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U.S. Public Health Policy

U.S. Public Health Policy

A Current Briefing

I. A. Moonesar

Chartridge Books Oxford Hexagon House Avenue 4 Station Lane Witney Oxford OX28 4BN, UK Tel: +44(0) 1865 598888 Email: editorial@chartridgebooksoxford.com www.chartridgebooksoxford.com First published in 2013 by Chartridge Books Oxford ISBN print: 978-1-909287-86-0 ISBN ebook: 978-1-909287-87-7 I. A. Moonesar, 2013 The right of I. A. Moonesar to be identied as author of this Work has been asserted by him/her in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. British Library Cataloguing-in-Publication Data: a catalogue record for this book is available from the British Library. All rights reserved. No part of this publication may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form, or by any means (electronic, mechanical, photocopying, recording or otherwise) without the prior written permission of the publisher. This publication may not be lent, resold, hired out or otherwise disposed of by way of trade in any form of binding or cover other than that in which it is published without the prior consent of the Publishers. Any person who does any unauthorised act in relation to this publication may be liable to criminal prosecution and civil claims for damages. Permissions may be sought directly from the Publishers, at the above address. Chartridge Books Oxford is an imprint of Biohealthcare Publishing (Oxford) Ltd. The use in this publication of trade names, trademarks, service marks, and similar terms, even if they are not identied as such, is not to be taken as an expression of opinion as to whether or not they are subject to proprietary rights. The Publishers are not associated with any product or vendor mentioned in this publication. The authors, editors, contributors and Publishers have attempted to trace the copyright holders if permission to publish in this form has not been obtained. If any copyright material has not been acknowledged, please write and let us know so we may rectify in any future reprint. Any screenshots in this publication are the copyright of the website owner(s), unless indicated otherwise. Limit of Liability/Disclaimer of Warranty The Publishers, author(s), editor(s) and contributor(s) make no representation or warranties with respect to the accuracy or completeness of the contents of this publication and specically disclaim all warranties, including without limitation warranties for tness of a particular purpose. No warranty may be created or extended by sales or promotional materials. The advice and strategies contained herein may not be suitable for every situation. The publication is sold with the understanding that the Publishers are not rendering legal, accounting or other professional services. If professional assistance is required , the services of a competent professional person should be sought. No responsibility is assumed by the Publishers, author(s), editor(s) or contributor(s) for any loss of prot or any other commercial damages, injury, and/or damage to persons or property as a matter of product liability, negligence or otherwise, or from any use or operation of any methods, products, instructions or ideas contained in the material herein. The fact that an organisation or website is referred to in this publication as a citation and/or potential source of further information does not mean that the Publishers or the author(s), editor(s) and contributor(s) endorse the information the organisation or website may provide or recommendations it may make. Further, readers should be aware that internet websites listed in this work may have changed or disappeared between when this publication was written and when it is read. Typeset by Domex e-Data Pvt. Ltd., India Printed in the UK and USA


Preface List of abbreviations About the author

vii ix xi

The policy process and case scenarios The role of presidential leadership and public opinion in policy making The policy and political environment and case scenarios Inuence of stakeholders on the policy-making process and case scenarios Specic strategies and tools and case scenarios Understanding policy and politics

1 2 4 5 6 7

Access challenges and policies

Health care reform to address access Access to insurance versus access to care Health access: care or insurance?

10 12 12

Quality challenges and policies

Government versus private options for quality Pros and cons of pay-for-performance

15 17

Cost challenges and policies

Challenges in containing health care costs Legislation on cost containment

21 24

5 6

Disease and emergency-related health policy Conclusion

Getting involved in health policy

31 33




This publication provides an appreciation of the United States (U.S.) health policy, which reflects authoritative decisions and the process of decisionmaking, carried out at the federal, state, and local levels, which affect personal health and access to and delivery of health services. Health policy is based on rules, laws, and regulations to implement legislatures or on legal standards established through judicial decisions. The U.S. Policy-Making Process has three major channels before it becomes a law through County/Local level, State level and Federal level. Overall, this publication examines the processes of health policy making in the U.S., including how health policy proposals move through the policy process. There is also a thorough assessment of the key challenges to addressing cost, access, and quality issues in health care and an evaluation of the existing policies in these arenas. The publication also contains an analysis of the diversity of perspectives held by policy makers, interest groups, healthcare professionals, and other stakeholders regarding existing and proposed health policy; in addition to the identification of the ways in which healthcare professionals can participate in and influence health policy development. Keywords: Health Policy-Making, Access, Quality, Cost.



