Posted: September 16th, 2022

Unit 1 Assignment – Examine Knowledge Framework. 1000w. due 9-10-22. 4 references

Unit 1 Assignment – Examine Knowledge Framework. 1000w. due 9-10-22. 4 references

Read chapter 1 and 2 of the textbook regarding health policy.

This assessment addresses the following learning objective(s):

Examine the effect of legal, ethical, and regulatory processes on nursing practices (and/or change to providers), healthcare delivery, and outcomes while maintaining balance with administrative and fiscal responsibilities.

Instructions

The US healthcare industry is made up of diverse people and teams. This includes individuals who create policies, groups who lobby for legislation, and the people and teams who implement and follow laws and policies. For this assignment, you will reflect on your role, past, present, and future, regarding health policies. While research is encouraged for this assignment, in-text citations are not necessary. The purpose of this assignment is to provide your instructor with your knowledge framework and allow you to reflect on your knowledge and identify biases.

1. In an introductory paragraph, briefly summarize your scope of knowledge regarding health policy, both state/federal, and organizational policies.

2. In a second paragraph, explain why you wish to develop a deeper understanding of the policy creation, implementation, and assessment process. For example, how will understanding health policy improve your professional practice?

3. In a closing paragraph, address the following questions:

4. What biases/strong opinions do you have regarding health policy (state, federal, organizational policies)?

5. What caused those biases/opinions to develop (personal experiences, patient interactions, etc.)?

6. How will you respectfully maintain or evolve your bias/opinions as you advance in this course, and your career?

7. What is your primary source of information for staying up-to-date on state and federal health policy (names of publications, websites, organization-disseminated information, etc.)?

APA style should be followed throughout this assignment. Please include a title page.

Research is encouraged, but references and in-text citations are not required.

Series Editor: Richard Riegelman
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H Health Policy

and Law
Sara E. Wilensky, JD, PhD
Department of Health Policy and Management, Milken Institute
School of Public Health, The George Washington University

Joel B. Teitelbaum, JD, LLM
Department of Health Policy and Management, Milken Institute
School of Public Health, The George Washington University

Essentials of

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© Mary Terriberry/Shutterstock

Prologue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

About the Editor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xv

About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix

PART I Setting the Stage:
An Overview of Health
Policy and Law 1

Chapter 1 Understanding the Role of

and Conceptualizing Health

Policy and Law . . . . . . . . . . . . . . . . . . 3

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Role of Policy and Law in Health Care

and Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Conceptualizing Health Policy and Law . . . . . . . . . . . . . 5

The Three Broad Topical Domains of Health

Policy and Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Social, Political, and Economic Historical Context . . . . 6

Key Stakeholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Chapter 2 Policy and the

Policymaking Process . . . . . . . . . . . 11

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Defining Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Identifying Public Problems . . . . . . . . . . . . . . . . . . . . . . . . 11

Structuring Policy Options . . . . . . . . . . . . . . . . . . . . . . . . . 12

Public Policymaking Structure and Process . . . . . . . . .13

State-Level Policymaking . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

The Federal Legislative Branch. . . . . . . . . . . . . . . . . . . . . . 14

The Federal Executive Branch . . . . . . . . . . . . . . . . . . . . . . 21

The Health Bureaucracy. . . . . . . . . . . . . . . . . . . . . . . . . . . .25

The Federal Government . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

State and Local Governments . . . . . . . . . . . . . . . . . . . . . . 28

Interest Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Chapter 3 Law and the Legal System . . . . . . . 33

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

The Role of Law. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

The Definition and Sources of Law . . . . . . . . . . . . . . . . .35

Defining “Law” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Sources of Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Key Features of the Legal System . . . . . . . . . . . . . . . . . .39

Separation of Powers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Federalism: Allocation of Federal

and State Legal Authority . . . . . . . . . . . . . . . . . . . . . . . . 40

The Role of Courts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47

Chapter 4 Overview of the

United States Healthcare

System . . . . . . . . . . . . . . . . . . . . . . . 49

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

Healthcare Finance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50

Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Direct Services Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Healthcare Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

The Uninsured . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

The Underinsured . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Insurance Coverage Limitations . . . . . . . . . . . . . . . . . . . . 61

Safety Net Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Workforce Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Healthcare Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68

Key Areas of Quality Improvement . . . . . . . . . . . . . . . . . 68

Assessment of Efforts to Improve Quality . . . . . . . . . . . 71

Contents

iii

Comparative Health Systems . . . . . . . . . . . . . . . . . . . . . .71

A National Health Insurance System: Canada . . . . . . . 71

A National Health System: Great Britain . . . . . . . . . . . . . 73

A Socialized Insurance System: Germany . . . . . . . . . . . 74

The Importance of Health Insurance Design . . . . . . . . 75

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Chapter 5 Public Health Institutions

and Systems . . . . . . . . . . . . . . . . . . . 81

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81

What Are the Goals and Roles

of Governmental Public Health Agencies? . . . . . . .81

What Are the 10 Essential Public Health Services? . . .83

What Are the Roles of Local and State Public

Health Agencies? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85

What Are the Roles of Federal Public Health

Agencies? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87

What Are the Roles of Global Health

Organizations and Agencies? . . . . . . . . . . . . . . . . . . . .90

How Can Public Health Agencies Work Together? . . .91

What Other Government Agencies

Are Involved in Health Issues? . . . . . . . . . . . . . . . . . . . .91

What Roles Do NGOs Play in Public Health? . . . . . . . .92

Nongovernmental Organizations . . . . . . . . . . . . . . . . . . . 92

How Can Public Health Agencies Partner

With Health Care to Improve the Response

to Health Problems? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93

How Can Public Health Take the Lead in

Mobilizing Community Partnerships

to Identify and Solve Health Problems? . . . . . . . . . .95

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96

Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

Other Sources Consulted . . . . . . . . . . . . . . . . . . . . . . . . . . 109

Source for Political Affiliation of Senate . . . . . . . . . . . . 109

Source for Political Affiliation of the

House of Representatives . . . . . . . . . . . . . . . . . . . . . . . 109

PART II Essential Issues in Health
Policy and Law 111

Chapter 6 Individual Rights in Health Care

and Public Health . . . . . . . . . . . . . 113

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

Individual Rights and Health Care: A Global

Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116

Individual Rights and the Healthcare System . . . . . 117

Rights Under Healthcare and Health

Financing Laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

Rights Related to Freedom of Choice and

Freedom From Government Interference . . . . . . . 119

The Right to Be Free From Wrongful

Discrimination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

Individual Rights in a Public Health Context . . . . . . 128

Overview of Police Powers . . . . . . . . . . . . . . . . . . . . . . . . 128

The Jacobson v. Massachusetts Decision. . . . . . . . . . . . 129

The “Negative Constitution” . . . . . . . . . . . . . . . . . . . . . . . 130

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134

Chapter 7 Social Determinants of Health

and the Role of Law in

Optimizing Health . . . . . . . . . . . . . 137

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138

Social Determinants of Health . . . . . . . . . . . . . . . . . . . 139

Defining Social Determinants of Health . . . . . . . . . . . 139

Types of SDH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

The Link Between Social Determinants and

Health Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

Law as a Social Determinant of Health . . . . . . . . . . . 142

Right to Criminal Legal Representation

vs. Civil Legal Assistance . . . . . . . . . . . . . . . . . . . . . . . . 144

Combating Health-Harming Social Conditions

Through Medical-Legal Partnership . . . . . . . . . . . . 146

The Evolution of an “Upstream” Innovation . . . . . . . . 147

The Benefits of MLPs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151

Chapter 8 Understanding Health 

Insurance . . . . . . . . . . . . . . . . . . . . 153

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

A Brief History of the Rise of Health

Insurance in the United States . . . . . . . . . . . . . . . . . 154

How Health Insurance Operates . . . . . . . . . . . . . . . . . 156

Basic Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156

Uncertainty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158

Setting Premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160

Medical Underwriting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161

iv Contents

Managed Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162

Cost Containment and Utilization Tools. . . . . . . . . . . . 163

Utilization Control Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

Common Managed Care Structures . . . . . . . . . . . . . . . 166

The Future of Managed Care . . . . . . . . . . . . . . . . . . . . . . 169

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171

Chapter 9 Health Economics in a

Health Policy Context . . . . . . . . . . 173

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

Health Economics Defined . . . . . . . . . . . . . . . . . . . . . . . 174

How Economists View Decision Making . . . . . . . . . . . 174

How Economists View Health Care . . . . . . . . . . . . . . . . 176

Economic Basics: Demand . . . . . . . . . . . . . . . . . . . . . . . 176

Demand Changers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176

Elasticity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178

Health Insurance and Demand . . . . . . . . . . . . . . . . . . . . 179

Economic Basics: Supply . . . . . . . . . . . . . . . . . . . . . . . . . 180

Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180

Supply Changers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180

Profit Maximization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180

Health Insurance and Supply . . . . . . . . . . . . . . . . . . . . . . 181

Economic Basics: Markets . . . . . . . . . . . . . . . . . . . . . . . . 182

Health Insurance and Markets . . . . . . . . . . . . . . . . . . . . . 182

Market Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182

Market Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187

Chapter 10 Health Reform in the

United States . . . . . . . . . . . . . . . . 189

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189

Difficulty Achieving Health Reform

in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190

Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191

U.S. Political System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191

Interest Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

Path Dependency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

Unsuccessful Attempts to Pass 

National Health Insurance Reform . . . . . . . . . . . . . 194

The Stars Align (Barely): How the ACA

Became Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197

Commitment and Leadership . . . . . . . . . . . . . . . . . . . . . 197

Lessons From Failed Health Reform Efforts . . . . . . . . . 199

Political Pragmatism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201

Overview of the ACA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201

Individual Mandate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203

State Health Insurance Exchanges/

Marketplaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206

Employer Mandate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

Changes to the Private Insurance Market . . . . . . . . . . 214

Financing Health Reform . . . . . . . . . . . . . . . . . . . . . . . . . . 215

Public Health, Workforce, Prevention,

and Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216

The U.S. Supreme Court’s Decision in the

Case of National Federation of Independent

Business v. Sebelius . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

States and Health Reform . . . . . . . . . . . . . . . . . . . . . . . . 218

Key Issues Going Forward . . . . . . . . . . . . . . . . . . . . . . . . 219

Congressional Activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220

Insurance Plan Premium Rates . . . . . . . . . . . . . . . . . . . . 222

ACA Litigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225

Chapter 11 Government Health Insurance

Programs: Medicaid, CHIP,

and Medicare . . . . . . . . . . . . . . . . 231

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232

Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233

Program Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . 233

Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234

Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238

Amount, Duration, and Scope,

and Reasonableness Requirements . . . . . . . . . . . . . 241

Medicaid Spending . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242

Medicaid Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243

Medicaid Provider Reimbursement . . . . . . . . . . . . . . . . 244

Medicaid Waivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247

The Future of Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248

Children’s Health

Insurance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248

CHIP Structure and Financing . . . . . . . . . . . . . . . . . . . . . 249

CHIP Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250

CHIP Benefits and Beneficiary Safeguards . . . . . . . . . . 251

CHIP and Private Insurance Coverage . . . . . . . . . . . . . . 252

CHIP Waivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252

The Future of CHIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252

Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253

Medicare Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253

Medicare Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255

Medicare Spending . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258

Medicare Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258

Medicare Provider Reimbursement . . . . . . . . . . . . . . . . 262

The Future of Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265

Contents v

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268

Chapter 12 Healthcare Quality Policy

and Law . . . . . . . . . . . . . . . . . . . . 271

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271

Quality Control Through Licensure

and Accreditation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272

Medical Errors as a Public

Health Concern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273

Promoting Healthcare Quality Through the

Standard of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275

The Origins of the Standard of Care. . . . . . . . . . . . . . . . 275

The Evolution of the Standard of Care . . . . . . . . . . . . . 276

Tort Liability of Hospitals, Insurers, and MCOs . . . . 278

Hospital Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278

Insurer Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279

Managed Care Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280

Federal Preemption of State Liability

Laws Under ERISA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281

Overview of ERISA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281

ERISA Preemption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282

The Intersection of ERISA Preemption

and Managed Care Professional

Medical Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283

Measuring and Incentivizing Healthcare Quality . . . 284

Quality Measure Development . . . . . . . . . . . . . . . . . . . . 286

Quality Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286

Public Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286

Value-Based Purchasing . . . . . . . . . . . . . . . . . . . . . . . . . . . 287

National Quality Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . 288

Private Payer Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289

Role of Health Information Technology . . . . . . . . . . . . 289

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291

Chapter 13 Public Health Preparedness

Policy . . . . . . . . . . . . . . . . . . . . . . 293

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293

Defining Public Health Preparedness . . . . . . . . . . . . . 294

Threats to Public Health . . . . . . . . . . . . . . . . . . . . . . . . . 295

CBRN Threats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295

Naturally Occurring Disease Threats . . . . . . . . . . . . . . . 299

Natural Disasters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300

Man-Made Environmental Disasters . . . . . . . . . . . . . . . 303

Public Health Preparedness Policy . . . . . . . . . . . . . . . 303

Federal Response Agencies and Offices . . . . . . . . . . . 303

Preparedness Statutes, Regulations,

and Policy Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305

Presidential Directives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307

International Agreements . . . . . . . . . . . . . . . . . . . . . . . . . 308

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311

PART III Basic Skills in Health
Policy Analysis 315

CHAPTER 14 The Art of Structuring

and Writing a Health Policy

Analysis . . . . . . . . . . . . . . . . . . . . 317

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317

Policy Analysis Overview . . . . . . . . . . . . . . . . . . . . . . . . . 317

Client-Oriented Advice . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317

Informed Advice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318

Public Policy Decision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318

Providing Options and a

Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318

Your Client’s Power and Values . . . . . . . . . . . . . . . . . . . . 318

Multiple Purposes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319

Structuring a Policy Analysis . . . . . . . . . . . . . . . . . . . . . 319

Problem Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320

The Background Section . . . . . . . . . . . . . . . . . . . . . . . . . . 322

The Landscape Section. . . . . . . . . . . . . . . . . . . . . . . . . . . . 323

The Options Section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326

The Recommendation Section . . . . . . . . . . . . . . . . . . . . 330

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337

vi Contents

© Mary Terriberry/Shutterstock

Prologue

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About the Editor

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Preface

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▸ Implementation of the ACA

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Education

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Contributors

▸ Chapter 5: Public Health
Institutions and Systems

Richard Riegelman, MD, PhD, MPH

The

▸ Chapter 13: Public Health
Preparedness Policy

Rebecca Katz, PhD, and Claire Standley, PhD

xix

© Mary Terriberry/Shutterstock

1

PART I

Setting the Stage:
An Overview of
Health Policy
and Law

CHAPTER 1

Understanding the Role of
and Conceptualizing Health
Policy and Law

LEARNING OBJECTIVES

By the end of this chapter you will be able to:

■ Describe generally the important role played by policy and law in the health of individuals and populations
■ Describe three ways to conceptualize health policy and law

By the end of this chapter you will be able to:

■ Describe generally the important role played by policy and law in the health of individuals and populations
■ Describe three ways to conceptualize health policy and law

▸ Introduction

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Health Care and Public Health

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▸ Conceptualizing Health Policy
and Law

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of Health Policy and Law

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BOX 1-1 Three Conceptual Frameworks for Studying

Health Policy and Law

Study based on the broad topical

domains of:

a. Health care

b. Public health

c. Bioethics

Study based on historically dominant

social, political, and economic perspectives:

a. Professional autonomy

b. Social contract

c. Free market

Study based on the perspectives of

key stakeholders:

a. Individuals

b. The public

c. Healthcare professionals

d. Federal and state governments

e. Managed care and traditional insurance

companies

f. Employers

g. Healthcare industries (e.g., the pharmaceutical

industry)

h. The research community

i. Interest groups

j. Others

Healthcare Policy and Law

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Social Contract Perspective
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9

CHAPTER 2

Policy and the Policymaking
Process

LEARNING OBJECTIVES

By the end of this chapter you will be able to:

■ Describe the concepts of policy and policymaking
■ Describe the basic function, structure, and powers of the legislative branch of government
■ Describe the basic function, structure, and powers of the executive branch of government
■ Explain the role of federal and state governments in the policymaking process
■ Explain the role of interest groups in the policymaking process

By the end of this chapter you will be able to:

■ Describe the concepts of policy and policymaking
■ Describe the basic function, structure, and powers of the legislative branch of government
■ Describe the basic function, structure, and powers of the executive branch of government
■ Explain the role of federal and state governments in the policymaking process
■ Explain the role of interest groups in the policymaking process

▸ Introduction
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Identifying Public Problems
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▸ Public Policymaking Structure
and Process

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The Federal Legislative Branch

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TABLE 2-1 ifies

Committee/Subcommittee Health-Related Jurisdiction

Senate Finance Committee

■ Subcommittee on Health Care  ■ Department of Health and Human Services

Centers for Medicare and Medicaid Services (includes

Children’s Health Insurance Program [CHIP])

Administration for Children and Families
■ Department of the Treasury

Group health plans under the Employee Retirement

Income Security Act (ERISA)

Senate Appropriations Committee

■ Subcommittee on Labor, Health, Human

Services, Education, and Related Agencies

■ Department of Health and Human Services

All areas except Food and Drug Administration, Indian

Health, and construction activities

■ Subcommittee on Agriculture, Rural

Development, Food and Drug Administration,

and Related Agencies

■ U.S. Agricultural Department (except Forest Service)

Includes child nutrition programs; food safety and

inspections; nutrition program administration; special

supplemental nutrition program for Women, Infants,

Children (WIC); Supplemental Nutrition Assistance

Program (SNAP)
■ Food and Drug Administration

(continues)

TABLE 2-1 Key Health Committees and Subcommittees

e and P 15

Committee/Subcommittee Health-Related Jurisdiction

■ Subcommittee on Interior, Environment, and

Related Agencies

■ Department of Health and Human Services

Indian Health Services

Agency for Toxic Substances and Disease Registry

Senate Health, Education, Labor, and Pensions Committee

■ Subcommittee on Children and Families

■ Subcommittee on Primary Health and

Retirement Security

■ Occupational safety and health, public health, Health

Resources Services Act, substance abuse and mental

health, oral health, healthcare disparities, ERISA

Senate Committee on Agriculture, Nutrition, and Forestry

■ Subcommittee on Nutrition, Specialty Crops,

and Agricultural Research

■ Food from fresh waters; SNAP; human nutrition; inspection

of livestock, meat, and agricultural products; pests and

pesticides; school nutrition programs; other matters related

to food, nutrition, and hunger

Senate Committee on Environment and Public Works

■ Subcommittee on Clean Air and Nuclear Safety ■ Air pollution, environmental policy, research and

development, noise pollution, water pollution, nonmilitary

control of nuclear energy, solid waste disposal and recycling

House Committee on Ways and Means

■ Subcommittee on Health ■ Programs providing payments for health care, health

delivery systems, and health research

■ Social Security Act

■ Maternal and Child Health Block Grant

■ Medicare

■ Medicaid

■ Peer review of utilization and quality control of healthcare

organizations

■ Tax credit and deduction provisions of the Internal Revenue

Service relating to health insurance premiums and

healthcare costs

■ Subcommittee on Human Resources ■ Social Security Act

Public assistance provisions

Supplemental Security Income provisions

Mental health grants to states

House Committee on Appropriations

■ Subcommittee on Labor, Health and Human

Services, Education, and Related Agencies

■ Department of Health and Human Services

Administration for Children and Families

Administration for Community Living

Agency for Healthcare Research and Quality

Centers for Disease Control and Prevention

Centers for Medicare and Medicaid Services

TABLE 2-1 Key Health Committees and Subcommittees

16 Chapter 2

(continued)

Health Resources Services Administration

National Institutes of Health

Substance Abuse and Mental Health Services

Federal Mine Safety and Health Review Commission

Medicaid and CHIP Payment and Access Commission

Medicare Payment Advisory Committee

National Council on Disability

Occupational Safety and Health Review Commission

Social Security Administration

■ Subcommittee on Agriculture, Rural

Development, Food and Drug Administration,

and Related Agencies

■ Food and Drug Administration

■ Department of Agriculture (except Forestry)

■ Subcommittee on Energy, Water Development,

and Related Agencies

■ Department of Energy

National Nuclear Strategy Administration

Federal Energy Regulatory Commission

■ Department of Interior

■ Bureau of Reclamation

■ Defense Nuclear Facilities Safety Board

■ Nuclear Regulatory Commission

■ Subcommittee on Interior, Environment, and

Related Agencies

■ Department of Interior

■ Environmental Protection Agency

■ Indian Health Service

■ National Institute of Environmental Health Sciences

■ Chemical Safety and Hazards Investigation Board

House Committee on Agriculture

■ Subcommittee on Nutrition ■ Nutrition programs, including SNAP

■ Subcommittee on Biotechnology, Horticulture,

and Research

■ Policies and statutes relating to horticulture, bees, organic

agriculture, pest and disease management, bioterrorism,

biotechnology

■ Subcommittee on Livestock and Foreign

Agriculture

■ Policies and statutes relating to inspections of livestock,

dairy, poultry, and seafood; aquaculture; animal welfare

Congressional Commissions
and Staff Agencies

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How Laws Are Made

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FIGURE 2-1 How a Bill Becomes a Law

18 Chapter 2

Representative introduces bill
in the House

Senator introduces bill
in the Senate

Bill is read in the House and
assigned to a committee by the

Speaker

Bill is read in the Senate and
assigned to a committee by the

majority leader

Bill leaves committee,
is scheduled for floor

consideration and debate,
may be amended

Bill leaves committee,
is scheduled for floor

consideration and debate,
may be amended

House passes bill Senate passes bill

Bill is sent to Senate Bill is sent to House

A conference committee is created to resolve differences if both chambers do not pass an identical bill

Identical bill is passed by both House and Senate OR one branch agrees to the other branch’s version
OR bill is amended and both branches vote again and pass amended version

Bill is presented to the
President, who has four options

Option 1:
President
signs bill
into law

Option 2:
During congressional

session, bill becomes law
after 10 days without
presidential signature

Option 3:
When not in session, bill

does not become law
without presidential

signature

Option 4:
President vetoes bill.

Two-thirds vote in
House and Senate
can override veto

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Congressional Budget
and Appropriations Process

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TABLE 2-2

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Constituents of Legislative Branch

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TABLE 2-2 Federal Budget Process Timeline

First Monday in February President submits budget proposal to Congress.

March House completes its budget resolution.

April Senate completes its budget resolution.

April 15 House and Senate complete concurrent budget resolution.

May Authorizing committees develop reconciliation language when necessary and report

legislation to budget committees. House and Senate develop conference report on

reconciliation, which is voted on by each chamber.

June 10 House concludes reporting annual House appropriations bills.

June 15 If necessary, Congress completes reconciliation legislation.

June 30 House completes its appropriations bills.

September 30 Senate completes its appropriations bills. House and Senate complete appropriations

conference reports and vote separately on the final bills.

October 1 Fiscal year begins.

Modified from House Committee on the Budget Majority Caucus, Basics of the Budget Process, 107th Cong. Briefing Paper, 2001.

20 Chapter 2

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The Federal Executive Branch

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The Presidency
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BOX 2-1 Office of Management and Budget

The Office of Management and Budget (OMB) reports

directly to the president and plays an important role

in policy decisions. OMB is responsible for preparing

the presidential budget proposal, which includes

reviewing agency requests, coordinating agency

requests with presidential priorities, working with

Congress to draft appropriation and authorization bills,

and working with agencies to make budget cuts when

needed. In addition to these budgetary functions,

OMB provides an estimate of the cost of regulations,

approves agency requests to collect information,

plays a role in coordinating domestic policy, and

may act as a political intermediary on behalf of the

president. OMB also has an oversight and evaluation

function over select federal agencies as a result of

the Government Performance and Results Act, which

requires agencies to set performance goals and have

their performance evaluated.

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FIGURE 2-2 Executive Agency Policymaking
Source: Courtesy of Jeff Levi, Professor of Health Policy, George Washington University.

e and P 23

Should this be
on the agenda? Agency Staff

What are the
options?

Is there a
problem?

What is
recommended to
decision-maker?

Congress

Media

White House

CONSUMERS, CITIZENS, &
CONSTITUENCY GROUPS

Political
Players

ffice

ffice

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24 Chapter 2

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▸ The Health Bureaucracy

The Federal Government

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TABLE 2-3 Summary of Public Policymaking Entities

Congress President Administrative Agencies

Main function Legislative body Chief executive of the country Implement statutes through

rule making

Main tools/

powers

Support/oppose/pass

legislation

Appropriations

Oversight

Agenda setting

Persuasion

Propose solutions

Budget proposals

Executive orders

Sign legislation into law

Create regulations

Provide information

Constituents Voters in state or district

Voters in nation if in leadership

role or have national

aspirations

Party

President

Nation (all voters)

Public who voted for the

president

Party

Other nations

International organizations

President

Congress

Individuals and entities

regulated or served by the

agency

25

Department of Health and Human
Services

FIGURE 2-3

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TABLE 2-4

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FIGURE 2-3 Department of Health and Human Services Organizational Chart
Source: Reproduced from: the U.S. Department of Health and Human Services. HHS Organizational Chart. Retrieved from https://www.hhs.gov/about/agencies/orgchart/index.html#

26 Chapter 2

Secretary
Deputy Secretary

Chief of Staff

The Executive
Secretariat (ES)

Office of Health Reform
(OHR)

Office of the Secretary

Office of the Assistant Secretary for
Administration (ASA)

Administration for Children and
Families (ACF)

Administration for Community Living
(ACL)

Agency for Healthcare Research and
Quality (AHRQ)

Agency for Toxic Substances and
Disease Registry (ATSDR)

Centers for Disease Control and
Prevention (CDC)*

Centers for Medicare & Medicaid
Services (CMS)

Food and Drug Administration (FDA)*

Health Resources and Services
Administration (HRSA)*

Indian Health Service (IHS)*

National Institutes of Health (NIH)*

Substance Abuse and Mental Health
Services Administration (SAMHSA)*

Office of the Assistant Secretary for
Financial Resources (ASFR)

Office of the Assistant Secretary for
Health (OASH)

Office of the Assistant Secretary for
Legislation (ASL)

Office of the Assistant Secretary for
Planning and Evaluation (ASPE)

Office of the Assistant Secretary for
Preparedness and Response (ASPR)*

Office of the Assistant Secretary for
Public Affairs (ASPA)

Center for Faith-Based and
Neighborhood Partnerships (CFBNP)

Office for Civil Rights (OCR)

Departmental Appeals Board (DAB)

Office of the General Counsel (OGC)

Office of Global Affairs (OGA)*

Office of Inspector General (OIG)

Office of Medicare Hearings and
Appeals (OMHA)

Office of the National Coordinator for
Health Information Technology (ONC)

*denotes the components of the Public Health Service

Operating Divisions

Office of
Intergovenmental and
External Affairs (IEA)

TABLE 2-4 Department of Health and Human Services Agencies

Agency Main Purpose of Agency

Administration for Children and

Families (ACF)

To promote economic and social well-being of families, children,

individuals, and communities through educational and supportive

programs

Administration for Community

Living (ACL)

To increase access to community support and resources for older adults

and people with disabilities

Agency for Healthcare Research and

Quality (AHRQ)

To produce evidence to make health care safer, high quality, more

accessible, and affordable, and to work with HHS and other partners to

make sure the evidence is understood and used

Agency for Toxic Substances and

Disease Registry (ATSDR)

To prevent exposure to toxic substances and reduce the adverse health

effects associated with such exposure

Centers for Disease Control and

Prevention (CDC)

To protect the nation’s health by providing leadership in the prevention and

control of diseases and other preventable conditions, and to respond the

public health emergencies

Center for Medicare and Medicaid

Services (CMS)

To provide oversight of Medicare, the federal portions of Medicaid and CHIP,

and the Health Insurance Marketplace, and to engage in quality assurance

activities

Food and Drug Administration (FDA) To assure the safety of human and veterinary drugs, biological products,

and medical devices, and to ensure the safety and security of the nation’s

food supply and products that emit radiation

Health Resources and Services

Administration (HRSA)

To provide health care to populations that are geographically isolated, or

economically or medically vulnerable

Indian Health Services (IHS) To provide American Indians and Alaska Natives with comprehensive health

services

National Institutes of Health (NIH) To support and conduct biomedical and behavioral research, to train

promising young researchers, and to promote collecting and sharing

knowledge

Substance Abuse and Mental Health

Services Administration (SAMHSA)

To improve access to and reduce barriers to high-quality, effective programs

for individuals who suffer from addictive or mental disorders, and for their

families and communities

Department of Health and Human Services (2015).

Source: Department of Health and Human Services. (2015). HHS agencies and offices. Retrieved from https://www.hhs.gov/about/agencies/hhs-agencies-and-offices/index.html

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31

CHAPTER 3

Law and the Legal System

LEARNING OBJECTIVES

By the end of this chapter you will be able to:

■ Describe the role of law in everyday life
■ Define the term “law”
■ Identify the various sources of law
■ Describe key features of the legal system

“It is perfectly proper to regard and study the law simply as a great anthropological document.”

(1899, p. 444).

By the end of this chapter you will be able to:

■ Describe the role of law in everyday life
■ Define the term “law”
■ Identify the various sources of law
■ Describe key features of the legal system

▸ Introduction

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▸ The Role of Law
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▸ The Definition and Sources
of Law

Defining “Law”

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Sources of Law
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Constitutions

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36 Chapter 3

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Administrative Regulations
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Common Law

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fir TABLE 3-1

▸ Key Features of the
Legal System

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Separation of Powers
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39

TABLE 3-1 Summary of the Primary Sources of American Law

Source of Law Key Points

Constitutions ■ Establish governments and delineate fundamental rights and obligations of government

and individuals.
■ There is a federal constitution and separate constitutions in each state.
■ The federal constitution restrains government more than it confers individual rights;

however, the Bill of Rights specifically guarantees several important individual rights.
■ The Supreme Court has the final word on the constitutionality of laws created by the

political branches of government.

Statutes ■ Created by legislatures at all levels of government.
■ Two hallmarks: prospectivity and generality.
■ As broad policy statements, statutes are often ambiguous as applied to specific cases

or controversies, requiring courts to interpret them through the practice of statutory

construction.
■ State legislatures can use statutes to regulate across a broader range of issues than can

Congress; however, federal statutes have primacy over conflicting state statutes.

Regulations ■ Created by executive branch administrative agencies to implement statutes and clarify

their ambiguities.
■ Play a particularly critical role in health policy and law.

Common law ■ Court opinions interpreting and applying law to specific cases.
■ Also referred to as case law, judge-made law, or decisional law.
■ Based on the traditions and customs of society, yet heavily influenced by legal precedent

and the doctrine of stare decisis.

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Federalism: Allocation of Federal
and State Legal Authority

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The Role of Courts

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Enforcing Legal Rights

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Reviewing the Actions of the Political
Branches

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Maintaining Stability in the Law

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48 Chapter 3

CHAPTER 4

Overview of the United States
Healthcare System

LEARNING OBJECTIVES

By the end of this chapter you will be able to:

■ Identify the key players who provide and finance health care in the United States
■ Identify common characteristics of the uninsured
■ Understand the effect of insurance on access to care and on health status
■ Identify barriers to accessing health care
■ Understand concerns regarding the quality of health care provided in the United States
■ Describe differences in how health care is delivered in various countries

By the end of this chapter you will be able to:

■ Identify the key players who provide and finance health care in the United States
■ Identify common characteristics of the uninsured
■ Understand the effect of insurance on access to care and on health status
■ Identify barriers to accessing health care
■ Understand concerns regarding the quality of health care provided in the United States
■ Describe differences in how health care is delivered in various countries

▸ Introduction
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▸ Healthcare Finance

FIGURE 4-1 Thi

FIGURE 4-1 National Health Expenditures as a Share of Gross Domestic Product, 1987–2016

50 Chapter 4

Source: Reproduced from: Centers for Medicare and Medicaid Services, Office of the Actuary. (n.d.). National Health Care Spending in 2016. Retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports

/NationalHealthExpendData/Downloads/NHE-Presentation-Slides

10.0

P
er

ce
nt

o
f G

D
P

Calendar Years

17.9%

19
87

19
88

19
89

19
90

19
91

19
92

19
93

19
94

19
95

19
96

19
97

19
98

19
99

20
00

20
01

20
02

20
03

20
04

20
05

20
06

20
07

20
08

20
09

20
10

20
11

20
12

20
13

20
14

20
15

20
16

12.0

14.0

16.0

18.0

July 1990–
March 1991
recession

20.0

December 2007–
June 2009
recession

March 2001–
November
2001
recession

The Share of GDP Devoted to Health Expenditures Was 17.9% in 2016

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FIGURE 4-3

Health Insurance
fin

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FIGURE 4-2 Factors Accounting for Growth in per Capita National Health Expenditures, Selected Calendar Years, 2004–2016

51

6.5%
6.0%
5.5%
5.0%
4.5%
4.0%
3.5%
3.0%

0.0%

2004–2007

A
nn

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Per Capita Health Spending Grew 3.5% in 2016

5.8%

3.0%

4.3%

5.0%

3.5%

2008–2013 2014 2015 2016

1.0%
0.5%

2.0%
1.5%

2.5%

Age and sex factors
Medical prices
Residual use and intensity

Notes: Medical price growth, which includes economy-wide and excess
medical-specific price growth (or changes in medical-specific prices in excess of
economy-wide inflation), is calculated using the chain-weighted national health
expenditures (NHE) deflator for NHE. “Residual use and intensity” is calculated by
removing the effects of population, age and sex factors, and price growth from the
nominal expenditure level.

Source: Reproduced from: Centers for Medicare and Medicaid Services, Office of the Actuary. (n.d.). National Health Care Spending in 2016. Retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports

/NationalHealthExpendData/Downloads/NHE-Presentation-Slides

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FIGURE 4-3 The Nation’s Health Dollar, Calendar Year 2016: Where it Went

FIGURE 4-4 Healthcare Coverage in the United States,

March 2016

52 Chapter 4

Note: “Other spending” includes dental services, other professional services, home health care,
durable medical equipment, other nondurable medical products, government public health
activities, and investment.

Hospital care,
32%

Physician and clinical
services,

20%Nursing care facilities
and continuing care

retirement communities,
5%

Prescription drugs,
10%

Government
administration and net

cost of health insurance,
8%

Other health, residential,
and personal care,

5%

Other
spending,

20%

Source: Reproduced from: Centers for Medicare and Medicaid Services, Office of the Actuary. (n.d.). National Health Care Spending in 2016. Retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports

/NationalHealthExpendData/Downloads/NHE-Presentation-Slides

Employer,
153 million

(47.3%)

Medicare,
55.5 (17.2%)

Medicaid,
49 (15.2%)

Medicaid/CHIP
23.6 (7.3%)

Affordable Care Act
9.1 (2.9%)

Other
4 (1.2%)

Total U.S. population
323.2 million

Uninsured
29 (9%)

Source: Hiltzik, M. (2016, March 29). Where America gets its health coverage: Everything you wanted to know in one handy chart. L.A.

