Health Policy

All policy involves decisions that influence the daily life of citizens. Longest (2010) has defined health policy as the authoritative decisions pertaining to health or health care, made in the legislative, executive, or judicial branches of government, that are intended to direct or influence the actions, behaviors, or decisions of citizens.

Although there are many definitions of policy and politics, policy generally refers to decisions resulting in a law or regulation. Politics refers to power relationships. It is the responsibility of a multitude of policymakers, whether mayors, county supervisors, government employees, legislators, governors, or presidents, to make health policy. Overall responsibility generally places authority with the legislative branch to crafts laws, the executive branch crafts rules to implement the laws, and the judicial branch interprets conflicts among the spheres of government, citizens, and a public or private entity. The federal government plays a substantial role in setting health policy, although to a far lesser degree than Canada or Great Britain, where policymakers have integrated, centralized, government-run health care systems. The federal government is a provider of health services via the prison system and Veterans Administration. However, for the most part, health care delivery is still largely under private sector control, making U.S. health policy development incremental, fragmented, and decentralized.

Politics

Politics is the process used to influence those who are making health policy. Politics introduces nonrational, divisive, and self-interested approaches to policymaking, often along ideological lines. Any political maneuvering to enhance one’s power or status within a group may be described as politics. Politics is largely associated with a struggle for ascendancy among groups having different priorities and power relationships. Preferences and interests of stakeholders and political bargaining (favor swapping) are important and extremely influential political factors that overlie the policymaking process. The self-interest paradigm suggests that human motives are not any different in political arenas than they are in the private marketplace. This behavioral assumption implies that it is rational for people and organizations to use the power of government to achieve what they cannot accomplish on their own. Ideally, elected officials seek office to serve the public interest, not their own. However, to be successful in the electoral process, they need electoral support through financial contributions, rendering them beholden to fundraising and funders (Feldstein, 2006). Highly politicized decisions may often create outcomes that have little to do with efficient use of scarce resources and what is best for the general public. These forces, which may or may not be based on evidence, contribute to the lack of coordination among health policies in the United States, making policy formulation highly complex and exceedingly interesting.

APN’s must engage in the political process to influence public policy and resource allocation decisions within political, economic, and social systems and institutions. APN political advocacy facilitates civic engagement and collective action, which may be motivated by patient-centered moral or ethical principles or simply to protect what has already been allocated. Advocacy can include many activities undertaken by a person or organization, such as media campaigns, public speaking, commissioning and publishing policy-relevant research or polls, and filing an amicus curiae (friend of the court) briefs. Lobbying as a political advocacy tool is only effective if a relationship between the lobbyist and legislator influences or shapes a policy issue. Social media for political advocacy is playing an increasingly significant role in modern politics (Non-Profit Action, 2012).

United States Differs from the International Community

The U.S. health system and political process for creating health care policy is unique in that the system is decentralized. In the United States, there is no single entity responsible for health care delivery, payment, or policymaking. There are many spheres of policymaking with overlapping authority involving a wide diversity of people, cultures, traditions, and illness patterns. Although the federal government may create broad guidelines, states, for the most part, have the autonomy to create policies that best serve their citizenry—hence, the large patchwork of public, private, local, state and federal entities. These can be operating as governmental, nonprofit, or for-profit entities, all of which are creating policies and/or delivering care. For most of the rest of the world, and in countries such as China, Switzerland, and the Netherlands, there is a highly centralized health authority for policymaking and care delivery. These nations, with centralized systems of care, are able to track the impact of their policy decisions more closely and build more tightly controlled surveillance systems to follow epidemics, immunization rates, spending, workforce, and other important markers of a strong health care system. Moreover, centralized health care systems limit the number of policymakers that need to be influenced, which can be a great advantage. Although there are a smaller number of people to influence, if those policymakers are strongly opposed to expanded APN practice or patient-centered care, centralization becomes disadvantageous. The unique U.S. public-private, federal-state, nonprofit and for-profit arrangements make it difficult to transport programs that are effective in other nations into the United States.

In a review of published literature, Docteur and Berenson (2009) tried to determine how the quality of U.S. health care compares internationally. Compared with other developed nations, life expectancy is shorter and rates of death from treatable conditions such as asthma and diabetes are higher in the United States. Their findings suggested no support for the oft-repeated claim that U.S. health care is the best in the world. The United States does relatively well in some areas, including cancer care, and less well in others, including chronic conditions amenable to prevention and coordinated management. The United States ranks below other nations in patient safety. The authors concluded that health reform is needed and will not diminish the areas of health care that are excellent (Docteur & Berenson, 2009). Exemplar 22-1 depicts the experience of nurse practitioners (NPs) who practice across the boundaries of two countries’ health care systems, Canada and the United States.