American Association of Retired Persons Affordable Care Act Ryan White Comprehensive AIDS Resource Emergency Act Congressional Budget Office Diabetes Mellitus Health System Change Health Resources and Services Administration Long-Term Care Medicare Prescription Drug, Improvement, and Modernization Act Pay-For-Performance Patient Protection and Affordable Care Act Pharmaceutical Research of Manufacturers of America Quality and Patient Safety Joint Commission International Accreditation Strengths-Weakness-Threats-Opportunities

About the author

The author, Immanuel Azaad Moonesar, is 28 years old and is from the Republic of Trinidad and Tobago and currently residing in Dubai, United Arab Emirates (UAE). He is the Managing Director at I AM Consulting (Trinidad & Tobago, Caribbean). He was formerly the Institutional Research Officer at the University of Wollongong in Dubai (UOWD) and now heading the Institutional Effectiveness & Accreditation department at Mohammed Bin Rashid School of Government (MBRSG). He is also the Vice President (Database Marketing & Outreach) and Executive Board member of the Academy of International Business Middle East North Africa (AIB-MENA) Chapter. His qualifications include a Master of Quality Management (Distinction) from the University of Wollongong Australia (UOW), a Postgraduate Diploma in Institutional Community Nutrition & Dietetics (Distinction) & a Bachelor of Science in Human Ecology: Nutrition and Dietetics from the University of West Indies (UWI), Trinidad & Tobago. He is also a Registered Dietitian and possesses certifications in NEBOSH Occupational Health and Safety, European Foundation for Quality Management (EFQM) Assessor, Project Management: Certified Business Professional (CBP) and Quality Management System Internal Auditors (ISO 9001:2008). He has published over 28 publications in peer-reviewed journal articles, peer-reviewed international conferences, co-authored books and book chapters thus far. His career experience includes quality assurance and management, nutrition and dietetics, teaching and institutional research. He is currently pursuing a Doctor of Philosophy (PhD) in Health Services: Leadership. Email: Immanuel.moonesar@outlook.com


The Policy Process and Case Scenarios

The United States (U.S.) policy-making process has three major channels before it becomes a law through County/Local level, State level and Federal level (Laureate Education, 2009). Even though every Congressional session since 1916 has generated at least one piece of Federal legislation proposing to modify the healthcare policy system in some way (Dewar, 2010), there are issues and concerns that have remained the same in terms of quality, access and affordability across the U.S. (Shi and Singh, 2008, p. 548), for instance, particularly for Long-Term Care (LTC). The U.S. is actually the only developed country where the government does not guarantee access to health care to its citizens (Navarro, 2003). As a result, there have been underlying supports for government policies in enhancing access to care (Shi and Singh, 2008, p. 548). Over the past 20-years, State and Federal Government have played an ever expanding role in the financing of the LTC. However, more than 12 million U.S. citizens need access to LTC services; despite this, not all can receive such services due to the financial access cost for the care (Barton, 2010, p. 348). Healthcare reform is a daunting challenge for U.S. policy makers and healthcare administrators. The people certainly want change, but offer little consensus on how to achieve it. Though the main challenges and weaknesses at present are the financing of LTC expenses in middle-class families, for instance, there are limited resources in terms of financing, unattractive infrastructure/environment, limited workforce and transitions in Information Technology (Laureate Education, Inc. 2008; Shi and Singh, 2008). In this instance, healthcare administrators have the responsibility for pushing for new legislation LTC

