US Political System: Federal Level

US Political System - Federal Level

• The US Federal Government is made up of three branches: Legislative, Executive, and Judicial

Legislative Branch - US Congress

• The US Congress is composed of the House of Representatives, which has 435 districts, and the Senate, which has two senators from each state
• Congress has the power to use any reasonable means not directly prohibited by the Constitution to carry out the will of the people, through the Tenth Amendment
• Congress can tax and spend, where the House of Representatives must initiate all revenue bills via the Origination Clause

Executive Branch

• The Executive Branch is led by the President of the United States, along with cabinet members and department heads
• The Executive branch crafts legislation that reflects the administration's preferred policies but cannot introduce legislation themselves
• The Executive branch attempts to convince legislators to enact those policies
• The Executive branch creates policy by establishing rules and regulations used to implement statutes and laws

Judicial Branch

• The US court system consists of District, Appellate, and Supreme Courts
• The Judicial branch can enforce legislation on behalf of the government as granted by the Constitution
• The Judicial branch can declare federal and state laws unconstitutional if asked
• Federal judges are appointed for life

The Policymaking Process

• There are three stages include policy formulation, policy implementation, and policy modification

Policy Formulation Stage: Agenda Setting

• This stage involves selecting a health problem as a policy target
• Factors include impact of the issue (magnitude/severity), public opinion (interest groups), presidential involvement (policy position), legislative interest, and media

Policy Formulation Stage: Federal Legislative Process

• A bill must be introduced in Congress
• The bill is assigned to a congressional committee
• Upon committee approval, the bill is scheduled for congressional consideration
• The Bill is passed in Congress
• The Bill must be introduced in each chamber, then reconciled by a special joint committee and then passed by Congress
• The Bill is presented to the president, who must sign or veto the bill

Policy Formulation Stage: Terminologies

• The Speaker of the House and Senate Majority Leader allow a bill to be introduced, or not, which gives them power
• Tabling legislation is an action undertaken by Congress (or a committee) to postpone consideration of legislation
• An amendment is a change or addition to current law or piece of legislation that can be unrelated to the purpose of the bill
• The President can veto a bill, which automatically becomes law if not vetoed
• A "Pocket veto" means In the last 21 days of session, bill may pass through congress, but not be signed into law so it is passive

Policy Formulation Stage: House and Senate Committees

• There are 14 committees and subcommittees in the House of Representatives, including Energy and Commerce, Appropriations, and Ways and Means
• There are 24 committees and subcommittees in the Senate, including Health, Education, Labor and Pensions, and Finance
• There are more than 60 legislative panels

Policy Implementation

• The US Department of Health and Human Services (DHHS) operating divisions include:
• Administration for Children and Families
• Administration on Aging
• Agency for Healthcare Research and Quality
• Agency for Toxic Substances and Disease Registry
• Centers for Disease Control and Prevention
• Centers for Medicare & Medicaid Services
• Food and Drug Administration
• Indian Health Service
• National Institutes of Health (NIH)
• Substance Abuse and Mental Health Services Administration
• Rule making, is published in the Federal Register
• Operation

Policy Implementation: Rule Making

• It is a process by which implementation agencies set detailed rules and regulations for the application of laws
• Experts agree on rules by which the new law will be enforced
• The Public may also have an opportunity to provide input
• Once rules or regulations are finalized, they become guidelines for operationalizing the law

Policy Implementation: Operation

• Legislation is operationalized by the specific HHS agency assigned to develop the regulations to implement or enforce it

Policy Implementation: Operation Requirements

• Ability to attain the policy objective depends on the presence of a host of requirements:
• The logic of the potential solution has to be sound
• The structure is in place
• Program activities are designed to reflect the policy intent and logic model
• Program activities are carried out effectively and efficiently
• Unintended outcomes cannot jeopardize continuation of the program
• External factors cannot jeopardize the impact of the program
• Events or influence from additional determinants

Policy Modification Stage

• Revisions to the rules or regulations pertaining to a piece of original legislation
• Policy modification takes place typically after policy implementation, during agenda setting, during legislation development, in rule making, and/or in operation
• It includes updating the logic model, addressing unintended consequences of implementation, conducting policy analysis and reevaluation
• It also addresses resource constraints, changing goals, interest group involvement/interference, oversight by three branches of government, and the incremental nature of policy development

Characteristics of Health Policymaking in the United States

• The government is in "subordinate role to the private sector in providing healthcare services"
• Policymaking by government is limited to addressing market failures and deficiencies, like the creation of Medicare for the elderly and Medicaid for the poor
• The government and its programs are fragmented

Fragmented Healthcare Programs: Funding of Health Insurance

• The Employed are predominantly covered by voluntary private insurance to which they and their employers make contributions
• The Elderly are funded by Social Security tax revenues (Medicare Part A) and government-subsidized voluntary insurance for physician, supplementary, and prescription drug coverage (Medicare Parts B and D)
• The Poor are covered by Medicaid, which is financed with federal, state, and local revenues
• Special population groups are covered by the federal government directly

Characteristics of Health Policymaking in the United States

• Incremental approach to reform is seen with the Medicaid's disjointed expansion in the 1980s and 1990s
• Congressional support is important when both congressional chambers are controlled by the same party
• When the president is of the same party affiliation, chances of success are even greater

The Role of Interest Groups in US Health Policymaking

• Well-organized interest groups, policy demanders, combine and concentrate their members’ resources
• They pursue an active agenda to influence all phases of policymaking, from formulation to implementation to modification
• Interest groups represent a variety of individuals and entities, and usually counterbalance each other

Role of Interest Groups

• Physicians' groups, like the American Medical Association and American Academy of Pediatrics, come together on issues that threaten the interests of physicians
• These groups work to address the reimbursement system, income maintenance, professional autonomy, and malpractice reform
• Senior citizens, like the AARP, assist people aged 50 or older by providing them with information, and advocate for their needs
• They advocates expansion of financing public benefits for the elderly for housing, food, income, and health
• The AARP supported Medicare Prescription Drug Improvement and Modernization Act and prescription drug benefits
• The American Hospital Association represents approximately 5,000 hospitals, health systems, and other providers of care in matters of national health policy development
• Its current interests include administrative simplification, reduction of bad debt write-offs, and profitability/sustainability
• America’s Health Insurance Plans represents over 1,000 health insurance companies, working to ensure affordable healthcare coverage which is expanded to include all Americans through universal coverage
• AHIP's interests include eliminating cost shifting and addressing the implications of administrative simplification
• Pharmaceutical Research Manufacturers of America represents US pharmaceutical research and biotechnology companies
• PhRMA supports efforts to discover new medicines, alerts its members to changes in health policy, and attempts to influence policy formulation related to the approval and monitoring of drugs and pharmaceutical