Longest Model

Longest (2010) has conceptualized policymaking as an interdependent process. The Longest model defines a policy formulation phase, implementation phase, and a modification phase (Fig. 22-1). This has immense usefulness for nursing because it illustrates the incremental and cyclical nature of policymaking, two of the most important features of the U.S. health care policymaking process. Essentially, all health care policy decisions are subject to modification because policymaking in the United States involves making decisions that are revisited when circumstances shift. Our system is not designed for big bold reform. Rather, it considers intended or unintended consequences of existing policy and tweaks changes (Longest, 2010).

Federalism

The locus of responsibility between the states and federal government is highly relevant to most health care programs, such as Medicare, Medicaid, the State Children’s Health Insurance Program (SCHIP) and the creation of an interoperable health information system. Federalism refers to the allocation of governing responsibility between the states and federal government. The states and federal government have a complex relationship governing health policy, which explains a large part of our chaotic and fragmented approach to health care in place today. Passage of the PPACA in 2010 requires states to expand access, enhance quality, and lower costs, albeit with a great degree of flexibility. The PPACA has amplified the tensions between federal mandates and states’ rights, to the degree that the Supreme Court had to clarify the constitutionality of the federal government’s powers in requiring individuals to purchase health insurance.

The Constitution unambiguously gives the federal government absolute power to preempt state laws when it chooses to do so. However, the states are also granted unfettered authority, such as regulation of health care professionals and health insurance plans (Bodenheimer & Grumbach, 2012). Ambiguity between state and federal authority allows states to experiment with policy solutions. The “states as learning laboratory” concept has grown out of local health policy problems and enables states to experiment with innovative policy solutions that could not be done on a national level. Moreover, states have local health care problems, requiring local, flexible, and humane solutions. Many federal health policy decisions are devolving decision making to the states, as evidenced by the increase in block grants (a large sum of money granted by the federal government to a state, with only general provisions as to the way it is to be spent, contrasted with a categoric grant, which has stricter and more specific provisions) and Medicaid waivers. Because much of health care is experienced at the local level, APNs must be aware of the overlapping state and federal spheres of government and the tension between their authorities.

Incrementalism

Although the policymaking process is a continuous interrelated cycle, most efforts to change policy stem from the negative effects of an existing policy. The modification phase creates a feedback loop to the agenda-setting process. This concept of continuous, often modest modification of existing polices is termed incrementalism. Major reforms of health policy are seen rarely, usually one in a generation, such as Medicare and Medicaid in 1965 and the PPACA in 2010. Minor changes of existing policies play out slowly over time and are therefore more predictable. Incrementalism promotes stability and stakeholder compromise. A good example of incrementalism is the gradual increase in federal spending for biomedical research from $300 in 1887 to more than $31 billion in 2013, going to NIH’s 27 institutes and centers. Within that structure, the National Center for Nursing Research was created in 1985 by a congressional override of a presidential veto as a result of the influence of strong nurse leaders. In 1993, the Center for Nursing Research was elevated to the Institute for Nursing Research and funded with $50 million; funding levels in 2013 will exceed $145 million.

The Kingdon Model

Agenda setting is a major component of the Longest policy formulation phase. With so many health policy problems in this country, why do some problems get attention and others languish at the bottom of the policy agenda for decades? Kingdon (1995) conceptualized an open policy window, with three conditions streaming through the open window at once. First, the problem must come to the attention of the policymaker; second, it must have a menu of possible policy solutions that have the potential actually to solve the problem; and third, it must have the right political circumstances. If all three of these conditions occur simultaneously, the policy window opens and progress can be made on the issue (Fig. 22-2). Conversely, once shut, this policy window (opportunity) may never open again.

Policy problems come to the attention of policymakers in a number of ways, including constituents, litigation, research findings, market forces, fiscal environment, crisis, special interest groups, and the media, singly or collectively. Wakefield (2008) has identified policy dynamics particular to agenda setting (Table 22-1). Additional dynamics have been added and each dynamic has one or more so-called accelerators, which drives the agenda setting or triggers policymakers to take action on an issue. The political circumstances that push problems onto the agenda must have a high degree of public importance and low degree of stakeholder conflict surrounding the policy solution. If there is a great deal of stakeholder disagreement, there may be competing proposals put forth, weakening the likelihood that the problem will be addressed. Strong health services research can provide the evidence base to help policymakers specify and therefore accelerate agenda setting (Longest, 2010).

Entitlement Versus Discretionary Spending

Federal spending has two categories. People who are entitled to benefits must meet eligibility rules (age, income); the three largest entitlement programs are Medicare, Medicaid, and Social Security. These three programs consume two thirds of federal spending and do not go through the appropriations process because they are permanently enacted. These large programs are expected to consume progressively more of the federal budget as the demographic shifts to an older population. However, most of the debate and discourse regarding federal health spending is centered around the more modest discretionary programs. Discretionary spending includes almost every other government service, including the military, post office, education, national parks, and health care workforce (e.g., nursing). Once a program is authorized through legislation, Congress will then assign a funding amount, an entirely different procedure, termed appropriations, or spending legislation. All discretionary programs, such as the Nurse Reinvestment Act, must have their funding renewed each year to continue operating and almost all health programs (other than Medicare and Medicaid) are discretionary. Discretionary programs make up one third of all federal spending and the President’s budget spells out how much funding is recommended for each discretionary program.