U.S. Public Health Policy

reform through the development and implementation of policies to enable access to affordable healthcare coverage for U.S. citizens (Barton, 2010, p. 380). This in turn can promote quality care and address issues of health care costs. Change, even incremental change on the level of state government and there will likely be a need for national-level action in the long term (Barton, 2010, p. 380). Furthermore, healthcare administrators in todays organizations need to shift their focus on continuous improvement, implementation of health policies and procedures and revision and development of quality standards (Joint Commission International, Inc., 2010). Some challenges could be in terms of the governments timeframe to develop and implement the rules and regulations, the delinquency in implementing the health policies and procedures and even increased human resources (JCI, 2010). Another notion is the Patient Protection and Affordable Care Act (PPACA) which specifies the least amount benefits package will have an actuarial value of 0.6. This simply means that on average, the PPACA policy is estimated to pay up to 60 percent of an individuals health expenses while the individual will, on average, pay 40 percent out of pocket (Lewins Group, 2010). However, there may be variations in the cost-sharing amounts, depending on certain conditions and limitations. These would tend to include that the policy to consider the preventive services without cost sharing; there can be no lifetime or annual limits on benefits; there is a maximum out-of-pocket limit of 5,950 USD for individuals and 11,900 USD for families; and once the out-of-pocket cap is met, the policy pays for all covered costs without once-a-year or lifetime limits on benefits (Lewins Group, 2010). Therefore, having such limitations to this policy, it is quite difficult to change local policies, to the state level and then to the federal level. Sometimes it is even harder to get something done rather than stop a policy. Change is difficult and making healthcare policy changes is laborious and difficult.

The Role of Presidential Leadership and Public Opinion in Policy Making

A specific health policy, the Patient Protection and Affordable Care Act (PPACA), will be discussed in detail in the context of its political and social dimensions. This section highlights the success or failure of the Act by analyzing one aspect related to presidential leadership, one aspect related to the publics role, and other political factors or developments that influenced the outcome.


The PPACA was enacted into law on March 23, 2010 by President Barack Obama. The PPACAs main policy objectives are to provide Americans with strong consumer rights and protection, more choices of coverage and lower healthcare insurance costs (U.S. Department of Health & Human Services, 2012). This policy implementation and its regulations help to prevent insurance companies abuse and prohibit insurance companies from denying coverage: for instance, American children with pre-existing conditions (Stenrud, 2012; U.S. Department of Health & Human Services, 2012). PPACA was created from both sides of political leadership including State leaders and the Obama Administration, and healthcare professionals, in order to deal with some of the issues and problems (U.S. Department of Health & Human Services, 2012). The implementation of the PPACA is a clear indication of success. The presidential leadership was able to provide middle-class American families with access to health care and the insurance coverage they needed (Moonesar&Vel, 2012). As recorded by the Congressional Budget Office (CBO), the PPACA provided coverage for over 94% of Americans and stayed within the budget of $900 billion as stipulated by President Obama (Democratic Policy and Communications Center, 2012). Additionally, as reported in 2011 and even in 2010, greater than 5.1 million elderly and people with disabilities on Medicare had saved over $3.1 billion on prescription medicines, in addition to the new preventive benefits and services received (Stenrud, 2012). A classic example for the success of the PPACA, is in summer 2011: Amy Ward who had a very rare disease was allowed to live another day today because of PPACA (Wallen, 2012). Amy was able to a have a lifetime limit to her medical expenses through the PPACA policy where before she had only a limit of $1 million with her health insurance (Stenrud, 2012). Therefore, equity regarding health insurance coverage was without doubt not attained prior to the implementation of the PPACA policy (Andersen, Rice, & Kominski, 2007). It is evident that in the last two years of the newly reformed healthcare act, there has been higher quality care, investments on public health, the strengthening of Medicare, increased access to affordable care and the prevention of fraud and abuse by the insurance companies towards the Americans (Stenrud, 2012; The Henry J. Kaiser Family Foundation, 2011).