Times. Retrieved June 11, 2018 from http://www.latimes.com/business/hiltzik/la-fi-hiltzik-gaba-20160329-snap-htmlstory.html

Direct Services Programs

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FIGURE 4-5 Insurance Company–Consumer–Provider Interaction

53

Insurance Company

Consumer

Accepts payment
Accepts rules

Sets reimbursement rates
Sets quality control requirements

Enroll in plan
Pays plan
Questions

Appeals

Sets plan rules
Covers some consumer costs

Provider

Accepts patient
Provides services
May accept payment

Chooses provider
Receives services
May pay provider

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The Uninsured

Characteristics of the Uninsured
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54 Chapter 4

FIGURE 4-8

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FIGURE 4-9

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FIGURE 4-6 Percentage Point Change in Uninsured Rate Among the Nonelderly Population by Selected Characteristics,

2013–2016

FIGURE 4-7 Reasons for Being Uninsured Among Uninsured

Nonelderly Adults, 2016

55

<1 00 % F PL 10 0 to 1 99 % F PL ≥2 00 % F PL W hi te Bl ac k H is pa ni c As ia n C hi ld re n 0– 17 N on el de rly ad ul ts 1 8– 64 Yo un g ad ul ts 19 –2 5 0.0% –9.5% –3.6% –4.8% –7.4% –7.3% –1.4% –8.2% –12.8% –11.1%–11.3% –2.0% –4.0% –6.0% –8.0% –10.0% –14.0% Notes: Includes nonelderly individuals ages 0–64. –12.0% Poverty level Race/ethnicity Age Source: Foutz et al., 2017, Figure 4; Kaiser Family Foundation analysis of the 2013 and 2016 National Health Interview Survey. 0 5 10 15 20 25 30 35 40 45 Share who say they are uninsured because: Cos t is to o hig h Lo st job o r c ha ng ed em plo ye rs Lo st m ed ica id Em plo ye r d oe s n ot o ffe r o r ine lig ibl e for co ve ra ge Fa m ily st at us ch an ge No ne ed fo r h ea lth co ve ra ge 45 % 23% 12% 10% 9% 2% Notes: Includes nonelderly adults ages 18–64. Respondents can select multiple reasons. Status change includes marital status change, death of spouse or parent, or ineligible due to age or leaving school. Source: Kaiser Family Foundation. (n.d.). Key facts about the uninsured population. Retrieved from https://www.kff.org /uninsured/fact-sheet/key-facts-about-the-uninsured-population/ et  FIGURE 4-10 ff et  fie FIGURE 4-8 After 3 Years of the ACA, Uninsured Rates for Blacks, Latinos, and Whites Have Declined Significantly, but Large Numbers of Immigrant Latinos Remain Uninsured FIGURE 4-9 Cumulative Increase in Family Premiums, Worker Contribution to Premiums, and Worker Earnings, 1999–2017 56 Chapter 4 0 White P er ce nt A du lts A ge s 19 –6 4 U ni ns ur ed 16 21 13 36 29 24 47 43 14 9 Black Latino (total) Latino (U.S.-born) Latino (foreign-born) 20 10 50 40 30 July-Sept. 2013 Feb.-April 2016 Source: Reproduced from Foutz et al., 2017; The Commonwealth Fund Affordable Care Act Tracking Surveys. July–September 2015 and February–April 2016. Source: Kaiser/HRET Survey of Employer-Sponsered Health Benefits, 1999-2017; Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), 1999-2017; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 1999-2017 (April to April). 1999 0% 38% 38% 29% 24% 109% 113% 47% 172% 180% 270% 224% 64% 47% 38% 8% 11% 50% 100% 150% 200% 250% 300% C um ul at iv e G ro w th 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Overall inflation Worker earnings Family premiums Worker contributions fir ff ff Th ft Th ff Th FIGURE 4-11 Th Th diff Thi Th ft FIGURE 4-10 Characteristics of the Nonelderly Uninsured, 2016 57 100–199% FPL 25% 200–399% FPL 31% 400%+ FPL 20% <100% FPL 24% Total = 27.5 Million Nonelderly Uninsured Family work status Family income (%FPL) Race One or more full-time workers 75% No workers 15%11% Part-time workers White 44% Black 15% Hispanic 33% Asian/Native Hawaiian or Pacific Islander 5% Other 3% Notes: Includes nonelderly individuals ages 0–64. The U.S. Census Bureau’s poverty threshold for a family with two adults and one child was $19,318 in 2016. Data may not total 100% due to rounding. Persons of Hispanic origin may be of any race; all other race/ethnicity groups are non-Hispanic. Source: Kaiser Family Foundation analysis of the March 2017 Current Population Survey, Annual Social and Economic Supplement. ff The Importance of Health Insurance Coverage to Health Status efi ff efi tz et a et  fie FIGURE 4-12 Th et  et  ft diffic FIGURE 4-11 Uninsured Rates Among the Nonelderly by State, 2016 Source: Reproduced from Centers for Disease Control and Prevention, MMWR 1996;45: 526–528. 58 Chapter 4 AK HI WA ID MT WY CO ND MN IA MO AR LA MS AL GA FL NJ DE MD DC SC NCTN KY INIL WI MI OH PA WV VA NY ME VT NH MA CT RI SD NE KS OK TX NMAZ UTNV OR CA Notes: Includes nonelduals individuals ages 0–64. <7% (11 states including DC) 7–12% (28 states) >12% (12 states)

Source: Kaiser Family Foundation analysis of the March 2017 Current Population Survey, Annual Social and Economic Supplement.

BOX 4-1 Discussion Questions

From a policy perspective, are the characteristics just

described interrelated, or should they be addressed

separately? If you are trying to reduce the number

of uninsured, do you believe the focus should be on

altering insurance programs or changing the effect of

having one or more of these characteristics? Whose

responsibility is it to reduce the number of uninsured?

Government? The private sector? Individuals?

BOX 4-2 Discussion Questions

The ACA made it a priority to reduce the number of

uninsured. At what point, if any, should the government

step in to provide individuals with assistance to

purchase insurance coverage? Do you think such

assistance should be a federal or a state responsibility?

cific

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Ways to Assess the Cost of Being
Uninsured
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FIGURE 4-13

fici et 

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FIGURE 4-12 Barriers to Health Care Among Nonelderly Adults by Insurance Status, 2016

59

0
No usual source

of care
Postponed seeking

care due to cost

Note: Includes nonelderly adults ages 18–64. Includes barriers experienced in past 12 months.
Respondents who said usual source of care was the emergency room were included among those not
having a usual source of care. All differences between uninsured and insurance groups are statistically
significant (p < 0.05). 49% 12% 12% 23% 9% 6% 20% 8% 18% 14% 6% 3% Went without needed care due to cost Postponed or did not get needed prescription drug due to cost 10 5 25 30 35 40 45 50 20 15 Uninsured Medicaid/other public Employer/other private Source: Foutz et al., 2017; Kaiser Family Foundation analysis of the 2016 National Health Interview Survey. Thi eff ffice sfie Thi uff efi ffice fi uff The Underinsured fin ft efici et  Th ff et  ff et  hift ff FIGURE 4-13 Problems Paying Medical Bills by Insurance Status, 2016 60 Chapter 4 0 Problems paying or unable to pay medical bills Worried about being able to pay costs for normal care Note: Includes nonelderly adults ages 18–64. All differences between uninsured and insured groups are statistically significant (p < 0.05). 29% 14% 63% 26% 76% 44% 30% 24% Worried about paying medical bills if get sick Medical bills being paid off over time 20 10 50 60 70 80 40 30 Uninsured Insured Source: Foutz et al., 2017; Kaiser Family Foundation analysis of the 2016 National Health Interview Survey. Insurance Coverage Limitations Th cific Cost Sharing ft Th FIGURE 4-14 FIGURE 4-14 Average Annual Premiums for Single and Family Coverage, 1999–2017 61 19 99 20 00 20 01 20 02 20 03 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 $0 $6,000 $8,000 $10,000 $12,000 $18,000 $20,000 $16,000 $14,000 $4,000 $2,000 $3 ,3 83 * $9 ,0 68 * $3 ,6 95 * $9 ,9 50 * $4 ,0 24 * $1 0, 88 0* $4 ,2 42 * $1 1, 48 0* $4 ,4 79 * $1 2, 10 6* $4 ,7 04 * $1 2, 68 0* $5 ,0 49 * $1 3, 77 0* $5 ,4 29 * $1 5, 07 3* $5 ,8 84 * $1 6, 35 1* $6 ,4 35 $1 8, 14 2* $6 ,6 90 * $1 8, 76 4* $6 ,2 51 * $1 7, 54 5* $6 ,0 25 $1 6, 83 4* $5 ,6 15 * $1 5, 74 5* $4 ,8 24 $1 3, 37 5* $2 ,6 89 * $7 ,0 61 * $2 ,4 71 * $6 ,4 38 * $2 ,1 96 $5 ,7 91 $3 ,0 83 * $8 ,0 03 * Single coverage Family coverage *Estimate is statistically different from estimate for the previous year shown (p < 0.05). Source: Kaiser/HRET Survey of Employer-Sponsered Health Benefits, 1999–2017. infl Th diff cific ffice ffice nific fir fir nific FIGURE 4-15 cific fir efici fir Thi Reimbursement and Visit Caps cific FIGURE 4-15 Percentage of Covered Workers Enrolled in a Plan With a General Annual Deductible of $1,000 or More for Single Coverage, by Firm Size, 2009–2017 62 Chapter 4 80% 40% 30% 20% 10% 0% 50% P er ce nt ag e of C ov er ed W or ke rs 60% 70% 2012 2013 2014 2016 20172015201120102009 40% 46% 50% 49% 58%* 61% 63% 65% 58% 51% 48% 51% 45% 46% 39%* 41% 32% 38% 28% 34% 26% 31% 22%* 27%* 17% 22% 13% *Estimate is statistically different from estimate for the previous year shown (p < 0.05). Note: These estimates include workers enrolled in HDHP/SOs and other plan types. Average general annual health plan deductibles for PPOs, POS plans, and HDHP/SOs are for in-network services. All small firms (3–199 Workers) ALL FIRMS All large firms (200 or more workers) Source: “2017 Employer Health Benefits Survey,” 2017. Service Exclusions cifie Th efi ff Safety Net Providers diffic ft ft diffic fin Th defin nific diffic Th fi defini lifie 63 ft et  ft cific ft fin diffic Th infl et  Th ft nific ff diffic ff   64 Chapter 4 ff Workforce Issues Thi ff Th ft nific et  h et a et  ffices ffice-b Th fie et  Th Th ffice FIGURES 4-16 4-18 defici defici BOX 4-3 Discussion Questions Safety net providers mostly serve uninsured and publicly insured low-income patients. Many of the safety net provider features you just read about are in place to assist these patients in accessing health care. Instead of pursuing universal coverage, would it be an equally good strategy to expand the number of safety net providers? Are there reasons for both safety net providers and health insurance to exist? How does having insurance relate to accessing care? 65 AK HI WA ID MT WY CO ND MN IA MO AR LA MS AL GA FL SC NCTN KY INIL WI MI OH PA WV VA NYSD NE KS OK TX NMAZ UTNV OR CA *Note: Estimates in states with an RSE > 20% should be used with caution because of large
sampling error.

902–4,032

4,033–7,017

7,018–13,986

13,987–26,841

26,842–94,385

RSE 20–29%*

DC

Total number

NJ
DE
MD

ME
VT

NH
MA

CT
RIWY

ND

FIGURE 4-16 Number of Physicians by State, 2008–2010
Source: See Figure 2 from The US Health Workforce Chartbook, HRSA, 2013, retrieved from https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/chartbookpart1

AK

HI

WA

ID

MT

WY

CO

ND
MN

IA

MO

AR

LA

MS AL GA

FL

NCTN

INIL

WI

MI

OH

PA

WV
VA

NYSD

NE

OK

TX

NMAZAZ

UTNV

OR

CA

*Note: Estimates in states with an RSE > 20% should be used with caution because of large
sampling error.
**Data are not reported at the state level, because the RSE ≥ 30%; estimate does not meet
standards of reliability.

597–763

764–1,394

1,394–2,204

Not reportable**

2,205–3,649

3,650–10,198

RSE 20–29%*

DC

Total number

NJ
DE
MD

ME
VT

NH
MA

CT
RI

ID

MS

WV

NE

OK

NV

KYKYKS

SCSC

KS

LA

IA

FIGURE 4-17 Number of Physician Assistants by State, 2008–2010
Source: See Figure 7 from The US Health Workforce Chartbook, HRSA, 2013, retrieved from https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/chartbookpart1

66 Chapter 4

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110 

Th

AK

HI

WA

ID

MT

WY

CO

ND
MN

IA

MO

AR

LA

MS AL GA

FL

SC

NCTN

KY

INIL

WI

MI

OH

PA

WV
VA

NYSD

NE

KS

OK

TX

NMAZ

UTNV

OR

CA

4,296–22,260
Total number

22,261–50,861

50,842–90,663

90,664–167,476

167,477–274,722

DC

NJ
DE
MD

ME
VT

NH
MA

CT
RI

FIGURE 4-18 Number of Nurse Practitioners by State, 2008–2010
Source: See Figure 21 from The US Health Workforce Chartbook, HRSA, 2013, retrieved from https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/chartbookpart1

67

eff

▸ Healthcare Quality

fin

Th

ff
et 

Th

et 

et 

y et a

Key Areas of Quality Improvement

Th

effic effi

Safety

diff

Efficacy
ific

eff eff

Thi eff
eff

68 Chapter 4

eff
fin

Patient-Centeredness

nific

fi

diff

diff defin

(Office

Timeliness

ffices,

Th

ff diffic

efficien

Efficiency
efficien

Th

nific

efficien

ft

diff

eff

BOX 4-4 Discussion Questions

Unfortunately, evidence is not available to support the

effectiveness or cost–benefit of every procedure or

drug. How should policymakers and providers make

decisions when faced with a dearth of evidence?

Do you prefer a more cautious approach that does

not approve procedures or drugs until evidence

is available or a more aggressive approach that

encourages experimentation and use of treatments

that appear to be effective? What about medical care

for children, who are generally excluded from clinical

and research trials for ethical reasons? When, if ever, is

it appropriate for insurers to cover or the government

to pay for treatments that are not proven effective?

69

Th

diffic

Th

FIGURE 4-19

ft

Equity

efi

ufficien
Th

ff
ufficien

ft

Th

*Or nearest year; data from 2014 for Australia and Canada. No recent data for New Zealand (since 2007).
Data reflect current spending on governance and health system and financing administration, in current
prices, current PPPs. ‘OECD median’ reflects the median of 34 OECD countries.

34
89 90

123 141
206

255 272 286

787

0

100

200

300

400

500

600

700

800

900

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Dollars ($US)

OECD

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Adjusted for Differences in Cost of Living

FIGURE 4-19 Spending on Health Insurance Administration per Capita, 2015
Source: Retrieved from https://www.commonwealthfund.org/publications/publication/2017/nov/multinational-comparisons-health-systems-data-2017

70 Chapter 4

fl

diff

Assessment of Efforts to Improve Quality
Th

nifi

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nflic

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▸ Comparative Health Systems

fl ft

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FIGURE 4-20

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A National Health Insurance System:
Canada

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71

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18

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014

P
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e

United States (16.6%)

Switzerland (11.4%)

Sweden (11.2%)

France (11.1%)

Germany (11.0%)

Netherlands (10.9%)

Canada (10.0%)

United Kingdom (9.9%)

New Zealand (9.4%)

Norway (9.3%)

Australia (9.0%)

GDP refers to gross domestic product. Data in legend are for 2014.

FIGURE 4-20 Healthcare Spending as a Percentage of Gross Domestic Product, 1980–2014
Source: Retrieved from https://www.commonwealthfund.org/chart/2017/health-care-spending-percentage-gdp-1980-2014

TABLE 4-1 Comparison of Health Systems Across Four Countries

United States Canada Great Britain Germany

System type No unified system National health

insurance

National

health system

Socialized health insurance

Universal

coverage

Near universal if ACA

fully implemented

Yes Yes Yes

Role of private

insurance

Significant Supplemental to

Medicare, two-thirds

purchase

Minimal Minimal

Financing Private payments and

tax revenue

Mostly tax revenue

(federal, provincial,

territorial)

All federal

income tax

revenue

Mandatory employer and

employee contributions to

national health fund

Hospital

reimbursement

Varies by payer (DRGa,

FFSb, capitation,

per diem)

Global budget Global

budget

DRGa

Physician

reimbursement

Fee schedule or

capitation

Negotiated fees with

provinces/ territories

Salary or

capitation

Negotiated fees with funds

DRGa = diagnostic-related group (payment based on bundle of services needed for diagnosis). FFSb = fee for service (payment per service rendered).

72 Chapter 4

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A National Health System: Great Britain

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74 Chapter 4

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FIGURES 4-21 4-25

ff

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BOX 4-5 Discussion Questions

Do you prefer one of these health systems to the

others? Why or why not? Are there features that you

think should be incorporated into the U.S. healthcare

system? Are there reasons why certain features might be

difficult to incorporate into the U.S. healthcare system?

FIGURE 4-21 Cost-Related Access Barriers in the Past Year
Source: Retrieved from https://www.commonwealthfund.org/publications/surveys/2016/nov/2016-commonwealth-fund-international-health-policy-survey-adults

et a

The Importance of Health
Insurance Design

Diff

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75

7 7 8 8 10
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*Had a medical problem but did not visit doctor; skipped medical test, treatment, or follow-up
recommended by doctor; and/or did not fill prescription or skipped doses

▸ Conclusion
Thi

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FIGURE 4-23 Waited 2 Months or Longer for a Specialist Appointment
Source: Retrieved from https://www.commonwealthfund.org/publications/surveys/2016/nov/2016-commonwealth-fund-international-health-policy-survey-adults

FIGURE 4-22 Did Not Get Same or Next-Day Appointment Last Time You Needed Care
Source: Retrieved from https://www.commonwealthfund.org/publications/surveys/2016/nov/2016-commonwealth-fund-international-health-policy-survey-adults

76 Chapter 4

19 22

31

41 41 42 43 44 47 50 53

0

20

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60

80

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Base: Excludes adults who did not need to make an appointment to see a doctor or nurse

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FIGURE 4-24 Used the ED in the Last 2 Years
Source: Retrieved from https://www.commonwealthfund.org/publications/surveys/2016/nov/2016-commonwealth-fund-international-health-policy-survey-adults

8

16 16
20 23 24

28 30 30 31

43

7 6 7 8 7
13

18
14 13

22

32

0

20

40

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Low income adults
All other adults

