care to determine an individual’s health status.
➤➤
Health policy formulation is influenced by broad determinants (health problems,
sociocultural norms, and political system) and narrow determinants (solutions,
stakeholders, leadership, and resources).
➤➤
The major stakeholders in US health policy include consumers and patients, healthcare
providers, healthcare organizations, payers and insurers, regulators, medical device
and pharmaceutical manufacturers, educational and research institutions, and
businesses and corporations.
00_Shi (2374) Book.indb 28
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Chapter 1: Overview of Health Policy
➤➤
29
US health policy has evolved over time and will continue to change in response to new
health concerns and interests.
Case Study Questions
C ase S tudy 1
After researching the events surrounding the healthcare reform initiatives undertaken by the
Clinton, Obama, and Trump administrations, answer the following questions:
1.
What factors might explain why the Obama plan succeeded? What events may have
caused the Clinton plan and Trump’s initial attempts to fail?
2.
How do you think the failure of the Clinton healthcare reform effort influenced the
outcome of the congressional election that followed?
3.
Why does health reform continue to be controversial despite widespread opinion in
favor of change?
C ase S tudy 2
After researching the current developments in healthcare reform, answer the following questions:
1.
What are the similarities and differences in the…

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