U.S. Public Health Policy

The Policy and Political Environment and Case Scenarios

Why Did MMA (Medicare Part D) Pass? The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) was enacted in 2003. In 2005, with particular interest to the pharmaceutical industries, the Denver Post reported that 10-year projected costs would be $329 billion higher than original estimates; however, in 2011, the CBO reported that the 10-year actual costs and projections through 2013 are $322 billion, which is a 41% lower than 2004 projections (Pharmaceutical Research of Manufacturers of America, PHRMA, 2012). On the other hand, over the years, the cost of drugs in the U.S. has increased, becoming unaffordable, especially for the elderly. The MMA was passed, which provided affordable prescription coverage to the most vulnerable population: the elderly. As a matter of fact, many seniors view the Medicare: Part D as a success since they gained access to medicines at affordable prices. Medicare Today reported that 88% were satisfied with their Medicare drug coverage (PHRMA, 2012). However, the bill did not pass without opposition from several interest groups and stakeholders, such as the pharmaceutical industry (Keene & Byington, 2007). Despite its unpopularity among stakeholders, the legislation was passed, possibly due to the strategy of the Bush Administration, in which the Republicans followed Democratic concerns and made progress with elderly voters (Oberlander, 2007). Consequently, with much support from the hefty funders, allies and even the support of the AARP, the Democrats conceded. Nevertheless, the pharmaceutical industry was challenged with the idea of restricting drug prices and allowing the importation of cheaper drugs (Hahn, 2005). It found an important ally in legislators who believed that the government should not subsidize drugs but allow market forces to control drug prices (Hahn, 2005). Extensive lobbying of legislators by the pharmaceutical industry helped create what is termed the doughnut hole. Oberlander (2007) described the doughnut hole theory as the gap in coverage for prescription benefits from $2250.00 to $5100.00, where the recipient would have to cover the costs for anything within that range. The most logical issue with this theory is the fact that people who cannot afford prescriptions costs from 1.00 to 2249.00 USD would definitely not be able to afford costs that exceeded that amount. Additionally, there were issues outside of this theory that have definitely caused some angst and opposition against the policy. Despite this, for the pharmaceutical industry, the MMA was funded and supported by pharmaceutical companies and


insurance agencies. The pharmaceutical and insurance industries benefited more than Medicare Part D recipients: for instance, the pharmaceutical industry gained in excess of 139 million dollars over the eight years after the bill was implemented, while beneficiaries were faced with loopholes, such as the doughnut hole theory (Slaughter, 2006). Over recent times, there have been many attempts to implement the MMA revisions to the Medicare program, focusing specifically on the pharmaceutical industrys reception to the policy. Part D or MMA is not the first disenchantment in the U.S. where health policy is concerned. In fact, Medicare itself was a compromised attempt at a national U.S. healthcare program. This compromise was as a result of a political nature where the reformed Medicare benefit, MMA had many critics, but however was still able to be enacted today.

Influence of Stakeholders on the Policy-Making Process and Case Scenarios

In this section it is vital to synthesize the understanding of policy and politics in relation to the reasons why Medicare Part D (MMA) was passed, in addition to the influence of the various key players in the policy process. The policy-making process of Medicare Part D in 2003 involved key stakeholders such as the AHA, AMA, AARP, Pharmaceutical Industries, Congress, Media, White House, Political players and Agency Staff (Teitelbaum & Wilensky, 2007). The American Hospital Association (AHA) was not in favor of this policy due to concerns about President Obamas proposal to withdraw Medicare and Medicaid provider rates, that could lead to a 200,000 job loss by the year 2012 (Galewitz, 2011). AARP is one of those powerful interest groups that helped passed a flawed policy such as Medicare Part D is, because of the benefits to the members (AARP, 2012). AARP, formerly the American Association of Retired Persons, is a United States-based non-governmental organization and interest group, founded in 1958 by Ethel Percy Andrus, PhD, a retired educator from California, and based in Washington, D.C. According to its mission statement it is a nonprofit, nonpartisan membership organization for people age 50 and over. According to the recent report by the AARP Public Policy Institute, Who relies on Medicare?, this was a clear attempt to stress the importance of the profiles of the population in need of Medicare Part D (Multack & Noel-Miller, 2012). Even though the pharmaceutical industry was concerned regarding the lowering of drug prices, which meant that there would be a

U.S. Public Health Policy

potential compromise for cheaper drugs (Hahn, 2005), Medicare Part D was supported and funded by these pharmaceutical industries, together with health insurers, because of its long term benefits. For instance, there was a prediction that this industry would have gained over 139 million USD over the next eight years from when the Bill was passed in 2003 (Slaughter, 2006; Sager and Socolar, 2004; Connolly, 2003). As for Congress, White House and other political leaders, under the Bush Administration the goal included provision of a better livelihood for the elderly but, furthermore, to create a health care system shift toward a market-oriented, consumer-directed health insurance which accentuated individual rights and preferences (Getzen, 2010; Keene and Byington, 2007).