P
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*Indicates differences are significant at p<0.05. Note: “Low income” defined as household income less than 50% the country median. Sample sizes are small (n<100) in the Netherlands and UK. Net he rla nd s* Can ad a* Unit ed K ing do m Nor way * Switz er lan d* Swed en * Unit ed S ta te s* Fra nc e* Ger m an y* New Z ea lan d* Aus tra lia * FIGURE 4-25 Cost-Related Access Barriers in the Past Year, By Income Source: Retrieved from https://www.commonwealthfund.org/publications/surveys/2016/nov/2016-commonwealth-fund-international-health-policy-survey-adults 77 ff ff Th ff ff fi ff ffic Th ff ff Office ff ff ff ff Th a/fi Th g/fi GA/fi Th Th fie Th ff ff ff ff eff ft ff ff ff ff 78 Chapter 4 ff efi ff efi Th Th eff et—Th Th eff Th ff Office Office Th e-fi ff ff ff ff Th ff ff ffin A  fie Th g Office 79 g Office g Office ff ff 80 Chapter 4 81 © Mary Terriberry/Shutterstock CHAPTER 5 Public Health Institutions and Systems LEARNING OBJECTIVES By the end of this chapter you will be able to: ■ Identify goals of governmental public health ■ Identify the 10 essential services of public health ■ Describe basic features of local, state, and federal public health agencies in the United States ■ Identify global public health organizations and agencies and describe their basic roles ■ Identify roles in public health for federal agencies not identified as health agencies ■ Illustrate the need for collaboration by governmental public health agencies with other governmental and nongovernmental organizations ■ Describe approaches to connecting public health and the healthcare system By the end of this chapter you will be able to: ■ Identify goals of governmental public health ■ Identify the 10 essential services of public health ■ Describe basic features of local, state, and federal public health agencies in the United States ■ Identify global public health organizations and agencies and describe their basic roles ■ Identify roles in public health for federal agencies not identified as health agencies ■ Illustrate the need for collaboration by governmental public health agencies with other governmental and nongovernmental organizations ■ Describe approaches to connecting public health and the healthcare system ▸ Introduction BOX 5-1 efle ▸ What Are the Goals and Roles of Governmental Public Health Agencies? ft Th ft defin Th defin ■ ■ ■ ■ 82 Chapter 5 nstitutions and S BOX 5-1 Vignette A young man in your dormitory is diagnosed with tuberculosis. The health department works with the student health service to test everyone in the dorm, as well as in his classes, with a tuberculosis skin test. Those who are positive for the first time are advised to take a course of a medicine called INH. You ask, is this standard operating procedure? You go to a public health meeting and learn that many of the speakers are not from public health agencies, but from the Departments of Labor, Commerce, Housing, and Education. You ask, what do these departments have to do with health? You hear that a new childhood vaccine was developed by the National Institutes of Health (NIH), approved by the Food and Drug Administration (FDA), endorsed for federal payment by the Centers for Disease Control and Prevention (CDC), and recommended for use by the American Academy of Pediatrics. You ask, do all these agencies and organizations always work so well together? A major flood in Asia leads to disease and starvation. Some say it is due to global warming, others to bad luck. Coordinated efforts by global health agencies, assisted by nongovernmental organizations (NGOs) and individual donors, help get the country back on its feet. You ask, what types of cooperation are needed to make all of this happen? A local community health center identifies childhood obesity as a problem in the community. The center collects data demonstrating that the problem begins as early as elementary school. They develop a plan that includes clinical interventions at the health center and also at the elementary school. They ask the health department to help them organize an educational campaign and assist in evaluating the results. Working together, they are able to reduce the obesity rate among elementary school children by 50%. This seems like a new way to practice public health, you conclude. What type of approach is this? Source: © maxstockphoto/ShutterStock, Inc. ■ ■ Th defin Th Th Th defin Th cific 83 Th defin ■ defin cific definin ■ eff ■ eff ft Th TABLE 5-1 10 Essential Public Health Services Essential Service Meaning of Essential Service Examples Core function: assessment 1. Monitor health status to identify and solve community health problems This service includes accurate diagnosis of the community’s health status; identification of threats to health and assessment of health service needs; timely collection, analysis, and publication of information on access, utilization, costs, and outcomes of personal health services; attention to the vital statistics and health status of specific groups that are at a higher risk than the total population; and collaboration to manage integrated information systems with private providers and health benefit plans. Vital statistics Health surveys Surveillance, including reportable diseases 2. Diagnose and investigate health problems and health hazards in the community This service includes epidemiologic identification of emerging health threats; public health laboratory capability using modern technology to conduct rapid screening and high-volume testing; active communicable disease epidemiology programs; and technical capacity for epidemiologic investigation of disease outbreaks and patterns of chronic disease and injury. Epidemic investigations CDC–Epidemic Intelligence Service State public health laboratories Core function: policy development 3. Inform, educate, and empower people about health issues This service includes social marketing and media communications; providing accessible health information resources at community levels; active collaboration with personal healthcare providers to reinforce health promotion messages and programs; and joint health education programs with schools, churches, and worksites. Health education campaigns, such as comprehensive state tobacco programs defini Th defin lfi Th defin ▸ What Are the 10 Essential Public Health Services? TABLE 5-1 lfi   (continues) 84 Chapter 5 nstitutions and S Essential Service Meaning of Essential Service Examples 4. Mobilize community partnerships and action to identify and solve health problems This service includes convening and facilitating community groups and associations, including those not typically considered to be health-related, in undertaking defined preventive, screening, rehabilitation, and support programs; and skilled coalition-building to draw upon the full range of potential human and material resources in the cause of community health. Lead control programs: testing and follow-up of children, reduction of lead exposure, educational follow-up, and addressing underlying causes 5. Develop policies and plans that support individual and community health efforts This service requires leadership development at all levels of public health; systematic community and state-level planning for health improvement in all jurisdictions; tracking of measurable health objectives as a part of continuous quality improvement strategies; joint evaluation with the medical/healthcare system to define consistent policy regarding prevention and treatment services; and development of codes, regulations, and legislation to guide public health practice. Newborn screening and follow-up programs for PKU and other genetic and congenital diseases Core function: assurance 6. Enforce laws and regulations that protect health and ensure safety This service involves full enforcement of sanitary codes, especially in the food industry; full protection of drinking water supplies; enforcement of clean air standards; timely follow-up of hazards, preventable injuries, and exposure-related diseases identified in occupational and community settings; monitoring quality of medical services (e.g., laboratory, nursing home, home health care); and timely review of new drug, biologic, and medical device applications. Local: Fluoridation and chlorination of water State: Regulation of nursing homes Federal: FDA drug approval and food safety 7. Link people to needed personal health services and ensure the provision of health care when otherwise unavailable This service (often referred to as “outreach” or “enabling” services) includes ensuring effective entry for socially disadvantaged people into a coordinated system of clinical care; culturally and linguistically appropriate materials and staff to ensure linkage to services for special population groups; ongoing “care management”; and transportation. Community health centers 8. Ensure the provision of a competent public and personal healthcare workforce This service includes education and training for personnel to meet the needs of public and personal health services; efficient processes for licensure of professionals and certification of facilities with regular verification and inspection follow-up; adoption of continuous quality improvement and lifelong learning within all licensure and certification programs; active partnerships with professional training programs to ensure community-relevant learning experiences for all students; and continuing education in management and leadership development programs for those charged with administrative/ executive roles. Licensure of physicians, nurses, and other health professionals TABLE 5-1 10 Essential Public Health Services (continued) 85 Monitor Health Evaluate Assure Competent Workforce Diagnose and Investigate Inform, Educate, Empower Link to / Provide Care Enforce Laws Develop Policies Mobilize Community Partnerships ResearchResearch A S S U R A N C E ASSESSM ENT S ys te m Managem ent POLICY DEVELO PM E N TS FIGURE 5-1 Essential Public Health Services and Institute of Medicine’s Core Functions Source: Centers for Disease Control and Prevention. (2017). The public health system & the 10 essential public health services. Retrieved from https://www.cdc.gov/stltpublichealth/publichealthservices/essentialhealthservices.html Governmental Public Health Agencies Other Government Agencies Local State Federal Global Healthcare Delivery System Community and Private Organizations FIGURE 5-2 Framework for Viewing Governmental Public Health Agencies and Their Complicated Connections FIGURE 5-1 FIGURE 5-2   fin ▸ What Are the Roles of Local and State Public Health Agencies? Th 9. Evaluate effectiveness, accessibility, and quality of personal and population- based health services This service calls for ongoing evaluation of health programs, based on analysis of health status and service utilization data, to assess program effectiveness and to provide information necessary for allocating resources and reshaping programs. Development of evidence-based recommendations All three IOM core functions 10. Research for new insights and innovative solutions to health problems This service includes continuous linkage with appropriate institutions of higher learning and research and an internal capacity to mount timely epidemiologic and economic analyses and conduct needed health services research. NIH, CDC, AHRQ, other federal agencies Abbreviations: Agency for Healthcare Research and Quality = AHRQ; Centers for Disease Control and Prevention = CDC; Food and Drug Administration = FDA; National Institutes of Health = NIH; phenylketonuria = PKU. Source: Data from Public Health in America. Essential public health services. Retrieved from http://www.cdc.gov/nphpsp/ essentialservices.html. Accessed October 26, 2015. 86 Chapter 5 nstitutions and S BOX 5-2 Brief History of Public Health Agencies in the United States An understanding of the history of U.S. public health institutions requires an understanding of the response of local, state, and federal governments to public health crises and the complex interactions among these levels of government. The colonial period in the United States saw repeated epidemics of smallpox, cholera, and yellow fever, primarily focused in the port cities. These epidemics brought fear and disruption of commerce, along with accompanying disease and death. One epidemic in 1793 in Philadelphia, which was then the nation’s capital, nearly shut down the federal government. These early public health crises brought about the first municipal boards of health, made up of respected citizens authorized to act in the community’s interest to implement quarantine, evacuation, and other public health interventions of the day. The federal government’s early role in combating epidemics led to the establishment in 1798 of what later became known as the U.S. Public Health Service. Major changes in public health occurred in the last half of the 1800s, with the great expansion of the understanding of disease and the ability to control it through community actions. The Shattuck Commission in Massachusetts in 1850 outlined the roles of state health departments as responsible for sanitary inspections, communicable disease control, food sanitation, vital statistics, and services for infants and children. Over the next 50 years, the states gradually took the lead in developing public health institutions based on delivery of these services. Local health departments did not exist outside of the largest cities until the 1900s. The Rockefeller Foundation stimulated and helped fund early local health departments and campaigns, in part to combat specific diseases, such as hookworm. There was no standard model for local health departments; they developed in different ways in the various states and were chronically underfunded. The federal government played a very small role in public health throughout the 1800s and well into the 20th century. However, an occasional public health crisis stimulated federal action, often as a result of media attention. The founding of the FDA in 1906 resulted in large part from the journalistic activity known as “muckraking,” which exposed the status of food and drug safety. The early years of the 1900s set the stage for expansion of the federal government’s role in public health through the passage of the 16th Amendment to the Constitution, which authorized federal income tax as a major source of federal government funding. The Great Depression, in general, and the Social Security Act of 1935, in particular, brought about a new era in which federal funding became a major source of financial resources for state and local public health departments and NGOs. The founding of the CDC (which at that time stood for Communicable Disease Center) in 1946 led to a national (and eventually international) leadership role for the CDC, which attempts to connect and hold together the complex local, state, and federal public health efforts and integrate them into global public health efforts. The Johnson administration’s War on Poverty, as well as the Medicare and Medicaid programs, brought about greatly expanded funding for healthcare services and led many health departments to provide direct healthcare services, especially for those without other sources of care. The late 1980s and 1990s saw a redefinition of the roles of governmental public health, including the IOM definition of core functions and the development of the 10 essential public health services. These documents have guided the development of a broad population focus for public health and a move away from the direct provision of healthcare services by health departments. The terrorism of September 11, 2001, and the subsequent anthrax scare moved public health institutions to the center of efforts to protect the public’s health through emergency response and disaster preparedness. The development of flexible efforts to respond to expected and unexpected hazards is now a central feature of public health institutions’ roles and funding. The success of these efforts has led to new levels of coordination of local, state, federal, and global public health agencies using state-of-the-art surveillance, laboratory technology, and communications systems. BOX 5-2 iefl ft ft fir Th ft 87 ffice ffice Th Th Th ffices ■ ■ ■ ft fin ■ ■ ■ ■ ■ Thi ft eff Th Th Th Th ft ffice Th Th Thr eff fir Th ft ▸ What Are the Roles of Federal Public Health Agencies? Th ifie ft Th Th TABLE 5-2 Th Th defin 88 Chapter 5 nstitutions and S Th ifie BOX  5-3 fir ffici fir TABLE 5-2 Key Federal Health Agencies of the Department of Health and Human Services Agency Roles/Authority Examples of Structures/Activities Centers for Disease Control and Prevention (CDC) and the Agency for Toxic Substances and Disease Registry (ATSDR) The CDC is the lead agency for prevention, health data, epidemic investigation, and public health measures aimed at disease control and prevention. The CDC administers the ATSDR, which works with the Environmental Protection Agency to provide guidance on health hazards of toxic exposures. The CDC and ATSDR work extensively with state and local health departments. The CDC’s Epidemic Intelligence Service functions domestically and internationally at the request of governments. National Institutes of Health (NIH) Serves as lead research agency; also funds training programs and communication of health information to the professional community and the public. NIH comprises 17 institutes in all—the largest being the National Cancer Institute. The National Library of Medicine is part of NIH Centers, which also include the John E. Fogarty International Center for Advanced Study in the Health Sciences. NIH is the world’s largest biomedical research enterprise, with intramural research at NIH and extramural research grants throughout the world. Food and Drug Administration (FDA) Acts as consumer protection agency with authority for safety of foods and safety and efficacy of drugs, vaccines, and other medical and public health interventions. Divisions of FDA are responsible for food safety, medical devices, drug efficacy, and safety pre- and post-approval. Health Resources and Services Administration (HRSA) Seeks to ensure equitable access to comprehensive quality health care. HRSA funds community health centers, HIV/AIDS services, and scholarships for health professional students. Agency for Healthcare Research and Quality (AHRQ) Sets research agenda to improve the outcomes and quality of health care, including patient safety and access to services. AHRQ supports U.S. Preventive Services Task Force, evidence-based medicine research, and Guidelines Clearinghouse. Substance Abuse and Mental Health Services Administration (SAMHSA) Works to improve quality and availability of prevention, treatment, and rehabilitation for substance abuse and mental illness. SAMHSA provides research, data collection, and funding of local services. Indian Health Service (IHS) Provides direct health care and public health services to federally recognized tribes. IHS provides services to approximately 550 federally recognized tribes in 35 states. It is the only comprehensive federal agency responsibility for health care plus public health services. 89 Source: Reproduced from Centers for Disease Control and Prevention, MMWR 1996;45: 526–528. BOX 5-3 History of the CDC The following is reprinted as it originally appeared in 1996 in the Morbidity and Mortality Weekly Report (CDC, 1996): The Communicable Disease Center was organized in Atlanta, Georgia, on July 1, 1946; its founder, Dr. Joseph W. Mountin, was a visionary public health leader who had high hopes for this small and comparatively insignificant branch of the Public Health Service (PHS). It occupied only one floor of the Volunteer Building on Peachtree Street and had fewer than 400 employees, most of whom were engineers and entomologists. Until the previous day, they had worked for Malaria Control in War Areas, the predecessor of CDC, which had successfully kept the southeastern states malaria-free during World War II and, for approximately 1 year, from murine typhus fever. The new institution would expand its interests to include all communicable diseases and would be the servant of the states, providing practical help whenever called. Distinguished scientists soon filled CDC’s laboratories, and many states and foreign countries sent their public health staffs to Atlanta for training. Medical epidemiologists were scarce, and it was not until 1949 that Dr. Alexander Langmuir arrived to head the epidemiology branch. Within months, he launched the first-ever disease surveillance program, which confirmed his suspicion that malaria, on which CDC spent the largest portion of its budget, had long since disappeared. Subsequently, disease surveillance became the cornerstone on which CDC’s mission of service to the states was built and, in time, changed the practice of public health. The outbreak of the Korean War in 1950 was the impetus for creating CDC’s Epidemic Intelligence Service (EIS). The threat of biological warfare loomed, and Dr. Langmuir, the most knowledgeable person in PHS about this then- arcane subject, saw an opportunity to train epidemiologists who would guard against ordinary threats to public health while watching out for alien germs. The first class of EIS officers arrived in Atlanta for training in 1951 and pledged to go wherever they were called for the next 2 years. These “disease detectives” quickly gained fame for “shoe-leather epidemiology,” through which they ferreted out the cause of disease outbreaks. The survival of CDC as an institution was not at all certain in the 1950s. In 1947, Emory University gave land on Clifton Road for a headquarters, but construction did not begin for more than a decade. PHS was so intent on research and the rapid growth of the National Institutes of Health that it showed little interest in what happened in Atlanta. Congress, despite the long delay in appropriating money for new buildings, was much more receptive to CDC’s pleas for support than either PHS or the Bureau of the Budget. Two major health crises in the mid-1950s established CDC’s credibility and ensured its survival. In 1955, when poliomyelitis appeared in children who had received the recently approved Salk vaccine, the national inoculation program was stopped. The cases were traced to contaminated vaccine from a laboratory in California; the problem was corrected, and the inoculation program, at least for first and second graders, was resumed. The resistance of these 6- and 7-year-olds to polio, compared with that of older children, proved the effectiveness of the vaccine. Two years later, surveillance was used again to trace the course of a massive influenza epidemic. From the data gathered in 1957 and subsequent years, the national guidelines for influenza vaccine were developed. CDC grew by acquisition. When CDC joined the international malaria-eradication program and accepted responsibility for protecting the earth from moon germs and vice versa, CDC’s mission stretched overseas and into space. CDC then played a key role in one of the greatest triumphs of public health: the eradication of smallpox. In 1962 it established a smallpox surveillance unit, and a year later tested a newly developed jet gun and vaccine in the Pacific island nation of Tonga. CDC also achieved notable success at home tracking new and mysterious disease outbreaks. In the mid- 1970s and early 1980s, it found the cause of Legionnaires disease and toxic-shock syndrome. A fatal disease, subsequently named acquired immunodeficiency syndrome (AIDS), was first mentioned in the June 5, 1981, issue of MMWR. Although CDC succeeded more often than it failed, it did not escape criticism. For example, television and press reports about the Tuskegee study on long-term effects of untreated syphilis in black men created a storm of protest in 1972. This study had been initiated by PHS and other organizations in 1932 and was transferred to CDC in 1957. Although the effectiveness of penicillin as a therapy for syphilis had been established during the late 1940s, participants in this study remained untreated until the study was brought to public attention. CDC was also criticized because of the 1976 effort to vaccinate the U.S. population against swine flu, the infamous killer of 1918–1919. When some recipients of the vaccines developed Guillain-Barre syndrome, the campaign was stopped immediately; the epidemic never occurred. As the scope of CDC’s activities expanded far beyond communicable diseases, its name had to be changed. In 1970 it became the Center for Disease Control and in 1981, after extensive reorganization, Center became Centers. The words “and Prevention” were added in 1992 but, by law, the well-known three-letter acronym was retained. In health emergencies, CDC means an answer to SOS calls from anywhere in the world, such as the recent one from Zaire where Ebola fever raged. Fifty years ago, CDC’s agenda was non-controversial (hardly anyone objected to the pursuit of germs), and Atlanta was a backwater. In 1996, CDC’s programs are often tied to economic, political, and social issues, and Atlanta is as near to Washington as the tap of a keyboard. 90 Chapter 5 nstitutions and S Th eff eff Th Th ft eff eff e-fin eff ▸ What Are the Roles of Global Health Organizations and Agencies? eff Th fin eff TABLE 5-3 TABLE 5-3 Global Public Health Organizations Type of Agency Structure/Governance Role(s) Limitations World Health Organization United Nations Organization Seven “regional” semi- independent components (e.g., Pan American Health Organization covers North and South America) Policy development (e.g., tobacco treaty, epidemic control policies) Coordination of services (e.g., SARS control) Vaccine development Data collection and standardization (e.g., measures of healthcare quality, measures of health status) Limited ability to enforce global recommendations, limited funding, and complex international administration Other UN agencies with focused agenda UNICEF UNAIDS Focus on childhood vaccinations Focus on AIDS Limited agendas and limited financing 91 Th ft diffic Th ▸ How Can Public Health Agencies Work Together? Eff efficien Th fie BOX 5-4 uffin & S eff ▸ What Other Government Agencies Are Involved in Health Issues? ff defin Th eff . Th Th infl Th   International financing organizations The World Bank Other multilateral regional banks (e.g., InterAmerican and Asian Development Banks) World Bank is largest international funder. Increasingly supports “human capital” projects and reform of healthcare delivery systems and population and nutrition efforts Provides funding and technical assistance, primarily as loans Criticized for standardized approach with few local modifications Bilateral governmental aid organizations USAID Many other developed countries have their own organizations and contribute a higher percentage of their gross domestic product to those agencies than does the United States Often focused on specific countries and specific types of programs (e.g., the focus on HIV/AIDS in the United States), and maternal and child health May be tied to domestic politics and global economic, political, or military agendas AIDS = acquired immunodeficiency syndrome; HIV = human immunodeficiency virus; SARS = severe acute respiratory syndrome; UN = United Nations; UNAIDS = Joint United Nations Programme on HIV/AIDS; UNICEF = United Nations International Children’s Emergency Fund; USAID = U.S. Agency for International Development. 92 Chapter 5 nstitutions and S BOX 5-4 SARS and the Public Health Response The SARS epidemic of 2003 began with little notice, most likely somewhere in the heartland of China, and then spread to other areas of Asia. The world took notice following televised reports of public health researchers who were sent to Asia to investigate the illness subsequently contracting and dying from the disease. Not an easily transmissible disease except for between those in very close contact, such as investigators, family members, and healthcare providers, the disease spread slowly but steadily through areas of China. Among those infected, the case-fatality rate was very high, especially without the benefits of modern intensive care facilities. The disease did not respond to antibiotics and was thought to be a viral disease by its epidemiologic pattern of spread and transmission, but at first, no cause was known. The outside world soon felt the impact of the brewing epidemic when cases appeared in Hong Kong that could be traced to a traveler from mainland China. Fear spread when cases were recognized that could not be explained by close personal contact with a SARS victim. The epidemic continued to spread, jumping thousands of miles to Toronto, Canada, where the second-greatest concentration of disease appeared. Soon, the whole world was on high alert, if not quite on the verge of panic. At least 8,000 people worldwide became sick, and nearly 10% of them died. Fortunately, progress came quite quickly. Researchers coordinated by WHO were able to put together the epidemiologic information and laboratory data and establish a presumed cause—a new form of the coronavirus never before seen in humans—leading to the rapid introduction of testing. WHO and the CDC put forth recommendations for isolation, travel restrictions, and intensive monitoring that rapidly controlled the disease, even in the absence of an effective treatment aimed at a cure. SARS disappeared as rapidly as it emerged, especially after systematic efforts to control spread were put in place in China. Not eliminated, but no longer a worldwide threat, SARS left a lasting global impact. WHO established new approaches for reporting and responding to epidemics, which now have the widespread formal acceptance of most governments. Once the world could step back and evaluate what happened, it was recognized that the potential burden of disease posed by the SARS epidemic had worldwide implications and raised the threat of interruption of travel and trade. Local, national, and global public health agencies collaborated quickly and effectively. Infection control recommendations made at the global level were rapidly translated into efforts to identify disease at the local level and manage individual patients in hospitals throughout the world. It is a model of communicable disease control that will be needed in the future. eff e eff Th ffi eff Th eff Th cific cific cific Thi eff eff Th infl eff ▸ What Roles Do NGOs Play in Public Health? Nongovernmental Organizations   93 BOX 5-5 National Vaccine Plan In 1994, a National Vaccine Plan was developed as part of a coordinated effort to accomplish the following goals: 1. Develop new and improved vaccines. 2. Ensure the optimal safety and effectiveness of vaccines and immunizations. 3. Better educate the public and members of the health profession on the benefits and risks of immunizations. A recent IOM report evaluated progress since 1994 on achieving these goals and made recommendations for the development of a revised National Vaccine Plan (IOM, 2008). The IOM highlighted a number of successes since 1994 in achieving each of the goals of the plan. These successes illustrate the potential for improved collaboration between public health systems and healthcare systems. In terms of the development of new and improved vaccines since 1994, over 20 new vaccine products resulting from the collaborative efforts of the NIH, academicians, and industry researchers were approved by the FDA. Novel vaccines introduced include vaccines against pediatric pneumococcal disease, meningococcal disease, and the human papillomavirus—a cause of cervical cancer. In terms of safety, vaccines and vaccination approaches with improved safety have been developed since 1994, including those directed against rotavirus, pertussis (whooping cough), and polio. The FDA Center for Biologics Evaluation and Research, which regulates vaccines, now has an expanded array of regulatory tools to facilitate the review and approval of safe and efficacious vaccines. The FDA and the CDC have collaborated on surveillance for and evaluation of adverse events. Efforts have also been made to increase collaboration with the Centers for Medicare and Medicaid Services, the Department of Defense, and the Department of Veterans Affairs to improve surveillance and reporting of adverse events following immunization in the adult populations these agencies serve. In terms of better education of health professionals and the public, progress has also been made. The American Academy of Pediatrics collaborates with the CDC for its childhood immunization support. The American Medical (continues) infl nfi eff fi eff eff Th eff Th eff eff Th Th eff eff ▸ How Can Public Health Agencies Partner With Health Care to Improve the Response to Health Problems? t-eff nfiden Th Th BOX 5-5 94 Chapter 5 nstitutions and S Association cosponsors the annual National Influenza Vaccine Summit, a group that represents 100 public and private organizations interested in preventing influenza. Despite the growing collaboration and success in vaccine development and use, new issues have appeared in recent years. Vaccines are now correctly viewed by health professionals and the broader public as having both benefits and harms. In recent years, the public has grown more concerned about the safety of vaccines, including the issue of the use of large numbers of vaccines in children. The limitations of vaccines to address problems, such as HIV/AIDS, have also been increasingly recognized. Hopefully, the continued efforts to develop and implement national vaccine plans will build upon these recent successes and address the new realities and opportunities. BOX 5-5 National Vaccine Plan BOX 5-6 Community-Oriented Primary Care Community-oriented primary care (COPC) is a structured effort to expand the delivery of health services from a focus on the individual to include an additional focus on the needs of communities. Serving the needs of communities brings healthcare and public health efforts together. COPC can be seen as an effort on the part of healthcare delivery sites, such as community health centers, to reach out to their community and to governmental public health institutions. TABLE 5-4 outlines the six steps in the COPC process and presents a question to ask when addressing each of these steps. Notice the parallels between COPC and the evidence-based approach. A series of principles underlies COPC: ■ Healthcare needs are defined by examining the community as a whole, not just those who seek care. ■ Needed healthcare services are provided to everyone within a defined population or community. ■ Preventive, curative, and rehabilitative care are integrated within a coordinated delivery system. ■ Members of the community directly participate in all stages of the COPC process. The concept of COPC, if not the specific structure, has been widely accepted as an approach for connecting the organized delivery of primary health care with public health. It implies that public health issues can and should be addressed, when possible, at the level of the community with the involvement of healthcare providers and the community members themselves. TABLE 5-4 The Six Sequential Steps of Community-Oriented Primary Care Steps in the COPC Process Questions to Ask 1. Community definition How is the community defined based on geography, institutional affiliation, or other common characteristics (e.g., use of an Internet site)? 2. Community characterization What are the demographic and health characteristics of the community, and what are its health issues? 3. Prioritization What are the most important health issues facing the community, and how should they be prioritized based on objective data and perceived need? 4. Detailed assessment of the selected health problem What are the most effective and efficient interventions for addressing the selected health problem based on an evidence-based assessment? 5. Intervention What strategies will be used to implement the intervention? 6. Evaluation How can the success of the intervention be evaluated? Data from Mullan, F., & Epstein, L. (2002). Community-oriented primary care: New relevance in a changing world. American Journal of Public Health, 92(11), 1748–1755. (continued) 95 BOX 5-7 Child Oral Health and Community-Oriented Public Health The problem of childhood dental disease illustrates the potential for COPH. A lack of regular dental care remains a major problem for children in developed, as well as developing, countries. Oral health is often high on the agenda of parents, teachers, and even the children themselves. The history of public health interventions in childhood oral health is a story of great hope and partial success. Public health efforts to improve oral health go back to the late 1800s and early 1900s, when toothbrushes and toothpaste were new and improved technologies. The public health campaigns of the early 1900s were very instrumental in making (continues) fie eff efficien BOX 5-6 fin fin, 2011). eff eff eff efficien ▸ How Can Public Health Take the Lead in Mobilizing Community Partnerships to Identify and Solve Health Problems? Th eff Thr Th eff Eff eff ifie eff eff eff eff BOX 5-7 eff 96 Chapter 5 nstitutions and S BOX 5-7 Child Oral Health and Community-Oriented Public Health (continued) toothbrushing a routine part of life in the United States. Unfortunately, the fluoridization of drinking water, despite the well-grounded evidence of its benefits, has not been so readily accepted. The American Dental Association and the American Medical Association have supported this intervention for over half a century. Resistance from those who view it as an intrusion of governmental authority, however, has prevented universal use of fluoridation in this country. After over a half century of effort, fluoridation has reached less than 66% of Americans through the water supply. Today, new technologies, from dental sealants to more cost-effective methods for treating cavities, have again made oral health a public health priority. However, the number of dentists has not grown in recent years to keep up with the growing population. In addition, dental care for those without the resources to pay for it is often inadequate and inaccessible. Thus, a new approach is needed to bring dental care to those in need. Perhaps a new strategy using a COPH approach can make this happen. COPH can reach beyond the institutional and geographical constraints that COPC faces when based in a community health center or other institutions serving a geographically defined population or community. COPH as a government- led effort allows a greater range of options for intervention, including those that require changes in laws, incentives, and governmental procedures. Interventions may include authorizing new types of clinicians, providing services in nontraditional settings such as schools, funding innovations to put new technologies into practice, and addressing the regulatory barriers to rapid and cost-effective delivery of services. ▸ Conclusion ff Th References Th uffin, fin, fin, Th ffic ▸ Endnotes Thi Thi Th Thi 97 P A R T I A D D EN D U M : T IM EL IN E P re -1 80 0 18 00 s 18 20 s P re si d e n t Fe d e ra lis t (1 7 8 9 – 1 8 0 1 ) D e m -R e p ( 1 8 0 1 – 1 8 2 9 ) G e o rg e W a sh in g to n ( 1 7 8 9 – 1 7 9 7 ); Jo h n A d a m s (1 7 9 7 – 1 8 0 1 ) T h o m a s Je ff e rs o n ( 1 8 0 1 – 1 8 0 9 ); Ja m e s M a d is o n ( 1 8 0 9 – 1 8 1 7 ); Ja m e s M o n ro e ( 1 8 1 7 – 1 8 2 5 ); Jo h n Q u in c y A d am s (1 8 2 5 – 1 8 2 9 ) U .S . H o u se o f R e p re se n ta ti ve s P ro -A d m in is tr a ti o n ( 1 7 8 9 – 1 7 9 3 ); A n ti -A d m in is tr a ti o n (1 7 9 3 – 1 7 9 5 ); Je ff e rs o n ia n R e p u b lic a n ( 1 7 9 5 – 1 7 9 7 ); Fe d e ra lis t (1 7 9 7 – 1 8 0 1 ) Je ff e rs o n ia n R e p u b lic a n ( 1 8 0 1 – 1 8 2 3 ) A d a m s– C la y R e p u b lic a n (1 8 2 3 – 1 8 2 5 ); A d a m s (1 8 2 5 – 1 8 2 7 ); Ja ck so n s (1 8 2 7 – 1 8 2 9 ) U .S . S e n a te P ro -A d m in is tr a ti o n ( 1 7 8 9 – 1 7 9 5 ); Fe d e ra lis t (1 7 9 5 – 1 8 0 1 ) R e p u b lic a n ( 1 8 0 1 – 1 8 2 3 ) Ja ck so n -C ra w fo rd R e p u b lic an (1 8 2 3 – 1 8 2 5 ); Ja ck so n ia n (1 8 2 5 – 1 8 3 3 ) a n d  in cr e a se d u rb a n iz a ti o n ( 1 8 1 2 – 1 8 1 4 ) a n d p o st - w a r e co n o m ic g ro w th U .S . P u b lic H e a lt h S e rv ic e A c t: C re a te s th e , p re d e ce ss o r to t h e P u b lic H e a lt h S e rv ic e , t o p ro v id e m e d ic a l c a re t o m e rc h a n t se a m e n . 5 U .S . 1 3 7 (1 8 0 3 ): Es ta b lis h e d t h e S u p re m e C o u rt ’s p o w e r o f j u d ic ia l r e vi e w ; ffi c e st ab lis h e d . S ta te P o o r La w s re q u ir e c o m m u n it ie s to c ar e fo r re si d e n ts w h o a re p h ys ic al ly o r m e n ta lly in ca p ab le o f ca ri n g fo r th e m se lv e s; S ta te s b e g in b u ild in g d is p e n sa ri e s in t h e la te 1 7 0 0 s to p ro vi d e m e d ic at io n t o t h e p o o r; A lm sh o u se s se rv e as p ri m it iv e h o sp it al s, p ro vi d in g li m it e d c ar e t o t h e in d ig e n t; P u b lic h e al th fo cu se s o n fi g h ti n g p la g u e , c h o le ra , a n d sm al lp o x e p id e m ic s, o ft e n t h ro u g h q u ar an ti n e . 98 18 30 s 18 40 s 18 50 s P re si d e n t D e m o cr a t (1 8 2 9 – 1 8 4 1 ) W h ig ( 1 8 4 1 – 1 8 4 5 ); D e m o cr a t (1 8 4 5 – 1 8 4 9 ); W h ig ( 1 8 4 9 – 1 8 5 3 ); D e m o cr a t (1 8 5 3 – 1 8 6 1 ) A n d re w J a ck so n ( 1 8 2 9 – 1 8 3 7 ); M a rt in V a n B u re n (1 8 3 7 – 1 8 4 1 ) W ill ia m H e n ry H a rr is o n ( 1 8 4 1 ); Jo h n T yl e r (1 8 4 1 – 1 8 4 5 ); Ja m e s K . P o lk ( 1 8 4 5 – 1 8 4 9 ); Z a ch a ry T ay lo r (1 8 4 9 – 1 8 5 0 ) M ill a rd F ill m o re ( 1 8 5 0 – 1 8 5 3 ); Fr a n kl in P ie rc e (1 8 5 3 – 1 8 5 7 ); Ja m e s B u ch a n a n ( 1 8 5 7 – 1 8 6 1 ) U .S . H o u se o f R e p re se n ta ti ve s Ja ck so n s (1 8 2 9 – 1 8 3 7 ); D e m o cr a t (1 8 3 7 – 1 8 4 1 ) U .S . S e n a te A n ti -J a ck so n ia n ( 1 8 3 3 – 1 8 3 5 ); Ja ck so n ia n (1 8 3 5 – 1 8 3 7 ); D e m o cr a t (1 8 3 7 – 1 8 4 1 ) W h ig ( 1 8 4 1 – 1 8 4 5 ) (2 7 th – 2 8 th ); D e m o cr a t (1 8 4 5 – 1 8 6 1 ) (2 9 th – 3 6 th ) a n d in cr e a se d u rb a n iz a ti o n ( 1 8 4 6 – 1 8 4 8 ) (1 8 5 3 – 1 8 5 6 ) In it ia te s d ru g r e g u la ti o n ; U .S . C u st o m s S e rv ic e is r e q u ir e d t o e n fo rc e p u ri ty s ta n d a rd s fo r im p o rt e d m e d ic a ti o n s. F ir st p u b lic iz e d u se o f g e n e ra l a n e st h e ti c; U se o f a n e st h e ti cs in cr e a se s th e n u m b e r o f su rg e ri e s p e rf o rm e d ; A m e ri ca n M e d ic a l A ss o ci a ti o n ( A M A ) is f o u n d e d . S tu d ie s b y E d w in C h a d w ic k in E n g la n d , L e m u e l S h a tt u ck in M a ss a ch u se tt s, a n d o th e rs r e ve a l t h a t o ve rc ro w d e d a n d u n sa n it a ry c o n d it io n s b re e d d is e a se , a n d a d vo ca te e st a b lis h m e n t o f lo ca l h e a lt h b o a rd s; B y th e e n d o f th e 1 8 0 0 s, 4 0 s ta te s a n d se ve ra l l o ca lit ie s e st a b lis h h e a lt h d e p a rt m e n ts . 99 18 60 s 18 70 s 18 80 s P re si d e n t R e p u b lic a n ; D e m o cr a t R e p u b lic a n R e p u b lic a n ( 1 8 8 1 – 1 8 8 5 ); D e m o cr a t (1 8 8 5 – 1 8 8 9 ) A b ra h a m L in co ln ( 1 8 6 1 – 1 8 6 5 ); A n d re w J o h n so n (1 8 6 5 – 1 8 6 9 ) U ly ss e s S . G ra n t (1 8 6 9 – 1 8 7 7 ); R u th e rf o rd B . H ay e s (1 8 7 7 – 1 8 8 1 ) Ja m e s A . G a rfi e ld ( 1 8 8 1 ); C h e st e r A . A rt h u r (1 8 8 1 – 1 8 8 5 ); G ro ve r C le ve la n d ( 1 8 8 5 – 1 8 8 9 ) U .S . H o u se o f R e p re se n ta ti ve s R e p u b lic a n ( 1 8 5 9 – 1 8 7 5 ) D e m o cr a t (1 8 7 5 – 1 8 8 1 ) R e p u b lic a n ( 1 8 8 1 – 1 8 8 3 ); D e m o cr a t (1 8 8 3 – 1 8 8 9 ) U .S . S e n a te R e p u b lic a n ( 1 8 6 1 – 1 8 7 9 ) (3 7 th – 4 5 th ) D e m o cr a t (1 8 7 9 – 1 8 8 1 ) (4 6 th ) R e p u b lic a n ( 1 8 8 1 – 1 8 9 3 ) (4 7 th – 5 2 n d ) a n d in cr e a se d u rb a n iz a ti o n ( 1 8 6 1 – 1 8 6 5 ) a n d p o st -w a r e xp a n si o n in in te rs ta te c o m m e rc e ( 1 8 4 6 – 1 8 4 8 ) (1 8 5 3 – 1 8 5 6 ) ( fo re ru n n e r o f th e F o o d a n d D ru g A d m in is tr a ti o n [ F D A ]) is e st a b lis h e d a s a s ci e n ti fi c la b o ra to ry in t h e D e p a rt m e n t o f A g ri cu lt u re . E st a b lis h st a te r e g u la ti o n o f p h ys ic ia n li ce n si n g ; is c e n tr a liz e d a s a se p a ra te b u re a u o f th e T re a su ry D e p a rt m e n t; G ra n ts t h e M a ri n e H o sp it a l S e rv ic e q u a ra n ti n e a u th o ri ty d u e t o it s a ss is ta n ce w it h y e llo w f e ve r o u tb re a k. N a ti o n a l H yg ie n ic L a b o ra to ry , p re d e ce ss o r la b t o th e N a ti o n a l I n st it u te s o f H e a lt h , i s e st a b lis h e d in S ta te n Is la n d , N e w Y o rk , b y th e N a ti o n a l M a ri n e H e a lt h S e rv ic e . F ir st n u rs in g s ch o o l i s fo u n d e d a n d t h e ro le o f n u rs in g is e st a b lis h e d d u ri n g t h e C iv il W a r; L o u is P a st e u r d e ve lo p s th e g e rm t h e o ry o f d is e a se ; is in tr o d u ce d b y Jo se p h L is te r, d e cr e a si n g d e a th r a te s fr o m su rg ic a l o p e ra ti o n s; W it h t h e a d ve n t o f lic e n si n g , th e p ra c ti ce o f m e d ic in e b e g in s to b e co m e a m o re e xc lu si ve r e a lm . L o u is P a st e u r d is co ve rs t h a t a n th ra x is c a u se d b y b a c te ri a ; S ci e n ti st s fi n d b a c te ri o lo g ic a g e n ts c a u si n g t u b e rc u lo si s, d ip h th e ri a , t yp h o id , a n d y e llo w f e ve r; Im m u n iz a ti o n s a n d w a te r p u ri fi ca ti o n in te rv e n ti o n s fo llo w r e ce n t d is co ve ri e s; S ta te a n d lo ca l h e a lt h d e p a rt m e n ts c re a te la b o ra to ri e s; S ta te s b e g in p a ss in g la w s re q u ir in g d is e a se r e p o rt in g a n d e st a b lis h in g d is e a se r e g is tr ie s. F ir st h o sp it a ls e st a b lis h e d a n d t h e im p o rt a n ce o f h o sp it a ls in t h e p ro v is io n o f m e d ic a l c a re in cr e a se s; fi rs t m a jo r e m p lo ye e -s p o n so re d m u tu a l b e n e fi t a ss o ci a ti o n w a s cr e a te d b y N o rt h e rn P a ci fi c R a ilw ay , i n cl u d e s h e a lt h ca re b e n e fi t; S o ci a l I n su ra n ce m o ve m e n t re su lt s in t h e c re a ti o n o f “ si ck n e ss ” i n su ra n ce th ro u g h o u t m a n y co u n tr ie s in E u ro p e ; X -r ay s d is co ve re d . 100 18 90 s 19 00 s P re si d e n t R e p u b lic a n ( 1 8 8 9 – 1 8 9 3 ); D e m o cr a t (1 8 9 3 – 1 8 9 7 ); R e p u b lic a n ( 1 8 9 7 – 1 9 0 1 ) R e p u b lic a n /P ro g re ss iv e B e n ja m in H a rr is o n ( 1 8 8 9 – 1 8 9 3 ); G ro ve r C le ve la n d ( 1 8 9 3 – 1 8 9 7 ); W ill ia m M cK in le y (1 8 9 7 – 1 9 0 1 ) T h e o d o re R o o se ve lt ( 1 9 0 1 – 1 9 0 9 ) U .S . H o u se o f R e p re se n ta ti ve s R e p u b lic a n ( 1 8 8 9 – 1 8 9 1 ); D e m o cr a t (1 8 9 1 – 1 8 9 5 ); R e p u b lic a n ( 1 8 9 5 – 1 9 1 1 ) U .S . S e n a te D e m o cr a t (1 8 9 3 – 1 8 9 5 ) (5 3 rd ); R e p u b lic a n ( 1 8 9 5 – 1 9 1 3 ) (5 4 th – 6 2 n d ) R e p u b lic a n (1 9 0 0 – 1 9 2 0 ): C h a ra c te ri ze d b y p o p u la r su p p o rt f o r so ci a l r e fo rm , p a rt o f w h ic h in cl u d e d c o m p u ls o ry h e a lt h in su ra n ce ; R o o se ve lt c a m p a ig n e d o n a s o ci a l in su ra n ce p la tf o rm in 1 9 1 2 . P ro h ib it s in te rs ta te t ru st s so e co n o m ic p o w e r w o u ld n o t b e c o n ce n tr a te d in a fe w c o rp o ra ti o n s. dd in gfi el d, 5 9 N .E . 1 0 5 8 ( In d . 1 9 0 1 ): P h ys ic ia n s a re u n d e r n o d u ty t o t re a t, a n d a p h ys ic ia n is n o t lia b le f o r a rb it ra ri ly r e fu si n g t o r e n d e r m e d ic a l a ss is ta n ce ; r e n a m e d t h e a s it s ro le in d is e a se c o n tr o l a c ti v it ie s e xp a n d s; R e g u la te s sa fe ty a n d e ff e c ti ve n e ss o f v a cc in e s, s e ru m s, e tc .; 1 9 7 U .S . 1 1 ( 1 9 0 5 ): S ta te s ta tu te r e q u ir in g c o m p u ls o ry v a cc in a ti o n a g a in st s m a llp o x is a c o n st it u ti o n a l e xe rc is e o f p o lic e p o w e r; ( W ile y A c t) : G iv e s re g u la to ry p o w e r to m o n it o r fo o d m a n u fa c tu ri n g , l a b e lin g , a n d s a le s to F D A p re d e ce ss o r; F e d e ra l E m p lo ye rs L ia b ili ty A c t: C re a te s w o rk e rs c o m p e n sa ti o n p ro g ra m f o r se le c t fe d e ra l e m p lo ye e s. A M A r e o rg a n iz e s a t lo ca l/ st a te le ve l a n d g a in s st re n g th , b e g in n in g e ra o f “ o rg a n iz e d m e d ic in e ” a s p h ys ic ia n s a s a g ro u p b e co m e a m o re c o h e si ve a n d in cr e a si n g ly p ro fe ss io n a l a u th o ri ty . 101 19 10 s 19 20 s P re si d e n t R e p u b lic a n D e m o cr a t R e p u b lic a n R e p u b lic a n W ill ia m H . T a ft ( 1 9 0 9 – 1 9 1 3 ) W o o d ro w W ils o n ( 1 9 1 3 – 1 9 2 1 ) W a rr e n G . H a rd in g (1 9 2 1 – 1 9 2 3 ) C a lv in C o o lid g e (1 9 2 3 – 1 9 2 9 ) U .S . H o u se o f R e p re se n - ta ti ve s D e m o cr a t (1 9 1 1 – 1 9 1 9 ) (6 2 n d – 6 5 th ) D e m o cr a t (1 9 1 3 – 1 9 1 9 ) (6 3 rd – 6 5 th ); R e p u b lic a n ( 1 9 1 9 – 1 9 3 3 ) (6 6 th – 7 2 n d ) R e p u b lic a n (1 9 1 9 – 1 9 3 1 ) (6 6 th – 7 1 st ) R e p u b lic a n U .S . S e n a te R e p u b lic a n D e m o cr a t (1 9 1 3 – 1 9 1 9 ) (6 3 rd – 6 5 th ); R e p u b lic a n ( 1 9 1 9 – 1 9 3 3 ) (6 6 th – 7 2 n d ) R e p u b lic a n R e p u b lic a n ( 1 9 1 4 – 1 9 1 9 ; U n it e d S ta te s e n te rs in 1 9 1 7 ) e st a b lis h e d in D e p a rt m e n t o f C o m m e rc e ( la te r m o ve d t o D e p a rt m e n t o f La b o r) ; is r e n a m e d t h e a n d is a u th o ri ze d t o in ve st ig a te h u m a n d is e a se a n d s a n it a ti o n ; C la ri fi e s th e S h e rm a n A n ti tr u st A c t a n d in cl u d e s a d d it io n a l p ro h ib it io n s. F ir st s ta te w o rk e rs c o m p e n sa ti o n la w e n a c te d ; P ro v id e s fi rs t fe d e ra l g ra n ts t o s ta te s fo r p u b lic h e a lt h s e rv ic e s; E st a b lis h e s th e V e te ra n s A d m in is tr a ti o n ; P ro v id e s g ra n ts f o r th e C h ild re n ’s B u re a u a n d s ta te m a te rn a l a n d c h ild h e a lt h p ro g ra m s, a n d is t h e fi rs t d ir e c t fe d e ra l f u n d in g o f h e a lt h s e rv ic e s fo r in d iv id u a ls . F le xn e r R e p o rt o n M e d ic a l E d u ca ti o n c re a te s m e d ic a l s ch o o l s ta n d a rd s; “s ic kn e ss ” i n su ra n ce e st a b lis h e d b y B ri ta in in 1 9 1 1 a n d R u ss ia in 1 9 1 2 ; S o ci a lis t a n d P ro g re ss iv e p a rt ie s in t h e U n it e d S ta te s su p p o rt s im ila r “ si ck n e ss ” i n su ra n ce . is f o u n d e d ; A C S b e g in s a cc re d it a ti o n o f h o sp it a ls ; 1 91 8– 19 19 p an de m ic fl u ki lls o ve r 6 0 0 ,0 0 0 p e o p le in t h e U n it e d S ta te s; A M A p a ss e s re so lu ti o n a g a in st c o m p u ls o ry h e a lt h in su ra n ce ; A M A o p p o si ti o n c o m b in e d w it h e n tr y in to W o rl d W a r I ( a n d t h e a n ti -G e rm a n s e n ti m e n ts a ro u se d ), u n d e rm in e s su p p o rt fo r n a ti o n a l h e a lt h r e fo rm a n d g o ve rn m e n t in su ra n ce ; e st a b lis h e d it s fi rs t h o sp it a l i n su ra n ce p la n a t B ay lo r U n iv e rs it y ; C h ro n ic il ln e ss e s b e g in t o r e p la ce in fe c ti o u s d is e a se s a s m o st s ig n ifi ca n t h e a lt h t h re a t; W it h in n o v a ti o n s in m e d ic a l c a re , h e a lt h ca re c o st s b e g in t o r is e . 