Health Policy

Health Policy

Anne Deutsch

Betty Smith-Campbell

The purpose of the healthcare system must be to continuously reduce the impact and burden of illness, injury, and disability and to improve the health and functioning of the people of the United States.

—The President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry: Final Report, 1998


For individuals with chronic illness, access to high-quality healthcare services that are safe, effective, patient centered, timely, efficient (affordable), and equitable is critical. Although many Americans receive high-quality healthcare services, others receive care that is substandard (The President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry, 1998). Much of the work that healthcare professionals perform and experience as they deliver care to patients is influenced by laws, regulations, and other policies. For example, policy affects the availability of affordable health insurance for individuals and families, coverage of home health care, outpatient therapy, and durable medical equipment. Further, changes in health policy can positively or negatively affect access to the healthcare delivery system and the quality of care delivered.

Increasingly, nurses are expected to have knowledge of key health policy issues and the policy development process. This knowledge is fundamental for nurses who want to improve the healthcare delivery system by influencing the policymaking process. To have an impact on patient care and nursing practice, nurses should be able to: 1) assess and understand current health policies, 2) identify the strengths and limitations of healthcare policies, and then 3) act to influence changes in health policy to improve care for patients with chronic illnesses and conditions and their caregivers.

Health Policy Defined

Policy has been defined as the “choices society, segments of society, or organizations make regarding its goals and priorities and the ways it will allocate its resources to attain those goals” (Mason, Leavitt, & Chaffee, 2007, p. 3). Policy is never static; it is continuously influenced by cultural, political, and financial factors in the environment (Chopoorian, 1986). The U.S. healthcare delivery system is influenced by a complex mix of private- and public-sector policies. Privatesector policies are decisions made by executives at private entities, such as private insurance companies and pharmaceutical companies, whereas
public health policy decisions are made within any of the three branches of government (the executive, legislative, or judicial branches) and at any level of government (federal, state, or local) (Longest, 2006). Examples of federal legislation include Medicare’s prescription drug program and funding to the National Institutes of Health to support research related to chronic diseases such as Alzheimer’s disease, stroke, arthritis, and diabetes. Local government examples include city or county governments restricting smoking in public buildings. State and local boards of health have policies that monitor water quality and provide minimum safety requirements for nursing homes and daycare centers.

Health is determined by many factors, including our genetic makeup, our physical environment, our employment and home situations, our social environment, our behaviors, and access to healthcare services and the delivery of healthcare services. This chapter focuses primarily on health policy related to the access to and delivery of healthcare services.

Major Stakeholders in the U.S. Healthcare Industry

An important feature of the U.S. healthcare delivery system is its large and diverse collection of stakeholders (Kovner & Knickman, 2008; Sultz & Young, 2009). Health policies can affect individuals with a common characteristic (e.g., nurses, the elderly, the disabled, the poor) or certain types of organizations (e.g., hospitals, skilled nursing facilities [SNFs], health plans, biotechnology companies, or employers). A stakeholder group’s interest level and its support for or opposition to health policy changes vary by issue, and it is not uncommon for some stakeholder groups to agree on one issue, but disagree on another issue (Kovner & Knickman, 2008; Sultz & Young, 2009). For most stakeholder groups, their perspective on key issues can be anticipated. For example, a key stakeholder group is patients, who tend to favor comprehensive insurance coverage, high-quality healthcare delivery, and low out-of-pocket expenses and tend to oppose limited access to care and increased patient payments. A second key stakeholder group is providers, including individuals and entities, who tend to favor maintaining income, autonomy, and comprehensive coverage and tend to oppose limits on provider payments. Another key stakeholder group is taxpayers, who tend to favor limits on provider payments and tend to oppose higher taxes. Regulators (government) are also a stakeholder group and tend to favor disclosure and reporting by providers, cost containment, access to care, and high-quality health care, and tend to oppose provider autonomy. Another key stakeholder group is employers, who tend to favor cost containment, administrative simplification, and the elimination of cost shifting, and tend to oppose government regulation. Pharmaceutical manufacturers, biotechnology companies, assistive technology vendors, and suppliers tend to favor comprehensive coverage and tend to oppose limits on provider payments, and private insurance companies tend to favor business autonomy. Consumer organizations, such as the American Stroke Association and the Paralyzed Veterans Association, favor securing money for research and public education.


