HHS Budget Analysis 2021-2022

Government and the Health Care System

• The role of government in the U.S. health care system has gradually developed over time
• The level of government involvement in providing health care in the U.S. is less than in any other industrialized country
• The government's role is significant despite being restricted compared to other countries

The Constitutional Basis of Governmental Authority in Health Care

• The amount the government spends justifies its significant role in health care delivery
• A basic principle of the U.S. Constitution is that sovereign power is shared between federal and state governments, known as federalism
• The U.S. Constitution is an agreement among the original 13 states to delegate some powers to a federal government
• The 10th Amendment to the Constitution reserves powers not delegated to the U.S. to the states or the people
• The "police power" is among the powers reserved to the states and forms the basis of their role in health
• Government authority in the states to regulate for public health protection and provide health services
• The authority doesn't need to be expressly stated, because it's a plenary power of every sovereign government
• State governments are sovereign for police power purposes, predating the federal government
• States delegate some of their health powers to local government creating a third tier
• The federal government's health authority is based on the powers to tax, spend for general welfare, and regulate interstate/foreign commerce
• The Constitution divides federal government power among the executive, legislative, and judicial branches
• The three branches have separate authority and responsibilities
• The Constitution spells out curbs on each branch's powers exercised by the others, known as checks and balances
• Judicial review, or the constitutionality of actions, is a check on the legislative and executive branches
• The state governments follow the tripartite form established under the U.S. Constitution, with checks, balances, and separation of powers
• Separation of powers may blur at the tertiary level of government

Health Care Functions of the Government

• The health care functions are: (a) purchase health care, (b) provide health care, (c) ensure access to quality care for vulnerable populations, (d) regulate health care markets, (e) support acquisition of new knowledge, (f) develop and evaluate health technologies and practices, (g) monitor health care quality, (h) inform health care decision-makers, (i) develop the health care workforce, and (j) convene stakeholders from across the health care system
• Each government branch has a unique role
• The legislative branch creates laws to safeguard public health, covering water supply and workplace health
• Legislatures determine the legal framework for the health care delivery system
• They authorize individuals/institutions to deliver services to specific people under set requirements
• Legislatures establish legal authority for government participation in health care financing, service delivery, and research support
• The judiciary supports the work of the other two branches of government
• The judicial branch has important powers relating to health and health services at all three levels of government
• In criminal law, the judiciary tries transgressors and determines punishment, working with law enforcement
• The state legislature creates licensing law for physicians, which the executive branch administers, and the judicial system determines guilt/innocence
• The criminal justice system safeguards public health through sanitary protection and pollution control legislation
• The judicial system handles disputes from health services, like malpractice litigation, in the civil arena
• It adjudicates contract cases in health care disputes between providers/patients and third-party payers
• It protects individual rights under the Constitution's Fifth and 14th Amendments
• The judicial and executive branches form the civil and criminal justice systems at federal, state, and local levels.
• The term "government in health care" refers to the executive branch that delivers services/regulations/financing
• The executive branch is not the legislature or the courts
• At the federal level, personal health services primarily cater to specific groups, including uniformed services, Native Americans, and military veterans
• State governments mainly offer personal health services to individuals with specific diseases, such as mental illness and tuberculosis.
• Local governments' personal health services are stratified by class and generally cater to the poor.
• Governments at all levels provide health services for prisoners, one category of person
• Government is the major provider of communitywide public health services at all levels
• These services include water supply, sewage disposal, food/drug inspection, communicable disease control, vital statistics, and environmental regulation
• Community health activities are shared with the private sector
• Government participates in health care financing by paying for the operation of its own programs, personal and community
• It pays directly through entities like the Department of Veterans Affairs (VA) hospital system or a municipal hospital for the poor
• Governments support health-related programs through grants and contracts to nongovernmental agencies
• The major role of government in financing is paying providers for care delivery through Medicare and Medicaid
• Federal, state, and local public funds accounted for about 49% of National Health Expenditures (NHE) in 2021
• The powers to tax/spend for general welfare and regulate interstate commerce provide the basis for most federal activity in the health arena
• The powers to tax/spend for general welfare and regulate interstate commerce provide the basis for most federal activity in the health arena
• The federal government's activities generally fall into four groups: (a) resource allocation, (b) information generation/distribution, (c) health care access assurance, and (d) regulation/enforcement
• The federal government collects/distributes funds to promote the nation's welfare
• Its spending funds its own projects/programs, finances contracts, and makes direct contributions like grants
• Federal government provides personal health services through Medicaid, Medicare, CHIP, community health centers and health care plans for active military