102 19 30 s 19 40 s P re si d e n t R e p u b lic a n D e m o cr a t H e rb e rt H o o ve r (1 9 2 9 – 1 9 3 3 ) Fr a n kl in D . R o o se ve lt ( 1 9 3 3 – 1 9 4 5 ) U .S . H o u se o f R e p re se n ta ti ve s D e m o cr a t (1 9 3 1 – 1 9 4 7 ) (7 2 n d – 7 9 th ) D e m o cr a t U .S . S e n a te D e m o cr a t (1 9 3 3 – 1 9 4 7 ) (7 3 rd – 7 9 th ) D e m o cr a t ( 1 9 2 9 t h ro u g h 1 9 3 0 s) ; ( 1 9 3 3 – 1 9 3 9 ) ( 1 9 3 9 – 1 9 4 5 ), P e a rl H a rb o r 1 9 4 1 ) e st a b lis h e d ; p ro v id e s lim it e d m e d ic a l s e rv ic e s fo r th e m e d ic a lly in d ig e n t; P ro v id e s fe d e ra l g ra n t- in -a id f u n d in g f o r st a te s to c re a te a n d m a in ta in p u b lic h e a lt h s e rv ic e s a n d t ra in in g , e xp a n d s re sp o n si b ili ti e s fo r th e C h ild re n ’s H e a lt h B u re a u , a n d e st a b lis h e s A id t o F a m ili e s w it h D e p e n d e n t C h ild re n ( A F D C ) w e lf a re p ro g ra m ; is c re a te d , i n cl u d in g p ro je c ts t o b u ild a n d im p ro ve h o sp it a ls ; E xp a n d s re g u la to ry s co p e o f F D A t o r e q u ir e p re m a rk e t a p p ro v a l ( in re sp o n se t o d e a th s fr o m a n u n te st e d p ro d u c t) ; P u b lic H e a lt h S e rv ic e is t ra n sf e rr e d f ro m t h e T re a su ry D e p a rt m e n t to t h e n e w F e d e ra l S e cu ri ty A g e n c y. F u n d s w a rt im e e m e rg e n c y b u ild in g o f h o sp it a ls ; r u le s th a t th e p ro v is io n o f b e n e fi ts , i n cl u d in g h e a lt h in su ra n ce , d o e s n o t v io la te w a g e f re e ze ; C o n so lid a te s th e la w s re la te d t o t h e f u n c ti o n s o f th e P H S ; F u n d s h o sp it a l c o n st ru c ti o n t o im p ro ve a cc e ss t o h o sp it a l- b a se d m e d ic a l c a re ; o p e n s a s p a rt o f th e P u b lic H e a lt h S e rv ic e ; T ru m a n ’s n a ti o n a l h e a lt h in su ra n ce p ro p o sa l is d e fe a te d . T h e G re a t D e p re ss io n t h re a te n s fi n a n ci a l s e cu ri ty o f p h ys ic ia n s, h o sp it a ls , a n d in d iv id u a ls ; C o m m e rc ia l i n su ra n ce in d u st ry r is e s in t h e a b se n ce o f g o ve rn m e n t- sp o n so re d in su ra n ce p la n s; In t h e t h e B lu e C ro ss (h o sp it a l s e rv ic e s) a n d B lu e S h ie ld ( p h ys ic ia n s e rv ic e s) h e a lt h in su ra n ce p la n cr e a te d ; P re p a id g ro u p h e a lt h p la n s/ m e d ic a l c o o p e ra ti ve s g a in p o p u la ri ty w it h s o m e p ro v id e rs a n d c o n su m e rs , b u t a re o p p o se d b y A M A . N o b e l P ri ze in M e d ic in e a w a rd e d f o r d e ve lo p m e n t o f p e n ic ill in t re a tm e n t fo r h u m a n s, w h ic h is u se d e xt e n si ve ly in t h e w a r; K a is e r P e rm a n e n te , a la rg e p re p a id , i n te g ra te d h e a lt h p la n is o p e n e d t o t h e p u b lic ; 1 9 4 6 t h e E m e rs o n R e p o rt r e le a se d p ro p o si n g o ve ra ll p la n f o r p u b lic h e a lt h in t h e U n it e d S ta te s; A M A o p p o se s Tr u m a n ’s p la n f o r n a ti o n a l h e a lt h in su ra n ce a n d s e n ti m e n ts a g a in st n a ti o n a l h e a lt h r e fo rm a ls o f u e le d b y th e C o ld W a r; E m p lo ye r- b a se d h e a lt h in su ra n ce g ro w s ra p id ly w it h n o n a ti o n a l h e a lt h in su ra n ce p ro g ra m a n d a s e m p lo ye rs c o m p e te f o r a s h o rt s u p p ly o f e m p lo ye e s d u e t o t h e w a r a n d b e ca u se h e a lt h b e n e fi ts a re e xe m p te d f ro m t h e w a g e f re e ze ; A ft e r W W II, la b o r u n io n s g a in e d t h e r ig h t to b a rg a in c o lle c ti ve ly , l e a d in g t o a n o th e r e xp a n si o n in e m p lo ye e h e a lt h p la n s; C o m m e rc ia l i n su ra n ce h a s ta ke n o ve r 4 0 % o f th e m a rk e t fr o m B lu e C ro ss . 103 19 50 s 19 60 s P re si d e n t D e m o cr a t R e p u b lic a n D e m o cr a t D e m o cr a t H a rr y S . T ru m a n ( 1 9 4 5 – 1 9 5 3 ) D w ig h t D . E is e n h o w e r (1 9 5 3 – 1 9 6 1 ) Jo h n F . K e n n e d y (1 9 6 1 – 1 9 6 3 ) Ly n d o n B . J o h n so n ( 1 9 6 3 – 1 9 6 9 ) U .S . H o u se o f R e p re se n - ta ti ve s R e p u b lic a n ( 1 9 4 7 – 1 9 4 9 ) (8 0 th ); D e m o cr a t (1 9 4 9 – 1 9 5 3 ) (8 1 st – 8 2 d ) R e p u b lic a n ( 1 9 5 2 – 1 9 5 5 ) (8 3 rd ); D e m o cr a t (1 9 5 5 – 1 9 9 4 ) (8 4 th – 1 0 3 rd ) D e m o cr a t D e m o cr a t U .S . S e n a te R e p u b lic a n ( 1 9 4 7 – 1 9 4 9 ) (8 0 th ); D e m o cr a t (1 9 4 9 – 1 9 5 3 ) (8 1 st – 8 2 n d ) R e p u b lic a n ( 1 9 5 3 – 1 9 5 5 ) (8 3 rd ); D e m o cr a t (1 9 5 5 – 1 9 8 1 ) (8 4 th – 9 6 th ) D e m o cr a t D e m o cr a t C o ld W a r id e o lo g y a n d M cC a rt h yi sm ( 1 9 5 0 – 1 9 5 4 ); ( 1 9 5 0 – 1 9 5 3 ) E co n o m ic d o w n tu rn is c re a te d fr o m t h e F e d e ra l S e cu ri ty A g e n c y, a n d t h e P u b lic H e a lt h S e rv ic e is t ra n sf e rr e d to H E W ; In te rn a l R e ve n u e S e rv ic e d e cl a re s th a t e m p lo ye rs c a n p ay h e a lt h in su ra n ce p re m iu m s fo r th e ir e m p lo ye e s w it h p re -t a x d o lla rs ; 3 4 7 U .S . 4 8 3 ( 1 9 5 4 ): R a ci a l s e g re g a ti o n in p u b lic e d u ca ti o n v io la te s th e E q u a l P ro te c ti o n C la u se o f 1 4 th A m e n d m e n t; C re a te s g o ve rn m e n t m e d ic a l c a re p ro g ra m fo r m ili ta ry a n d d e p e n d e n ts o u ts id e t h e V e te ra n s A ff a ir s sy st e m ; is a m e n d e d t o p ro v id e S o ci a l S e cu ri ty D is a b ili ty In su ra n ce . re q u ir e t h a t n e w d ru g s b e “e ff e c ti ve .” p ro v id e s fe d e ra l f u n d in g t h ro u g h ve n d o r p ay m e n ts t o s ta te s fo r m e d ic a lly in d ig e n t e ld e rl y ; 3 2 3 F .2 d 9 5 9 (4 th C ir . 1 9 6 3 ): R a ci a l s e g re g a ti o n in p ri v a te h o sp it a ls r e ce iv in g fe d e ra l H ill -B u rt o n f u n d s v io la te s th e E q u a l P ro te c ti o n C la u se o f th e 1 4 th A m e n d m e n t; p a ss e d ; p ro g ra m s cr e a te d t h ro u g h S o ci a l S e cu ri ty A m e n d m e n ts ; 3 8 1 U .S . 4 7 9 ( 1 9 6 5 ): T h e C o n st it u ti o n p ro te c ts a r ig h t to p ri v a c y, st a te la w f o rb id d in g t h e u se o f co n tr a ce p ti ve s o r p ro v is io n o f th e m t o m a rr ie d c o u p le s v io la te s a c o n st it u ti o n a l r ig h t to m a ri ta l p ri v a c y ; ( C H A M P U S ) cr e a te d . is c re at e d to p ro vi d e v o lu n ta ry a cc re d it at io n ; S al k cr e at e s p o lio v ac ci n e ; fi rs t o rg an t ra n sp la n t is p e rf o rm e d ; C o n ti n u e d p ro g re ss io n in m e d ic al s ci e n ce a n d te ch n o lo g y le ad s to in cr e as e d c o st s; P o lit ic al fo cu s tu rn s to K o re an W ar a n d a w ay fr o m m e d ic al c ar e r e fo rm . M e d ic a re a n d M e d ic a id c re a te d ; fi rs t h u m a n h e a rt t ra n sp la n t. 104 19 70 s 19 80 s P re si d e n t R e p u b lic a n R e p u b lic a n D e m o cr a t R e p u b lic a n R ic h a rd M . N ix o n (1 9 6 9 – 1 9 7 4 ) G e ra ld R . F o rd ( 1 9 7 4 – 1 9 7 7 ) Ji m m y C a rt e r (1 9 7 7 – 1 9 8 1 ) R o n a ld R e a g a n ( 1 9 8 1 – 1 9 8 9 ) U .S . H o u se o f R e p re se n ta ti ve s D e m o cr a t D e m o cr a t D e m o cr a t D e m o cr a t U .S . S e n a te D e m o cr a t D e m o cr a t D e m o cr a t R e p u b lic a n ( 1 9 8 1 – 1 9 8 7 ) (9 7 th – 9 9 th ); D e m o cr a t (1 9 8 7 – 1 9 9 5 ) (1 0 0 th – 1 0 3 rd ) “N e w F e d e ra lis m ” o f th e R e a g a n a d m in is tr a ti o n ; B e rl in W a ll fa lls P re si d e n t N ix o n ’s p ro p o se d c o m p re h e n si ve h e a lt h in su ra n ce p la n f a ils ; p ro p o se d H e a lt h S e cu ri ty A c t fr o m S e n a to r E d w a rd K e n n e d y (D -M A ) fa ils ; C o m m u n ic a b le D is e a se C e n te r is r e n a m e d t h e e xt e n d M e d ic a re e lig ib ili ty a n d c re a te S u p p le m e n ta l S e cu ri ty In co m e (S S I) p ro g ra m ; 4 6 4 F .2 d 7 7 2 ( D .C . C ir . 1 9 7 2 ): E st a b lis h e d m o d e rn la w o f in fo rm e d c o n se n t b a se d o n a r e a so n a b le p a ti e n t st a n d a rd ; 4 1 0 U .S . 1 1 3 ( 1 9 7 3 ): C o n st it u ti o n a l r ig h t to p ri v a c y e n co m p a ss e s a w o m a n ’s d e ci si o n t o t e rm in a te h e r p re g n a n c y ; S u p p o rt s g ro w th o f h e a lt h m a in te n a n ce o rg a n iz a ti o n s; p a ss e d ; is c re a te d t o a d m in is te r th e M e d ic a re a n d M e d ic a id p ro g ra m s. C a rt e r in tr o d u ce s a N a ti o n a l H e a lt h P la n to C o n g re ss ; is c re a te d f ro m a re o rg a n iz e d H E W . M e d ic a re im p le m e n ts p ro sp e c ti ve p ay m e n t sy st e m fo r re im b u rs in g h o sp it a ls ; E n su re s a cc e ss t o e m e rg e n c y se rv ic e s in M e d ic a re -p a rt ic ip a ti n g h o sp it a ls r e g a rd le ss o f a b ili ty t o p ay ; C re a te s th e N a ti o n a l P ra c ti ti o n e r D a ta b a n k; In cl u d e s h e a lt h b e n e fi t p ro v is io n s th a t e st a b lis h c o n ti n u a ti o n o f e m p lo ye r- sp o n so re d g ro u p h e a lt h c o ve ra g e ; In cl u d e s o u tp a ti e n t p re sc ri p ti o n d ru g b e n e fi t a n d o th e r ch a n g e s in M e d ic a re ( re p e a le d  1 9 8 9 ). H e al th ca re c o st s co n ti n u e t o r is e d ra m at ic al ly , d u e t o a d va n ce s in m e d ic al t e ch n o lo g y, h ig h -t e ch h o sp it al c ar e , t h e n e w p o o l o f p ay in g p at ie n ts f ro m M e d ic ai d a n d M e d ic ar e , i n cr e as e d u ti liz at io n o f se rv ic e s, a n d in cr e as e d p h ys ic ia n s p e ci al iz at io n ; c o m p u te d t o m o g ra p h y (C T ) sc an fi rs t u se d ; fi rs t b ab y co n ce iv e d t h ro u g h in v it ro fe rt ili za ti o n is b o rn . W o rl d H e a lt h A ss e m b ly d e cl a re s sm a llp o x e ra d ic a te d ; S ci e n ti st s id e n ti fy A ID S ; t h e J o in t C o m m is si o n o n A cc re d it a ti o n o f H o sp it a ls c h a n g e s n a m e to t h e J o in t C o m m is si o n o n A cc re d it a ti o n o f H e a lt h ca re O rg a n iz a ti o n s (J C A H O ); S h if t aw ay f ro m t ra d it io n a l f e e -f o r- se rv ic e in su ra n ce p la n s a n d t o w a rd m a n a g e d c a re . 105 19 90 s P re si d e n t R e p u b lic a n D e m o cr a t G e o rg e B u sh ( 1 9 8 9 – 1 9 9 3 ) W ill ia m J . C lin to n ( 1 9 9 3 – 2 0 0 1 ) U .S . H o u se o f R e p re se n - ta ti ve s D e m o cr a t *F ir st t im e si n ce 1 9 5 5 t h a t b o th h o u se s a re R ep u b lic a n ; R e p u b lic a n ( 1 9 9 5 – 2 0 0 5 ) (1 0 4 th – 1 0 8 th ) U .S . S e n a te D e m o cr a t R e p u b lic a n ( 1 9 9 5 – 2 0 0 5 ) (1 0 4 th – 1 0 8 th [ Ja n . 3 – 2 0 , 2 0 0 1 , a n d J u n e 6 , 2 0 0 1 – N o v. 1 2 , 2 0 0 2 D e m o cr a t] ) G u lf W a r Fo re ig n c ri se s in H a it i a n d B o sn ia ; N o rt h A m e ri ca n F re e T ra d e A g re e m e n t (N A F TA ); W h it e w a te r in ve st ig a ti o n ; O kl a h o m a C it y b o m b in g ; P re si d e n t C lin to n im p e a ch e d cr e a te d ; P ro v id e s p ro te c ti o n a g a in st d is a b ili ty d is cr im in a ti o n ; C re a te s fe d e ra l s u p p o rt f o r A ID S - re la te d s e rv ic e s; 4 9 7 U .S . 2 6 1 ( 1 9 9 0 ): Fi rs t “ ri g h t to d ie ” c a se b e fo re S u p re m e C o u rt , i n w h ic h t h e C o u rt h e ld t h a t a c o m p e te n t p e rs o n h a s a c o n st it u ti o n a lly p ro te c te d li b e rt y in te re st in re fu si n g m e d ic a l t re a tm e n t. P re si d e n t C lin to n ’s p ro p o se d is d e fe a te d ; P H S r e o rg a n iz e d t o re p o rt d ir e c tl y to t h e S e cr e ta ry o f H H S ; In cl u d e s p ri v a c y ru le s to p ro te c t p e rs o n a l h e a lt h in fo rm a ti o n , a tt e m p ts t o s im p lif y co d in g f o r h e a lt h b ill s, m a ke s it d iffi cu lt t o e xc lu d e p a ti e n ts f ro m in su ra n ce p la n s d u e t o p re e xi st in g c o n d it io n s; re p la ce s A F D C w it h t h e T e m p o ra ry A ss is ta n ce f o r N e e d y Fa m ili e s (T A N F ) p ro g ra m ; R e q u ir e s in su ra n ce c a rr ie rs t h a t o ff e r m e n ta l h e a lt h b e n e fi ts t o p ro v id e t h e s a m e a n n u a l a n d lif e ti m e d o lla r lim it s fo r m e n ta l a n d p h ys ic a l h e a lt h b e n e fi ts ; R e la xe s re st ri c ti o n s o n d ir e c t- to -c o n su m e r a d ve rt is e m e n ts o f p re sc ri p ti o n d ru g s; A d d s M e d ic a re p a rt C , t h e M e d ic a re m a n a g e d c a re p ro g ra m , a n d cr e a te s th e S ta te H e a lt h In su ra n ce P ro g ra m , w h ic h a llo w s st a te s to e xt e n d h e a lt h in su ra n ce c o ve ra g e to a d d it io n a l l o w -i n co m e c h ild re n ; C re a te s a n e w s ta te o p ti o n t o h e lp in d iv id u a ls w it h d is a b ili ti e s st ay e n ro lle d in M e d ic a id o r M e d ic a re c o ve ra g e w h ile r e tu rn in g t o w o rk . E n ro llm e n t in m a n a g e d c a re d o u b le s; G re a te r u se o f o u tp a ti e n t se rv ic e s; R a te o f h e a lt h s p e n d in g is re la ti ve ly s ta b le a t ro u g h ly 1 2 % t o 1 3 % o f g ro ss d o m e st ic p ro d u c t; D ir e c t- to -c o n su m e r a d ve rt is in g o f p h a rm a ce u ti ca ls in cr e a se s d ra m a ti ca lly a n d t h e In te rn e t is u se d a s a s o u rc e o f m e d ic a l i n fo rm a ti o n ; O re g o n H e a lt h P la n r a ti o n s M e d ic a id s e rv ic e s th ro u g h a p ri o ri ti ze d li st o f m e d ic a l t re a tm e n ts a n d co n d it io n s; Ia n W ilm u t cl o n e s a s h e e p f ro m a d u lt h u m a n c e lls . 106 20 00 s P re si d e n t R e p u b lic a n D e m o cr a t G e o rg e W . B u sh ( 2 0 0 1 – 2 0 0 9 ) B a ra ck O b a m a ( 2 0 0 9 – 2 0 1 7 ) U .S . H o u se o f R e p re se n - ta ti ve s R e p u b lic a n ( 2 0 0 5 – 2 0 0 7 ) (1 0 9 th ); D e m o cr a t (2 0 0 7 – 2 0 0 9 ) (1 1 0 th ) D e m o cr a t (2 0 0 9 – 2 0 1 1 ) (1 1 1 th ); R e p u b lic a n 2 0 1 1 – ( 1 1 2 th ) U .S . S e n a te R e p u b lic a n ( 2 0 0 5 – 2 0 0 7 ) (1 0 9 th ); D e m o cr a t (2 0 0 7 – 2 0 0 9 ) (1 1 0 th ) D e m o cr a t (2 0 0 9 – 2 0 1 5 ) (1 1 1 th – 1 1 3 th ) t e rr o ri st a tt a ck s o n W o rl d T ra d e C e n te r in N e w Y o rk a n d t h e P e n ta g o n ; U .S . m ili ta ry a c ti o n in A fg h a n is ta n ; Ir a q W a r b e g in s G re a t R e ce ss io n ( b e g a n in D e ce m b e r 2 0 0 7 ), in cl u d in g fi n a n ci a l cr is is a n d c o lla p se o f h o u si n g m a rk e t; P a ss a g e o f th e 2 0 1 0 P a ti e n t P ro te c ti o n a n d A ff o rd a b le C a re  A c t C o n g re ss io n a l a tt e n ti o n a n d s p e n d in g t u rn s to in te rn a ti o n a l a n d s e cu ri ty c o n ce rn s, li tt le d is cu ss io n o f h e a lt h r e fo rm ; t ra n sf e rs s o m e H H S f u n c ti o n s, in cl u d in g t h e S tr a te g ic N a ti o n a l S to ck p ile o f e m e rg e n c y p h a rm a ce u ti ca l s u p p lie s a n d t h e N a ti o n a l D is a st e r M e d ic a l S e rv ic e , t o t h e n e w D e p a rt m e n t o f H o m e la n d S e cu ri ty ; A d d s a p re sc ri p ti o n d ru g b e n e fi t to M e d ic a re b e g in n in g in 2 0 0 6 ; P ro v id e s fu n d in g f o r v a cc in e s a n d m e d ic a ti o n s fo r b io d e fe n se a n d a llo w s e xp e d it e d F D A r e v ie w o f tr e a tm e n ts in r e sp o n se t o a tt a ck s; 2 00 5 D efi ci t M a ke s ch a n g e s to M e d ic a id c o st s h a ri n g , p re m iu m s, b e n e fi ts , a n d a ss e t tr a n sf e rs ; g o e s in to e ff e c t; a m e n d e d t o r e q u ir e in su re rs t o t re a t m e n ta l h e a lt h c o n d it io n s o n t h e s a m e b a si s a s p h ys ic a l c o n d it io n s. C o n g re ss io n a l f o cu s o n h e a lt h r e fo rm , s p e n d in g c u ts ; P re si d e n t O b a m a e st a b lis h e s th e ffi c ; c re a te s in ce n ti ve s to h e lp d e ve lo p h e a lt h in fo rm a ti o n t e ch n o lo g y a n d e xp a n d t h e p ri m a ry c a re w o rk fo rc e , a m o n g o th e r th in g s; e xt e n d in g ( fo r 4 .5 y e a rs ) a n d e xp a n d in g t h e p ro g ra m ; ff C o m p re h e n si ve h e a lt h r e fo rm in cl u d in g a n “i n d iv id u a l m a n d a te ” to p u rc h a se in su ra n ce c o ve ra g e , M e d ic a id e xp a n si o n , c re a ti o n o f st a te h e a lt h in su ra n ce e xc h a n g e s, a n d m u ch m o re . A ft e r th e S e p te m b e r 1 1 , 2 0 0 1 , a tt a ck s, p u b lic h e a lt h b e co m e s fo cu se d o n e m e rg e n c y p re p a re d n e ss ; S e q u e n ci n g o f h u m a n g e n o m e c o m p le te d ; S A R S e p id e m ic a n d 2 0 0 4 fl u v a cc in e s h o rt a g e r a is e s co n ce rn s a b o u t p u b lic h e a lt h r e a d in e ss ; W o rl d w id e co n ce rn a b o u t a p o ss ib le A v ia n fl u e p id e m ic ; H ig h le ve l o f co n ce rn in t h e U n it e d S ta te s a b o u t th e r is in g r a te o f o b e si ty ; G a rd a si l v a cc in e p ro te c ti n g a g a in st t w o s tr a in s o f th e h u m a n p a p ill o m a v ir u s, w h ic h is a ss o ci a te d w it h c e rv ic a l c a n ce r, a p p ro ve d b y th e F D A ; I n te rn a ti o n a l H e a lt h R e g u la ti o n s, p a ss e d b y th e W o rl d H e a lt h O rg a n iz a ti o n in 2 0 0 5 , a re im p le m e n te d b y m e m b e r st a te s. R a te o f h e a lt h s p e n d in g c o n ti n u e s to s ky ro ck e t, a cc o u n ti n g in 2 0 0 9 f o r 1 7 % o f th e g ro ss d o m e st ic p ro d u c t; H 1 N 1 s w in e fl u v ir u s p a n d e m ic . 107   20 10 s P re si d e n t D e m o cr a t R e p u b lic a n B a ra ck O b a m a ( 2 0 0 9 – 2 0 1 7 ) D o n a ld T ru m p ( 2 0 1 7 – ) U .S . H o u se o f R e p re se n ta ti ve s R e p u b lic a n 2 0 1 1 – P re se n t (1 1 2 th – 1 1 5 th )   U .S . S e n a te R e p u b lic a n 2 0 1 5 ( 1 1 4 th – 1 1 5 th )     b u t m a n y n o t p ro sp e ri n g d u ri n g t h e r e co ve ry ; , i n cl u d in g d e b a te s in n e a rl y h a lf t h e s ta te s co n ce rn in g w h e th e r to a d o p t th e A C A ’s M e d ic a id e xp a n si o n ; S e ve ra l st a te s co n ti n u e t o e xp e ri e n ce fi n a n ci a l a n d /o r te ch n ic a l i ss u e s in t h e e st a b lis h m e n t a n d o p e ra ti o n o f A C A in su ra n ce e xc h a n g e s; In cr e a si n g p o lit ic a l a n d le g a l a cc e p ta n ce o f sa m e -s e x m a rr ia g e li ke ly t o im p a c t u se a n d c o st o f h e a lt h in su ra n ce a n d p u b lic h e a lt h p ro g ra m s; G ro w th o f IS IS a s a t e rr o ri st t h re a t; s u d d e n ly in F e b ru a ry 2 0 1 6 , a ft e r w h ic h th e U .S . S e n a te , u n d e r R e p u b lic a n p o w e r, re fu se s to c o n si d e r P re si d e n t O b a m a’ s re p la ce m e n t n o m in a ti o n u n ti l a ft e r th e 2 0 1 6 e le c ti o n . M a in ly n a ti o n a l e le c ti o n r e su lt s in a b ru p t sh if t in f e d e ra l p o lic ym a ki n g , v ie w s a b o u t e n ti tl e m e n t a n d w e lf a re p ro g ra m s, a n d r e v is e d im m ig ra ti o n p o lic ie s, a m o n g o th e r ke y n a ti o n a l p o lit ic a l a n d s o ci a l is su e s; ; in 2 0 1 7 t o in ve st ig a te t h e a lle g e d r o le o f R u ss ia n in te rf e re n ce in t h e 2 0 1 6 n a ti o n a l e le c ti o n ; on fir m ed to t a ke J u st ic e S ca lia ’s s e a t o n t h e U .S . S u p re m e C o u rt ; a t th e e n d o f th e 2 0 1 7 – 2 0 1 8 t e rm , i s re p la ce d b y b y th e s m a lle st m a rg in f o r a S u p re m e C o u rt J u st ic e s in ce 1 8 8 1 a n d a ft e r a d e e p ly t ro u b lin g a n d p o la ri zi n g n o m in a ti o n p ro ce ss ; N a ti o n a l e co n o m y m a in ly re co ve rs f ro m G re a t R e ce ss io n , .   C o n g re ss io n al f o cu s co n ti n u e s to b e o n d e b at in g t h e A C A a s w e ll as in te rn at io n al se cu ri ty is su e s; e n d e d t h e d is cr im in at o ry m ili ta ry p o lic y re g ar d in g g ay s e rv ic e m e m b e rs ; S u p re m e C o u rt h e ld t h at t h e A C A ’s in d iv id u al in su ra n ce r e q u ir e m e n t w as c o n st it u ti o n al b u t al so r u le d t h at t h e A C A ’s r e q u ir e m e n t th at a ll st at e s e xp an d M e d ic ai d w as u n d u ly c o e rc iv e ; th e S u p re m e C o u rt h e ld t h at o n e p ro vi si o n o f th e A C A v io la te d f e d e ra l l aw b y re q u ir in g c lo se ly h e ld c o rp o ra ti o n s to p ay f o r in su ra n ce c o ve ra g e f o r ce rt ai n t yp e s o f co n tr ac e p ti o n ; r e p la ce d t h e S u st ai n ab le G ro w th R at e f o rm u la u se d fo r p h ys ic ia n p ay m e n t an d f u n d e d C H IP t h ro u g h 2 0 1 7 ; th e S u p re m e C o u rt h e ld t h at t h e f u n d am e n ta l r ig h t to m ar ri ag e is g u ar an te e d t o sa m e -s e x co u p le s; In t h e S u p re m e C o u rt u p h e ld t h e A C A ’s st at u to ry a n d r e g u la to ry s ch e m e p e rm it ti n g f e d e ra l s u b si d ie s to fl o w t h ro u g h b o th st at e -r u n a n d f e d e ra lly f ac ili ta te d in su ra n ce e xc h an g e s; T h e au th o ri ze d a c o m p re h e n si ve , s tr at e g ic a p p ro ac h f o r U .S . f o re ig n as si st an ce t o d e ve lo p in g c o u n tr ie s to r e d u ce g lo b al p o ve rt y an d h u n g e r, ac h ie ve fo o d s e cu ri ty , p ro m o te s u st ai n ab le a g ri cu lt u ra l- le d e co n o m ic g ro w th , a n d im p ro ve n u tr it io n al o u tc o m e s, p ar ti cu la rl y fo r w o m e n a n d c h ild re n ; T h e b e ca m e la w in 2 0 1 6 a n d w as d e si g n e d t o h e lp a cc e le ra te m e d ic al p ro d u c t d e ve lo p m e n t an d b ri n g n e w in n o va ti o n s an d a d va n ce s to p at ie n ts w h o n e e d t h e m fa st e r an d m o re e ffi ci e n tl y ; I n W h o le ( 2 0 1 6 ), th e S u p re m e C o u rt s tr u ck d o w n s tr ic t Te xa s ab o rt io n r e g u la ti o n s, r u lin g t h at a b o rt io n p ro vi d e r re g u la ti o n s m u st b e b as e d o n c o n vi n ci n g m e d ic al e vi d e n ce a n d c an n o t u n d u ly b u rd e n a w o m an ’s r ig h t to a b o rt io n . A ft e r P re si d e n t Tr u m p ’s in a u g u ra ti o n , m u lt ip le R e p u b lic a n e ff ff ( th o u g h s e ve ra l e xe cu ti ve / re g u la to ry a c ti o n s h a lt o r lim it t h e r e a ch o f th e A C A ); a n d f u n d e d t h ro u g h 2 0 2 7 ; T h e r e p re se n ts th e b ig g e st f e d e ra l t a x o ve rh a u l i n 3 0 y e a rs — a m o n g o th e r th in g s, it c u t th e m a xi m u m c o rp o ra te in co m e t a x ra te t o 2 1 % , e lim in a te d t h e t a x o n p e o p le w h o d o n o t o b ta in a d e q u a te h e a lt h in su ra n ce c o ve ra g e , a n d in cr e a se d t h e st a n d a rd d e d u c ti o n a n d t h e e st a te t a x e xe m p ti o n , w h ic h t o g e th e r w ill r e d u ce fe d e ra l r e ve n u e s b y si g n ifi ca n t a m o u n ts a n d li ke ly m a ke t h e d is tr ib u ti o n o f a ft e r- ta x in co m e m o re u n e q u a l. In ( 2 0 1 7 ), th e S u p re m e C o u rt r u le d t h a t ra ci a l g e rr ym a n d e ri n g v io la te d t h e r ig h ts o f vo te rs t o e q u a l p ro te c ti o n o f th e la w s; T h e S u p re m e C o u rt r u le d 5 – 4 t h a t P re si d e n t Tr u m p h a d th e le g a l a u th o ri ty t o r e st ri c t tr a ve l f ro m s e ve ra l m o st ly M u sl im c o u n tr ie s in t h e 2 0 1 8 c a se o f ; I n ( 2 0 1 8 ), th e S u p re m e C o u rt r u le d in f a vo r o f a C o lo ra d o b a ke r w h o r e fu se d t o c re a te a w e d d in g c a ke f o r a g a y co u p le , d e te rm in in g th a t th e b a ke r h a d b e e n m is tr e a te d b y th e s ta te c iv il ri g h ts c o m m is si o n b a se d o n r e m a rk s o f o n e o f it s m e m b e rs in d ic a ti n g h o st ili ty t o r e lig io n ; I n 2 0 1 8 , th e S u p re m e C o u rt r u le d 5 – 4 t h a t fo re ig n c o rp o ra ti o n s m ay n o t b e s u e d in A m e ri ca n c o u rt s fo r co m p lic it y in h u m a n r ig h ts a b u se s a b ro a d . 108   20 10 s   c h o le ra o u tb re a k in H a it i, o n e o f th e w o rs t o u tb re a ks in r e ce n t h is to ry ; e m e rg e n ce o f M E R S -C o V , a v ir a l r e sp ir a to ry il ln e ss t h a t is n e w t o h u m a n s, fi rs t re p o rt e d in t h e M id d le E a st b u t la te r sp re a d t o s e ve ra l c o u n tr ie s in cl u d in g t h e U n it e d S ta te s; h e a lt h ca re s p e n d in g r e a ch e d a lm o st $ 3 t ri lli o n a n d a cc o u n te d fo r 1 7 .4 % o f th e g ro ss d o m e st ic p ro d u c t; E b o la o u tb re a k w a s th e la rg e st in h is to ry a n d fi rs t E b o la e p id e m ic ; E b o la r e se a rc h a d v a n ce s q u ic kl y, s ci e n ti st s d is co ve re d a n e w c la ss o f a n ti b io ti cs , a n d d o c to rs p e rf o rm e d t h e w o rl d ’s fi rs t ri b c a g e t ra n sp la n t u si n g a t h re e -d im e n si o n a l- p ri n te d c h e st p ro st h e ti c; re p re se n ts t h e s ta rt o f a w o rl d w id e Z ik a v ir u s e p id e m ic ; m a rk s th e p o in t a t w h ic h t h e n a ti o n ’s o p io id c ri si s fi n a lly b e co m e s fr o n t- p a g e n e w s; t h e U .S . D ru g E n fo rc e m e n t A g e n c y p e rm it s th e fi rs t- e ve r cl in ic a l t ri a l i n w h ic h p a ti e n ts w ill b e s m o ki n g m a ri ju a n a , i n o rd e r to e st a b lis h w h e th e r p o t- sm o ki n g c a n h av e p o si ti ve m e d ic a l b e n e fi ts f o r p a ti e n ts w it h p o st -t ra u m a ti c st re ss d is o rd e r; w it n e ss e s b o th H u rr ic a n e M a tt h e w , w h ic h k ill s n e a rl y 5 0 p e o p le a n d c a u se s m o re t h a n $ 1 5 b ill io n in d a m a g e in F lo ri d a , G e o rg ia , a n d t h e C a ro lin a s, a n d a ls o th e G re a t S m o ky M o u n ta in w ild fi re s in T e n n e ss e e , w h ic h d e st ro ye d n e a rl y 2 ,0 0 0 st ru c tu re s a n d b u rn e d n e a rl y 1 8 ,0 0 0 a cr e s o f la n d . s ci e n ti st s su cc e ss fu lly c u t o u t th e H IV v ir u s fr o m m o u se c e lls u si n g g e n e e d it in g t h e ra p y ; h e a lt h ca re s p e n d in g a cc o u n te d f o r 1 8 % o f th e g ro ss d o m e st ic p ro d u c t; H u rr ic a n e s H a rv e y, Ir m a , a n d M a ri a , r e su lt in th o u sa n d s o f d e a th s a n d h u n d re d s o f b ill io n s o f d o lla rs in d a m a g e s in T e xa s, Lo u is ia n a , A la b a m a , F lo ri d a , S o u th C a ro lin a , G e o rg ia , P u e rt o R ic o , a n d m u lt ip le is la n d s in t h e e a st e rn C a ri b b e a n S e a . 109 Other Sources Consulted Source for Political Affiliation of Senate Source for Political Affiliation of the House of Representatives Further Reading fin Th References Th 111 PART II Essential Issues in Health Policy and Law © Mary Terriberry/Shutterstock 113 © Mary Terriberry/Shutterstock© Mary Terriberry/Shutterstock CHAPTER 6 Individual Rights in Health Care and Public Health LEARNING OBJECTIVES By the end of this chapter you will be able to: ■ Describe the meaning and importance of the “no-duty to treat” principle ■ Explain generally how the U.S. approach to health rights differs from that of other developed countries ■ Describe the types and limitations of individual legal rights associated with health care ■ Describe the balancing approach taken when weighing individual rights against the public’s health By the end of this chapter you will be able to: ■ Describe the meaning and importance of the “no-duty to treat” principle ■ Explain generally how the U.S. approach to health rights differs from that of other developed countries ■ Describe the types and limitations of individual legal rights associated with health care ■ Describe the balancing approach taken when weighing individual rights against the public’s health ▸ Introduction BOX 6-1 efin defin Th diffic g infl ft Thi sifie eff Thi 114 Chapter 6 ublic Health ▸ Background Thi fi fir lific Th fi fi Th lifie fie ufficien fie cific cific ff nific defin BOX 6-1 Vignette At the turn of the 20th century, an Indiana physician named George Eddingfield repeatedly refused to come to the aid of Charlotte Burk, who was in labor, even though he was Mrs. Burk’s family physician. Doctor Eddingfield conceded at trial that he made this decision for no particular reason and despite the facts that he had been offered monetary compensation in advance of his performing any medical services and that he was aware that no other physician was available to provide care to Mrs. Burk. Unattended by any medical providers, Mrs. Burk eventually fell gravely ill, and both she and her unborn child died. It was determined upon trial and subsequent appeals that Dr. Eddingfield did not wrongfully cause either death. Around the same time as the scenario just described, the Cambridge, Massachusetts, Board of Health ordered everyone within city limits to be vaccinated against the smallpox disease under a state law granting local boards of health the power, under certain circumstances, to require the vaccination of individuals. After refusing to abide by the Cambridge Board’s order, Henning Jacobson was convicted by a state trial court and sentenced to pay a $5 fine. Remarkably, Mr. Jacobson’s case not only made its way to the U.S. Supreme Court, it resulted in one of the court’s most important public health rulings and a sweeping statement about limitations to fundamental individual rights in the face of threats to the public’s health. 115 cific Th iffs Th fin fi iffs ff fin fin lfi ff 116 Chapter 6 ublic Health fin eff diff Th ft eff iefl Thr ▸ Individual Rights and Health Care: A Global Perspective fin fide cific e S 117 fin efi ▸ Individual Rights and the Healthcare System Th infl Thi Thi efi ffir fir Th fin Th BOX 6-2 Discussion Question Depending on one’s personal experience in obtaining health care, or one’s view of the role of physicians in society, of law as a tool for social change, of the scope of medical ethics, or of the United States’ place in the broader global community, the no-duty principle might seem appropriate, irresponsible, or downright wrong. Imagine you are traveling in a country where socialized medicine is the legal norm, and your discussion with a citizen of that country turns to the topic of your countries’ respective health systems. When asked, how will you account for the fact that health care is far from being a fundamental right rooted in American law? 118 Chapter 6 ublic Health Rights Under Healthcare and Health Financing Laws iefl Rights Under Healthcare Laws: EMTALA ft eff eff ffici Th fir defin ufficien eff Th defini eff Th Th fi Rights Under Healthcare Financing Laws: Medicaid fin Th diff e S 119 fin fin Thi ft Thi efi Rights Under Health Insurance Laws: The ACA eff iefl eff Thr sifie Th hift ifici fin efi lifies Th ft Rights Related to Freedom of Choice and Freedom From Government Interference The Right to Make Informed Healthcare Decisions Thi Th lifier 120 Chapter 6 ublic Health Th Th difie uff     Th ft uff Thi uff Th Th Th fir Th The sfies ufficien ufficien The fin fir The Right to Personal Privacy Th Th fir defin e S 121 Th Thi Th Th ft flo Th ff fi Th Th ft Th BOX 6-3 Discussion Questions Go back to the first legal principle drawn from the Canterbury decision: namely, that physicians have a duty of reasonable disclosure to include therapy options and the dangers potentially involved with each. Do you agree with the court that this duty is both a logical and modest extension of physicians’ “traditional” obligation to their patients? Why or why not? Depending on your answer, are you surprised to learn that some states have opted not to follow the Canterbury court’s patient-oriented standard of informed consent, relying instead on the more conventional approach of measuring the legality of physician disclosure based on what a reasonable physician would have disclosed? 122 Chapter 6 ublic Health ufficien Th fir eff left fir fin ft diffic ifie fin ff Th eff fi Th Thir ific Th iffs Th iffs cific defin n. Th ffir e S 123 s eff nfir ft Th Thir Th ific fin ific Th ff Th er defin Th fin fi ft Th Th Th diff fles defini Th 124 Chapter 6 ublic Health defini n eff Th Th nific ft ft Thi eff defini ff ft eff cific w defin adfir Th fi Th Th Th ffir Th fir e S 125 Th cific Th hift The Right to Be Free From Wrongful Discrimination fin ft ft eff ft ft Thi cific fin eff fie eff Th Th iefl 126 Chapter 6 ublic Health Race/Ethnicity Discrimination Th Thi fi ies—diff infl diff ft fin Thi Th efi fin difie fie Th ffe Thi eff flo Th BOX 6-4 Discussion Question If you were asked to distill, down to their most essential parts, the constitutional right to privacy and the right to privacy as it applies to abortion, what elements would you include? e S 127 Physical and Mental Disability Discrimination ff Th Th cific cific lific efi defin Thi diff ff dific dific ft efi Socioeconomic Status Discrimination eff 128 Chapter 6 ublic Health ff ufficien Gender Discrimination Thi diffic ufficien d-eff uff Age Discrimination efi efi fir efi diff efi ▸ Individual Rights in a Public Health Context Th diff cific ffs ff sifie ft Th Overview of Police Powers Th Th 129 Th ets. Th Th ft ft Thi efin Thi eff ffici The Jacobson v. Massachusetts Decision Th ifie Thi Th ff uff fin Th Th Th ft ffici 130 Chapter 6 ublic Health ■ Th fir ■ Th e fir ■ efi ■ nific Thi Th d li The “Negative Constitution” Th ffir Thi Thi Thi Thi Thi ft ffici BOX 6-5 Discussion Question Jacobson v. Massachusetts is a product of the early 20th century, and the public health law principles supporting it are vestiges of an even earlier time. This, coupled with a century of subsequent civil liberties jurisprudence and societal advancement, has led some commentators to question whether Jacobson should retain its paradigmatic role in terms of the scope of government police powers. At the same time, other public health law experts call for Jacobson’s continued vitality, arguing that it is settled doctrine and a still-appropriate answer to the private interest/collective good question. What do you think? 131 fi ft ft Th uffi Thi uff left fi ffici Th ffici ffici ffir Th ffir Th ffir eff ft ffir Thi efi efi ft Thi nfir ft left fficer Thir ft fficer fficer eff ft 132 Chapter 6 ublic Health gunfig eff Th fficer efi ffici fficer Th efici ▸ Conclusion Thi ff ft Th hifts ft diff efi BOX 6-6 Discussion Questions The “negative constitution” is a concept over which reasonable people can easily disagree. Notwithstanding the “defensive” manner of some of the Constitution’s key provisions, there are several arguments in support of more affirmative action on the part of government health and welfare officials than current Supreme Court jurisprudence requires. For example, the dissent in DeShaney argues persuasively that Wisconsin’s implementation of a child protection program effectively created a constitutional duty to actually protect children from seemingly obvious danger. As one leading scholar put it, If an agency represents itself to the public as a defender of health, and citizens justifiably rely on that protection, is government “responsible” when it knows that a substantial risk exists, fails to inform citizens so they might initiate action, and passively avoids a state response to that risk? (Gostin, 2000) What do you think of this argument? Can you think of other arguments that call into question the soundness of the negative theory of constitutional law? 133 References Th Th Th fi Th Th Th Th Th Th fie Th nflic efle Th Th ft fin fixi hift 134 Chapter 6 ublic Health ▸ Endnotes Th infl Th Th Th nific fig Th Th C: Th ff C: Th Th Th Th fi Th ff ff ft Th C: Th , MI: Th Th ft Th Th Th efle Th Th Th 135 Th ft nfiden Th ft eff Thi Th efle Th fl fin Th 137 © Mary Terriberry/Shutterstock CHAPTER 7 Social Determinants of Health and the Role of Law in Optimizing Health LEARNING OBJECTIVES By the end of this chapter you will be able to: ■ Describe the meaning of social determinants of health and the significance of social factors on individual and population health ■ Describe how law can create or perpetuate health-harming social conditions ■ Explain how law can be used to ameliorate health-harming social conditions ■ Understand how innovative interventions to improve health, such as medical-legal partnership, can help address health-harming social conditions at the individual and population levels By the end of this chapter you will be able to: ■ Describe the meaning of social determinants of health and the significance of social factors on individual and population health ■ Describe how law can create or perpetuate health-harming social conditions ■ Explain how law can be used to ameliorate health-harming social conditions ■ Understand how innovative interventions to improve health, such as medical-legal partnership, can help address health-harming social conditions at the individual and population levels BOX 7-1 Vignette Living through brief periods without heat or electricity is a fact of life for most of us, perhaps as a result of a powerful weather system or a blown generator. But have you thought about what it would be like to be without heat or electricity more chronically, due to homelessness, inadequate housing, or an unscrupulous landlord who neglects a property without concern for tenants? Even for the healthiest among us, this social factor would be incredibly challenging; for those with chronic illness, it can mean increased asthma attacks, severe pain associated with sickle cell disease, an inability to refrigerate needed medicine, and much more, including death. The social factors just noted— homelessness, dilapidated homes, slum landlords—and many others have nothing to do with biology, genetics, personal choice, or access to healthcare services, but have a great deal to do with individual and public health. 138 Chapter 7 ▸ Introduction diff diff diff ff diff diff fin diff ff cific ft diff ff   efi efi fig nific nific BOX 7-2 Discussion Questions Do you think trying to achieve wide-scale health equity is a laudable goal? Why or why not? If yes, what do you think are the keys to achieving it? And what about people who are given the opportunity to achieve optimal health but do not take advantage of it; should they face consequences of some sort? 139 ▸ Social Determinants of Health Defining Social Determinants of Health nflic fin ff Th defin Th nific infl ff defin uff defin cific fin eff e diff Types of SDH Th diff ■ ff ff efi diffic ■ ft ff efi ■ Th 140 Chapter 7 fin ■ Th ■ Th ff ifie eff ■ eff eff eff ■ ■ ff ft ■ ft uff ■ iffin, Th nific ff Th Th Th 40  ff 141 ■ uffice eff fin diff eff ■ ff n eff The Link Between Social Determinants and Health Outcomes fl   Th Th eff defini cific eff   Th uff ff infl ff BOX 7-3 Group Activity Each student should begin by rank-ordering a list of the half-dozen social determinants (from those listed in this chapter or otherwise; broad or specific) that he or she believes most significantly affect individual health. Then get together in groups of three or four people to compare lists, discussing disagreements and making the case for some determinants over others. 142 Chapter 7 nific cific fin ▸ Law as a Social Determinant of Health infl Thr Th fi The ff ft ft The Th 143 ufficien fir Thi eff   efi lfi fin fi fin Th 144 Chapter 7 Th fir fl Thi ft ifie Th Th Th Th infl infl Th ft Th infl Right to Criminal Legal Representation vs. Civil Legal Assistance ff diff fir diff BOX 7-4 Group Activity Get together in groups of three or four people. As a group, take 20 minutes to make a list of all the specific ways you can think of that the law has been used to directly respond to health-harming social needs (examples exist in category 5 in this section). When time is up, compare lists across groups, discuss disagreements, and see which group thought of the greatest number of legal interventions. 145 Criminal Legal Representation Th ff Th ff The flim ff Th 5 m ft Th Th eff Civil Legal Assistance efi ff w fir Thi Th fin 146 Chapter 7 fin fi ft Th lifie Th diff fin efi nific nfiden ▸ Combating Health-Harming Social Conditions Through Medical-Legal Partnershipf Th ft efi ff Th diff BOX 7-5 Discussion Questions What do you think about the differences that exist between rights that attach in the area of criminal legal representation versus those that exist in the realm of civil legal assistance? Does it seem fair to you? Why or why not? Even if you believe it is fair, do you think all individuals should have access to at least a baseline level of civil legal assistance? 147 fficer fficer The Evolution of an “Upstream” Innovation Th fir Th Office Th ft ff fir uff eff   ft efi FIGURE 7-1 Th ft eff efici FIGURE 7-2 Th 148 Chapter 7 fix The Benefits of MLPs eff ff efi fin Housing & Utilities Education & Employment Legal Status Income $ $$ Personal & Family Stability 1. Less violence at home means less need for costly emergency healthcare services. 2. Stable family relationship significantly reduce stress and allow for better decision-making, including decisions related to health care. 1. Clearing a person’s criminal history or helping a veteran change their discharge status helps make consistent employment and access to public benefits possible. 2. Consistent employment provides money for food and safe housing, which helps people avoid costly emergency healthcare services. 1. A quality education is the single greatest predicator of a person’s adult health. 2. Consistent employment helps provide money for food and safe housing, which also helps avoid costly emergency healthcare services. 3. Access to health insurance is often linked to employment. 1. A stable, decent, affordable home helps a person avoid costly emergency room visits related to homelessness. 2. Consistent housing, heat and electricity helps people follow their medical treatment plans. 1. Increasing someone’s income means s/he makes fewer trade-offs between affording food and health care, including medications. 2. Being able to afford enough healthy food helps people manage chronic diseases and helps children grow and develop. Education & Employment Units: Secure specialized education services; Prevent and remedy employment discrimination and enforce workplace rights Benefits Unit: Appeal denials of food stamps, health insurance, cash benefits, and disability benefits Housing Unit: Secure housing subsidies; Improve substandard conditions; Prevent eviction; Protect against utility shut-off Family Law Unit: Secure restraining order for do- mestic violence; Secure adoption, custody and guardianship for children Veterans & Immigration Units: Resolve veteran discharge status; Clear criminal/credit histories; Assist with asylum applications Civil Legal Aid Interventions That Help Availability of resource to meet daily basic needs Access to the opportunity to learn and work Healthy physical environments Access to the opportunity to work Expose to violence Common Social Determinant of Health Impact of Civil Legal Aid Intervention on Health /Health Care I-HELP ® Issue JOB FIGURE 7-1 Framing Legal Care as Health Care Source: Reproduced from: Marple, K. Framing Legal Care as Health Care. National Center for Medical-Legal Partnership. http://medical-legalpartnership.org/new-messaging-guide-helps-frame-legal-care-health-care/. Published January 21, 2015. Accessed August 27, 2015. Train & Identify Need Treat Patients with direct legal assistance Transform Clinic Practice through enhanced screening, toolkits, and EHR template letters Improve Population Health through joint policy advocacy FIGURE 7-2 The Medical-Legal Partnership Approach to the Social Determinants of Health Source: Reproduced from: The MLP Approach to the Social Determinants of Health. National Center for Medical-Legal Partnership. 2013. 149 ft dfie fin efi $1  efi fin efi efi fiden efi efi nfiden ▸ Conclusion fin efi ufficien ft fir eff 150 Chapter 7 References Th Th Th effler infl dfie Th ff diff Th : Th ffl Th Th f  151 ▸ Endnotes fi ff Th dfie A p nfiden infl fi efi Th eff C: Th ffin Th Office iffin, h_defini © Mary Terriberry/Shutterstock CHAPTER 8 Understanding Health Insurance LEARNING OBJECTIVES By the end of this chapter you will be able to: ■ Understand the role of risk and uncertainty in insurance ■ Define the basic elements of health insurance ■ Differentiate various insurance products ■ Discuss incentives created for providers and patients in various types of insurance arrangements ■ Discuss health policy issues relating to health insurance By the end of this chapter you will be able to: ■ Understand the role of risk and uncertainty in insurance ■ Define the basic elements of health insurance ■ Differentiate various insurance products ■ Discuss incentives created for providers and patients in various types of insurance arrangements ■ Discuss health policy issues relating to health insurance ▸ Introduction ft affe   ff ff fin ff 153 BOX 8-1 ff ff ff ft Th ff efi fi efficien Thi ▸ A Brief History of the Rise of Health Insurance in the United States Th ft Th eff flo fir Th BOX 8-1 Vignette William owns a small business that sells all kinds of wheels and gears. He has nine employees and has always made it a priority to offer competitive benefits, including health insurance. Unfortunately, last year one of his employees was diagnosed with cancer, which he continues to fight. Due to the sharp increase in use of health services by his employee group, the insurance company doubled his group premiums for the upcoming year. When William contacted other carriers, several of them would not consider insuring his group, and most of the others gave him quotes as expensive as his current carrier. One company gave him a lower quote, but it covered only catastrophic care; his employees would have to pay for the first $5,000 of care out of their own pockets. After reviewing his company’s finances, William is left with several unattractive options: stop offering health insurance; offer comprehensive health insurance but pass on the cost increase to his employees, which would make it unaffordable for most of them; offer the bare-bones catastrophic plan only; or significantly lower wages and other benefits to defray the rising health insurance costs. In addition to wanting to offer competitive benefits, William is concerned that adopting any of these options will cause his employees to leave and make it hard to attract others, threatening the sustainability of his company. The 2010 health reform law, the Patient Protection and Affordable Care Act (ACA), attempts to help small businesses like William’s by creating state health insurance exchanges. Starting in 2014, these exchanges were intended to offer a variety of plans to individuals and small businesses that otherwise might not be able to afford health insurance coverage. By creating large groups of purchasers through the exchanges, it is possible to pool risk and keep prices lower than if individuals or small businesses were attempting to purchase insurance coverage on their own. 154 Chapter 8 Understanding Health I eff eff efi fi ft efi   Th fir Th fi left fin ff BOX 8-2 Discussion Questions Most people in this country obtain health insurance through employer-sponsored plans. Although the historical background you just read explains how this system came about, it does not discuss whether it is a good or bad thing. Is our reliance on employer- sponsored health insurance ideal for individuals? Providers? Employers? Society? What are the benefits and drawbacks to having employers as the primary source of health insurance? How different are the benefits and drawbacks when considered from various stakeholder perspectives? Would it be better to have more federal government involvement in providing health insurance? What primary policy goal would you use to decide how to answer these questions? 155 Th Th ff flo efici fie ▸ How Health Insurance Operates Thi Basic Terminology fir diff Th Th fic efici efi efici efini efici Th efi fin efi efici efici efici fir Th cific efici ft ft efici 156 Chapter 8 Understanding Health I efici efici efici Thi efici ft Uncertainty Th eft, fir ff fin efi fin ff Th diffic fig BOX 8-3 Discussion Questions As a general matter, all types of insurance under traditional economic models cover expensive and unforeseen events, not events that have small financial risk or little uncertainty (Council of Economic Advisors, 2004, p. 195). For example, auto insurance does not cover regular maintenance such as an oil change, and home insurance does not protect against normal wear and tear, such as the need to replace an old carpet. Accordingly, many economists argue that health insurance should not cover regular, foreseeable events such as physical exams or low-cost occurrences such as vaccinations. Other economists support a different school of thought. An alternative economic view is that health insurance should insure one’s health, not just offer protection against the financial consequences of major adverse health events. Because people without health insurance are less likely to obtain preventive care such as physical exams or vaccinations, these economists believe it is in everyone’s best interest, ethically and financially, to promote preventive care. Therefore, it is appropriate for insurance to cover both unpredictable and expensive events as well as predictable and less expensive events. Which theory do you support? What do you think is the best use of insurance? If insurance does not cover low-cost and predictable events, should another resource be available to assist individuals, or should people pay out of their own pockets for these healthcare needs? BOX 8-4 Discussion Questions As discussed earlier, risk and uncertainty are important concepts in health insurance. Individuals purchase health insurance policies to protect themselves financially against healthcare costs, and insurance carriers try to set premiums that will cover the cost of the services used by their beneficiaries. Currently (when allowed by law), insurance carriers may consider factors such as medical history, demographics, type of occupation, size of the beneficiary pool, and similar criteria when setting the terms of an insurance policy. Should health insurance carriers also have access to and be able to use genetic testing results when deciding whether to insure an individual, what premiums to charge, or which services to cover? If you think the answer to that question should be “no,” why is genetic information different from all of the other kinds of information insurance carriers may take into account when making those decisions? Conversely, what is the strongest argument you can make in favor of allowing insurance carriers to consider an applicant’s genetic information? How would allowing genetic testing alter an individual’s or a provider’s diagnosis and treatment decisions? What is the primary policy goal that affects your view? 157 Risk efi fin diff Th eff ft efi Th efici efici efici efi diffic Thi ft efici efici Thi Th Thi ff efici efici efici efici Th fin left Thi defin ft cifie ff 158 Chapter 8 Understanding Health I 4% 40% 30% 20% 10% 0% 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 6% 3% 3% 7%* 3% 6% 6% 9% 7%* 9%* 12% 11% 8% 8% 9% 20% 21% 7% 14% 15% 9% 24% 28% 28% 9% 9% 19%19%* 13%* 17%* 20% 3%2% 2% 4%* * Estimate is statistically different from estimate for the previous year shown (p < 0.05). Note: Covered workers enrolled in an HDHP/SO are enrolled in either an HDHP/HRA or a HSA-Qualified HDHP. HDHP/HRA HSA-qualified HDHP 70% 60% 50% 40% 30% 20% 10% 0% 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 8% 16%* 18% 21% 26%* 32% 41%* 40% 43% 45% 52%* 57% 58% 5% 13%* 18% 26% 39% 38% 38% 49%* 52% 33% 21% 15% 4% 7% 10% 22% 27% 25% 27% 23% 31% 23% 15% 11% 13% * Estimate is statistically different from estimate for the previous year shown (p < 0.05). 