Longest's Health Policymaking in the United States (Chapter 1) PDF

CHAPTER HEALTH AND HEALTH POLICY 1 Learning Objectives...

CHAPTER HEALTH AND HEALTH POLICY 1 Learning Objectives After reading this chapter, you should be able to define health and describe health determinants; define public policy and health policy; begin to appreciate the important historical roles of Medicare and Medicaid; begin to appreciate the significance of the Patient Protection and Affordable Care Act (ACA); identify some of the important challenges for health policy; understand and distinguish between the two fundamental forms of health policies, allocative and regulatory; and understand the impact of health policy on health determinants and health. H ealth and its pursuit have long been woven tightly into the social and economic fabric of nations. Health is essential not only to the physical and mental well-being of people but also to nations’ economies. The United States spent about $3.5 trillion in pursuit of health in 2017, represent- ing about 17.9 percent of the nation’s gross domestic product (GDP) and Copyright © 2020. Health Administration Press. All rights reserved. equaling about $10,739 per person (CMS 2020a). This aggregate spending for healthcare and health services is referred to as National Health Expenditures (NHE). Exhibit 1.1 provides a projection of NHE. Because policymakers, particularly elected officials, often view this type of large abstract concept on an individual level, exhibit 1.2 brings the point a bit closer to home, as it displays the projected US healthcare expenditures per capita. Note the magnitude of the projected increase: approximately 60 percent over 10 years. Exhibit 1.2 also demonstrates NHE’s continued growth as a percent of GDP. Over time, the growth rate in the cost of healthcare continues to exceed the growth rate in the national economy. 11 Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com Meacham, M. R. (2020). Longest's health policymaking in the united states, seventh edition. Health Administration Press. Created from sdsu on 2025-01-28 23:02:31.  12 Lo n g es t ’s H e a l th Po l i c y ma k i n g i n th e U n i ted States EXHIBIT 1.1 Actual NHE, $7,000.0 2017, and $5,963.2 Projected NHE, $6,000.0 $5,650.8 $5,344.8 2018–2027 $5,048.7 $5,000.0 $4,767.1 (in billions) $4,501.5 $4,255.2 $4,031.1 $4,000.0 $3,823.1 $3,646.9 $3,492.1 $3,000.0 $2,000.0 $1,000.0 $0.0 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 Source: Adapted from CMS (2020b). Exhibit 1.3 provides an important comparison regarding the source of the money that pays for healthcare costs. The public insurance (Medicaid, Medi- care, Veterans Administration, Department of Defense) portion continues to grow and will pay for an increasing share of the total NHE. This growth EXHIBIT 1.2 Actual (2017) $18,000 20.0% and Projected $16,000 19.5% (2018–2027) $14,000 NHE per $12,000 19.0% Capita and as Copyright © 2020. Health Administration Press. All rights reserved. $10,000 Percentage of 18.5% GDP for 2017 $8,000 $6,000 18.0% $4,000 17.5% $2,000 $0 17.0% 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 Per capita spending $10,739 $11,121 $11,559 $12,087 $12,656 $13,281 $13,954 $14,660 $15,396 $16,148 $16,907 NHE as % of GDP 17.9% 17.8% 17.8% 17.9% 18.0% 18.2% 18.5% 18.7% 18.9% 19.2% 19.4% Per capita spending NHE as % of GDP Source: Adapted from CMS (2020a). Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com Meacham, M. R. (2020). Longest's health policymaking in the united states, seventh edition. Health Administration Press. Created from sdsu on 2025-01-28 23:02:31.  C hap ter 1: H ealth and H ealth Polic y 13 EXHIBIT 1.3 50.0% NHE by Source: 44.4% 45.0% 40.7% Actual 2017 and 40.0% Projected 2027 33.9% 35.0% 31.8% 30.0% 25.0% 20.0% 15.0% 13.9% 15.0% 10.5% 9.8% 10.0% 5.0% 0.0% Public Insurance Other Third-Party Out of Pocket Private Insurance Payers 2017 actual Projected 2027 Source: Adapted from CMS (2020b). is primarily attributable to the increase in Medicare expenditures, because of the growing percentage of elderly in the population and their greater use of healthcare resources, and Medicaid, because of the expansion funded in part by the Affordable Care Act. Thus, it is not surprising that governments at all levels are keenly interested in health and how it is pursued. As will be discussed throughout this book, government’s interest is expressed largely through public policy. The projections forecast that, in less than a decade, absent a significant event to change the course of events, nearly one-half of NHE will most likely come from public sources. The proportion of NHE provided by private insur- ance will decline slightly, as will out-of-pocket expenditures and funding from other third-party payers. (This category includes things such as workplace clinics, workers’ compensation, vocational rehabilitation, and others, some of Copyright © 2020. Health Administration Press. All rights reserved. which are also publicly sourced [Sisko et al. 2019]). Despite government’s substantive role through health policy, most of the necessary clinical, diagnostic, and ancillary resources used in the pursuit of health in the United States are owned and controlled by the private sec- tor. This unique public–private connection means that when government is involved in the pursuit of health for its citizens, it often seeks broader access to health services—for classes of people (Medicare: elderly and disabled people; Medicaid: the indigent) or to obtain broader access for everyone to address specific disease states (polio and flu vaccines)—that are provided predomi- nantly through the private sector. While the private sector owns or controls the majority of the resources, government’s role has expanded over time (as examined in detail in chapter 4). Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com Meacham, M. R. (2020). Longest's health policymaking in the united states, seventh edition. Health Administration Press. Created from sdsu on 2025-01-28 23:02:31.  14 Lo n g es t ’s H e a l th Po l i c y ma k i n g i n th e U n i ted States The long-established Medicare and Medicaid programs provide clear examples of this public–private approach, which is continued in the more recent expansion of insurance coverage in the Patient Protection and Affordable Care Act (P.L. 111-148) of 2010. The ACA, as it is known, continues the pattern of using public dollars to purchase services in the private sector for beneficiaries, as is done under Medicare and Medicaid. These policies are critically important to understanding health policy and its effect on health in the United States. Appendix 1.1 provides an overview of the ACA, and appendix 1.2 offers similar summaries of the Medicare and Medicaid programs. This book explores the intricate public policymaking process through which government influences the pursuit of health in the United States. The primary focus is on policymaking at the federal level, although much of the information also applies to state and local levels of government. This chapter discusses the basic definitions of health, health determinants, and health policy and their relationships to one another. Chapter 2 describes the context in which policymaking takes place. Chapter 3 discusses the dynamic nature of federal- ism and its impact on health policy, underscoring the different responsibilities between the federal and state governments. Chapter 4 presents a model of the public policymaking process and specifically applies this model to health policymaking. Building on the foundational material presented in the first four chapters, subsequent chapters cover in more detail the various interconnected components of the policymaking process. Chapter 10 concludes the book with attention to how health professionals, whether managers or clinicians, can build a more comprehensive and integrated, therefore more useful, level of policy competence. In this book, policy competence simply means that health professionals understand the policymaking process sufficiently to exert some influence and achieve their goals—improved healthcare services delivery. The path toward policy competence begins with some key definitions—of health, health determinants, public policy, and health policy. Copyright © 2020. Health Administration Press. All rights reserved. Health Defined A careful definition of health is important because it gives purpose to any consideration of health policy. Being precise about what causes or determines health is similarly important. As will be discussed more fully later, policy affects health through its impact on the determinants of health. The World Health Organization (WHO; www.who.int) defines health as the “state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity,” a definition first appearing in the organiza- tion’s constitution in 1946 and continuing unchanged through today (WHO 1946). Other definitions have embellished the original, including one that Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com Meacham, M. R. (2020). Longest's health policymaking in the united states, seventh edition. Health Administration Press. Created from sdsu on 2025-01-28 23:02:31.  C hap ter 1: H ealth and H ealth Polic y 15 says health is “a dynamic state of well-being characterized by a physical and mental potential, which satisfies the demands of life commensurate with age, culture, and personal responsibility” (Bircher 2005). Another variation on the definition views health as a “state in which the biological and clinical indica- tors of organ function are maximized and in which physical, mental, and role functioning in everyday life are also maximized” (Brook and McGlynn 1991). Yet another definition adds the concept of health as a human right by saying health is “a condition of well-being, free of disease or infirmity, and a basic and universal human right” (Saracci 1997). The former European commissioner for health and consumer protection provides a definition with an important expansion by considering good health as “a state of physical and mental well- being necessary to live a meaningful, pleasant, and productive life” and further