Health Care Policy & Politics
This article explores the policy making process as applied to the study of health care. The policy process is outlined and defined and then considered within the context of the larger political environment. The unique attributes of health care are identified and discussed in terms of how they contribute to the complexity of healthcare policy-making.
Broadly defined public policy is the recognition of a problem and the subsequent actions of the government to solve the problem. Solutions to the problem, in the form of laws and regulations, are enacted in the legislative branch of government. The laws are put into effect, i.e. implemented, by the executive branch. The laws can be challenged, reviewed, or modified by the judicial branch. This series of steps from problem recognition to solution to implementation is known as the policy process and can occur at any level of government -- federal, state or local.
Health policy is made within every branch of government and at every level of government. At the federal level, health policy addresses issues that affect or can potentially affect every citizen in the nation. Examples include Medicare, which provides health care for every citizen age 65 and over. At the state level, regulatory policies are issued that cover licensure of health care providers and healthcare institutions. At the local level, most of the policies impact public health such as food inspections at restaurants and other public places, sanitation, and immunization. Indoor smoking bans are another example of public health policies that have been enacted. In some states, Ohio for example, local health departments and municipalities have been so successful at implementing indoor smoking bans that the policy was adopted at the state level.
The policy process does not take place in isolation. The larger environment within which the policy process takes place includes biological, cultural, economic, demographic, ethical, and technological influences (Longest, 1994). Within this larger arena are policy communities who exert their power on each phase of the policy process: Stakeholders who are committed to a particular policy solution; competitors who offer alternative solutions; and opponents who oppose specific solutions or prefer the status quo.
The Policy Process
Agenda setting, the first stage of the policy process, refers to the when, how, and why an issue comes to the attention of policymakers. John Kingdon in his book, Agenda, Alternatives and Public Policies (1984) describes agenda setting as three concurrent streams of activities: Problems, policies, and politics.
In the problem stream, multiple problems are free-floating, bump and collide, and compete for attention. The problems can be identified in multiple ways; the occurrence of a catastrophic event, economic concerns, or findings in research studies. In health care, for example, problems could be the spread of contagious disease such as HIV/AIDS, a shortage of health providers, or public health reports documenting regional incidence or prevalence of cancer linked to environmental factors. Most recently, health care problems include the rising costs of health care, lack of access to health insurance (in the fall of 2013 there were forty-eight million uninsured Americans), and the lack of access to health services due to geography, e.g. rural areas and inner cities.
The second stream, policy, is the flow of alternative solutions to the problems. There is not necessarily a one to one connection between any given problem and a potential policy solution. Usually, there are multiple solutions for any given issue. Sometimes there are solutions without any corresponding issue. New technologies are an example of this. A technology may exist without an identified suitable application. In health care, the problem of rising costs has been problematic due to the complexity of health delivery services, insurance availability, and increasing technological advances. Some propose that the U.S. adopt a single payer solution where the government is the single payer. The model for this solution is the British Health Service. Managed competition is another solution proposed by Alain Enthoven. In this proposed solution, the federal government sets out the minimum level of services and benefits that health plans will be required to offer. Large networks offering vertically integrated services would then compete to provide them to large groups of consumers. This plan blends a market cost-control approach with a consumer-driven health care delivery model (Longest, 1994).
The third stream is politics or the political environment. Politicians, interests groups, the public, the media, public opinion, and other players in the political arena are in this stream. The healthcare political stream includes patients, providers, the American Medical Association, the American Hospital Association, and other interest groups, businesses, managed care organizations, etc. The politics stream also includes events and issues competing for the public's attention as well as the politicians' attention. For example, in the 2004 presidential candidates' platforms concerning health care, which had been a prominent issue during previous elections, were in a secondary position. In 2012, however, health care reform was again a major issue as President Barack Obama ran for reelection.
Green-Pederson and Wilkerson further explored this idea of attention in a 2006 article comparing agenda-setting attributes in health policy in Denmark and the United States. Their hypothesis was that problems on an agenda may have particular attributes that cause the problems to become the particular focus of political attention. They argue that the issue of healthcare is a particularly salient issue with politicians because no politician wants to be viewed as "opposing health care or access to health care" (Green-Pederson & Wilkerson 2006, p.1041). In addition, they found that healthcare innovation has raised the public's expectations for receiving the latest health care technologies and treatments. Innovation and technological advances are leading contributors to rising health costs, which in turn, puts pressure on politicians to allocate greater resources for healthcare. Although the structure of health care systems and service delivery is very different in Denmark, which has government paid healthcare, and the United States, which has both public and private healthcare, the political attention that healthcare receives is similar.
Although a particular problem or issue may be the focus of political attention, it may not have yet...
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