U.S. Health Care: A Fragmented System of Care

The United States does not have a national healthcare system or health insurance system.
The prevailing value of individual choice over government care and a strong cultural belief that if one works hard enough, one should be able to support one’s self and one’s family imply that one should then be able to afford health care (Bellah, Madsen, Sullivan, Swidler, & Tipton, 1985). In addition, current health policy is guided by society’s value that a competitive market is the best way to provide healthcare services. Policymakers, with the approval of society, have agreed that some segments of the population need assistance, such as the elderly, the very poor, and the disabled. This has led to separate programs for the elderly and disabled (Medicare), the poor (Medicaid), and uninsured children (SCHIP—State Children’s Health Insurance Program). Policymakers have also agreed to reward, through healthcare coverage, those who have provided service to the nation (military and veterans), leading to another separate healthcare system (Veterans Affairs). The mix of privately and publicly funded healthcare coverage has given us a fragmented and complex healthcare system. To better understand this system, an overview of health insurance, including privately and publicly funded options, is discussed.

Health Insurance

Most Americans under the age of 65 have private health insurance coverage through an employer, and almost all older adults receive coverage through Medicare. Medicaid and SCHIP provide insurance for millions of non-elderly, low-income people and children. However, program limits and gaps in employer coverage have resulted in many people not having health insurance. In 2010, 22.7% of individuals under 65 (60.2 million people) were uninsured for part of the past year, and this rate increased for adults 18 to 65 years of age to 26.8% (51 million) (Martinez & Cohen, 2010). More recently, an estimated 26 million adult workers who lost their jobs between 2007 and 2010 reported that they bought or tried to buy a health plan in the individual market; more than one third (35%), or 9 million people, were turned down or charged a higher price because of a health problem. It can be assumed that many of these health problems were chronic conditions (Collins, Doty, Robertson, & Garber, 2011). The Affordable Care Act of 2010 seeks to eliminate the increasing gap in health insurance coverage by making affordable coverage more accessible, including an expansion of the Medicaid program and a requirement that individuals obtain health insurance. Starting in 2014 no one will be charged a higher premium or denied coverage because of a preexisting health condition.

Health insurance coverage does not always ensure access to care. As of 2007, there were an estimated 25 million underinsured adults in the United States, 60% more than the 16 million who were underinsured in 2003 (Schoen, Collins, Kriss, & Doty, 2008). There are often limitations on coverage for special services, such as behavioral health care, preventive care, long-term care, catastrophic illnesses or accidents, and psychiatric care. Also, exclusions or waiting periods for illnesses or conditions may exist at the time the person enrolls in the health plan. Most health insurance plans also include copayments or deductibles to discourage overuse of services and to reduce premium costs. Copayments and high deductibles can discour-age some patients from seeking preventive care (e.g., immunizations, mammograms) and essential care for the management of a chronic condition. This is particularly a problem for people with a low income. Rising costs have become a major problem for insured people with chronic
conditions. Nearly 40% of nonelderly adults with three or more chronic conditions had out-of-pocket expenses and premiums exceeding 5% of their income compared with 14% of those who had no chronic conditions (Cunningham, 2009).

Traditional or Conventional Health Insurance

In the 1970s, the most common type of health insurance was a traditional fee-for-service (FFS) plan. Traditional health insurance plans generally allowed the insured person to choose a healthcare provider, and the healthcare provider made most healthcare decisions with minimal oversight by the insurance company. The covered services included acute care services, such as hospitalization, medication, and medical equipment, with little or no emphasis on prevention, health maintenance, or supportive healthcare services. This type of coverage typically included acute care services and limited the services needed to prevent chronic conditions and long-term care services. The number of traditional or conventional plans have declined dramatically from 73% in 1988 to just 1% in 2010 (Kaiser Family Foundation [KFF] & Health Research and Education Trust [HRET], 2010).

A major problem with the traditional FFS plans has been the lack of control on service use that led to high costs. Healthcare providers have few incentives to control costs. Therefore, insurance premiums increased to cover the rising costs of services. Rising insurance costs have become a major issue for employers, who pay for some of the insurance premiums on behalf of employees. As the cost of providing insurance continues to rise above inflation, employers often look for less costly options to provide coverage for their employees. One solution for employers has been to select managed care organizations (MCOs) for health insurance plans.