noting that “good health is also an integral part of thriving modern societies, a cornerstone of well performing economies, and a shared principle of... democracies” (Byrne 2004). The WHO definition, especially as embellished with considerations of health as a right and a key principle of most democracies, not only permits consideration of the well-being of individuals and the health of the larger communities and societies they form, but also facilitates assessments of govern- mental performance in promoting health (Shi 2019). Throughout this book, health is defined as WHO defined it long ago, as its foundation has withstood the test of time: Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. Health is important in all nations, although the resources available for its pursuit vary widely. Current international health expenditure comparisons for the member countries of the Organisation for Economic Co-operation and Development (OECD), all of which share a commitment to democratic government and market economies, reflect some of this variation and are avail- Copyright © 2020. Health Administration Press. All rights reserved. able online at www.oecd.org. The relative importance that leaders and citizens of nations place on the health of their populations is partially reflected in the proportions of available resources devoted to the pursuit of health. Exhibit 1.4 shows per capita health spending and percentage of GDP devoted to health in selected countries. The other important lesson in exhibit 1.4 is the clear “most expensive in the world” position of the United States in spending for healthcare services. By whatever measure, the US spends more on healthcare services than any other nation: in total dollars, dollars per capita, or percentage of the GDP. But does that spending represent value? Are we getting a good return for our investment? More about this later in the chapter, but the short answer for Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com Meacham, M. R. (2020). Longest's health policymaking in the united states, seventh edition. Health Administration Press. Created from sdsu on 2025-01-28 23:02:31.  16 Lo n g es t ’s H e a l th Po l i c y ma k i n g i n th e U n i ted States EXHIBIT 1.4 2017 NHE of $12,000 16.9 18.0 Selected OECD $10,586 16.0 $10,000 14.0 Countries per $8,000 12.0 Capita and as a 10.0 $6,000 Percentage of 8.8 8.0 $3,992 GDP (in dollars) $4,000 6.0 4.0 $2,000 2.0 $– 0.0 OECD CAN FRA DEU ITA JPN NLD NOR POL ESP SWE CHE GBR USA Avg Per Capita Expenditure $4,974 $4,965 $5,986 $3,428 $4,766 $5,288 $6,187 $2,056 $3,323 $5,447 $7,317 $4,070 $10,586 $3,992 Percentage of GDP 10.7% 11.2% 11.2% 8.8% 10.9% 9.9% 10.2% 6.3% 8.9% 11.0% 12.2% 9.8% 16.9% 8.8% Per Capita Expenditure Percent of GDP Source: Adapted from OECD (2019). the moment is no: the US does not obtain good results, especially in light of costs, in a number of metrics intended to elucidate the quality of a healthcare system. Over time, the United States has opted for policies resulting in the most expensive healthcare system in the world. Although it is beyond the scope of this book to address how and why that came to be, you will see some interest- ing comparisons in the following sections. Important to appreciating the role health policy plays in the pursuit of health is the fact that health is a function of several variables, referred to as health determinants. The existence of multiple determinants provides governments with a wide variety of ways to intervene in any society’s pursuit of health. Health determinants are defined as factors that affect health or, more formally, as a “range of personal, social, economic, and environmental fac- Copyright © 2020. Health Administration Press. All rights reserved. tors that influence health” both at the individual and population levels (HHS 2020). The question of what determines health in humans has been of interest for a long time. An important early theory about the determinants of health was the Force Field paradigm (Blum 1974). In this theory, four major influences, or force fields, determine health: environment, lifestyle, heredity, and medical care. In another conceptualization, the determinants are divided into two categories (Dahlgren and Whitehead 2006). One category, named fixed fac- tors, is unchangeable and includes such variables as age and gender. A second category, named modifiable factors, includes lifestyles, social networks, com- munity conditions, environments, and access to products and services such as education, healthcare, and nutritious food. Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com Meacham, M. R. (2020). Longest's health policymaking in the united states, seventh edition. Health Administration Press. Created from sdsu on 2025-01-28 23:02:31.  