3–199 Workers 1,000 or more workers 200–999 Workers Source: Reproduced from: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2017 https://www.kff.org/report-section/ehbs-2017-section-8-high-deductible-health-plans-with-savings-option/ Source: Reproduced from: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2017. https://www.kff.org/report-section/ehbs-2017-section-8-high-deductible-health-plans-with-savings-option/ lifie lifie FIGURES 8-1 8-2 Th fin t-eff eff BOX 8-5 FIGURE 8-1 Percentage of Covered Workers Enrolled in a High-Deductible Health Plan (HDHP) or Health Reimbursement Arrangement, or in a Health Savings Account–Qualified HDHP, 2006–2017 FIGURE 8-2 Among Firms Offering Health Benefits, Percentage That Offer a High-Deductible Health Plan With a Savings Option, 2005–2017 159 ff ff flo ff Setting Premiums Th efici efici Th difie efficien efficien hift BOX 8-5 Discussion Questions A literature review of studies relating to consumer behavior with HDHPs found that these plans reduced the use of both appropriate care, such as preventive screenings, and inappropriate care, such as unnecessary emergency department visits (Argwal, Mazurenko, & Menachemi, 2017). To date, research generally has not focused on health outcomes of HDHP users. Some recent studies have shown consumers rarely engaging in price-conscious behavior, instead achieving savings through use of fewer services (Kullgren, Cliff, & Krenz, 2018; Sinaiko, Mehrotra, & Sood, 2016; Sood, Wagner, Huckfeldt, & Haviland, 2013). Do HDHPs achieve the right balance of providing insurance coverage while incentivizing consumers to use resources prudently? Or are they simply a way to lower employer healthcare costs while making it unaffordable for many consumers to obtain the health care they need? How easy is it for consumers to compare costs for healthcare providers and services? What additional challenges might an HDHP present for individuals who are low-income, live in rural areas, speak a primary language other than English, or have low health literacy? BOX 8-6 Discussion Questions In general, people with low incomes or no health insurance (or both) tend to be less healthy than those who are financially better off or insured (or both). As a result, policy proposals that suggest including poor, uninsured individuals in already-existing insurance plans are met with resistance by individuals in those plans and by carriers or employers who operate them. Yet, if an insurance plan is created that subscribes only a less-healthy, poor, or uninsured population, it is likely to be an unattractive business opportunity because beneficiaries are likely to need a high quantity of health care that will be costly to provide. Given what you know about adverse selection and risk, what, in your opinion, is the best way to provide insurance coverage to the poor and uninsured? Should they be included in current plans? Should the government provide financial incentives for private carriers to insure them? Should a separate plan or program be created to serve them? In these various scenarios, what incentives are created for plans, current plan members, government, and so on? 160 Chapter 8 Understanding Health I hift y efficien efficien Th ft ffs ffs Thi ff ft ff ff efi   Medical Underwriting Th diffic Th lifie Th BOX 8-7 Discussion Questions What populations or types of people pay more under experience rating? Does experience rating create any incentives for individuals to act in a certain way? What populations or types of people pay more under community rating? Does community rating create any incentives for individuals to act in a certain way? Which rating system seems preferable to you? What trade-offs are most important to you? Should the focus be on the good of the individual or the good of the community? Are these mutually exclusive concerns? 161 Thi eff ft eff Th   Th ▸ Managed Care Th cific fin ffice cific Th Th Thr defin efi 162 Chapter 8 Understanding Health I ff Th fin Cost Containment and Utilization Tools Th hift fin eff Th t-eff y p Provider Payment Tools ff- Th ft hift fin cific Th fin fix Th ts. Th fin hift Th TABLE 8-1 Th diff TABLE 8-1 Provider Payment Cost Containment Strategies Strategy Provider Payment Method How Costs Are Controlled Who Assumes Financial Risk Salary and bonuses/ withholdings Provider receives a salary as an employee of an MCO Incentive for provider to perform fewer and/or less-costly services MCO and provider Discounted fee schedule Provider receives a lower fee than under FFS for each service to members Pays provider less per service rendered than under FFS MCO (but also has lower costs) Capitation Provider receives a set payment per month for each member regardless of services provided Incentive for provider to perform fewer and/or less-costly services Provider Abbreviations: FFS = fee for service; MCO = managed care organization. 163 t-eff t-efficien Th defini infl diff     fi fi   Utilization Control Tools ft Thi fin ft 164 Chapter 8 Understanding Health I ft Thi efi Th efi t-eff TABLE  8-2 ff Thi diff cifics, Th ff Th TABLE 8-2 Service Utilization Control Strategies Strategy Description Potential Concerns Gatekeeper Uses a primary care provider to make sure only necessary and appropriate care is provided Gatekeepers may have financial incentive to approve fewer services or less-costly care Utilization review Uses MCO personnel to review and approve or deny services requested by a provider to make sure only necessary and appropriate care is provided Interferes with patient–provider relationship; someone other than the patient’s provider decides whether treatment is appropriate Case management Uses MCO personnel to manage and coordinate patient care to make sure care is provided in the most cost-effective manner May act as a barrier to receiving care if the case manager does not approve a desired service or service provider Abbreviation: MCO = managed care organization. 165 Source: Reproduced from: Kaiser/HRET Employer Health Benefits Survey, 2017. Retrieved from https://www.kff.org/health-costs/report/2017-employer-health-benefits-survey/ Common Managed Care Structures Th diff FIGURE 8-3 Health Maintenance Organizations fir Th 0% 10% 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1996 1993 1988 73% 46% 21% 26% 28% 39% 42% 46% 52% 54% 55% 61% 60% 57% 58% 60% 58% 55% 56% 57% 58% 52% 48% 48%14% 15% 14% 13% 14% 16% 17% 19% 20% 20% 21% 20% 21% 25% 24% 27% 24% 29% 28% 31%27% 10% 8% 7% 4% 5% 5% 3% 3% 3% 7% 14% 24% 21% 23% 18% 17% 15% 15% 4% 5% 8% 8% 13% 17% 19% 20% 20% 24% 29% 28%10% 9% 10% 8% 9% 9% 10% 8% 10% 12% 13% 13% 16% 11% 20% 30% 40% 50% 60% 70% 80% 90% 100% Note: Information was not obtained for POS plans in 1988 or for HDHP/SO plans until 2006. A portion of the change in plan type enrollment for 2005 is likely attributable to incorporating more recent Census Bureau estimates of the number of state and local government workers and removing federal workers from the weights. See the Survey Design and Methods section from the 2005 Kaiser/HRET Survey of Employer-Sponsored Health Benefits for additional information. Conventional POSHMO PPO HDHP/SO FIGURE 8-3 Distribution of Health Plan Enrollment for Covered Workers by Plan Type, 1988–2017 166 Chapter 8 Understanding Health I ■ Th efici ■ Th ■ Th ■ Th ■ Th ff TABLE 8-3 Preferred Provider Organizations TABLE 8-3 Key Characteristics of Common HMO Models HMO Model HMO-Provider Relationship and Payment Type Provider Employment Arrangement Must Members Seek Care From Network? May Providers Care for Nonmembers? General Comments Staff model/ closed-panel HMO employs providers and pays a salary that often includes bonuses or withholdings. Employed by HMO. Yes No Provides services only in HMO’s office and affiliated hospitals. Relatively speaking, HMO has the most control over providers and service utilization, but has fixed costs of building and staff. HMO may contract with outside providers if necessary. Providers and consumers often do not like restrictions imposed by HMO. Providers do not need to solicit patients. Consumers may find it to be the most cost- effective option. Group HMO contracts with one multispecialty group for a capitated rate. Employed by own provider group. Yes Depends on terms of contract HMO has less control over utilization. HMO contracts for hospital care on a prepaid or FFS basis. Providers may prefer this model because they remain independent as opposed to becoming an employee of the HMO and because they may serve nonmembers if their contract permits. (continues) 167 HMO Model HMO-Provider Relationship and Payment Type Provider Employment Arrangement Must Members Seek Care From Network? May Providers Care for Nonmembers? General Comments Network HMO contracts with several group practices (often primary care practices) for a capitated rate. Employed by own provider group. Yes Depends on terms of contract The group practices may make referrals but are financially responsible for reimbursing outside providers. HMO has less control over utilization due to greater number of contracts and ability of providers to subcontract. Providers may prefer additional autonomy, but also take on financial risk of providing primary and specialty care. Members may have a relatively greater choice of providers. IPA HMO contracts with IPA for a capitated rate. IPA is intermediary between HMO and solo practitioners and groups. IPA pays providers a capitated rate. Yes Depends on terms of contract HMO has reduced control over providers but may have less malpractice liability because IPA is an intermediary. HMO may contract with specialty physicians as needed and for hospital care on a prepaid or FFS basis. Providers may prefer contracting with IPA instead of HMO to retain more autonomy. Members may have greater choice of providers. Direct- contract HMO contracts directly with individual providers for a capitated rate. Self- employed. Yes Depends on terms of contract HMO has more leverage over providers because it contracts with them as individuals, but its administrative costs are much higher than having one contract or a few contracts with groups. Providers have less leverage regarding practice restrictions when contracting on an individual basis. Abbreviations: fee for service = FFS; HMO = health maintenance organization; IPA = individual practice association. TABLE 8-3 Key Characteristics of Common HMO Models (continued) 168 Chapter 8 Understanding Health I ft ft ft   fin fin fin ft Th Point-of-Service Plans eff fin Th ff The Future of Managed Care BOX 8-8 Discussion Questions Cost containment strategies embraced by MCOs were a direct result of the FFS experience with ever-increasing utilization and healthcare costs. However, many consumers and providers chafe at the restrictions imposed by MCOs and are concerned that someone other than the provider is making treatment decisions. Are these restrictions appropriate and necessary? Do you favor some of the restrictions over others? Is it appropriate for one entity to be responsible for both paying for and providing care? Should someone other than an MCO—say the federal or state governments—have primary responsibility for making determinations about service utilization? BOX 8-9 Discussion Questions In terms of containing healthcare costs and improving healthcare quality, do you think healthcare consumers and professionals need even more restrictions than are currently used in managed care? Are there any reasons to revert back to the FFS system, even knowing its inflationary qualities? If you think that managed care is not the answer to our still-rising healthcare costs and quality concerns, what other tools might help lower costs and improve the quality of care? Should any tools be imposed by government regulation or agreed to voluntarily by insurers and the insured? 169 fin ▸ Conclusion Thi References ff ff g Office efi ff efi liff fin difie ff fi fie ff A  Th Th 170 Chapter 8 Understanding Health I ▸ Endnotes Th fi fi fi fi 171 173 © Mary Terriberry/Shutterstock CHAPTER 9 Health Economics in a Health Policy Context LEARNING OBJECTIVES By the end of this chapter you will be able to: ■ Understand why it is important for health policymakers to be familiar with basic economic concepts ■ Understand how economists view decision making and options analysis ■ Describe the basic tenets of supply, demand, and markets ■ Understand how health insurance affects economic conditions ■ Apply economic concepts to health policy problems By the end of this chapter you will be able to: ■ Understand why it is important for health policymakers to be familiar with basic economic concepts ■ Understand how economists view decision making and options analysis ■ Describe the basic tenets of supply, demand, and markets ■ Understand how health insurance affects economic conditions ■ Apply economic concepts to health policy problems ▸ Introduction Thi ft eff efficien Th BOX 9-1 ■ ffici ff 174 Chapter 9 onomics in a Health P lifie ■ fl fl e fl Thi ff diff ▸ Health Economics Defined fir fir h fie How Economists View Decision Making ff Thi diff fin diff Utility Analysis BOX 9-1 Vignette Jaia is Governor Jara’s chief health policy analyst. Governor Jara is interested in improving the health status of residents in the state but is concerned about the impact any new initiative will have on the state’s economy. She asks Jaia to compare the economic consequences of three options: tax incentives for individuals to purchase exercise equipment or gym memberships, tax incentives for employers to offer wellness programs, and a mandate requiring that all stores selling food in the state provide fresh food and other healthy options. Fortunately, Jaia has a background in economics and knows that she needs to be concerned with basic principles of supply, demand, and market functions to help her governor make the best choice. This knowledge will lead her to ask questions such as: How big of a tax incentive is necessary to compel individuals or employers to act? Will tax incentives encourage behaviors, such as people joining a gym or employers offering wellness programs, that would not occur otherwise, or will the government simply be subsidizing transactions that would take place anyway? Is the problem that exercise options and healthy foods are not available and affordable, or are individuals simply making the choice not to engage in healthy behavior because they prefer to spend their time and money on other goods and activities? Will a mandate lead to the proliferation of healthy food stores or encourage stores to leave the state? The answers to these questions will help Jaia supply the governor with informed policy recommendations. efined 175 diff uff fir Thi ff Th ff efi Scarce Resources Th fini Th fin   ffs m efficien efficien ff ff Thi efficien o-efficien ft Th efficien ffi effici effici efficien efi efficien effi 176 Chapter 9 onomics in a Health P Th efficien ffs diff efi ft efficien Th fini ff fl ff ff Th efficien infl efficien efficien y diffic How Economists View Health Care mific ifies, efi 28  Th Th fie ▸ Economic Basics: Demand fir cifie Demand Changers 177 ■ ff ■ ■ diff sfies ■ Th hifts BOX 9-2 Discussion Questions Consider each of the following issues and discuss whether you support Theory X, Theory Y, neither theory, or some combination of them. Issue Theory X Theory Y Your view about how an individual’s health is determined Whether a person is healthy or sick is determined randomly. Whether a person is healthy or sick depends on lifestyle choices such as whether a person smokes, drinks, or wears a seatbelt. Your view of medical practice Medicine is a science, and experts will ultimately discover the best means for treating every illness. Medicine is an art and there will never be one best way to treat every illness because illnesses are often patient-specific and because there will always be a demand for lower-cost and less painful treatments. Your view of medical care Medical care is a unique commodity. Medical care is similar to any other good or service. Your view of the government’s role in health care Government regulations are necessary to protect this unique commodity, to control profiteering at the cost of patient care, to control resources spent on health care, and to improve information sharing. Government regulations are not necessary, technological advances and more services are desirable, and competition, not regulation, should drive the market. Source: From Musgrave, GL. Health economics outlook: two theories of health economics. Bus Econ. 1995;30:7–13. 178 Chapter 9 onomics in a Health P Th fi ffs fin fi Thi Elasticity hifts hifts Th Th Price Elasticity of Demand ft Thi Th Th 179 ft defin Th Income Elasticity of Demand eff Health Insurance and Demand ff uff ft efi eff Th fir ft ft ft efi Th 180 Chapter 9 onomics in a Health P Th fir ff ▸ Economic Basics: Supply ft ft ff Costs ff fin Th fin fin a diff diff ■ Th cific t y ■ Th Supply Changers ■ fi Thi ■ fi hift (fi ffice fie Profit Maximization fi 181 fi fi fi fie fi fi fi fi fi fi fi fin efi Th Th Th Th ft nific Health Insurance and Supply ff Thi fin fin fin fin Thi Th 182 Chapter 9 onomics in a Health P   ft diffic ▸ Economic Basics: Markets hifts hifts ff Health Insurance and Markets Th Th Th ft Thi diffic diffic ft ft t-eff Market Structure efficien fini cific Th fir TABLE 9-1 183 fir fir fir Market Failure efficien defin effi ff ff cific efficien efficien efficien efficien fi TABLE 9-1 Characteristics of Key Market Structures   Perfectly Competitive Monopoly Monopolistically Competitive Number of firms Many One (in a pure monopoly) Many Market share No dominant firms One firm has all market share and price and output. There may be many firms with market share and or a few dominant firms. Firms can set price because of product differentiation. Barriers to entry for new firms into market No Yes—absolute barriers; no new firms may enter market. Some barriers, due to differentiation of product, licensure, etc. Product differentiation No. Products are for each other. No. Only one product; no substitutes are available. Yes. Many products; they are not substitutes for each other (brand loyalty). Access to information and resources Consumers and producers have perfect information. One firm controls all information (asymmetric information). All firms have equal access to resources and technology unless there are a few dominant firms with more access to resources. Cost of transaction Consumers bear cost of consumption, and producers bear cost of production. Higher price to consumer because firm has ability to reduce quantity, retain excess profits. Blend of costs in perfectly competitive market and monopoly market. 184 Chapter 9 onomics in a Health P Public Goods efi efi efi diffic efi fie efi Th ff ff efficien defini efi efi efi fi fir Th efi Externalities ff efi Th ff e diff fin efi 185 Th Th efi efi efi Government Intervention efficien fin fin infl fin Th diff fin diff Th fin fi fin cific p fini Thi t-eff hift or  eff fix ft efi 186 Chapter 9 onomics in a Health P Thi eff fix fir ft Th fir fir Th Thi fi ■ ■ ■ hift ■ ft eff Thi in fie Redistribution of Income efficien BOX 9-3 Discussion Questions Some people argue that the government should not intervene in the case of a market failure because the government itself is inefficient and will simply create new problems to replace the ones it is trying to fix. In addition, critics contend that the government is usually less efficient than private sectors. Do you think the government is less efficient than the private sector? Does it depend on the issue involved? If you think it is inefficient in a particular area, does that lead you to recommend against government intervention, or is there a reason that you would still support government intervention? If you think the government should intervene, which intervention options do you prefer and why? 187 efi efi efficien et eff ▸ Conclusion Thi fie ff mific References lift : Th fi Th Th ▸ Endnotes fin 189 © Mary Terriberry/Shutterstock CHAPTER 10 Health Reform in the United States LEARNING OBJECTIVES By the end of this chapter you will be able to: ■ Describe previous national health reform attempts ■ Understand why national health reform has been difficult to achieve in the United States ■ Analyze why national health reform succeeded in 2010 when so many previous attempts had failed ■ Understand the key components of the Patient Protection and Affordable Care Act ■ Understand the core rulings of multiple U.S. Supreme Court decisions related to the Affordable Care Act ■ Evaluate the political climate regarding repealing and replacing the Affordable Care Act, and understand the main features of legislation drafted toward that end ■ Describe key issues going forward related to implementation of the Affordable Care Act By the end of this chapter you will be able to: ■ Describe previous national health reform attempts ■ Understand why national health reform has been difficult to achieve in the United States ■ Analyze why national health reform succeeded in 2010 when so many previous attempts had failed ■ Understand the key components of the Patient Protection and Affordable Care Act ■ Understand the core rulings of multiple U.S. Supreme Court decisions related to the Affordable Care Act ■ Evaluate the political climate regarding repealing and replacing the Affordable Care Act, and understand the main features of legislation drafted toward that end ■ Describe key issues going forward related to implementation of the Affordable Care Act ▸ Introduction ff ff 50  ffs eff Th BOX 10-1 diff ff le diff 190 Chapter 10 ed S lfi Th diffic Th diff Thi diffic Thr flexi fin definin fi ff efici ▸ Difficulty Achieving Health Reform in the United States Th Th diff ft Th BOX 10-1 Vignette A group of friends were talking about the ACA, illustrating the wide-ranging viewpoints about the law. Katherine, whose friend Sophia is struggling to make a living as an artist, is pleased that Sophia has health insurance for the first time since graduating from college. Although Sophia cannot stay on her parents’ insurance because she just turned 27 years old, she can now afford a good health insurance plan that she found on her state’s health exchange. While Katherine has not noticed much of a change in her own health insurance coverage, which she obtains through her government employer, her cousin Mia is upset about health reform. She does not want the government forcing her to purchase health insurance (although she always chose to be insured in the past), and she recently found out that her old plan was cancelled because it did not meet the law’s requirements. Mia found several new plan options to choose from, but none had her former plan’s exact combination of benefits, providers, and price. In addition, Katherine’s uncle, Ethan, is 55 years old and self-employed. He purchases his health insurance on his state’s exchange and because he has preexisting conditions, he is grateful to be able to find a plan. Even so, Ethan’s premiums will increase by 15% this year and his deductible is $5,000, making health care difficult to afford even with insurance. Katherine’s husband, Calvin, thinks we should all be willing to pay a little more or change some aspects of our plans to help the millions of people who can now afford insurance for the first time as a result of the ACA. After witnessing her uncle’s experience, however, Katherine is doubtful that the government will be able to keep its promises. ifficult 191 diffic nific Culture Thi Th Thi diff diffic efi Th fir fix U.S. Political System Th diffic diffic eff efficien 192 Chapter 10 ed S   m eff Th ft diffic ft defi Th eff Th ft left eff efi efi eff efi efi efi diffic nific infl Th ft diff Thi ft o diff Th uff diffic nfiden fi Th diffic eff fi fi Th ifficult 193 fin ft fi sfies Thi Interest Groups ft infl Th Th fi ofit Th cific ft infl ft Th ff Th diffic Thi Th Th eff nific Path Dependency Th Th Th Th m diffic 194 Chapter 10 ed S diffic efi ff diff Th ff ff Th Th Th ▸ Unsuccessful Attempts to Pass National Health Insurance Reform Th fir eff Th ft Th ft ft Thi efi efi efi Th fin Th Th efi efi ft efi fi efi efi eff ass National Health Insur 195 Th hift Th diffi nific ff Th Th Thi fig fin left ff fir Th Th hift r eff e 1970s. Th 196 Chapter 10 ed S diff fix Th nific iffi fir Thi Th Th fir fin efficien Th ft efi efi ift efi Th ft ff efi hift, ft Th hift efi defin efi Office w the A 197 Th efi efi diffic Th ▸ The Stars Align (Barely): How the ACA Became Law Th fin fin fin ff ff eff Thi eff eff diff Th et a diff eff Commitment and Leadership eff Th 198 Chapter 10 ed S ft fir ffice eff Office eff diff fir ff cific nific fi fi Th ffice Th fi eff eff ft eff fixin fin fini w the A 199 eff eff Lessons From Failed Health Reform Efforts Th eff eff ft ft fin fin ffice ft ffice ffi ft diff eff eff nific eff diff Th fin ft diff cifics. infl Th nific   200 Chapter 10 ed S cifics ft efi fin left ft fles eff ff defici Th eff eff Th Th ff Th eff Th ft diff diff fi fi ft diff left fi eff Th ft 201 Th Th ff Th fin Th diffic eff eff Political Pragmatism fin fl ▸ Overview of the ACA left ft fin ff fi Th ff 202 Chapter 10 ed S Th Th fir fin Thi Th Th Th Th fin d  Thi nific efi ff efi Th ft 203 eff eff Individual Mandate Thi ft eff BOX 10-2 flexi Source: Center on Budget and Policy Priorities, 2018. BOX 10-2 Select Trump Administration Executive Actions Relating to the ACA ■ Issued Executive Order ordering federal agencies to begin dismantling the ACA “to the maximum extent permitted by law” and to grant exemptions or delay implementation of ACA provisions that impose a tax, fee, or other costs (January 2017) ■ Issued an insurance regulation that made it more difficult for individuals to sign up for insurance during a special enrollment period, shortened the length of the enrollment period, lowered premium tax credits, made it easier for insurers to collect back premiums, and provided states more flexibility to define Essential Health Benefits (April 2017) ■ Ended contracts to navigators that provided one-on-one enrollment assistance to consumers, slashed funding for enrollment outreach efforts, and limited weekend access to online enrollment functions (July–August 2017) ■ Created an expanded option for employers who choose not to provide contraceptive coverage due to religious or moral reasons (October 2017) ■ Ceased cost-sharing reduction payments to insurers (October 2017) ■ Signed the Tax Cut and Jobs Act, which eliminated individual mandate penalties (December 2017) ■ Proposed Association Health Plan (AHP) rules that would allow these plans to offer insurance products that are exempt from many ACA provisions, such as the Essential Health Benefits provision and another one that limits the charging of higher premiums based on one’s age, gender, or occupation (January 2018) ■ Issued guidance allowing work requirements to be applied to Medicaid recipients. Approved Kentucky’s Medicaid waiver that includes work requirements, higher premiums, and coverage lockouts (January 2018) (Note that this waiver was subsequently vacated by a federal court and the question of whether states can mandate work requirements for Medicaid recipients is the subject of ongoing litigation.) ■ Proposed rules to extend short-term limited duration health plans (that do not need to meet many of the ACA’s requirements) from 3 months to 1 year (February 2018) ■ Filed a brief in Texas v. United States declining to defend the constitutionality of the ACA (June 2018) ■ Delayed risk-adjustment transfers that provide payments from insurers with low-risk pools to insurers with high-risk pools (July 2018) ■ Slashed the budget (again) for enrollment outreach and navigation efforts (July 2018) 204 Chapter 10 ed S diff ft eff Thi hift ff diffic ft fir ff ff ff lio et a Th eff Thi Th Th Thi Office Th eff fin nific fir 205 g et a Th Thi Th efi ff Th Th ax-fi Th fie efi efi ft Thi ff 206 Chapter 10 ed S Thi State Health Insurance Exchanges/ Marketplaces Th Th efi Th Th eff efi Th lifie fin efficien eff ff efi Th Office   Thi nific diff hift Th ff ft ffs Th ff defin cifie fi BOX 10-3 Discussion Questions Are there alternatives to the individual mandate that accomplish the same goals without engendering so much political turmoil? Could policymakers have designed an incentive system that would be as effective as a mandate? What are the pros and cons of using a mandate versus an incentive? Can you think of incentives to encourage enrollment that have occurred in other parts of the healthcare system? 207 Office ff Th Th efi Th efi fi efi   et  ff diffic Th ffici Essential Health Benefit Requirement lifie ff efi efi BOX 10-5 Thi fir efi ff Th efi efi efi left nific 208 Chapter 10 ed S Th efi et  ff ft efi Th defi eff fi Th Source: Data from: McDermott Will & Emery. Challenges facing “narrow” provider networks on the ACA health insurance exchanges. http://www.mwe.com /files/Uploads/Documents/News /Challengs-Facing-Narrow-Provider-Networks . Published April 20, 2015. Accessed July 7, 2015. BOX 10-4 Provider Networks An emerging policy and care delivery issue has been the question of whether provider networks available in plans offered in the exchanges are adequate. Prior to the ACA, insurers could control costs through a variety of mechanisms, including limiting benefits, excluding consumers with preexisting conditions, and using medical underwriting to charge higher premiums to higher-risk individuals and groups. Plans would compete with each other based on price, benefits, cost-sharing, and other features. The ACA includes a variety of rules that eliminate these options, such as prohibition of exclusions based on preexisting conditions, guaranteed issue requirements, community rating requirements, essential health benefit requirements, and actuarial tiering of plans. As a result of ACA restrictions, many plans are trying to control costs by limiting provider networks and/or provider reimbursement. Of course, some providers may choose not to participate in exchange plans if the reimbursement is not sufficient. Many consumers who purchase plans in an exchange choose plans based on the premium price and indicate they would prefer cheaper plans with narrow networks as opposed to expensive plans with broader networks. On the other hand, consumers who purchase plans through employer-sponsored insurance often prefer broader networks, even if the coverage is more expensive. Complaints about narrow networks range from consumers being disappointed that their usual doctor or local hospital is not in network, to questions about access to care, network transparency, and quality of care. Several lawsuits have been filed against plans regarding network transparency and provider terminations. In 2014 the Office of the Insurance Commissioner issued federal rules regarding network adequacy in individual and small-group plans, and CMS continues to issue guidance regarding network adequacy for qualified health plans. State responses to network adequacy concerns have spanned the gamut, from Massachusetts requiring plans to develop tiered and narrow networks to promote cost savings, to several failed attempts by state legislatures to pass “any willing provider” laws that require insurers to include any provider willing to accept the insurers’ terms. BOX 10-5 Essential Health Benefits All plans in the state exchanges must offer the following benefits: ■ Ambulatory patient services ■ Emergency services ■ Hospitalization ■ Maternity and newborn care ■ Mental health services and substance use disorder services, including behavioral health treatment ■ Prescription drugs ■ Rehabilitative and habilitative services and devices (rehabilitative therapies improve, maintain, or prevent deterioration of functions that have been acquired [e.g., after an adult has surgery], whereas habilitative therapies are provided to achieve functions and skills never acquired [e.g., as with a developmentally disabled child]) ■ Laboratory services ■ Prevention and wellness services and chronic disease management services ■ Pediatric services, including vision and dental services 209 Th   Th efi Th efi efi efi efi diff et  diff efi et  fin s flexi efi defini nifi defini defini defin efi et  defini diff efi efi efi efi diffic nific ff Th cific ifie Th Th Th 210 Chapter 10 ed S nific 11  ff ff fin Th ff Th ff ff Th Premium and Cost-Sharing Subsidies diff ff efi Th ffs Th ff Th ff Th eff BOX 10-6 Discussion Questions There was a lengthy debate about whether to include a public option in health reform. A public option is some type of government-run health plan that would be available to compete with private plans. A public option could exist within the health exchange model or outside of it. Instead of a public option, Congress voted to require the Office of Personnel Management, which runs the Federal Employees Health Benefit Program, to contract with at least two multistate plans in every state health insurance exchange. What are the pros and cons of having a public option? Does the Office of Personnel Management compromise achieve all or some of the goals of having a public option? Why do you believe the Office of Personnel Management compromise was acceptable to legislators but the public option was not? 211 ff ff efi (Office Th Th TABLE 10-1 Th diff efle TABLE 10-2 Th 6  lifie Th fir iffs Th ft TABLE 10-1 Premium Tax Credit Schedule Income Level by Federal Poverty Level (FPL) Premium as a Percentage of Income 100–133% FPL 2% of income 133–150% FPL 3–4% of income 150–200% FPL 4–6.3% of income 200–250% FPL 6.3–8.05% of income 250–300% FPL 8.05–9.5% of income 300–400% FPL 9.5% of income TABLE 10-2 Cost-Sharing Subsidy Schedule Income Level by Federal Poverty Level (FPL) Actuarial Value 100–150% FPL 94% 150–200% FPL 87% 200–250% FPL 73% 212 Chapter 10 ed S Th fi Th ff et  TABLE 10-3 Th Th Th The  flo ft fir ff [Th TABLE 10-3 Out-of-Pocket Spending Limits Income Level by Federal Poverty Level (FPL) Out-of-Pocket Limit 100–200% FPL 2/3 of maximum 200–300% FPL 1/2 of maximum 300–400% FPL 1/3 of maximum BOX 10-7 Discussion Questions CBO estimates that premium subsidies and CSRs will cost the federal government $760 billion over the years 2019–2028 (CBO, 2018). Is this a good use of resources? Are these subsidies well designed? Are they sufficient to make health insurance affordable? Do they cover people with incomes that are too high? Should they cover more people? 213 diff Th nific left Thi Th mific eff diffic Employer Mandate lifies ff ff Th ff ff Th ff Th Th ff ff fi ff hift ff ft fir × ff ff ff ff fir Th ff ff × × × ft ff Th s. Th 214 Chapter 10 ed S fir infl ffs eff et  et  Th nific efi g et a Changes to the Private Insurance Market Th efi fi left Th eff ■ ■ ■ ■ ■ ■ eff Th Th efi defini 43  Th fin fi eff nific efi Thi Th nific ■ 215 ■ ■ ■ fi fi ■ ff Th ff ff nific Th Th efi nific efi ff Th efi Financing Health Reform fin fin Th in fin ■ Thi ■ ■ ■ efici ■ ■ Thi Th eff ■ ■ ifie 216 Chapter 10 ed S ■ ■ eff fir Thir diff left fin Public Health, Workforce, Prevention, and Quality Th Th ffs Th hift et  eff Th eff eff BOX 10-8 Discussion Questions The ACA includes a tax on insurers for more generous health plans. Because it is likely insurers will pass on the cost of the tax to consumers, the idea behind the tax is to provide incentives for people to choose lower-cost plans. In theory, the less money employers spend on healthcare costs (and other fringe benefits), the more they will spend on wages. The income tax paid for by workers on their higher wages will provide revenue that can be used to pay for health reform. In addition, people may be less likely to obtain unnecessary care if fewer services are covered by their plan or if cost-sharing is higher. Is it likely that employers will trade lower benefits for higher wages? Are there times or industries where this trade-off is more or less likely to occur? In 2017 the average cost of premiums for an employer plan was $6,690 for single coverage and $18,764 for family coverage (KFF & HRET, 2017, Section 1). Beginning in 2020, plans that exceed $10,800 for individual coverage and $29,050 for family coverage are taxed. Congress rejected lower thresholds for the tax ($8,500/$23,000) that would have raised an estimated $149 billion. Did Congress pick the right thresholds for the tax? Should they be higher or lower? Why did Congress delay implementation of the tax until 2020? What are the pros and cons to having the tax start well after the main provisions of health reform are in place? 217. S Th eff Th fin Th ▸ The U.S. Supreme Court’s Decision in the Case of National Federation of Independent Business v. Sebelius fir t  Th defie Th fir eff Sources: United States Preventive Services Taskforce. (2016, January). Breast cancer: Screening. Retrieved from https://www.uspreventiveservicestaskforce.org/Page /Document/UpdateSummaryFinal/breast-cancer-screening1?ds=1&s=breast%20cancer; American College of Obstetricians and Gynecologists. (2016, January 11). ACOG statement on breast cancer screening guidelines. Retrieved from https://www.acog.org/About -ACOG/News-Room/Statements/2016/ACOG-Statement-on-Breast-Cancer-Screening -Guidelines; American Cancer Society (n.d.). American Cancer Society guidelines for the early detection of cancer. Retrieved July 19, 2018 from https://www.cancer.org/healthy /find-cancer-early/cancer-screening-guidelines/american-cancer-society-guidelines-for -the-early-detection-of-cancer.html BOX 10-9 Discussion Questions There is a debate about the proper age at which to start regular mammogram screenings to detect breast cancer in women who do not have specific risk factors for the disease. As of 2009, the U.S. Preventive Services Task Force recommends waiting until age 50 years to begin mammogram screening for breast cancer and further recommends that screening should occur every 2 years. It also stated, however, that the final decision about the initial timing and frequency of breast cancer screening should be made by the patient and her physician. In making its recommendations, the Task Force found that physicians would need to screen 1,000 women to save 1 woman’s life and concluded that earlier and/or more frequent screening was not worth the harm associated with false positives (anxiety, unnecessary biopsies, overtreatment). Other organizations disagree with the U.S. Preventive Services Task Force and conclude that the lifesaving effects of more routine mammogram screening outweigh the potential harm. Thus, the American Cancer Society recommends having routine annual mammograms from age 45 to 54 years (or 40 if the patient so chooses) and then every 2 years thereafter. The American College of Obstetricians and Gynecologists recommends starting annual mammograms at age 40 years. The idea of comparative effectiveness research is to provide information about the value of different tools. Once that information is available, however, who should make the decisions about whether to provide coverage and reimbursement for a particular good or service? Can one objectively assess the potential harms and benefits associated with mammograms or other services or medications? Should decisions be made solely by the patient and treating provider? Does it matter if decisions affect taxpayers (for example, if a patient is covered by a government program such as Medicare or the Veterans Administration)? 218 Chapter 10 ed S Th ff Th Th Th ff fin   eff Thi fin Th Th Th nific ff ff Thi eff ▸ States and Health Reform left 219 nific eff Th nific mific nific Thi eff fie Th efici Th Th ff Th efle fie Th defini left-le flo efici ▸ Key Issues Going Forward eff t eff ft nific 220 Chapter 10 ed S Congressional Activity Th ft fie eff Th ff ft ft Th ft ufficien Th (eff Thi ffice Th ft Th Th ufficien TABLE 10-4 eff nific nific defici fin eff 221 TABLE 10-4 Comparison of U.S. House and Senate Bills Designed to Replace the Affordable Care Act   American Health Care Act (House) Better Care Reconciliation Act (Senate) Premium tax credits Replaces with tax credits based on age only, not income or geographic area Keeps tax credits, lowers eligibility to 350% FPL, includes those under 100% FPL, tied to less expensive benchmark, changes individual contribution levels so older consumers pay more Individual mandate Eliminates penalties, replaces with 1-year 30% premium surcharge if lapse in coverage Eliminates penalties, replaces with 6-month waiting period if lapse in coverage Employer mandate Eliminates penalties Eliminates penalties Medicaid expansion Phases out at end of 2019 Phases out by end of 2024 ACA taxes Eliminates most key taxes Eliminates many key taxes, keeps Medicare surtax and investment tax on high-income earners Essential health benefits Allows state waivers to redefine Allows state waivers to redefine Medicaid program Changes to block grant or per- capita allotment in 2020, allows work requirements Changes to block grant or per-capita allotment in 2020, allows work requirements CSR funds Funds through 2019, repeals in 2020 Funds through 2019, repeals in 2020 Women’s health services Defunds Planned Parenthood for 1 year; redefines qualified plan to exclude plans that provide abortion services except for rape, incest, or life of mother in danger Defunds Planned Parenthood for 1 year; redefines qualified plan to exclude plans that provide abortion services except for rape, incest, or life of mother in danger Private market rules Keeps guaranteed issue, dependent coverage until 26; keeps preexisting condition protection Keeps guaranteed issue, dependent coverage until 26; keeps preexisting condition protection; permits sale of noncompliant plans as long as selling one ACA-compliant plan State stabilization pool Provides $123 billion over 9 years Provides $182 billion over 9 years Public health prevention fund Eliminates Eliminates Age rating band Changes to 5-to-1 but allows for state variation Changes to 5-to-1 but allows for state variation CBO estimate—uninsured 23 million more uninsured by 2026 22 million more uninsured by 2026 CBO estimate— federal savings $119 billion $321 billion ACA = Affordable Care Act; CBO = Congressional Budget Office; FPL = federal poverty level. 222 Chapter 10 ed S ufficien mific et  et  ft eff fixin Th definin ific Th ffs Th diffic diffic efi fir Thi Thi Th diffic ft fi Thi lifie fin mific Insurance Plan Premium Rates ff 223 ft Th eff infl ff efi fi Th Thi Th nflic fin Thi diffic eff Th fin Th eff ff Th 224 Chapter 10 ed S diffic Th ACA Litigation fixt Th iffs fi nific iff Th ft ffs ft ff Th fi ft t a defini fin ff fi fi ft ufficien diff Th fir eff fin Th fin diff fi 225 References ff ff ff Th ffor fi iefin ff fie Th eff fin d-fin Th Th fi iffs, iffs diffic ▸ Conclusion ft ff ff Th 226 Chapter 10 ed S Th ffic Th Th Th   eff fi e-fig Office Office Office ff Office em/files?fi Office Th eff fi ffor e-fi ff ff l-fin Th ff 227 ff fie The ff ps://fi g/fi ff efi ff efi Th Th ff efi ffa ffa eff ffa ft   ff ff l-fin fi -fin ff 228 Chapter 10 ed S ff l-fin Th ff Th ff ff efi ff efi ff ff ff ff ffa ffa ffa fi ffa t. 2480 (2015). eff ff l-fin n-eff fi o-fi ff ff eff 229 fi ff ff Office ff Th ff Th ff l-in-eff ff ff ff Th Th efi Th efi iefin Office g Office Th C: Office o Office Th C: Office o ffa © Mary Terriberry/Shutterstock CHAPTER 11 Government Health Insurance Programs: Medicaid, CHIP, and Medicare LEARNING OBJECTIVES By the end of this chapter you will be able to: ■ Describe the basic structure, administration, financing, and eligibility rules for: Medicaid The Children’s Health Insurance Program (CHIP) Medicare ■ Understand how the Patient Protection and Affordable Care Act alters Medicaid, CHIP, and Medicare ■ Discuss key health policy questions and themes relating to each of these public programs By the end of this chapter you will be able to: ■ Describe the basic structure, administration, financing, and eligibility rules for: Medicaid The Children’s Health Insurance Program (CHIP) Medicare ■ Understand how the Patient Protection and Affordable Care Act alters Medicaid, CHIP, and Medicare ■ Discuss key health policy questions and themes relating to each of these public programs BOX 11-1 Vignette Governor Jadyn is in a quandary. She believes everyone should have access to health care and would like to support state policies that make care accessible and affordable. While she supported President Obama’s goal of reducing the number of uninsured, she is concerned that some of the provisions in the Patient Protection and Affordable Care Act are too burdensome on the states, particularly in a fragile economy. The governor wonders how her state can afford the mandated Medicaid expansion when the recent trend has been to cut services across the board. How will state agencies cope with their new responsibilities when positions are being defunded and employees are being furloughed? Should she spend her state’s time and resources to establish a health insurance exchange when the federal government will step in if she does not act? At the same time, does she want to leave decisions about how the exchange will be operated in her state to bureaucrats in Washington, DC? 231 ▸ Introduction nifi fin flexi ff ff fi Th efici diff Th infl ft Th fin Th nific efi fin efi efici o diff cific Thi flexi fin definin fi ff efici diff efi efici Th 232 Chapter 11 fi ft defin ft efi fin Th fi fini ▸ Medicaid efi fin efici Program Administration Th defin Th fi efi eff efici Th Th h  efi efi efi flo nific flexi efi efi ff efi ft diff diff efi BOX 11-2 Discussion Questions Do you think it makes more sense to structure government healthcare programs as entitlements or block grants? What are the economic and healthcare risks and benefits of each approach? Does your answer depend on who is paying for the program? Who the program serves? What kinds of benefits the program provides? Do you think various stakeholders would answer these questions differently? How might the answers change if you ask a member of the federal government, a governor, a state legislator, an advocate, or a tax-paying citizen who is not eligible for benefits under the program? 233 Kaiser Family Foundation, Distribution of the non-elderly with Medicaid by Race/Ethnicity, 2016. Total Medicaid enrollees: 58.9 million White 43% Hispanic 30% Black 18% Other 9% Source: Kaiser Family Foundation, Distribution of the non-elderly with Medicaid by race/ethnicity, 2016. Retrieved from https:// www.kff.org/medicaid/state-indicator/distribution-by-raceethnicity-4/?currentTimeframe=0&selectedDistributions =white--black--hispanic--other&selectedRows=%7B%22wrapups%22:%7B%22united-states%22:%7B%7D%7D%7D&sort Model=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D Nonelderly below 100% FPL 55% 40% 38% 76% 17% 49% 20% 45% 42% 62% Percentage with Medicaid Coverage Nonelderly between 100% and 199% FPL All children Children below 100% FPL Parents Births (pregnant women) Medicare beneficiaries Elderly and people with disabilities Families Nonelderly adults with a disability Nonelderly adults with HIV in regular care Nursing home residents Note: FPL = Federal Poverty Level. The U.S. Census Bureau’s poverty threshold for a family with two adults and one child was $19,318 in 2016. Source: KFF Analysis of 2017 Current Population Survey, Annual Social and Economic Supplement; Birth data - Implementing Coverage and Payment Initiatives: results from a 50-State Medicaid Budget Survey for State Fiscal Years 2016 and 2017, KFF, October 2016.; Medicare data - Medicare Payment Advisory Commission, Data Book: Beneficiaries Dually Eligible for Medicare and Medicaid (January 2018); 2013 data. Disability - KFF Analysis of 2016 ACS; Nonelderly with HIV - 2014 CDC MMP; Nursing Home Residents - 2015 OSCAR/ CASPER data. Retrieved from https://kaiserfamilyfoundation.files.wordpress.com/2015/05/medicaid_s-role-for-selected-populations Eligibility efici fie efi efi FIGURE 11-1 efi efici FIGURE 11-2 BOX 11-3 Discussion Questions What are the benefits and drawbacks of having a health program that varies by state versus having one that is uniform across the country? Do you find that the positives of state flexibility outweigh the negatives, or vice versa? Does your analysis change depending on what populations are served? Does your analysis change depending on whose point of view you consider? Is it fair that similarly situated individuals may be treated differently in different states? Does this occur in other aspects of society? FIGURE 11-1 Medicaid Beneficiaries by Race/Ethnicity, 2016 FIGURE 11-2 Medicaid Plays a Key Role for Selected Populations, 2017 234 Chapter 11 BOX 11-4 et  left nific Traditional Medicaid Eligibility Requirements fin efi diff diff fiv fi efi TABLE 11-1 Th   efici Th   Medically Needy Th fi BOX 11-4 Federal Poverty Level Federal poverty guidelines are determined annually and calculated based on the number of individuals in a family. The guidelines are commonly referred to as the federal poverty level, but the U.S. Department of Health and Human Services (HHS) discourages the use of this term because the Census Bureau also calculates, using different methods, a figure referred to as the federal poverty thresholds. However, because the term federal poverty level is still commonly used when discussing eligibility for federal and state programs, we use it here. The poverty guidelines are somewhat higher for Alaska and Hawaii due to administrative procedures adopted by the Office of Economic Opportunity. 235 efici lifie Th lifie ft ft ft TABLE 11-1 Select Medicaid Mandatory and Optional Eligibility Groups and Income Requirements Prior to ACA Eligibility Category Mandatory Coverage Optional Coverage Infants <1 year ≤133% FPL ≤185% FPL Children 1–5 years ≤133% FPL >133% FPL