Specific Strategies and Tools and Case Scenarios

The strategy classifications that were considered and advocated for the policy-making process of Medicare Part D, included informational strategies, procedural strategies and compensation strategies (Patashnik, 2011). Firstly, the informational strategies involved the creation of the public awareness that Medicare Part D was in the policy-making process state, through campaigns, reports, media, surveys and political marketing forums (Pharmaceutical Research of Manufacturers of America, PHRMA, 2012; Oberlander, 2007; Hahn, 2005). Secondly, the procedural strategies were the stages that involved debates amongst Congress and political players in seeking to build support for the initial passage of Medicare Part D, and the development of guidelines and protocols for Medicare Part D coverage, in addition to the communication of information for Medicare Part D consumers (Getzen, 2010; Connolly, 2003). Thirdly, the compensation strategies would include those marketed benefits such as profits and revenues, not only to the beneficiaries (the elderly), but all stakeholders such as the AARP, Pharmaceutical Industries and even the U.S. government, in terms of relying on private insurance health plans preferred by the elderly, which handle and compensate for their personal care (AARP, 2012; PHRMA, 2012; Getzen, 2010; Slaughter, 2006; Sager and Socolar, 2004; Connolly, 2003).


Understanding Policy and Politics

It is known that policy-making and reforms usually breed enemies. Generally, it is already a tremendous achievement when a political system can muster the will and ability to tackle an important problem and to address it (Patashnik, 2011). The good thing about policy-making is that it provides law-makers and stakeholders with the opportunity for policy evaluations and reforms. Furthermore, elderly persons are, in general, ultimately more concerned with their short-term benefits as their lives are drawing closer to death. It is critical to note that policy and politics go hand in hand since there are always pressing priorities for any government, independent of their political heritage. As a result, new problems tend to emerge and old issues which are not addressed immediately may be thrown on the back burner where they are never dealt with. The key is that Medicare Part D was enacted and implemented mainly for the benefit of the elderly and, subsequently, its stakeholders.

Access Challenges and Policies

This publication will here focus on two specific challenges to access to health care: insurance coverage and the quality of care by healthcare providers (especially those faced by the African-American population and low-income populations). In addition, this publication highlights two recent polls on public opinion regarding the role of government and the private sector on access to healthcare, plus the inferences policy makers should draw from these polls. It is evident that there are not sufficient healthcare facilities and provisions to ensure a basic level of health coverage; therefore, some people may not have access to the care they need. Medicare and Medicaid are sometimes referred to as safety nets which may not reach all those without coverage (Andersen, Rice & Kominski, 2007). It is important to note that in the U.S. there are 47 million people who do not have health insurance and about 9 million of them are children (Dewar, 2010). Many are low-income workers who just simply cannot afford health coverage and others are healthy but opt out from having health insurance. African Americans have had a higher impact factor concerning access to employment-based insurance than other Americans such as the Whites (Anderson et al., 2005). More specifically, the unemployment rate among African Americans has remained consistently higher than Whites, leading to significant challenges in health insurance access for African Americans (Center for Studying Health System Change (HSC), 2012). When it comes to the quality of care, as an example, elderly care which is deemed as vital to the ageing population will be discussed (Shi.. 515). (Shi and Singh, 2008, p. 515); therefore the elderly require assisted living and skilled care facilities in order to prevent premature elderly deaths. Even though there are some health services resources across the U.S. (Barton, 2010, p. 8) such as the assisted-living residencies, offering cost-effective, quality care and help to promote the nutritional well-being of the elderly