C hap ter 1: H ealth and H ealth Polic y 17 EXHIBIT 1.5 Determinants of Physical Health Environment Access to Care Behaviors Health Socioeconomic Biological Conditions Factors Source: Adapted from CDC (2019). The research on determinants of health, which is now extensive, has led to a holistic approach to health determinants. The determinants are ­catalytic with one another. For individuals and populations, health deter- minants include the physical environments in which people live and work; people’s behaviors; their biology (genetic makeup, family history, and acquired physical and mental health problems); social factors (including economic circumstances, socioeconomic position, and income distribution; discrimination based on such factors as race and ethnicity, gender, and sexual orientation; and the availability of social networks or social support); and their access to health services. Exhibit 1.5 provides a visual representation of how these variables interact with one another, contributing to overall health. Scientists generally use the five determinants of health shown in exhibit 1.5 (CDC 2019). Another inclusive perspective on what factors determine health in Copyright © 2020. Health Administration Press. All rights reserved. humans is reflected in Healthy People 2020 (www.healthypeople.gov), a com- prehensive national agenda for improving health. Note that there are slight differences between the determinants advanced by the Centers for Disease Control and Prevention (CDC) and those that are part of a national health agenda. Why the differences? No one knows for certain, but consider the fact that the US health system has two components: public health and health- care services. Note that Healthy People 2020 is a function of the Office of Disease Prevention and Health Promotion in HHS. This agency is engaged in the public health function of advocacy and, therefore, would consider policymaking to be a health determinant. The following box provides a list of health determinants and brief definitions adapted from Healthy People 2020 (HHS 2020). Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com Meacham, M. R. (2020). Longest's health policymaking in the united states, seventh edition. Health Administration Press. Created from sdsu on 2025-01-28 23:02:31.  18 Lo n g es t ’s H e a l th Po l i c y ma k i n g i n th e U n i ted States Health Determinants Biology refers to the individual’s genetic makeup (those factors with which they are born), family history (which may suggest risk for disease), and physical and mental health problems acquired during life. Aging, diet, physical activity, smoking, stress, alcohol or illicit drug abuse, injury or violence, or an infectious or toxic agent may result in illness or disability and can produce a “new” biology for the individual. Behaviors are individual responses or reactions to internal stimuli and external conditions. Behaviors can have a reciprocal relationship with biology; in other words, each can affect the other. For example, smoking (behavior) can alter the cells in the lung and result in shortness of breath, emphysema, or cancer (biology), which then may lead an individual to stop smoking (behavior). Similarly, a family history that includes heart disease (biology) may motivate an individual to develop good eating habits, avoid tobacco, and maintain an active lifestyle (behaviors), which may prevent their own development of heart disease (biology). An individual’s choices and social and physical environments can shape their behaviors. The social and physical environments include all factors that affect the individual’s life—positively or negatively—many of which may be out of their immediate or direct control. Social environment includes interactions with family, friends, coworkers, and others in the community. It encompasses social institutions, such as law enforcement, the workplace, places of worship, and schools. Housing, public transportation, and the presence or absence of violence in the community are components of the social environment. The social environment has a profound effect on individual and community health and is unique for each individual Copyright © 2020. Health Administration Press. All rights reserved. because of cultural customs; language; and personal, religious, or spiritual beliefs. At the same time, individuals and their behaviors contribute to the quality of the social environment. According to the CDC, policymaking at the local, state, and federal level affects individual and population health. An increase in taxes on tobacco sales, for example, can improve population health by reducing the number of people using tobacco products. Some policies affect entire populations over extended periods of time while simultaneously helping to change individual behavior. For example, the 1966 Highway Safety Act and the National Traffic and Motor Vehicle Safety Act authorized the federal government to set and regulate standards Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com Meacham, M. R. (2020). Longest's health policymaking in the united states, seventh edition. Health Administration Press. Created from sdsu on 2025-01-28 23:02:31.  