US Health Policy: Values, Reform, and Definition

Foundational Values for Health Policy

• The US healthcare system is complex, fragmented, and imperfect
• The US spends the most on healthcare, but has poorer outcomes than most OECD countries
• Factors like homicide, suicide, and drug use may contribute to poorer outcomes
• Healthcare is available to all, however, the best care isn't attainable for everyone
• Healthcare outcomes are influenced by political, legislative, and judicial processes

Healthcare Reform

• Case studies include healthcare reforms pursued by Hillary Clinton and Barack Obama
• Also addressed is the Healthcare Reform after the Affordable Care Act (ACA)

Health Defined

• Health is defined as the state of complete physical, mental, and social well-being, not merely the absence of disease or infirmity
• The World Health Organization (WHO) defined it in 1946
• The US has not ratified this definition, and there is no universally accepted definition in the US
• Personal characteristics and choices affect the definition

Measures of Health

• Physical health is measured by:
  • Life expectancy, Mortality, Morbidity, Disability, and Quality of life
• Mental health accounts for 5.5% of all healthcare spending
  • It is measured by mental conditions, behaviors, perceptions, satisfaction, and services received
• Social well-being is measured by:
  • Socioeconomic status, including income, education, and occupational status
  • Quality of life, referring to the ability to perform certain roles, perceptions, and navigate one's living environment
  • Social contacts and resources, encompassing community, family, friends, church, school, and work

Public Health Defined

• Public Health is the science and art of preventing disease, prolonging life, and promoting health through sanitation, infection control, personal hygiene education, and medical service organization
• Winslow defined it in 1920
• The American Public Health Association defines two main goals:
  • Preventing disease and promoting good health within groups of people
  • Performing research and surveillance to comprehend health issues and develop effective health policies

Public Health vs Population Health

• Both differ from "Medical Care" but can interact with it
• Traditionally, Public Health addresses factors impacting health directly, like clean water and vaccinations
• Population Health seeks to identify and address less direct factors (determinants of health) such as poverty, social supports, and connectivity
• The two disciplines are beginning to merge

Population Health Model

• The approach seeks to explain and intervene in the reasons for systematic health differences among groups
• Health of the population is improved by enhancing the health of its subgroups
• It analyzes patterns/distribution of health between groups to identify factors causing outcome differences
• "Upstream" factors can influence health through sequences not immediately visible
• Health disparities will exist as subgroups always exist, but efforts should minimize the negative impact of these disparities

Health Policy Defined

• It pertains to or influences the attainment of health
• It includes the principles that guide the distribution of resources, services, and political influences that affect population health
• Health policy impacts public health as well as population health
• Health policy influences components in the determinants-of-health framework directly/indirectly
• It affects groups or classes of individuals/organizations
• Health policy and healthcare policy are synonymous

Underlying Values of Health Policy

• The healthcare system should reflect the values of policymakers and citizens
• A market approach distributes healthcare based on people's willingness to pay
• A social justice approach allocates care based on need
• Personal freedom is also important

Determinants of Health

• Health determinants arise from five domains that affect each other
  • Social and economic environment (e.g. income, education, social support, culture)
  • Physical environment (e.g. urban design, housing, air/water safety, environmental toxins)
  • Genetics and epigenetics (study of gene–environment interactions)
  • Medical care, including prevention, treatment, and disease management
  • Health-related behaviors (e.g. smoking, exercise, diet)
• Reverse causality is when health status influences determinants of health

Influence of Health Determinants

• Medical care differs from other goods and services because:
  • Demand comes from health needs
  • There is an agency relationship between providers and patients due to information asymmetry
  • Healthcare pricing varies based on who pays the fees, causing market failure
  • Provision depends on environmental factors with multiple interacting sub-markets
  • Trump's Executive Order on Hospital Price Transparency sought to break up sub-markets

Types of Health Policy

• Regulatory policy seeks to control particular group behaviors by surveillance and sanctions for non-compliance
  • Examples include public smoking bans, professional licensing, and FDA oversight
• Allocative policy provides income, services, or goods to certain individuals, groups, or institutions
  • Distributive policies offer benefits for all, such as funding research and public health promotion
  • Redistributive policies take resources from one group and give them to another, such as Medicaid, Medicare, and Social Security

Framework of Health Policy Formulation

• Broad determinants of health policy:
  • The nature of the health problem
    • Magnitude: its reach (how many affected)
    • Severity: how deadly/urgent
  • Sociocultural norms
    • Reflect society/group values, beliefs, attitudes, and behaviors
  • Political system
    • Democratic vs single party
      • Reflects desires of the populace, divisive, incremental
• Narrow Determinants of Health Policy:
  • Potential solutions to the identified health problem via policy research
  • Views and efforts of stakeholders collaborative or competitive
  • Availability of resources needed to implement the policy: financial and administrative feasibility
  • Demonstrated leadership of policymakers

Stakeholders in Health Policy

• Stakeholders are entities or individuals directly or indirectly involved in developing policy
• Stakeholders influence formulation, implementation, and modification, but are not a homogeneous group
• Interest groups or non-governmental organizations represent a unified position on health issues
  • Common examples include lobbying by organized interest groups

Stakeholders

• Consumers and patients are intended beneficiaries of health policy
• Healthcare providers value autonomy, prestige, and expertise
• Healthcare organizations deliver care and seek financial well-being
  • Resource allocation decisions that balance these goals
• Payers and insurers
  • Private insurers maintain their share of the market and remain profitable
  • Public insurers ensure coverage for vulnerable populations at reasonable prices
• Regulators aim to provide availability of services (access), high quality, and cost containment
• Medical device and pharmaceutical manufacturers seek payment for their products, R&D
• Educational and research institutions define the type/quantity of healthcare providers, and types of research to be done
• Businesses and Corporations focus on:
  • Regulations on insurance requirements
  • Aim to minimize costs while retaining healthy employees

Importance of Studying Health Policy

• Studying is the first step toward influencing it and allows for engaging in improvements
• It influences population health because it is integral to health determinants, and influences the others.