Department of Health and Human Services

• The DHHS is the most important federal actor in health and health care
• Two other federal agencies with major health care services responsibilities: the VA and the Department of Defense (DOD)
• Other agencies with responsibilities are the Department of Agriculture (USDA), the Environmental Protection Agency (EPA), and the DOL
• The DHHS aims to enhance health and well-being for all Americans
• The mission is pursued by providing for effective services and fostering scientific advances
• The DHHS has 12 operating divisions and administers over 100 health-related programs
• Programs address areas like health/biomedical research, disease prevention, primary care, and bioterrorism preparedness
• Programs protect health for all and serve those least able to help themselves
• The DHHS directly employed approximately 84,000 people and had a budget with $1.7 trillion in outlays in 2022
• About 80% of the budget funded Medicaid and Medicare programs
• The DHHS is vast, indicated by its many subagencies and offices
• Divisions carry out regulation, service provisioning, and financial support

Centers for Medicare & Medicaid Services

• CMS administers the largest insurance programs with a 2022 budget of approximately $1.4 trillion
• Programs: Medicare, Medicaid, CHIP, and the Basic Health Program (BHP)
• Medicare provides health insurance for people 65+, disabled, and those with end-stage renal disease
• Medicaid provides health coverage to low-income people
• CHIP provides states with federal matching funds to cover kids in families with incomes too high to qualify for Medicaid, but not high enough to afford private health insurance
• States may opt to implement the BHP to provide affordable coverage for those with income fluctuations above and below Medicaid/CHIP eligibility
• Health insurance coverage for millions of Americans provided due to these programs
• CMS administers the Center for Consumer Information and Insurance Oversight (CCIIO)
• The agency facilitates implementation of the Affordable Care Act, with CCIIO overseeing provisions related to private health insurance.

Health Resources & Services Administration

• HRSA's activities are mainly related to workforce development and ensure access to health care services
• HRSA aims to improve access to health care for underserved populations: the uninsured, isolated, or vulnerable
• It provides leadership and financial support to health care providers in all states and territories
• HRSA distributes funds to various community-based organizations, colleges, universities, hospitals, local and state governments, associations, and foundations.

Centers for Disease Control and Prevention

• Established 1946 as the Communicable Disease Center
• Plays roles of epidemiology, surveillance, and disease prevention
• Key functions include monitoring/reporting on the nation's health, detecting health problems/disease outbreaks, researching/implementing prevention strategies
• It also develops/advocates sound public health policies, promotes healthy behaviors, and provides public health leadership/training
• The nation's go-to agency for public health, is the voice of public health for the nation
• The CDC is home to expert scientists, researchers, analysts, and economists
• Staff travels worldwide for infectious disease outbreaks
• Publishes the MMWR containing information on reportable diseases, hazards, and emerging conditions
• The CDC prevents, controls, and detects communicable diseases
• Many units focus on noninfectious diseases and injuries
• Has three centers: NCIRD, NCEZID, NCHHSTP
• The NCHS collects and disseminates health data, being the premier organization
• It collects data from various sources
• The systems allows for, documentation of population and subpopulation health status
• The systems allow for, Identification of health and health care disparities by race or ethnicity, socioeconomic status, region, and other population characteristics
• The systems allow for, description of health care system experiences
• The systems allow for, monitoring health status and health care delivery trends
• The systems allow for, Identification of health problems
• The systems allow for, support of biomedical and health services research
• The systems allow for, provision of information for policy
• The systems allow for, evaluation of health policies and programs impact (NCHS, n.d.).
• Regulating drugs and most food products is the U.S. Food and Drug Administration (FDA)
• There are seven centers of the FDA