C hap ter 1: H ealth and H ealth Polic y 19 for motor vehicles and highways. This led to an increase in safety standards for cars, including seat belts, which in turn reduced rates of injuries and deaths from motor vehicle accidents. Public- and private-sector programs and interventions can have a powerful and positive effect on individual and community health. Examples include health promotion campaigns to prevent smoking; public laws or regulations mandating child restraints and seat belt use in automobiles; disease prevention services, such as immunization of children, adolescents, and adults; and clinical services such as enhanced mental health care. Programs and interventions that promote individual and community health, such as fitness or exercise programs, may be implemented by public agencies, including those that oversee transportation, education, energy, housing, labor, and justice, or through such private-sector endeavors as places of worship, community-based organizations, civic groups, and businesses. Quality health services can be vital to the health of individuals and communities. Expanding access to services could eliminate health disparities and increase the quality of life and life expectancy of all people living in the United States. Health services in the broadest sense include not only those received from health services providers but also health information and services received from other venues in the community. Source: Adapted from HHS (2020). Nations differ in the relative importance they assign to addressing the various determinants of health. For example, among the OECD nations, the United States ranks first in health expenditures but twenty-fifth in spending on social services. This expenditure pattern reflects a particular prioritization Copyright © 2020. Health Administration Press. All rights reserved. among determinants and is not necessarily the most cost-effective pattern. For example, the 1.5 million people in the United States who experience homeless- ness in any given year use disproportionately more costly acute care services (Doran, Misa, and Shah 2013). Not only do nations prioritize health determinants differently, but people, as individuals and populations, vary in their health and health-related needs. The population of the United States is remarkably diverse in age, gender, race and ethnicity, income, and other factors. Current census data put the US population at approximately 327 million people; 16 percent of them are older than 65. Persons of Hispanic or Latino origin make up about 18.3 percent of the population, and African Americans constitute approximately 13.4 percent of Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com Meacham, M. R. (2020). Longest's health policymaking in the united states, seventh edition. Health Administration Press. Created from sdsu on 2025-01-28 23:02:31.  20 Lo n g es t ’s H e a l th Po l i c y ma k i n g i n th e U n i ted States the population (US Census Bureau 2019). These demographics are important when considering health and its pursuit. Older people consume relatively more health services, and their health- related needs differ from those of younger people. Older people are more likely to consume long-term care services and community-based services intended to help them cope with various limitations in the activities of daily living. In discussing health and the healthcare system, we frequently encounter populations of people—minorities and the poor in particular—who do not enjoy the same level of health as others or who do not have the same kind of access to care as others. These differences are referred to as disparities. Healthcare disparities and health disparities, although related, are not the same. Health- care disparities refer to differences in such variables as access to care, insurance coverage, and quality of services received. Health disparities occur when one population group experiences higher burdens of illness, injury, death, or dis- ability than another group. The healthcare system continues to confront the challenge of eliminating health and healthcare disparities. There is evidence that the ACA contributed to reducing disparities that existed for Hispanics and African Americans (Hayes et al. 2017). In recent years, policymakers have paid greater attention to racial and ethnic disparities in care, with notable, although unfinished, progress. Congress directed the Institute of Medicine (IOM; www.iom.edu) to study health disparities and established the National Center on Minority Health and Health Disparities at the National Institutes of Health (NIH; www.nih. gov). Congress also required the Department of Health and Human Services (HHS; www.hhs.gov) to report annually on the nation’s progress in reduc- ing healthcare disparities and health disparities (HHS 2014). There are some differences in how each agency sees “disparity” because one is dealing strictly with the science of health determination (NIH), while the other is also dealing with the disparities created in access to care (HHS). The IOM (2002) report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care called for a multilevel strategy to address Copyright © 2020. Health Administration Press. All rights reserved. potential causes of racial and ethnic healthcare disparities, including raising public and provider awareness of racial and ethnic disparities in healthcare, expanding health insurance coverage, improving the capacity and quantity of providers in underserved communities, and increasing understanding of the causes of and interventions to reduce disparities. Progress in pursuing this multifaceted strategy continues, and it received a substantial boost from the passage of the ACA. Among the ACA’s numerous Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com Meacham, M. R. (2020). Longest's health policymaking in the united states, seventh edition. Health Administration Press. Created from sdsu on 2025-01-28 23:02:31.  