Managed Care Organizations

MCO generally refers to any non-FFS plan that attempts to contain costs and manage the delivery of care (KFF, 2004). Types of MCOs include health maintenance organizations (HMOs), preferred provider organizations (PPOs), and point of service (POS) plans. The percentage of persons with MCOs has risen dramatically from 27% in 1988 to 85% in 2010 (KFF & HRET, 2010). With the increase of MCOs in the 1990s, many were hopeful that there would be a system to promote health and assist in preventing disease, and reduce costs. MCOs could help eliminate inappropriate overutilization of services and also offer advantages in setting standard protocols by providing preventive healthcare services. Most experts agree that the main system change MCOs, especially HMOs, have emphasized is that of controlling costs. Average family annual premiums in 2010 were: MCO— $4,357 per employee and $9,768 per employer; PPO—$3,823 per employee and $10,210 per employer; POS—$5,195 per employee and $8,018 per employer.

Consumer-Directed Health Plans

Politicians and employers have been advocating health savings accounts (HSAs), which are a component of consumer-directed health plans (CDHPs) or high-deductible health plans with savings options (HDHP/SO). The majority of covered workers (58%) in 2010 were enrolled in an HDHP/SO (KFF & KRET, 2010). HSAs have lower premiums, but higher deductibles and out-of-pocket spending limits. In 2010, the
average family HDHP deduction was $3,577 (Claxton et al., 2010).

HDHP/SOs are insurance plans where financial incentives or disincentives are provided to the consumer or person to become more involved with purchasing their healthcare services. To enroll in an HSA, a consumer must be in an HDHP that meets certain requirements. For 2011, the U.S. Department of the Treasury (2010) defined a high-deductible health plan with an annual deductible that is not less than $1,200 for an individual or $2,400 for family coverage. Annual out-of-pocket expenses (deductibles, copayments, and other amounts, but not premiums) cannot exceed $5,950 for self-only coverage or $11,900 for family coverage. Supporters of these plans believe they will help individuals become more aware of their healthcare needs and, therefore, influence their decisions related to cost and quality of services. Opponents are concerned that individuals will not seek out preventive or needed healthcare services because of high cost. Research studies found enrollees of CDHPs are less satisfied with their plans; spend significantly more of their income on out-of-pocket expenses; and often avoid, skip, or delay health care because of costs. People in these healthcare plans were also more aware of the cost of their care and considered the cost of care when deciding to use healthcare services when compared to enrollees of other plans (Fronstin & Collins, 2006). The results of these and other studies suggest that CDHPs/HSAs negatively affect people with low incomes and those with chronic illnesses.


Medicare was implemented in 1965 through Title XVIII of the Social Security Act—Health Insurance for the Aged and Disabled (Pulcine & Hart, 2007). In 2010, Medicare provided health insurance coverage to 47 million people, of which 39 million were age 65 or older and 8 million people with permanent disabilities who were younger than 65. With federal government spending estimated to be $3.6 trillion in 2010, the Medicare program accounted for 12% of the federal budget and 23% of the national health expenditures (KFF, 2010; Medicare Payment Advisory Commission, 2010). Medicare includes four parts:

  • Part A: Hospital Insurance. The hospital insurance component includes coverage for inpatient hospital services, home health care (skilled care only), hospice care, and short-term stays in SNFs. Most Medicare beneficiaries do not pay a monthly premium for the hospital insurance plan but are responsible for a deductible ($1,100 in 2010) for a hospital stay, a co-insurance for an extended hospital stay ($275 per day for days 61 to 90 in 2010) and co-insurance for extended SNF stays ($137.50 per day for days 21 to 100 in 2010). Medicare Part A is financed through the Hospital Insurance Trust Fund by taxes paid by employers and their employees.

  • Part B: Supplemental Medical Insurance. The supplementary medical insurance program covers physician, outpatient, home health, and preventive services. It is financed through the Supplementary Medical Insurance Trust Fund by federal taxes and monthly premiums paid by beneficiaries (typically $110.50 in 2010).