U.S. Public Health Policy

(Mahan & Escott-Stump, 2004, p. 335), there is still much more that needs to be done, such as quality and patient safety (QPS) that helps hospitals to be safer, reduce medical errors, be more effective, patient-centered, improve timeliness, be more efficient and also equitable in the quality of care (JCIA, 2010; Laureate Education, Inc., 2008; Longo et al., 2007, p. 189). One of the critics of a research article stated that Patient safety must be an integral part of the mission of every hospital in the U.S. (Longo et al., 2007, p. 205). Improving long-term care and palliative care is furthermore endorsed by Dr Casals (AHRQ, 2011). Another critical change that was advised upon was a policy change to alter how insurance pays for medical services (Emanuel and Fuchs, 2008; Seshamani, Lambrew & Anotos, 2008). This will allow for more value-based co-payments, modelled on current tiered pharmaceutical benefits, which create an alignment with the patients payment and cost of health coverage alternatives (Emanuel and Fuchs, 2008). This could reduce over-utilization of health services, reduce malpractice of the safety nets programs which will ultimately lead to an alleviation of the strain of rising health care costs (Seshamani, Lambrew & Anotos, 2008; Anderson et al., 2005). According to the Henry J. Kaiser Family Foundation, in an unemployment survey conducted in 2011, 75% opt out of seeking medical care due to lack of access to health insurance as well as being unemployed. Fortunately, the presidential leadership in 2010 was able to provide middle-class American families with access to health care and the insurance coverage they needed via the Patient Protection and Affordable Care Act (PPACA) (U.S. Department of Health & Human Services, 2012). Recently, it was reported that 41% were in favor of the law, while 40% were not. These were drawn against party lines, where 75% of Republicans were against it and 66% of Democrats were in favor (Stenrud, 2012; The Henry J. Kaiser Family Foundation, 2011). In this poll there was no indication that poverty and unemployment influence the opinion of the populations.

Health Care Reform to Address Access

This section focuses on the key aspects of the federal health reform legislation enacted in 2010 relating to improving access to health care. This analysis will also include the basic values that underlie this approach to solving access to care problem and the alignment with specific political perspectives. A discussion is included on policymakers main approach to expanding access to care, and whether the current 2010 health care reform plan features the same approach.

Access Challenges and Policies


For over 100 years, health reform has been a national agenda in the U.S., originally advocated by President Theodore Roosevelt in 1912 (Riegelman, 2011). Among President Obamas eight guiding principles for health reform legislation, there are two principles that relate to improving access to healthcare: guarantee choice and invest in prevention and wellness (Riegelman, 2011; The Henry J. Kaiser Family Foundation, 2011). These two key aspects improve access to healthcare in terms of the overall approach to expanding access to coverage, tax changes in relation to health insurance or health financing health reform, improve quality or health system performance, and improve access to community health centers and school-based health centers/clinics (The Henry J. Kaiser Family Foundation, 2011). The basic values that underlie this approach to solving the access to care problems were that the majority of Americans were in support of the healthcare reform and the alignment with some political perspectives. In terms of the political perspectives, the main aim of these principles was to reduce access barriers to health care. The noteworthy barriers to access to care and access to insurance are at both the systems level and individual level, in addition to the the barrier factors that foresee such access include race, income, and occupation (Shi and Singh, 2008). Also, at the governmental level, it is vital to note that not all the legislation bodies such as government, politicians, lobbyists and special-interest groups were not in agreement with the health care reform. This policy appeared to align with the Democratic Party, where they seemed to be more considerate to the needs of the underserved and middle class populations (Andersen, Rice, & Kominski, 2007). As a policy maker, or perhaps as an individual with the ability to influence the policy makers working on expanding access to care, the author would use the approach of education, collaborative efforts, engaging the community stakeholders to speak up about how they support and embrace the healthcare reform, and consolidation of the wins of the new health care reform system by State and as a country at large, as a long term strategy. The author would use the tactics of the existing approach and be a strong advocate for changing our current health care delivery system in accordance with Kotters eight principles in managing change. Furthermore, the author would promote and empower others to act on the healthcare reform vision. The overall goal of the authors approach will be to document the strengths and weakness, opportunities and threats of the current healthcare reform system in expanding access to care.


U.S. Public Health Policy

Access to Insurance Versus Access to Care

The purpose of this section is to discuss the contrast between access to insurance and access to care, in relation to the Affordable Care Act (ACA), federal reform and its unanticipated consequences. Firstly, it is important to distinguish between access to care and access to insurance. Access to care is having a personal healthcare provider who delivers an adequate supply of quality healthcare services in terms of financial, social, cultural and organizational utilizations (Maxwell et al., 2011; Barton, 2010). More specifically, the financial utilizations would entail one aspect of access to insurance. Therefore, access to insurance is a contractual agreement with a healthcare insurance company, where the medical bill payments could be made through means such as co-payments or payment in full by the patient or healthcare provider/professional, then reimbursements for the medical treatments are made at a later time. Over the past thirty years, research has been conducted on the impact of having access to care in relation to access to health insurance (Cunningham & Hadley, 2004; Hadley, 2002).