C hap ter 1: H ealth and H ealth Polic y 21 goals, two of the most important are to reduce the number of uninsured people and to improve access to healthcare services for all citizens (Garfield, Orgera, and Damico 2019; Williams 2011). In spite of progress, continued racial disparity is easily identified. For example, an African American woman is 22 percent more likely to die from heart disease than her white counterpart, 71 percent more likely to die from cervical cancer, and 243 percent more likely to die from pregnancy- and childbirth- related causes (Hostetter and Klein 2018). As a matter of equity, statistics like these are unacceptable. Researchers are learning more about how health status is affected by income and other socioeconomic factors. Wealthier Americans tend to be in better health than their poorer counterparts primarily because of differences in education, behavior, and environment. Higher incomes permit people to buy healthier food; live in safer, cleaner neighborhoods; and exercise regularly (Luhby 2013). Exhibit 1.6 demonstrates this absence of equity in terms of access to care relative to income: the higher the income, the more likely one is to be able to access care, receive care, and be more satisfied with the care one receives. However, low income does not necessarily mean poorer health. In part, the impact of income depends on what government does about supporting people with low incomes. A national survey has shown that the income vari- able interacts importantly with the extant health policy in the various states (Schoen et al. 2013). Using 30 indicators of access, outcomes, prevention, and quality, the survey documents sharp healthcare disparities among states, revealing up to a fourfold disparity in performance for low-income popula- tions. The most important conclusion of this survey is that “if all states could reach the benchmarks set by leading states, an estimated 86,000 fewer people would die prematurely and tens of millions more adults and children would receive timely preventive care” (Schoen et al. 2013). Although its population is diverse, several widely, though not universally, shared values directly affect the approach to healthcare in the United States. Copyright © 2020. Health Administration Press. All rights reserved. EXHIBIT 1.6 400% FPL Access to Care by Income Level Relative to 25 Federal Poverty 23 6 7 17 10 4 3 19 6 4 Level (FPL) 15 11 1 7 No usual source Delayed getting Couldn’t afford Problems paying Dissatisfied with of care care prescriptions medical bills care Source: Commonwealth Fund (2018). Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com Meacham, M. R. (2020). Longest's health policymaking in the united states, seventh edition. Health Administration Press. Created from sdsu on 2025-01-28 23:02:31.  22 Lo n g es t ’s H e a l th Po l i c y ma k i n g i n th e U n i ted States For example, many Americans place a high value on individual autonomy, self-determination, and personal privacy and maintain a widespread, although not universal, commitment to justice. Other societal characteristics that have influenced the pursuit of health in the United States include a common deep- seated belief in the potential of technological rescue and a cultural preference for the prolonging of individual life regardless of the monetary costs (although this attitude is changing). These values shape the private and public sectors’ efforts related to health, including the elaboration of public policies germane to health and its pursuit. They also influence the prioritization of attention to the various determinants of health. Defining Health Policy A suitable context is necessary to understand the essence of health policy fully. First, it is important to realize that policy is made in both the private sector and the public, or governmental, sector. Policy is made in all sorts of organi- zations, including corporations such as Google, institutions such as the Mayo Clinic, health insurance companies, pharmaceutical companies, and govern- ments at federal, state, and local levels. In all settings, policies are officially or authoritatively made decisions for guiding actions, decisions, and behaviors of others (Longest and Darr 2014). The decisions are official or authoritative because they are made by people who are entitled to make them based on their positions in their entities. Executives and other managers of corporations