Children 6–19 years ≤100% FPL >100% FPL

Pregnant women ≤133% FPL ≤185% FPL

Parents Below state’s 1996 AFDC limit May use income level above

state’s 1996 AFDC limit

Parents in welfare-to-work families ≤185% FPL

Older adults and disabled SSI beneficiaries SSI limits Above SSI limits, below 100% FPL

Certain working disabled May not exceed specified

amount

Variable, SSI level to 250% FPL

Older adults—Medicare assistance onlya Variable, up to 175% FPL Variable up to 175% FPL

Nursing home residents Above SSI limits, below 300% SSI

Medically needy “Spend down” medical expenses

to state-set income level

aMedicare assistance only = payment for Medicare cost-sharing requirements.

Abbreviations: AFDC = Aid to Families With Dependent Children; FPL = federal poverty level; SSI = Supplemental Security Income (a federal program that provides cash assistance to older adults

and individuals who are blind or disabled who meet certain income and resource requirements).

236 Chapter 11

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Under the ACA

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BOX 11-5 Discussion Questions

Does the medically needy category make sense to

you? Do you think it is a good idea to discount medical

expenses of high-need individuals so they can access

the healthcare services they need through Medicaid?

If so, is the process described above cumbersome and

likely to result in people being on and off Medicaid

(and therefore likely on and off treatment) because

their eligibility is based on their spending patterns?

Why should individuals with high medical needs have

an avenue to Medicaid eligibility that is not available

to other low-income people who have other high

expenses, such as child care or transportation costs?

Would it make more sense to simply raise the eligibility

level for Medicaid so more low-income people are

eligible for the program? Politically, which option

would likely have more support? Does your view

about the medically needy category vary depending

on your primary decision-making goal (e.g., fiscal

restraint, equity, improved health outcomes)?

237

 

fi

flexi

ft

fie

Benefits
efi

efi

Traditional Medicaid Benefits
ff

efi

BOX 11-6 Discussion Questions

Looking at Medicaid’s traditional eligibility rules, you

notice numerous value/policy judgments: pregnant

women and children are favored over childless adults,

the medically needy are favored over other low-

income individuals with high costs, non-immigrants

are favored over immigrants. Under the ACA expansion,

these distinctions mostly disappear and eligibility

depends purely on income level in the case of the

biggest expansion group. Which approach do you

prefer? If the ACA approach were expanded beyond

133% of FPL, the costs of the Medicaid program would

soar. Given limited resources, do you think it would be

better to cover more people at a higher poverty level

across the board or continue to favor some groups

over others through the categorical requirement?

Should we decide that, for some populations, the

government should step in and provide coverage

regardless of the cost? In other words, is there a point

where equity trumps financial constraints?

BOX 11-7 Discussion Questions

What are the implications of a two-tiered Medicaid

system? Is there justification for offering some

beneficiaries a less generous benefit package than

others? Is it fair to impose additional requirements

(categorical, asset test) on only some beneficiaries? Why

do you think policymakers created these distinctions?

Do you think they will remain in place over time?