The federal budget process is not linear, in part because of the influence of stakeholders. Throughout the process, lobbyists and interest groups are vying to keep their funding cycle level or increased, depending on the fiscal and political circumstances.

Budget Cycle

The budget process begins with the President’s State of the Union Address (before the first Monday in February) to highlight the Executive Branch’s spending priorities for the upcoming fiscal year. The President’s budget guides the activities of the Office of Management and Budget (OMB) staff, appointed by the President to do the following: create the budget; communicate to Congress the President’s overall federal fiscal priorities; and propose specific spending recommendations for individual federal programs. The President’s budget is merely a suggestion until acted on by Congress. In February and March of each year, the House and Senate budget committees hold hearings on the proposed budget and these joint conference committees hammer out differences. On April 15, Congress passes a House-Senate budget resolution and no other spending bill can be considered until the budget resolution is adopted. Finally, the House and Senate appropriates or subdivides their allocations among the 13 appropriations subcommittees that have jurisdiction over specific spending legislation. If the appropriations process is not completed by October 1, Congress must adopt a continuing resolution to provide stop-gap funding (Congressional Research Service, 2011).

The budget resolution is not an ordinary bill, and therefore does not go to the President for his or her signature or veto. It requires only a majority vote to pass and is one of the few pieces of legislation that cannot be filibustered in the Senate.

Congressional Committees

There are over 200 Congressional committees and subcommittees, which are functionally structured to gather information, compare and evaluate highly specific legislative alternatives, identify policy problems and propose solutions, select, determine, and report measures for full chamber consideration, provide oversight to the executive branch, and investigate allegations of wrongdoing. Committee membership enables members of Congress to develop in-depth knowledge of the matters under their jurisdiction. There are more than 13 committees and subcommittees with jurisdiction over health care. In 1885, Woodrow Wilson said, “Congress in its committee rooms is Congress at work,” which still rings true today (Wilson, 1913).

The very first action that a committee can perform on a piece of legislation is not to take any action, which is equivalent to killing it. If the committee chair chooses to act on the legislation, the federal agency that would be affected by the legislation is queried for its opinions on the bill’s merit. The bill is assigned to a subcommittee and hearings may be held. Politically astute APN organizations will have developed relationships with committee staffers and seek invitations to testify before the committee. It is critical that the testimony has accurate data, is not purely self-serving, and attempts to solve the problem at hand. Subcommittees report their findings to the full committee, which holds a mark-up, session during which it will make revisions and additions. The House and Senate chambers must approve, change, or reject all committee amendments before conducting a final passage vote.

House or Senate Floor Action

The legislation is sent back to the entire House or Senate chamber for a vote and, if passed, is then sent to the other (House or Senate) chamber unless that chamber already has a similar measure under consideration. If either chamber does not pass the bill, it dies. If the House and Senate pass the same bill, it is sent to the President. If the House and Senate pass a different bill, which is more often the case, the bill goes to a conference committee. Members from the Senate and House form conference committees to work out the differences, with each chamber trying to maintain their version of the bill. Once the conference committee reaches a compromise, it prepares a written conference report, which must be voted on by both the House and the Senate and then signed into law by the President.

Presidential Action

A bill becomes law if signed by the President or if not signed within 10 days of receipt and Congress is in session. If Congress adjourns before the 10 days and the President has not signed the bill, it does not become law (termed a pocket veto). If the President vetoes the bill, it is sent back to Congress with a note listing her or his reasons. The chamber that originated the legislation can attempt to override the veto by a vote of two thirds of those present. If the veto is overridden in both chambers, it becomes law. Once a bill is signed by the President or his or her veto is overridden by both houses, it becomes a law and is assigned an official number with “PL” (public law) preceding it.

Interpretative Function of Rulemaking: Policy Implementation

Once the bill becomes public law, legislative activities shift to policy implementation in the executive branch. Rulemaking launches the formal regulatory process to operationalize fully what Congress has formulated. The executive agency responsible for implementing the law must make clear who is responsible for implementation and how it will be financed. These operational decisions are an important dimension of health policy and can have an enormous impact on health care. Regulations can be added, deleted, or modified at any time, making rulemaking a continuous process. Each federal agency has a number of public advisory bodies that inform the agency on rulemaking and policy. Serving on advisory bodies and engaging in the rulemaking process are key venues for APNs to influence policy. For example, the National Advisory Council on Nurse Education and Practice (NACNEP) of the Health Resources and Services Administration (HRSA) is an advisory body that advises the Secretary of the HHS and Congress on policy issues related to the Title VIII programs (nurse workforce supply, education, and practice improvement); HRSA’s National Advisory Council on Primary Care and Dentistry now requires the appointment of a nurse. Other important boards for APNs to serve on are each state’s highly influential board of nursing.