Other Federal Departments

• Substance Abuse and Mental Health Services Administration (SAMHSA) guides efforts to improve public health and behavioral well-being
• Many other federal departments have health services responsibilities
• Department of Veterans Affairs (VA) provides health services to veterans
• The Department of Defence (DOD) oversees health across the various branches of the military
• The United States Department of Agriculture (USDA) oversees a variety of services

State Government's Role in Health Care

• Federalism confers significant powers to the states, despite the federal government's influence
• States have lawmaking power related to public health under the 10th Amendment
• Each state can affect health care with autonomy, similarities not always from mandates
• Each state mirrors the federal government's legislative structure
• The governor is the highest elected state officer, with broad powers California passes laws that Alabama would likely not consider
• State public health departments are responsible for health care, preventive services, and policies
• States also involved in health care are: licensing, infectious disease control, medicaid program, health programs and collecting health statistics
• State autonomy depends on circumstances, can be overruled
• Federal and state relationships may change with legal challenges
• Courts previously affirmed abortion as a 14th amendment right, this was later reversed

Licensing

• Licensing is a basic government function in health care
• Licensing for practitioners sets minimum qualification standards
• It then determines who may deliver what health services
• Institutions are licensed to set minimum standards for each facility/personnel group
• It then determines the institution may operate
• Medical licensing significantly affects the health care delivery system
• Licenses give physicians control over the product of health care services and their structure

Controlling Infectious Diseases

• COVID-19 pandemic showed federalism's effect on state health care policy/practice
• At the pandemic's start, control measures including masking and social distancing
• After COVID-19 vaccine development vaccination was strongly encouraged, yet varied by state
• Some upheld mandates, other states provided exemptions
• States vary widely in their approach to childhood vaccinations, with differing medical, religious, and personal belief exemptions
• Medicaid programs serve low-income individuals, often the largest state budget item
• Administered by states with joint funding, each develops a program
• Programs vary due to differing state needs for the most part

Developing Innovative Health Programs

• State and local governments implement new ideas on a small scale, innovating health care practices in different areas
• States have value-based payment reforms
• MDAPM tested statewide all-payer system with capitated hospital payments.
• The MDAPM exempted Maryland hospitals from Medicare out/in patient
• Maryland's all-payer rate-setting system eliminates the payment differences

Collecting Health Statistics

• Analysis of vital statistics is among the oldest parts of the public health functions
• This function is between the states and the federal government's NCHS
• Authority to register births, deaths, marriages, divorces, fetal deaths resides with individual states
• States (and cities like NYC) are legal proprietors of records and data
• Responsible maintain laws that state for jurisdiction
• NCHS is the federal structure, cooperative relationship between states and the country
• This is managed and structured under various government agencies
• Health statistic data is the template for much of the health data collection in the United States
• Health statistic data includes reportable diseases, statistics and analysis.

Local Government's Role in Health Care

• Local communities can tailor implementation for local needs and conditions
• Local prerogatives include, medicolegal Death Investigations
• Conducted by a Coroner to determine why a person died. Unnatural and unexplained deaths of individuals are reported
• Death investigations may be needed to convict the guilty, and save the innocent
• The are criminal investigations related to malpractice or insurance claims
• Usually a state or county level task.
• Emergency Services include Fire departments, ambulance and police.
• They determine certain aspects of homelessness, mental health, and substance abuse.
• Municipal Health services include clinics, long-term, facilities, and other government organizations

Analyze changes in the U.S. Department of Health and Human Services (HHS) budget between 2021 and 2022. Questions cover program outlays, percentage increases, and trends. Evaluate mandatory programs and offsetting collections.