and institutions are entitled to establish policies for their organizations because they occupy certain positions. Similarly, in the public sector, certain people are positionally entitled to make policies. For example, members of Congress are entitled to make certain decisions, as are executives in government or members of the judiciary. Policies made in the private sector can certainly affect health. Examples include authoritative decisions made in the private sector by executives of Copyright © 2020. Health Administration Press. All rights reserved. healthcare organizations about such issues as their product lines, pricing, and marketing strategies. Insurance companies also fall into this group, as they determine the breadth and depth of the coverage they provide. Official or authoritative decisions made by such organizations as The Joint Commission (www.jointcommission.org), a private accrediting body for health-related orga- nizations, and the National Committee for Quality Assurance (www.ncqa.org), a private organization that assesses and reports on the quality of managed care plans, are also private-sector health policies. This book focuses on the public policymaking process and the public-sector health policies that result from this process. Private-sector health policies, however, also play vital roles in the ways societies pursue health. Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com Meacham, M. R. (2020). Longest's health policymaking in the united states, seventh edition. Health Administration Press. Created from sdsu on 2025-01-28 23:02:31.  C hap ter 1: H ealth and H ealth Polic y 23 Public Policy There are many definitions of public policy but no universal agreement on which is best. For example, Peters (2013, 4) defines public policy as the “sum of government activities, whether acting directly or through agents, as those activities have an influence on the lives of citizens.” Birkland (2001) defines it as “a statement by government of what it intends to do or not to do, such as a law, regulation, ruling, decision, or order, or a combination of these.” Cochran and Malone (1999) propose yet another definition: “Political deci- sions for implementing programs to achieve societal goals.” Drawing on these and many other definitions, we define public policy in this book as authoritative decisions made in the legislative, executive, or judicial branches of government that are intended to direct or influence the actions, behaviors, or deci- sions of others. The phrase authoritative decisions is crucial in this definition. It specifies deci- sions made anywhere in the three branches of government—and at any level of government—that are within the legitimate, official purview of those making the decisions. The decision-makers can be legislators, executives of government (presidents, governors, cabinet officers, heads of agencies), or judges. Part of these roles is the legitimate right—indeed, the responsibility—to make certain decisions. Legislators are entitled (and expected) to decide on laws, executives to decide on rules to implement laws, and judges to review and interpret deci- sions made by others. Exhibit 1.7 illustrates these relationships in conceptual form, while the policy snapshot at the beginning of part 1 demonstrates how this looks in the real world. In the United States, public policies—whether they pertain to health or to defense, education, transportation, or commerce—are made through a dynamic public policymaking process. This process, which is discussed in chap- ter 3, involves interaction among many participants in three interconnected phases: formulation, implementation, and modification. Copyright © 2020. Health Administration Press. All rights reserved. Health Policy Health policy is but a particular version of public policy. Public policies that pertain to health or influence the pursuit of health are health policies. Thus, we can define public-sector health policy as authoritative decisions regarding health or the pursuit of health made in the legis- lative, executive, or judicial branches of government that are intended to direct or influence the actions, behaviors, or decisions of others. In the policy snapshot introducing part 1, “The Affordable Care Act: A Cauldron of Controversy,” Congress and the executive branch sought to Copying and distribution of this PDF is prohibited without written permission. For permission, please contact Copyright Clearance Center at www.copyright.com Meacham, M. R. (2020). Longest's health policymaking in the united states, seventh edition. Health Administration Press. Created from sdsu on 2025-01-28 23:02:31.  24 Lo n g es t ’s H e a l th Po l i c y ma k i n g i n th e U n i ted States EXHIBIT 1.7 Roles of Three Ex y lic ecu Branches of Po tiv Government in ins tes eB ma Policymaking ula cy ms ran do P ro rm r p gra Ap ulga ch Fo pro tes m the pro Im oses toes d reg Pro s or les a Im o li ch ple ve ple p h o lth an oli nds ws me egis legis latio wit hea me Br s la nts lati lati ns v nts ru l ive e ct law on on he es a Ena lat Po f u s gis cy