238 Chapter 11

left TABLE 11-2

defin

TABLE 11-2 Traditional Medicaid Benefits

Mandatory Optional

Acute Care Benefits

Physician services

Laboratory and X-ray services

Inpatient hospital services

Outpatient hospital services

Early and periodic screening, diagnostic, and treatment

services (EPSDT) for beneficiaries <21 years Family planning services and supplies Federally qualified health center (FQHC) services Rural health clinic services Nurse–midwife services Certified pediatric and family nurse practitioner services Non-emergency transportation to medical care Prescription drugs Medical care or remedial care furnished by nonphysician licensed practitioners Rehabilitation and other therapies Clinic services Dental services, including dentures Prosthetic devices, eyeglasses, and durable medical equipment Primary care case management Tuberculosis-related services Other specified medical or remedial care Long-Term Care Benefits Nursing facility services for individuals ≥21 years Home healthcare services for individuals entitled to nursing facility care Intermediate care facility services for the mentally retarded (ICF/MR) Inpatient/nursing facility services for individuals ≥65 years in an institution for mental disease Inpatient psychiatric hospital services for individuals <21 years Home- and community-based waiver services Other home health care Targeted case management Respiratory care services for ventilator-dependent individuals Personal care services Hospice services Services furnished under a Program of All-Inclusive Care for the Elderly (PACE) New Benefits in ACA Tobacco cessation program for pregnant women Freestanding birth centers New state option for community-based care New state option for home health care New state option for family planning services Source: 42 U.S.C. 1396d; 42 CFR Parts 430–498. 239 efici efi ff efi efi ff The diff ft cific Benefits for Expansion Population Under the ACA efi efi Th efici BOX 11-8 ifie Th n (eff efi fici ifie ff Th BOX 11-8 Benchmark Benefit Options Federal Employee Health Benefits Plan State employee health plan Largest commercial non-Medicaid HMO in the state HHS secretary-approved plan Full actuarial value for the following services: ■ Inpatient and outpatient hospital ■ Physician (surgical and medical) ■ Laboratory and X-ray ■ Well-baby and well-child ■ Other appropriate preventive services (defined by HHS secretary) 75% actuarial value for the following services: ■ Prescription drugs ■ Mental heath ■ Vision ■ Hearing ff The 2017 essential health benefit (EHB) benchmark plan from any state An existing state benchmark with one or more EHB categories replaced by a benchmark from another state A new benchmark that meets the “typical employer plan” requirement Note: States must wrap around EPSDT coverage as necessary. 240 Chapter 11 Th diffic efi Th Th efi efi Th efici efi efi Th efi ff Th efi   lifie nific efici efici efi BOX  11-9 efi et a Amount, Duration, and Scope, and Reasonableness Requirements flexi efi Th efici fin BOX 11-9 Alternative Benefit Plan (Section 1973 Plan) Requirements ■ Align with an approved benchmark or benchmark equivalent ■ Provide EHBs ■ Include EPSDT to children up to age 21 years ■ Cover federally qualified health center/rural healthcare services ■ Cover non-emergency transportation to medical care ■ Cover family planning services and supplies ■ Comply with mental health parity law ■ Comply with traditional Medicaid cost-sharing rules ■ Do not cover care for beneficiaries in institutions for mental diseases ■ Exempt certain medically frail populations from benefit limits 241 TABLE 11-3 ifies Medicaid Spending FIGURE 11-3 TABLE 11-3 “Reasonableness” and “Amount, Duration, and Scope” Requirements in Medicaid Requirement Requirement Purpose Section 1937 Changes to the Requirement Reasonableness State must provide all services to categorically needy beneficiaries in sufficient amount, duration, and scope to achieve its purpose. States have to meet only amount, duration, and scope requirements found in the named benchmark or benchmark- equivalent plan. Comparability All categorically needy beneficiaries in the state are entitled to receive the same benefit package in content, amount, duration, and scope. States may apply benchmark or benchmark-equivalent packages to some, but not all, populations. Statewideness In most cases, states must provide same benefit package in all parts of the state. States may apply benchmark or benchmark-equivalent packages to some, but not all, populations. Nondiscrimination States may not discriminate against a beneficiary based on diagnosis, illness, or type of condition by limiting or denying a mandatory service. DRA does not include language changing Medicaid nondiscrimination rules, and ACA includes nondiscrimination protections regarding age, expected life span, diagnosis, disability, medical dependency, quality of life, or other health condition (42 CFR 440.347(e)). BOX 11-10 Discussion Questions The DRA also included new rules on citizenship verification. Prior to the DRA, all but four states allowed beneficiaries to self-attest to their citizenship status. Under the DRA, Medicaid and CHIP applicants now have to prove their citizenship status by providing original or certified copies of citizenship documents, such as a U.S. passport, state-issued driver’s license, or birth certificate. The exact requirements depend on what type of document is submitted. Subsequent laws eased this burden by giving states the option to conduct a data match with the Social Security Administration’s database to verify citizenship. Under the ACA, the matching system must be used to verify citizenship for individuals purchasing insurance in an exchange. These rules were intended to ensure that only eligible beneficiaries received Medicaid benefits. Many individuals have had difficulty obtaining access to these documents and as a result were dropped from the program despite being eligible. Do you think these rules are a good idea? Do you think this requirement is a reasonable burden? Does it matter that evidence was not available to support the claim that noncitizens or ineligible immigrants were accessing Medicaid benefits? Or, is the possibility that ineligible immigrants might enroll in Medicaid concerning enough to warrant the new documentation requirements? 242 Chapter 11 Source: Spending and enrollment estimates for FY2015 from the Congressional Budget Office’s March 2016 Medicaid baseline. Center on Budget and Policy Priorities. Retrieved from cbpp.org. Source: Data from Medicaid and CHIP Payment and Access Commission. (2017, December). MACSTATS: Medicaid and CHIP data book. Retrieved from https://www.macpac.gov/wp-content/uploads/2015/12/MACStats-Medicaid-CHIP-Data-Book-December-2017 Medicaid enrollment Medicaid spending Aged 8% Adults 36% Blind and disabled 13% Aged 14% Adults 32% Blind and disabled 34%Children 43% Children 19% To ta l ex pe nd itu re s Hos pit al ca re Phy sic ian / cli nic al se rv ice s Hom e he alt h ca re Nur sin g ho m e Pre sc rip tio n dr ug s 17% 17.9%77 11% 36.1% 31.7% 9.8% 0 5 10 15 20 25 30 35 40 efici e-fift FIGURE 11-4 nific efi Th Medicaid Financing Th fin fie fin Th Th FIGURE 11-3 Enrollment and Spending in Medicaid FIGURE 11-4 Medicaid Percentage of National Spending by Type of Service, 2016 243 fin fici Th Th efici efici efici efi fin   fin Th f-eff Thi Th nific defici Medicaid Provider Reimbursement BOX 11-11 Discussion Questions States have enormous flexibility in designing their Medicaid programs. States spend significant resources on optional services or mandatory services for optional populations. Yet, states complain that Medicaid expenditures are unsustainable and that significant reform, such as the DRA and expanded waiver options, are needed. If states have the ability to reduce Medicaid spending without any reforms, why do you think state politicians are focused on reforming the program? Why might states choose not to reduce their Medicaid program to cover only mandatory services and populations? Politically, what do you think is the most feasible way for states to reduce their Medicaid budgets? BOX 11-12 Discussion Questions What do you think of the MOE requirements? Is it fair for the federal government to impose new eligibility rules on states when the states are ultimately responsible for the cost of providing services? Does such a requirement violate a fundamental element of Medicaid to permit state flexibility? On the other hand, without an MOE requirement, wouldn’t many states simply reduce their eligibility rules, thwarting the intent of Congress to reduce the number of uninsured by expanding Medicaid coverage? Does the budget deficit exception undermine the rule? 244 Chapter 11 FFS Reimbursement ufficien Th Th et  diff ifie Th eff eff nific ft efficien cifie diffic diff nific fie nific Th eff Managed Care Reimbursement efici FIGURE 11-5 Th efici efici efici efici fin 245 AK HI WA ID MT WY CO ND MN IA MO AR LA MS AL GA FL PR NJ DE MD DC SC NCTN KY INIL WI MI OH PA WV VA NY ME VT NH MA CT RI SD NE KS OK TX NMAZ UTNV OR CA Note: Comprehensive managed care includes risk-based managed care organizations (MCOs) and Programs of All-inclusive Care for the Elderly (PACE). 0 (5 states) 51–65% (5 states) 81–100% (16 states, including PR) >0–50% (11 states)

66–80% (15 states,
including DC)

U.S Overall = 68.1%

Source: Medicaid.gov. (2018). Medicaid managed care enrollment and program characteristics, 2016. Retrieved from https://www.medicaid.gov/medicaid/managed-care/downloads/enrollment/2016-medicaid-managed-care-enrollment-report

efici

defin

diffic

Th

efici

FIGURE 11-5 State Comprehensive Managed Care Penetration as of July 1, 2016

BOX 11-13 Discussion Questions

Is higher Medicaid cost sharing a good idea? What are

the strongest arguments you can make for and against

higher cost sharing? Should Medicaid beneficiaries have

the same cost-sharing responsibilities as privately insured

individuals, or should the government bear more of the

cost because Medicaid beneficiaries are low-income

individuals? What is the primary decision-making goal

that led to the exclusion of so many populations and

services from the new cost-sharing options?

BOX 11-14 Discussion Questions

Who should determine Medicaid provider

reimbursement rates, and how should they compare

to other insurance programs or plans? Should the

federal government play a stronger role in setting

provider rates? Is this an area where it is better to

have state variation or national uniformity? Should

the federal or state governments be required to

ensure that Medicaid reimbursement rates match

private insurance reimbursement rates? What might

occur if poorer states were required to provide

higher reimbursement rates? What is the risk if

reimbursement rates are very low?

246 Chapter 11

Medicaid Waivers

flexi

flexi Th
diff

Th

Thi defin

Th

ff

efici

efficien efici

Th definin

The 

efici

efici

Th

ff
Th

BOX 11-15 Discussion Questions

Should states be allowed to impose work requirements

as a condition for receiving Medicaid benefits? Do

work requirements promote independence and

upward mobility, and, if so, are those two goals

legitimate objectives of the Medicaid program? Are

work requirements unnecessary barriers to care?

Those who oppose work requirements argue that

they do not further the objective of the program,

which is to provide coverage to those who cannot

afford it. As a practical matter, most beneficiaries

are already working, and most of those who are not

working are in poor health or disabled, are acting as

caregivers, or are students. Many of the nonworkers

would be exempt even under the recently approved

waivers. In addition, work requirements create

extensive administrative obligations for beneficiaries

and administrators alike. Of the 1 to 4 million

beneficiaries estimated to lose coverage if work

requirements are imposed broadly, most would be

disenrolled due to lack of reporting.

Those who support requirements contend that

everyone who can work should be working, both to

reduce the burden on the Medicaid program and to

support personal upward mobility. According to this

view, the ultimate goal should be to wean people off

of Medicaid and promote work requirements. Some

states with Republican legislatures, such as Virginia,

would not support expanding Medicaid under the

ACA without work requirements.

Do you support work requirements? Even if you

oppose work requirements, is it better to expand

coverage with work requirements than to not expand

coverage at all?

247

Th

cific

Th diff

efi

efi

efi
ft ff

The Future of Medicaid

defici
diff

nifi

eff
eff

diff

efi cific

efi

ff

fie Th

▸ Children’s Health
Insurance Program

difie

BOX 11-16 Discussion Questions

What type of Medicaid reform, if any, do you support?

Should Medicaid beneficiaries be treated like privately

insured individuals, meaning increased cost-sharing

requirements, fewer legal protections, and fewer

guaranteed benefits than in the current Medicaid

program? Is it fair to provide a more generous package

of benefits to publicly insured individuals than most

privately insured people receive? Can the country

afford a more generous Medicaid program? Can it

afford not to provide adequate health insurance and

access to care for the poor and near poor? Is it best

to let states experiment with new ideas? If you could

design a new Medicaid program, what would be your

primary decision-making goal?

248 Chapter 11

fir ffice

Th
fi


ft

 2018.

CHIP Structure and Financing

Th nific

Th

 
Th

ft

Th

cific

efle

Th

Thi fig

flo Th

TABLE 11-4 diff

diff

Th

efi
efici

249

CHIP Eligibility

Th
Th

TABLE 11-4 Comparing Key Features of Medicaid and CHIP

Feature Medicaid CHIP

Structure Entitlement Block grant

Financing Federal–state match Federal–state match at higher rate than

Medicaid

Use of funds for

premium assistance

No (without a waiver) Yes

Benefits Federally defined, with option to use benchmark

or benchmark-equivalent benefits package;

broad EPSDT services for children

Benefits undefined; use benchmark

package; limited “basic” services required

Cost sharing Limited or prohibited for some populations

and services, higher amounts allowed for some

populations and services

Cost sharing permitted within limits, but

prohibited for well-baby and well-child

exams

Antidiscrimination

provision

Yes No

Abbreviations: CHIP = Children’s Health Insurance Program; EPSDT = early and periodic screening, diagnosis, and treatment.

BOX 11-17 Discussion Questions

Why do you think that Medicaid was created as

an entitlement program but CHIP was established

as a block grant? Both programs are federal–state

insurance programs for low-income individuals, so

does the distinction make sense? Does it matter that

one program is for children and the other is broader?

Should one program be changed so they are both

either entitlements or block grants? Which structure

do you prefer?

250 Chapter 11

Th

Thi

ific

fin
lific

CHIP Benefits and Beneficiary Safeguards
efi

efi

ff
efi

efi

efi Th

■ Th ff

■ Th

efi

BOX 11-18 Discussion Questions

When designing CHIP, policymakers chose to follow

the private insurance model instead of the Medicaid

model. Although states have the choice to create a

generous Medicaid expansion program for their CHIP

beneficiaries, they also have the choice to implement a

more limited insurance program with fewer protections.

Similar choices were made when the DRA options were

created for Medicaid. These decisions raise essential

questions about the role of government in public

insurance programs. Does the government (federal

or state) have a responsibility to provide additional

benefits and protection to its low-income residents?

Or, is the government satisfying any responsibility it

has by providing insurance coverage that is equivalent

to major private insurance plans? What if the standard

for private insurance plans becomes lower—does

that change your analysis? Is it fair for low-income

individuals to receive more comprehensive health

insurance coverage than other individuals? Is there

a point where fiscal constraints trump equity or

the likelihood of improved health outcomes when

designing a public insurance program?

251

efi

efi

flexi efici

efi defini

CHIP and Private Insurance Coverage

CHIP Waivers

efi

efici

Th

The Future of CHIP
Th

efici
eff

Th

ff

252 Chapter 11

Source: Reproduced from 2013 Annual report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical insurance Trust Funds. Retrieved from https://www.kff.org/medicare/slide/projected-change-in-medicare-enrollment-2000-2050/

3.0%
2.4%

0.9%
0.4%

0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

10%92.4
88.9

81.5

64.3

47.7
39.7

1.9%

205020402030202020102000
0

10

20

30

40

50

60

70

80

90

100

Average annual
growth in enrollment

Medicare enrollment
(in millions)

ff

ff
Th

fir

▸ Medicare

fin diff
Thi

efi
fin

Th

Medicare Eligibility

Th figur

FIGURE 11-6

FIGURE 11-6 Projected Change in Medicare Enrollment, 2000–2050

BOX 11-19 Discussion Questions

Although many Medicare beneficiaries are poor,

there is no means test (income- or resource-specific

eligibility level) to determine eligibility as there is

with Medicaid and CHIP. Is there a good public policy

reason for this difference? What would be the basis for

making this distinction? Does the government have a

different role to play in providing health care based on

the population involved?

253

Source: Kaiser Family Foundation analysis of the Centers for Medicare & Medicaid Services Medicare Current Beneficiary 2013 Cost and Use file; Urban Institute/Kaiser Family Foundation analysis of DYNASIM data, 2017 (for income and savings). Retrieved from https://

www.kff.org/medicare/issue-brief/an-overview-of-medicare/

Note: ADL = activity of daily living.

Percent of total Medicare population

Age 85+

Long-term care
facility resident

Fair/poor health

5+ Chronic conditions

Savings below $74,450

Income below $26,200

Cognitive/mental
impairment

Functional implairment
(1+ ADL limitations)

Under age 65 with
permanent disabilities

50%

50%

36%

34%

4%

13%

17%

27%

30%

Th
Th

efici
efici

nific efici
FIGURE 11-7

efici

efici fi

efici

efici

efici nific

efici
uff

FIGURE 11-8

FIGURE 11-7 Characteristics of the Medicare Program

254 Chapter 11

Source: Kaiser Family Foundation analysis of CMS Medicarte Current Beneficiary Survey Cost & Use File, 2012.

65%

61%

33%

58%

29%

49%

21%

39%

11%

13%

1%

72%

In fair or poor health

Cognitive or
mental impairment

Require assistance
with 1+ self-care tasks

3+ Chronic conditions

Under 65 and disabled

Long-term care
facility resident

Medicare beneficiaries who
receive Medicaid
Other Medicare beneficiaries

efici

efici

Office
Office)

Medicare Benefits

cifie efici

Th

efici
efici efi

efi TABLE 11-5 efi
FIGURE 11-9

efi nific

  efi

et a
Th

nific
efi

FIGURE 11-10

n et a

 

FIGURE 11-8 Health and Functioning of Medicare Beneficiaries Who Receive Medicaid Compared to Other Medicare

Beneficiaries

255

Skilled nursing
facilities

4%

Home health
3%

Hospital outpatient
services

7%

Physician
payments

10%

Part D
prescription drugs

14%

Note: *Consists of Medicare benefit spending on hospice, durable medical equipment,
Part B drugs, outpatient dialysis, outpatient therapy, ambulance, lab, community mental
health center, rural health clinic, federally qualified health center, and other Part B services.

Total Medicare Benefit Payments, 2016: $675 billion

Hospital
impatient
services

21%

Other
services*

11%

Medicare
Advantage

30%

Source: Congressional Budget Office, June 2017 Medicare Baseline.

efici
et 

 
et 

ff

et 

TABLE 11-5 Medicare Benefits

Part Services Covered

A Inpatient hospital, 100 days at skilled nursing facility, limited home health following stay at a hospital or skilled

nursing facility, and hospice care.

B Physician, outpatient hospital, outpatient mental health, X-ray, laboratory, emergency department, and other

ambulatory services; medical equipment; limited preventive services, including one preventive physical exam,

mammography, pelvic exam, prostrate exam, colorectal cancer screening, glaucoma screening for high-

risk patients, prostrate cancer screening, and cardiovascular screening blood test; diabetes screening and

outpatient self-management; bone-mass measurement for high-risk patients; hepatitis B vaccine for high-risk

patients; pap smear; and pneumococcal and flu vaccinations. New ACA benefits: cost sharing eliminated

for select preventive services; coverage for personalized prevention plan, including comprehensive health

assessment.

C Managed care plans, private fee-for-service plans, special needs plans, and medical savings accounts. The

plans provide all services in Part A and Part B and generally must offer additional benefits or services as well.

D Prescription drug benefit.

FIGURE 11-9 Medicare Benefit Payments by Type of Service, 2016

256 Chapter 11

Source: Reproduced from Jacobson, G., Damico, A., Neuman, T., & Gold, M. (2017, June 6). Medicare Advantage 2017 spotlight: Enrollment market update. Retrieved from https://www.kff.org/medicare/issue-brief/medicare-advantage-2017-spotlight-enrollment

-market-update/

Share of Medicare Beneficiaries Enrolled in Medicare Private Health Plans, by State, 2017

1%

45%%45%45%

30%

31%

20%

3%

37%

17%
56%

18%

31%

21%

33%

16% 36% 34%

42%42%

21%
11%
11%
15%

24%

32%
36%

28%

26%21%

39%

34%%

35%

41%

25%%%
17%

38%

%27%%
8%

10%
21%

28%
37%

20%

12%

15%

18%

33%

33%39%

35%35%

44%

40%

Note: Includes Medicare Medical Savings Accounts (MSAs) cost plans and demonstrations.
Includes special needs plans as well asother Medicare Advantage plans. Excludes beneficiaries
with unknown county addresses and beneficiaries in territories other than Puerto Rico.