  • Part C: Medicare Advantage. The Medicare Advantage program allows beneficiaries to enroll in private health plans. Plans include
    PPOs, provider-sponsored organization (PSOs), private FFS plans, high-deductible plans linked to medical savings accounts, and special needs programs (SNPs) for individuals who are dually eligible for Medicare and Medicaid. Medicare Advantage covers hospital and physician care, often includes prescription drug coverage, and is an alternative to Part A, Part B, and Part D coverage. The plans receive payments from Medicare Advantage to provide Medicare-covered benefits; it is not separately financed from Parts A, B, and D. Medicare Advantage enrollees generally pay the monthly Part B premium and often pay an additional premium directly to their plan (average was $56 per month in 2010).

  • Part D: Prescription Drug Benefit. The prescription drug benefit provides coverage for outpatient prescription drugs offered through private companies. Coverage varies depending on the plan chosen. The prescription drug benefit is financed through taxes, beneficiary premiums, and state payments for individuals with both Medicare and Medicaid coverage.

Medicare services seem comprehensive and clearly defined; yet, as with all health insurance programs, when assessing how a policy is implemented, either through specific laws or administrative regulatory policy, services are often found to be neither comprehensive nor clearly defined. For example, to receive home health care through Medicare, an individual must meet each of the following requirements: 1) be confined to his or her home; 2) have a physician prescribe treatment; 3) need intermittent skilled nursing care, physical therapy, or speech therapy; and 4) receive services from a certified home health agency participating in Medicare. Therefore, if a nurse practitioner’s client with diabetes and congestive heart failure needed skilled nursing care for leg ulcers, the client would first have to be referred by a physician. Second, if the client could leave his or her home to obtain groceries from the store across the street but could not physically tolerate the half-hour bus ride to the practitioner’s office, the client would not be eligible to receive home health services through Medicare. It is important to note, especially for those with chronic illness and disabilities, that Medicare does not cover nursing home care.


Medicaid was an amendment to Title XIX of the Social Security Act in 1965 and was implemented in 1966. Medicaid was established to provide health insurance to low-income families with dependents. Individual states define the program, and it is jointly funded by federal and state governments. Medicaid covers a wide range of health and long-term care services, but because coverage by Medicaid is administered at the state level, coverage varies from state to state, and there are vast differences regarding who is eligible (Rowland & Tallon, 2004). In most states, adults who are not pregnant are usually not covered. To receive matching federal dollars, the state program must offer certain basic medical services, such as inpatient and outpatient hospital care and physician and family nurse practitioner services. Medicaid managed care and non-managed care options are available. Some states require enrollment in a managed care plan. Covered services include long-term care, mental health care, and services and supports needed by individuals with disabilities. Medicaid covers comprehensive services for children. Medicaid is
the largest funding source for coverage of longterm care, covering approximately 70% of all nursing home residents (The Kaiser Commission on Medicaid and the Uninsured [KCMU], 2010). Medicaid will cover services such as prescription drugs, eyeglasses, and hearing aids. Medicaid also covers those with disabilities and the elderly who are enrolled in Medicare, known as “dual eligibles,” but have incomes below a certain level. This limited coverage for low-income Medicare beneficiaries assists with premiums, deductibles, and coinsurance.

In 2007, Medicaid covered 59.4 million people (U.S. Department of Health and Human Services [USDHHS], 2011). Medicaid spending was approximately $339 billion in 2008. The Affordable Care Act is expected to provide coverage for an additional 16 million people by 2014 with eligibility reform, simplified enrollment, improved access to care, and changes in financing (KCMU, 2010). By 2014, Medicaid is anticipated to include the majority of people younger than 65 with income up to 133% of the poverty level (KCMU, 2010).

SCHIP: State Children’s Health Insurance Program

The Balanced Budget Act (BBA) of 1997 expanded health insurance coverage to children through SCHIP. SCHIP was created to help states cover uninsured children who do not meet Medicaid eligibility requirements (KCMU, 2007). Similar to Medicaid, SCHIP is administered through states, and the type of program offered varies by state. As employer insurance coverage has declined, the rate of children who are uninsured has risen. Without health insurance, children often do not receive care to prevent chronic conditions or illnesses such as complications from diseases that could have been prevented by immunizations (e.g., hepatitis) or disabilities created because of lack of treatment (e.g., hearing loss from otitis media). Early in 2009, President Obama signed into law the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) (Garner, 2009). CHIPRA provides additional resources to states to cover more children and women and expands the option for states to include low-income adults.

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Jun 29, 2016 | Posted by in NURSING | Comments Off on Health Policy

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