< 10% (3 states) 10%–19% (10 states + D.C.) 30%–39% (19 states) 20%–29% (12 states) ≥40% (6 states) National average, 2017 = 33% efi efici Th efi Th efi   efici Thr fir et    flexi et  fi et  efi   et a efici ff efi ff efi efici efi Th efici efici efici FIGURE 11-10 Enrollment in Medicare Advantage Plans Varies Across States 257 Source: KFF Analysis of Medicare spending data from 2008 and 2018 Annual Report of the Board of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. Table II.B1. 11% – $49 billion 2007 2017 41% – $176 billion 47% – $200 billion 42% – $293 billion $702 billion 44% – $309 billion 14% – $100 billion $425 billion Part A Part B Includes traditional Medicaii re and Medicare Advantagtt e Part D Medicare Spending FIGURE 11-11 efi Th efici efici efici ksi et a Th cifie Th efi Thi Medicare Financing fin fin fin FIGURE  11-12 efici o fin efi Th efici et  efi Thi FIGURE 11-11 Medicare Payments for Parts A, B, and D, 2007–2017 258 Chapter 11 Source: Reproduced from Cubanski, J. & Neuman, T. (2018, June 22). The facts on Medicare spending and financing. Retrieved from https://www.kff.org/medicare/issue-brief/the-facts-on-medicare-spending-and-financing/ 45% 87% 75% 23% 78% 36% 13% 3%3%3% Total $710.2 billion Note: Data are for the calendar year. $290.8 billion $313.2 billion $106.2 billion Part A Part B Part D 8% 1% 1% 1% <1% 1% 1% 1% 1% 13% 9% General revenue Payroll taxes Premiums Transfers from states Taxation of social security benefits Interest Other 3%3%3%3%3% FIGURE 11-13 fin efici efici efici efici efici efici efi efici efici FIGURE 11-12 Sources of Medicare Revenue, 2016 BOX 11-20 Discussion Questions Lawmakers were concerned that adding a prescription drug benefit to Medicare would encourage employers to drop prescription drug coverage to the beneficiaries who receive prescription drugs through retiree health plans. In an effort to avoid a shift in older people who rely on public insurance instead of private insurance for their prescription drug coverage, Congress included in the MMA a tax-free subsidy to encourage employers to maintain prescription drug coverage. While the ACA eliminates the tax deduction, the subsidy remains in place. The amount of the subsidy is based on the prescription drug costs of individuals who remain with the employer’s plan and do not enroll in Part D. In 2017, approximately 2 million beneficiaries purchased coverage through employer retiree plans and employers received a subsidy of 28% of their costs between $405 and $8,350 per retiree (KFF, 2017b). Is this subsidy a good idea? Is the proper role of government to pay private companies to maintain insurance coverage? If so, should it occur for other benefits? Do you have a preference regarding giving incentives for private entities to provide insurance coverage versus the government financing the coverage directly? 259 Source: Kaiser Family Foundation based on the 2014 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. Source: Kaiser Family Foundation. (2017a). An overview of Medicare. Retrieved on July 25, 2018 from https://www.kff.org/medicare/issue-brief/an-overview-of-medicare/ 39.7 47.7 64.4 81.8 89.2 92.8 4.0 3.4 2.8 2.3 2.2 2.3 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 0 10 20 30 40 50 60 70 80 90 100 2000 2010 2020 2030 2040 2050 Number of beneficiaries (in millions) Number of workers per beneficiary In m ill io ns Total Medicare Enrollment, 2013: 49 million Note: Analysis excludes beneficiaries enrolled in Part A or Part B only. Share of Traditional Medicare Enrollees, by Type of Supplemental Coverage: Employer- Sponsored 34% Medicaid 22% Medigap 23% Other – 2% None 19% Traditional Medicare 66% Medicare Advantage 34% efici Th   ff efi FIGURE  11-14 FIGURE 11-15 efici Th efi Th efici FIGURE 11-13 Number of Medicare Beneficiaries and Number of Workers per Beneficiary, 2000–2050 FIGURE 11-14 Distribution of Medicare Advantage and Traditional Medicare Enrollment and Types of Supplemental Coverage Among Medicare Beneficiaries, 2013 260 Chapter 11 Source: Kaiser Family Foundation. (2017a). An overview of Medicare. Retrieved on July 25, 2018 from https://www.kff.org/medicare/issue-brief/an-overview-of-medicare/ Source: Kaiser Family Foundation. (2017b). The Medicare Part D prescription drug benefit. Retrieved from https://www.kff.org/medicare/fact-sheet/the-medicare-prescription-drug-benefit-fact-sheet/ Average Total Out-of-Pocket Spending on Services and Premiums, 2013: $6,150 Note: Analysis excludes beneficiaries enrolled in Medicare Advantage plans those enrolled in Part A or Part B only. Share of spending by type of service: 18% 12% 9% 5% 4% 4% Services 53% $3,257 Premiums 47% $2,893 Long-term care facility Medical providers/supplies Prescription drugs Dental services Hospital services Skilled nursing facility and home health services Note: Some amounts rounded to nearest doller. 1Amount corresponds to the estimated catastrophic coverage limit for non-Low- Income Subsidy (LIS) enrollees ($7,509 for LIS enrollees), which corresponds to True Out-of-Pocket (TrOOP) spending of $5,000, the amount used to determine when an enrollee reaches the catastrophic coverage threshold in 2018. $8,000 Enrollee pays 5% Plan pays 15%; Medicare pays 80% Total drug spending:Benefit phase: Coverage gap Catastrophic coverage Initial coverage period Deductible $7,000 Catastrophic coverage threshold = $8,418 in estimated total drug costs1 ($5,000 in true-out- of-pocket spending) Initial coverage limit = $3,750 in total drug costs Deductible = $405 Plan pays 75% Generic drugs Enrollee pays 44% Plan pays 56% Enrollee pays 25% Brand-name drugs Enrollee pays 35% Plan pays 15% 50% manufacturer discount$6,000 $5,000 $4,000 $3,000 $2,000 $1,000 $0 et a efi fin FIGURE 11-16 efici FIGURE 11-15 Average Out-of-Pocket Spending on Services and Premiums by Medicare Beneficiaries, 2013 FIGURE 11-16 Standard Medicare Prescription Drug Benefit, 2018 261 fir efici Th efici efici efici et a ft ff efi fix ffs efici Th efici et a Th efi efi Thi Th fir fin fin efici TABLE 11-6 fin fin efici cifics o Medicare Provider Reimbursement Th   Physician Reimbursement efici TABLE 11-6 Medicare Financing by Part Medicare Part Government Financing Scheme Annual Deductible Monthly Premium Cost Sharing A Trust fund through mandated employer and employee payroll taxes Yes No, if Social Security work requirements are met Yes B General federal tax revenue Yes Yes—tiered by income Yes D General federal tax revenue and state clawback payments for dual enrollees Yes—except some low- income beneficiaries Yes—tiered by income (some low-income beneficiaries do not pay premiums) Yes—except some low-income beneficiaries 262 Chapter 11 Th efle Th diff defin fin hifts   Th efle ft Thi ft Th difier efi BOX 11-21 Discussion Questions The clawback provision is controversial and highlights some of the tensions about state flexibility and national uniformity that policymakers face when designing public programs. The clawback seems to contradict the prior decision to provide states with flexibility and program design responsibilities under Medicaid. In addition, it changes the decision to use only federal funds to pay for Medicare. Given decisions made by states prior to the MMA, there are many variations among state prescription drug benefits that will be “frozen” in place with the clawback provision. At the same time, the MMA creates a uniform rule about how all states finance prescription drug funding in the future, which could impact state-level decisions about dual enrollee coverage. Is the clawback provision a good idea? Should states help pay for federal prescription drug coverage? Is there a better design? Should states or the federal government control Medicaid prescription drug coverage that is provided to dual enrollees? Should dual enrollees be treated differently than other Medicaid beneficiaries? 263 fix fin Th flexi et  nific fin Hospital Reimbursement fi diff lifie lifie  43–44). diff sific cific diff Th Th MA Reimbursement efi BOX 11-22 Discussion Questions Controlling Medicare spending is a difficult task. Even if provider reimbursement rates are reduced, physicians and hospitals may increase volume and intensity of services to make up for lost revenue. The ACA included a number of pilot programs and demonstration projects to experiment with reforming the way health care is financed and delivered, and MACRA increased the incentives for physicians to participate in these experiments. Some of these projects include bundling payment for acute care services; using value-based purchasing, which ties payments to quality outcomes; and creating accountable care organizations that bring together providers across the healthcare spectrum and reward organizations with better outcomes. The ACA created the CMS Innovation Center to oversee these and other reform projects. What approach to reducing costs and improving quality do you prefer? What are the advantages and disadvantages of these ideas? 264 Chapter 11 Th diff efi et  efici Th nific et  Th et  fi The Future of Medicare eff Th eff fin efici efi diff efici efici hift cific fin efici nific fici ▸ Conclusion Thi ft Th defici efle flexi fin definin fi ff efici efici References efi efici iefin   265   fi efici Office Th eff Office Th /files?fi Th ff Th fin ff -fin iff ff fie   ff ff ff ff ff efici The eff fie The ff Th ff ff difie ffic 266 Chapter 11 ff ff The ffor ff ff ff efi ff efic efi ff efici efi ff efici ff ff Th efi ff efi ff ff efi efi fi 267 L. N fic ff efici ff ff ff ff ff fi s-fin fi aeff efi fie ff Th The e#_ft g Office efi fl efi ▸ Endnotes fin diff 268 Chapter 11 eff cifics Th ff efici ff 269 271 Credit line FPO© Mary Terriberry/Shutterstock CHAPTER 12 Healthcare Quality Policy and Law LEARNING OBJECTIVES By the end of this chapter you will be able to: ■ Discuss licensure and accreditation in the context of healthcare quality ■ Describe the scope and causes of medical errors ■ Describe the meaning and evolution of the medical professional standard of care ■ Identify and explain certain state-level legal theories under which healthcare professionals and entities can be held liable for medical negligence ■ Explain how federal employee benefits law often preempts medical negligence lawsuits against insurers and managed care organizations ■ Describe efforts to measure and incentivize high-quality health care By the end of this chapter you will be able to: ■ Discuss licensure and accreditation in the context of healthcare quality ■ Describe the scope and causes of medical errors ■ Describe the meaning and evolution of the medical professional standard of care ■ Identify and explain certain state-level legal theories under which healthcare professionals and entities can be held liable for medical negligence ■ Explain how federal employee benefits law often preempts medical negligence lawsuits against insurers and managed care organizations ■ Describe efforts to measure and incentivize high-quality health care ▸ Introduction infl cific ft ff 272 Chapter 12 Th fi fi ft nific defin Thi fin defies efi Th Th ff Th ▸ Quality Control Through Licensure and Accreditation Th fi defin lific Thi BOX 12-1 Vignette Michelina Bauman was born on May 16, 1995, in New Jersey. The managed care organization (MCO) through which her parents received healthcare coverage had precertified coverage for 1 day in the hospital postbirth, and both Michelina and her mother were discharged from the hospital 24 hours after Michelina was born. The day after the discharge, Michelina became ill. Her parents telephoned the MCO, but they were neither advised to take Michelina back to the hospital nor provided an in-home visit by a pediatric nurse as promised under the MCO’s “L’il Appleseed” infant care program. Michelina died that same day from meningitis stemming from an undiagnosed strep infection. 273 ufficien eff Thi eff Th Th eff Th fin definin defin fie defin fie fier defin cific Th ff ▸ Medical Errors as a Public Health Concern ft Th fin 274 Chapter 12 Thi fl Th eff sifie Th eff fie fi Th eff ff ifles ft hift Th Th 275 ▸ Promoting Healthcare Quality Through the Standard of Care Thi Th Thi diffic cific uff The Origins of the Standard of Care Th ff Thi cific Th eff fin (Thi eff eff Th fin fin BOX 12-2 Discussion Questions What do you think of the term medical error as a descriptor of adverse medical outcomes? After all, there are many medical procedures (e.g., invasive surgeries) and treatments (e.g., chemotherapy) that not only are inherently risky, but also cause painful and dangerous (and often unpreventable) side effects (i.e., that lead to “adverse” medical results). Given this fact, is it conceivable that the healthcare delivery system could ever operate free of “error”? Can you think of other terms that better (or more fairly) convey the range of adverse outcomes attending healthcare practice? 276 Chapter 12 (Thi Th eff diff efle eff efle infl efle eff fin Th The Evolution of the Standard of Care The Professional Custom Rule Th ific ific Th Th Th eff Th Thi The  Th 277     Thi ff a The Locality Rule eff Th difie Th eff ufficien eff   diff ff 278 Chapter 12 ▸ Tort Liability of Hospitals, Insurers, and MCOs Th Hospital Liability ffices cific fie Th Vicarious Liability Th fie eff iff Th BOX 12-3 Discussion Questions Give some thought to the term national standard of care. What do you think it means, from both a healthcare quality and legal (i.e., evidentiary) perspective? Are you aware of any national body— governmental or otherwise—that determines the efficacy of new diagnostic protocols or treatment modalities? In the absence of such an entity, how are health professionals put on notice that a new medical care standard for a particular procedure or treatment has emerged? 279 Corporate Liability Th iff uff Th ff—hi ff Th ff ufficien lifie ff. Insurer Liability efici Thi fir efici aft efici Thi eff efici Th ff efici eff uff Thi Th fin nifie 280 Chapter 12 Managed Care Liability definin Thi efici fin ft Th cific efici efici ft efici efi Th iff ft ffice Th 281 ff efici Thi ft Thi ▸ Federal Preemption of State Liability Laws Under ERISA efi Overview of ERISA ft efi ff efi efi efi fid efi efi ft fid efi diff fid efi fid fid Th efi efi fi Thi   ft cific efi ft fie efi ff efi ff efi Thi efi ff efi efi efi efi BOX 12-4 Discussion Questions What do you think about the role and success of tort law in promoting high-quality health care? Does it help to deter errors? If not, why? 282 Chapter 12 efi efi efici eff efi efi fid Th efi efi efi Thi efi ERISA Preemption efi Th fie fie fi Th fir flic cific nflic Th fie fie efi nflic Th nflic Th nflic Th ft efi efi efi Th Th efi nflic Th Thi efi Th cific ff efici Th eff Th fin nflic efi 283 fin efi fin efi efi efi Th efi eff efi efi Th efi Thi The Intersection of ERISA Preemption and Managed Care Professional Medical Liability Th fin Thi defin Fift Th ufficien efit p Thr Thir efi Th Thir diff efi efi efici efi ft Th fid diff Th ft 284 Chapter 12 Thi Th ufficien efici Th iffs efi uff ft fi Th iffs fl Th efi efi eff ▸ Measuring and Incentivizing Healthcare Qualityi fin BOX 12-5 Discussion Questions The critical intersection between health care and health insurance as exemplified by the Davila decision leads to an important question: is it reasonable to treat a healthcare coverage decision as having nothing to do with health care itself? Put another way, given the expense of health care today, do you believe that individuals and families can afford necessary health care if there is no third party responsible for covering at least some of the cost? 285e Q deficien   Th efici ft infl Th eff   fin efici cific ff cific Th nific fin Th fin Th eff eff eff Th efin Th difie Th cific, 286 Chapter 12 t eff Quality Measure Development eff Th A  defini diff cific cific Thi efficien eff cific Th ific definin defin Th ifie efficien Th Quality Measurement Th Th Th Public Reporting Th nific Th 287e Q efficien ifi Value-Based Purchasing Th cific cific cific Th fin cifie ft efficien efici Th diff difier Th cific Th ff 288 Chapter 12 National Quality Strategy Th ■ Th eff Th eff eff ff ■ eff eff ff ■ Th eff ff ific Th efi Th Th Th efficien Th diff Thi fift Th 289e Q Private Payer Efforts nific cific difie efici Th eff ff ft efin diff defini diff Thi eff eff efficien Thi eff Th Role of Health Information Technology diff Th eff diff Office Th eff Th 290 Chapter 12 Thi flexi Thi ifie ▸ Conclusion Thi iefl cific efle fin eff References cific-q . 1965). Th  P fie —Th Th Th ff § 3013 (2010), addin § 299 et s 291 : Th Th ff ▸ Endnotes fin fi ft efle Thi Th fir ific Th fin Th efficien fir cifi ifie hift ft Th o eff eff efi efi 292 Chapter 12 Tho ft Th   Credit line FPO© Mary Terriberry/Shutterstock CHAPTER 13 Public Health Preparedness Policy LEARNING OBJECTIVES By the end of this chapter you will be able to: ■ Describe what public health preparedness is and understand the scope of events that can lead to a public health emergency ■ Understand the threats from and history of the use of weapons of mass destruction ■ Define public health threats from biologic agents and naturally occurring diseases ■ Describe key policies and laws that support public health preparedness and the infrastructure that has been built to support preparedness activities at the federal, state, and local levels By the end of this chapter you will be able to: ■ Describe what public health preparedness is and understand the scope of events that can lead to a public health emergency ■ Understand the threats from and history of the use of weapons of mass destruction ■ Define public health threats from biologic agents and naturally occurring diseases ■ Describe key policies and laws that support public health preparedness and the infrastructure that has been built to support preparedness activities at the federal, state, and local levels ▸ Introduction Th eff fir ff ft 293 eff Th fie Thi definin Th ▸ Defining Public Health Preparedness Th fie Th defin eff efficien defini e fie Thi defini defini Th fi Th es, flo r fir fie Th eff defin defini 294 Chapter 13 Th Eff Thi ■ ■ ■ eff ■ ■ ■ ■ ■ fin Th ▸ Threats to Public Health Th fir fin Thi CBRN Threats Th Th ff t  Chemical Threats Th BOXES 13-2  13-3 BOX 13-1 Discussion Questions What is public health preparedness? How do you define it? What is the role of the public health professional in detecting, responding to, and recovering from a public health emergency? 295 Th Source: Ganesan et al. (2010). BOX 13-2 Types of Chemical Agents ■ primarily act on the nervous system, causing seizures and death. Examples of this category include sarin, VX, tabun, and soman. This category also includes fourth-generation chemical weapons, known as novichok agents, which are thought to be much more lethal than VX. ■ primarily cause irritation of the skin and mucous membrane. Examples of this category include mustard gas and arsenical lewisite. ■ primarily cause damage to the lungs, including pulmonary edema and hemorrhage. Examples include phosgene, diphosgene, and chlorine. ■ primarily cause seizures and respiratory and cardiac failure in high doses. Examples include hydrogen cyanide and cyanogen cyanide. ■ cause incapacitation due to irritation of eyes and respiratory system. Examples include CN, CS, PS, and CR. ■ , in low doses, cause psychiatric effects. An example is lysergic acid diethylamide (LSD). ■ cause symptoms that range from death to incapacitation, depending on the agent. Examples include ricin and saxitoxin. Sources: BBC (2018a, 2018b), Brunning (2018), Holmes and Solomon (2013), United Nations (2013), Vale, Mars, and Maynard (2018). BOX 13-3 Examples of Chemical Agents Impacting Public Health On March 19, 2013, a rocket landed in the village of Khan al-Assal, in the Aleppo region of Syria. Upon impact, a gas was released, ultimately leading to over 20 fatalities and wounding many dozens more. Samples analyzed by both Russia and the United States identified the agent as sarin. The Syrian government and the opposition faction were quick to trade accusations of responsibility, and the Syrian government requested that the United Nations investigate the incident further. After lengthy delays due to a lack of access and disagreement over the scope of the investigation, a United Nations team finally arrived in August 2013, only to have their mandate quickly overshadowed by a second sarin attack at Ghouda. The team eventually concluded that the perpetrators “likely” had access to the Syrian military’s chemical weapons stockpile but the “evidentiary threshold” for assigning responsibility was not met. At the time of the attack, Syria was not a signatory to the Chemical Weapons Convention. This example demonstrates the challenges of preparing for, responding to, and attributing responsibility for chemical incidents in the midst of a conflict situation. On March 4, 2018, Sergei Skripal, a former Russian military intelligence officer and double agent for the United Kingdom, and his daughter Yulia collapsed while sitting on a public bench in Salisbury, England. It was quickly determined by the local hospital that they had been poisoned by a toxic agent. Testing at the United Kingdom’s Defence Science and Technology Laboratory at Porton Down identified the cause as a novichok nerve agent, a potent organophosphate believed to have been developed by the Soviet Union during the Cold War. This finding was further confirmed by the Organization for the Prohibition of Chemical Weapons. A police officer involved in the initial response on March 4 was also exposed and required hospitalization. All three victims eventually recovered fully. After trace elements of the agent were found at public sites visited by the Skripals earlier in the day, Public Health England was forced to reassure the public of the “very low risk” of exposure and restricted access to nine locations for decontamination. On April 13, the United Kingdom’s National Security Advisor, Sir Mark Sedwill, stated the government’s assertion that only Russia possessed the technical and operational means, as well as motive, to carry out the attack. On June 30, a British couple without known links to the Skripals fell ill at their house and were also determined to have been exposed to novichok. Police believed they had possibly handled a contaminated item, highlighting the challenges of controlling even a small, likely targeted, poisoning attack with a lethal nerve agent. 296 Chapter 13 ft Th Th ■ ■ ■ n eff ■ ■ ■  eff Nuclear Threats fi Th Th Radiologic Threats Th Th Th uff Th nific ■ ■ ■ ■ ■ Biologic Threats ff ff ff eff ific eff BOXES 13-4  13-5 BOX 13-4 Biologic Agents in Nature Free-living unicellular organisms Core of DNA or RNA surrounded by a coat of protein; require host cell in order to replicate; much smaller than bacteria Toxic substances produced by living organisms 297 Th sific Thi fir sific (Th d defin ■ Th Th fini Th cific ■ Thi ■ Thi ■ Th fin ifici cific Th sific Thi eff Th Th Th ft cific Th ff Th nific Th Th Th ffa Th Th ft Th Source: CDC (2018a). BOX 13-5 Major Biologic Threat Agents Anthrax (Bacillus anthracis) Botulism (Clostridium botulinum toxin) Brucellosis (Brucella species) Food safety threats (e.g., Salmonella species, Escherichia coli O157:H7, Shigella) Glanders (Burkholderia mallei) Melioidosis (Burkholderia pseudomallei) Plague (Yersinia pestis) Psittacosis (Chlamydia psittaci) Q fever (Coxiella burnetii) Ricin toxin Smallpox (Variola major) Staphylococcal enterotoxin B Tularemia (Francisella tularensis) Typhoid fever (Salmonella Typhi) Typhus fever (Rickettsia prowazekii) Viral encephalitis (alphaviruses [e.g., Venezuelan equine encephalitis, eastern equine encephalitis, western equine encephalitis]) Viral hemorrhagic fevers (filoviruses [e.g., Ebola, Marburg] and arenaviruses [e.g., Lassa, Machupo]) Water safety threats (e.g., cholera [Vibrio cholera], Cryptosporidium parvum) Emerging infectious diseases such as Zika virus, Nipah virus, and hantaviruses 298 Chapter 13 figur fin fi Th ffice ff ff Th Th Naturally Occurring Disease Threats BOX 13-6 Th cific ff ff nflic ff ff nific ff ff Sources: CDC (2014a, 2014b, 2014d), Kaiser (2014), Maron (2014), Sun (2014). BOX 13-6 U.S. Biosafety Incidents in 2014 Over the summer of 2014, three significant biosafety incidents occurred involving U.S. government facilities. The first incident took place in early June at the Centers for Disease Control and Prevention’s (CDC’s) Roybal Campus in Atlanta. On June 5, a laboratory worker used an improper method to deactivate anthrax spores that were being transferred to several lower biocontainment laboratories on the same campus. The mistake was discovered over a week later, when culture plates left in the original laboratory showed signs of bacterial growth. Thirty-five staff and 67 visitors were considered at risk of exposure to anthrax as a result of the error. The second incident also involved the CDC. On July 9, it was discovered that a sample of low- pathogenic avian influenza shipped to the U.S. Department of Agriculture from the CDC was contaminated with highly pathogenic H5N1. Because the sample was assumed to be of low risk, safety and security precautions required for shipping of select agents were not carried out. All handling of the sample at both institutions took place under BSL-3 conditions, minimizing the risk of accidental exposure. The contamination was determined to have taken place at the CDC influenza laboratory, and the discovery was made by the USDA on May 23. However, the incident was not reported for another 6 weeks. The third incident occurred in mid-July, when several vials labeled as smallpox were discovered on the National Institutes of Health (NIH) campus in Bethesda, Maryland. The vials dated from the 1950s, when smallpox was still widespread, and are believed to have been part of a previous Food and Drug Administration (FDA) facility on the site. While some of the viral contents were shown to still be viable, the vials were well sealed and the risk of exposure was deemed to be very low. While no casualties resulted from any of these incidents, they highlight the potential risks of accidental exposure to dangerous biologic agents as a result of poor bio-risk management practices. In January 2016 an expert review, commissioned by the CDC, found that while the agency had made some progress, “considerable work” remained to be done to achieve a culture of safety. 299 fin Th diff ff leff & G Th ff Th ff ific eff ufficien Eff eff ffici ufficien Natural Disasters fir flo BOX 13-8 Th TABLE 13-1 Th ffici BOX 13-7 Discussion Question How can a naturally occurring disease event lead to a public health emergency? Describe how disease can impact national, regional, or international security. 300 Chapter 13 Sources: Barron (2017), Einbinder (2018), Greenough and Kirsch (2005), Greshko (2017), Lister (2005), Philipps (2017), The White House (2006). BOX 13-8 Recent U.S. Response to Hurricanes On August 29, 2005, Hurricane Katrina landed on the Gulf Coast of the United States, reaching Mississippi, Louisiana, and Alabama. It came ashore with winds of 115 to 130 miles per hour and brought with it a water surge that in some locations rose as high as 27 feet. The surge pushed 6–12 miles inland and flooded approximately 80% of the city of New Orleans. Some 93,000 square miles were affected, resulting in 1,300 fatalities, 2 million displaced persons, 300,000 destroyed homes, and almost $100 billion in property damage. Katrina was the worst domestic natural disaster in recent history, but the consequences of the event were made worse by a faltering levee system designed by the U.S. Army Corps of Engineers and a failure of government at all levels to properly prepare for and respond to the disaster. First, long-term warnings went unheeded. It was clear that a hurricane of this type would eventually hit the region, yet local and state officials, even after running exercises based on such a scenario, failed to properly prepare. Local and state officials were unable to evacuate all of the citizens, struggled with logistics, and did not make proper preparations for dealing with vulnerable populations, including nursing home residents. The federal government failed to adequately anticipate the needs of the state and local authorities, and the insufficient coordination resulted in a lack of resources and a too-slow response. The public health and medical response coordinated by the federal government followed the traditional response to a flood or hurricane: focus on sanitation and hygiene, water safety, surveillance and infection control, environmental health, and access to care. Katrina, though, also presented unique challenges, such as the inability of displaced persons to manage chronic disease conditions and access medications, death and illness from dehydration, and mental health problems, all associated with the widespread devastation among those affected. Almost all offices and branches of the federal Department of Health and Human Services (of which the CDC is a part) eventually became involved in the response to Katrina. The CDC sent staff to the affected areas, deployed the Strategic National Stockpile to provide drugs and medical supplies, and developed public health and occupational health guidance. The FDA issued recommendations for handling drugs that might have been affected by the flood. The NIH set up a phone-based medical consultation service for providers in the region. The Substance Abuse and Mental Health Services Administration set up crisis counseling assistance and provided emergency response grants. In addition, the National Disaster Medical System deployed 50 Disaster Medical Assistance Teams to try to accommodate and treat hurricane victims. Disaster Mortuary Operational Response Teams also deployed to help process bodies. The Department of Defense set up field hospitals at the New Orleans International Airport and aboard naval vessels. The Department of Veterans Affairs evacuated both of its local hospitals—one prior to the storm, one afterward. A combination of climatic conditions, including warmer-than-usual sea temperatures in the tropical Atlantic, led the 2017 Atlantic hurricane season to be the most devastating since 2005, and the fifth most active since recordkeeping began in the 1930s. In particular, three storms—Hurricanes Harvey, Irma, and Maria—had a substantial impact on the U.S. mainland and Puerto Rico. Along the Gulf Coast of Texas, Louisiana, and Florida, Hurricanes Harvey and Irma hit within 2 weeks of each other, causing an estimated $175 billion of damage. Ten days later, Hurricane Maria slammed directly into Puerto Rico, which had already been heavily impacted by Irma. The federal response was rapid, with President Trump immediately approving disaster declarations for all three storms. However, there were significant differences between the impact of the three storms, as well as the federal responses. The Federal Emergency Management Agency (FEMA) already had supplies and personnel stationed in Texas before Hurricane Harvey made landfall, and leveraged existing memoranda of understanding with local and state authorities, as well as the National Guard, to coordinate response efforts closely. Local and federal responders had even previously trained together, under the $2 billion invested by FEMA in training of local authorities since 2005. Similarly, within 4 days of Hurricane Irma’s landfall in Florida, FEMA had deployed more than 2,650 staff (out of a total of more than 40,000 federal response personnel) to support response efforts. In contrast, the federal response to Hurricane Maria in Puerto Rico was criticized by the United Nations and other observers for being sluggish and inadequate. Already stretched thin by the Harvey and Irma responses, only 10,000 federal response personnel were initially deployed, many of whom were trainees or lacked previous response experience. Few supplies were in place ahead of time, and being an island, FEMA faced considerable logistical challenges in sending provisions, tarpaulins, and other key supplies to Puerto Rico, leading to major shortages of food and shelter, particularly as Maria had destroyed more than one-third of homes on the island. The Army Corps of Engineers, deployed to help repair homes destroyed by the hurricane, managed to put up just over 400 roofs in the month following the storm, whereas they had repaired more than 10 times that many in Florida in the same time frame after Irma. The hurricane also crippled Puerto Rico’s electricity grid; as late as May 2018, over 100,000 residents were still without power, highlighting the slow recovery faced by the island. 301 Th Oft cific lifie   TABLE 13-1 Major Natural Disasters, 1900 to Present Date Event Location Approximate Death Toll June–November, 2017 Hurricanes Caribbean Basin Up to 8,750 April 25, 2015 Earthquake Gorkha, Nepal 9,000 March 11, 2011 Earthquake/tsunami Tohoku, Japan 15,800–18,500 January 12, 2010 Earthquake Port-au-Prince, Haiti 170,000–230,000 May 2, 2008 Cyclone Myanmar 138,000 December 26, 2004 Tsunami (Indian Ocean) Indonesia, Thailand, Sri Lanka, India, and more 220,000 (+) July 28, 1976 Earthquake Tangshan, China 242,000–655,000 November 13, 1970 Cyclone Bangladesh 500,000 May–August 1931 Yellow River and Yangtze River floods China 1–3.7 million May 22, 1927 Earthquake Xining, China 200,000 September 1, 1923 Earthquake and fires Tokyo, Japan 143,000 December 16, 1920 Earthquake Haiyuan, China 200,000 Sources: Associated Press (2010), CBC News (2010), Kishore et al., (2018), Noji (1997), Office of U.S. Foreign Disaster Assistance (1993), U.S. Geological Survey (2004). BOX 13-9 Discussion Questions How did the public health community respond to Hurricane Katrina? What lessons can be learned to better prepare for future response efforts? To what extent did the response to the 2017 hurricane season reveal improvements to public health preparedness for natural disasters, versus gaps still remaining? 302 Chapter 13 Man-Made Environmental Disasters Th Th BOX 13-10 ff Thi ▸ Public Health Preparedness Policy ffici ft ft Th fir nific Office Thi ffice Office ffa Thi ffice Th Thr Th ffices, ffices, Th ffices Federal Response Agencies and Offices Department of Health and Human Services (HHS) ffices Sources: Kaufmann and Penciakova (2011), Secretariat of the Investigation Committee on the Accidents at the Fukushima Nuclear Power Station (2012), Tanter (2013), Wheatley, Sovacool, and Sornette (2017). BOX 13-10 Fukushima Nuclear Disaster The most serious radiation accidents have been associated with nuclear power plants. While the total number of accidents occurring at nuclear power plants is a matter of debate, at least 33 significant accidents are believed to have taken place since the 1950s. The most recent serious incident occurred at Fukushima Nuclear Power Plant in Japan, starting on March 11, 2011. The incident began when the facility was struck by a tsunami, itself caused by the magnitude 9.0 Tohoku earthquake. Seawater flooding the nuclear facility caused the plant’s power (including backup generators) to fail. With no mechanism for continued cooling, the reactors began to heat up; eventually, three out of the facility’s six nuclear reactors melted, resulting in a massive release of radioactive material, and the largest nuclear incident since Chernobyl in 1986. Investigations into the Fukushima disaster concluded the catastrophe must be considered “man-made”: the findings of a 2008 tsunami risk assessment had been ignored by the facility’s management; there was institutionalized “corruption, collusion, and nepotism” between the nuclear industry and regulatory authorities; and the Japanese government’s eventual response to the disaster was thoroughly criticized for its poor crisis command, inadequate legal structure for nuclear crisis management, and lack of communication and transparency. While there were no immediate casualties from the incident, more than 100,000 people were evacuated from their homes and an estimated 1,000 died as a result of maintaining the evacuation. Concerns over the long-term impact of radiation exposure remain. 303 ffic Th Office ffice Office Office Office ffice Thi Th ffices Office Thi ffice Th ffices. Th Office Th The ffices Th ffices cific Office Th eff Th Office Thr Department of Agriculture (USDA) Th Thi infl Th Federal Bureau of Investigation (FBI) Th Thi Th fie 304 Chapter 13 Department of Defense (DoD) Th Th eff fig Th Th Thr Th ific Th Preparedness Statutes, Regulations, and Policy Guidance fie Th s eff Public Health Improvement Act of 2000 (Public Law 106-505) Th Thi Th eff USA PATRIOT Act of 2001 (Public Law 107-56) Th Thi fir Public Health Security and Bioterrorism Preparedness and Response Act of 2002 (Public Law 107-188) fir Th s fi ffici difies 305 Smallpox Emergency Personnel Protection Act of 2003 (Public Law 108-20) Th Th ft The Project Bioshield Act of 2004 (Public Law 108-276) difie Th fin Th fin Public Readiness and Emergency Preparedness Act of 2005 (Division C of the Department of Defense Emergency Supplemental Appropriations; Public Law 109-148) fin Th Pandemic and All-Hazards Preparedness Act of 2006 (Public Law 109-417) Th Thi 306 Chapter 13 Thi Th Th fin Thr Pandemic and All-Hazards Preparedness Reauthorization Act of 2013 (Public Law 113-5) Th Implementing Recommendations of the 9/11 Commission Act of 2007 (Public Law 110-53) Th cific eff cific ce eff National Defense Authorization Act of Fiscal Year 2017 (Public Law 114-328) Th ft ft Presidential Directives Biodefense for the 21st Century: National Security Presidential Directive 33/ Homeland Security Presidential Directive 10, April 2004 BOX 13-11 Discussion Questions The PAHPRA of 2013 included changes to each of the four main titles of the previous PAHPA law. Looking back at PAHPA (2006), how significant do you think these changes were, and what might have been the rationale behind the revisions? How does this act compare to the current reauthorization? 307 Th Thi Thr   Public Health and Medical Preparedness: Homeland Security Presidential Directive 21, October 2007 cific defin Th Th Establishing Federal Capability for the Timely Provision of Medical Countermeasures Following a Biological Attack, Executive Order 13527, December 2009 Th National Strategy for Countering Biological Threats, Presidential Policy Directive 2, November 2009 Th Thr Th fir ■ ■ ■ ■ ■ ■ eff ■ ific efici National Preparedness Presidential Policy Directive 8, March 2011 Th fi International Agreements eff Th 308 Chapter 13 eff Thi eff eff eff Th eff BOX 13-12 Discussion Questions Describe the federal preparedness infrastructure that evolved after 9/11. Are there things about the departments, agencies, and offices that to you represent improvements over the pre-9/11 infrastructure? Are there aspects that seem redundant or misplaced? BOX 13-13 Policy Case Study: Domestic Response to the 2014–2016 Ebola Outbreak Several of the federal preparedness laws and regulations of the early 2000s focused on the need to develop and stockpile a ready supply of medical countermeasures to be deployed in the event of a public health emergency. However, many pathogens of concern are relatively rare, or occur endemically only in lower-income or resource- constrained countries. As such, there was reluctance from the pharmaceutical and drug manufacturing industries to commit significant research and development dollars to products that might not have a commercially viable market. The Project Bioshield Act of 2004 sought to change that by establishing a government-funded market for such countermeasures, and thus incentivize the development of vaccines and therapeutics that would not otherwise be cost-effective. Subsequent legislation changed how the development of medical countermeasures were funded to better incentivize private sector companies to remain committed and financially viable during the lengthy process between initial development of a product and final approval by the FDA. Given the length of time required for a product to come to market, the Project Bioshield Act also allowed for HHS to authorize the emergency use of countermeasures even if they had not yet been approved by the FDA. Of course, FDA approval processes are critical for determining safety and efficacy, so the concern was raised about liability in the event that a non-FDA-approved countermeasure, used for a legitimate public health emergency, produced a severe side effect or failed as a treatment. Manufacturers feared that liability in these situations would fall on them, leading to a reticence to even engage in the development of the product. In response, Congress passed the PREP Act, which provides immunity from liability for any claims resulting from the use of a medical countermeasure approved for use during a public health emergency. There have been eight PREP Act Declarations since its inception, addressing countermeasures for smallpox, pandemic influenza, botulinum toxin, and anthrax, as well as for nonbiologic threats such as radiation. Starting in late 2013, erupting in 2014, and continuing into 2015 and 2016, Ebola virus disease spread through Guinea, Sierra Leone, and Liberia, infecting and killing thousands more people than any previous Ebola outbreak. The virus spread to countries outside of West Africa, including the United States, through global travel and the return of infected medical volunteers. The scale of the outbreak prompted several pharmaceutical companies to accelerate research and development of Ebola vaccines and therapeutics; despite such products being incentivized under the (continues) 309 ▸ Conclusion Th Thi infl eff ft fin defici fic fi ifie ific ff fi fig eff ufficien . Th ■ The Thi ■ Th ■ Th ■ Project Bioshield Act, virtually no companies had focused on Ebola virus, and few countermeasures were at an advanced stage of testing. There was tremendous public fear and pressure mounted on public health and medical officials to ensure that U.S. patients with Ebola were given every available treatment, even if experimental. In August 2014, the media widely reported on the remarkable recovery of two American Ebola patients in Liberia, who had been given doses of an experimental drug called ZMapp. It is not clear if and what liability protections were waived for the initial use of this and other experimental Ebola therapeutics on U.S. patients, though the provision of these treatments were sanctioned under the auspices of the FDA’s “compassionate use exemption” whereby a patient may receive unapproved treatment outside of already-approved clinical trials. However, HHS subsequently issued a PREP Act declaration providing immunity from liability for the manufacturing, administration, and use of Ebola-related vaccines, including several Ebola vaccines under development, and later issued a declaration for therapeutics such as ZMapp. This example demonstrates the importance of establishing a legal framework for preparedness to ensure the appropriate and timely use of medical countermeasures in the event of a public health emergency. Having a process in place to protect manufacturers allowed them to move forward with getting potentially lifesaving products to a frightened, at-risk population. Sources: FDA (2018b), HHS (2017), Health Resources and Services Administration (2017), Kadlec (2013), Monahan and Halabi (2015). BOX 13-13 Policy Case Study: Domestic Response to the 2014–2016 Ebola Outbreak (continued) 310 Chapter 13 ■ ■ eff eff References   Th The nflic nflic eff Th ffic fi ffic BOX 13-14 Discussion Question What are the distinct roles of local, state, federal, and international governments and organizations in managing a public health emergency of international concern? 311 leff Th .fbi Th /fi Th ft   Th fl ific y-fl fig Th The A  /fi definin 312 Chapter 13 Th Office fi Th fin Th l-fin ft Th Th Th ff ff ft lflo ffa. Th eff Th 313 315 © Mary Terriberry/Shutterstock PART III Basic Skills in Health Policy Analysis 317 © Mary Terriberry/Shutterstock CHAPTER 14 The Art of Structuring and Writing a Health Policy Analysis LEARNING OBJECTIVES By the end of this chapter you will be able to: ■ Understand the concept of policy analysis ■ Analyze a health policy issue ■ Write a health policy analysis ■ Develop descriptive and analytic side-by-side tables By the end of this chapter you will be able to: ■ Understand the concept of policy analysis ■ Analyze a health policy issue ■ Write a health policy analysis ■ Develop descriptive and analytic side-by-side tables ▸ Introduction eff Th ff defini iefl defini ▸ Policy Analysis Overview defin Client-Oriented Advice Th (Th 318 CHAPTER 14 fic Th Informed Advice Th eff Public Policy Decision ff Providing Options and a Recommendation ifies cific Your Client’s Power and Values defin Th Th defin Th Th ifie ft cific   ft 319 fini definin ft ifie Th diff defini defini ft ft Multiple Purposes Th cific iefin Thi eff ft ft nific Th infl ft a c ▸ Structuring a Policy Analysis fi eff diff ■ fic efin ■ ■ ■ ■ Off Th 320 CHAPTER 14 Problem Identification Define the Problem Th fir defin ific ifies ific defin ft diffic Th ific ific ft diff ific fic fic Th fir ific Th ific ific fir ific ific fic fic fir ific Th Th ific ific diff y) diff ific efle ific diff ific g firm: fir Th diff ifi efle diff fir fi fi 321 Th ft fi fir fi fir ific s fir ific Make the Problem Identification Analytically Manageable diff ific cific efle Th ific ifi fl ifi y fl Th fir fl fin ific Th fl cific ific diff fin   ft ific fin ifi defin ific cific cific ific figur cific ifi 322 CHAPTER 14 Thi ific Th ifi Thi cific Thi ific Do Not Include the Recommendation in Your Problem Identification ft ific defin cific fi defin ific ifi Thi cific Th ific cific ific Thi ific Thi ific ifie Th ft The Background Section   ■ ■ Th ■ 323 eff fir fir Th The Landscape Section Th Identifying Key Stakeholders Th ft Th ifie nific o  ue? Th ■ ■ ■ ■ ■ ■ ■ ■ defini ffice 324 CHAPTER 14 Th Th BOX 14-1 cific cific Identifying Key Factors BOX 14-1 Possible Factors to Include in a Landscape Section What is the political salience of the issue? Is this a front-burner issue? Is this a controversial issue? Are your client, legislators, and the general public interested in addressing this issue? Has this or a similar healthcare issue been addressed recently? Do key constituents, opponents, interest groups, or other stakeholders have an opinion about the issue? Who is likely to support or oppose change? Is there bipartisan support for the issue? Is there a reason to act now? Is there a reason to delay action? Who is affected by this problem? According to the client who assigned the analysis, are influential or valued people or groups affected by this problem? Is there a fairness concern relating to this issue? Is there a stigma associated with this issue? What is the economic impact of addressing this problem? Of not addressing it? Are various people or groups impacted differently? Are there competing demands for resources that relate to this issue? What is the economic situation of the state or nation? How does this affect the politics relating to this issue? How will addressing this issue affect healthcare costs/healthcare spending? Is it realistic to try to solve this problem? Do others need to be involved to be able to solve this problem? Is the technology available to solve this problem? Would it be more practical to solve this problem later? Are other people in a better position to solve this problem? What do we know about solutions that do or do not work? If this problem cannot be solved, is it still necessary (politically, socially) to act in some way to address the problem? Is evidence available to support potential solutions? Are there legal restrictions affecting this problem? Is there a need to balance public health concerns and individual legal rights? Are there legal requirements that impact the analysis? Is new legislative authority necessary to solve the problem? Is there legal uncertainty relating to this problem? Is future litigation a concern if action is taken? 325 Th ft fi Th ■ w infl ■ efi ■ ■ fi infl Structuring the Landscape Section Th ft r  Th ft ffs. Th Th Th Does this problem address quality-of-care issues? Do some solutions focus on quality of care more than others? Do quality-of-care concerns vary based on which provider is involved? Is evidence available about the best ways to improve quality of care? Has the client already taken any actions to improve quality of care? 326 CHAPTER 14 The Options Section fini Th Thi fi Thi Identifying Options Th fir fin fin ■ ■ ■ ■ Thin e fie ■ ■ ■ ft ■ ■ ■ ■ ■ ■ ■ ■ ■ fi ffs fin ft Th cific fin diff Th fin ifie ific ific 327 flo ific fin Assessing Your Options ft eff ft fi fi fi diffic efle ifie cific cific ific BOX 14-2 Structuring the Options Section fin Th fir ifie ft ft (2)  BOX 14-2 Sample Options Criteria How much does this option cost? (You may have to break this down: how much does it cost the federal government, state government, individuals, etc.?) enefit: How much “bang for the buck” does this option provide? (This is a difficult criterion to assess in shorter, less complicated policy analyses because you often do not have the information necessary to make this determination.) Is this option politically viable? Is it likely to become law? Even if it is not likely to become law, is it likely to help your client politically? Is this option legal? If so, are there any restrictions? Does this option have steep implementation hurdles? Are people affected by this option treated fairly/equally? Can this option be implemented in an appropriate or useful amount of time? Does this option target the population/issue involved? ff How well does this option accomplish the goal set out in the problem identification? ecific crit Does this option improve quality of care, lower healthcare spending, reduce the incidence of a particular disease, etc.? 328 CHAPTER 14 Side-by-Side Tables Thi diffic ufficien TABLES 14-1 14-2 diffic ufficien diffic + − diff Th Th diffic Th nifi y eff TABLE 14-1 Descriptive Side-by-Side Table Increasing Access to Care for Immigrants—Options Description Public Education Campaign Grants to States Health Center Funding General description Campaign on radio, television, and public areas Federal government provides funds to states to increase access to care for immigrants Federal government provides funding to health centers for services Populations affected All will hear, focus on immigrants in community Only immigrants in the state All health center patients, including immigrants Length of option 1 year 5 years, subject to annual appropriations 2 years Payer Federal Federal Federal 329 uffice—j TABLE 14-2 Analytic Side-by-Side Table Increasing Access to Care for Immigrants—Options Assessment Options Criteria Public Education Campaign Grants to States Health Center Funding Cost to federal government Low Medium High Political feasibility Medium Low High Increase in access for immigrants Low High Medium BOX 14-3 Checklist for Writing a Policy Analysis tific Is my problem written as one sentence in the form of a question? Can I identify the focus of my problem ? Can I identify several options (but not many) for solving the problem? Does my background include all necessary factual information? Have I eliminated information that is not directly relevant to the analysis? Is the tone of my background appropriate? Does the landscape identify all of the key stakeholders? Are the stakeholders’ views described clearly and accurately? Is the structure of the landscape consistent and easy to follow? Is the tone of the landscape appropriate? Does the reader have all the information necessary to assess the options? Do my options directly address the issue identified in the problem identification? Did I assess the pros and cons of each option? Did I apply all of the criteria to each option’s assessment? Are the options sufficiently different from each other to give the client a real choice? Are all of the options within the power of my client? Is my recommendation one of the options assessed? Did I recommend only one of my options? Did I explain why this recommendation is the best option, despite its flaws? 330 CHAPTER 14 References liffs, Th Th The Recommendation Section Th fin Th Th ifies ▸ Conclusion Th BOX 14-3 © Mary Terriberry/Shutterstock Th Th cific cific Thi t-eff efi flexi fix efi The Th Th efi efici efi efi fi ff eff diff Glossary 331 enefits efici efi fl a fix Th efi ff fix Thi efici ft Th ff efi efi efi efi fl efi ff ft efi Th enefits efi ff ff efi enefit ff Th efi efi cifie cifie Th efi sifies 332 Glossary ffici qualified ifie e-efficien Thi efi fix y  defin diff Th Th cific p cific p Th ff Glossary 333 Th infl infl Th Th efi cifie efi fin t efficien ff ff Th ff efici efi notifiable ffic ffice efici efi diff efi fin ff ff 334 Glossary fi efi efi Th Th Th Th Th ft efici enefits efi fin Th fi Th Th cifie ff Th Th Glossary 335 Th Th efi ff efi Th Th Th 336 Glossary © Mary Terriberry/Shutterstock e figur A efi ff ff efi fin efi eff efficien efi sific sific Index 337 B efici ffice ific C Office ifie ifie Officer efi efici fin 338 Index ff nflic Office ff fi Thr t-eff diff D efici efi ffa Index 339 efici E efici fie effic efficien efi efi efi F Office ff ffices lifie 340 Index fid fie fi lifie Th G Office iffi H defin fi efi Index 341 efi fin eff fin effic efficien eff eff 342 Index fi I fin Th J eff Th Th K Index 343 L definin ific fir M f-eff ific fin efi efici efi fin Office efi efi fin 344 Index efi difie f-eff N ific Thr ific fi fi fi Index 345 O Office Office Office Office Office Office Office Office efi P fl o-efficien ff ff Th defin ific definin ff 346 Index efi Thr efi eff efficien fi fin definin ffices, ff Q Index 347 R cific Th Th S defini efi eff ff-m efi 348 Index fi T efficien U ific V ffa W Index 349 Office Y Z 350 Index

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