Health Access: Care or Insurance?

U.S., healthcare reformation has been a national agenda for over one hundred years- since the time of President Theodore Roosevelt in 1912 (Riegelman, 2011). Among President Obamas eight guiding principles for health reform legislation, three of the principles relate to improving access to healthcare: protect families financial health, guarantee choice and invest in prevention and wellness (Riegelman, 2011; The Henry J. Kaiser Family Foundation, 2011). There are many ways in which access to insurance was addressed through the Affordable Care Act (ACA). Firstly, health insurance became affordable to many American families since there were structured health coverage packages. These were in the form of copayments and did not exceed 10% of a familys annual income in the federal poverty levels (Stenrud, 2012; Riegelman, 2011). It has been reported that over 2.5 million more young adults (18 to 25 years) were able to have access to insurance under their respective parents health coverage. Those on Medicare, such as the elderly and people with special needs, totaling just over 5.1 million, were able to save over 3.1 billion USD on prescription medicines (Stenrud, 2012). Secondly, a further principle of the ACA was making health insurance coverage transferable despite an

Access Challenges and Policies


employee changing his/her place of employment. This allows employees to retain health insurance coverage while they move into other employment (Stenrud, 2012; Riegelman, 2011). Thirdly, another principle that addresses access to insurance is having the choice of health insurance coverage known as Exchanges from four different levels; bronze, silver, gold and platinum (Stenrud, 2012). Consequently, the ultimate goal of expanding insurance coverage is to eliminate the barriers to acquiring access to healthcare services for uninsured people and low-income people (Cunningham & Hadley, 2004). One of the main underlying barriers to having universal coverage in the U.S. includes the lack of political support for healthcare reformers (Anderson, Rice, & Kominski, 2007, p. 103; Gorin, 1997). For instance, in 1992, Bill Clinton received 42 percent of votes for advocating universal health coverage in the U.S. (Gorin, 1997). Others include opposition from influential interest groups and stakeholders, and lack of creating a sense of urgency for such a change (Dewar, 2010; Gorin, 1997). Some strategies used in addressing these were simply to gain political support for health care reform, creating that sense of urgency and collaborating with the key stakeholders, including patients, payers, employers, and providers, healthcare professionals, and public, pharmaceutical and insurance companies and even the influential interest groups (U.S. Department of Health & Human Services, 2012; Dewar, 2010). Specifically, one strategy was to legislate that most Americans were required to purchase health insurance or be faced with penalties (Stenrud, 2012; Riegelman, 2011). Other specific strategies included developing the Exchanges for health coverage across four different schemes, in addition to benefit packages and reducing the cost of health insurance to individuals and families, thus making it more affordable. Overall, these strategies are valuable in the light of future potential for healthcare reform. There is much more in terms of investments, time and energy that needs to be contributed to attain universal health coverage. However, it is important to mention that there has been some success in achieving this, for instance, in Hawaii, where a mandatory employer-based insurance system was legislated for almost 32 years ago (Dewar, 2010). Other individual state initiatives include the Oregon Health Plan, Minnesota Care, and several other states such as Maryland, Montana, Vermont and Washington also have plans (Dewar, 2010; Teitelbaum & Wilensky, 2007). These are some classic examples of benchmarking practices that can be further used to develop universal coverage. Access to insurance is one aspect to accessing care. Increased access to medical care through healthcare reform, specifically, by increasing access to


U.S. Public Health Policy

insurance, could result in unanticipated consequences. For instance, people with insurance can choose which methods serve their needs best, which can be demanding of health care systems due to the coordination of care, and some replication and overuse of the health services can take place (Dewar, 2010). Therefore, over-utilization can occur in terms of acquiring more office visits, hospitalizations, tests, procedures, prescriptions and pharmaceuticals (Emanuel and Fuchs, 2008).

Quality Challenges and Policies

Government Versus Private Options for Quality

The purpose of this section is to discuss quality and patient safety (QPS) in relation as the quality initiative and the involvement of government and/or private entities in developing, implementing and monitoring quality. It also considers the pros and cons of allowing quality efforts to be voluntary, versus regulating them. It is alarming to know that medical error deaths in U.S. hospitals run at 98,000 per annum and that at least 58 percent of these deaths could have been prevented, one way or another (Longo, Hewitt, Ge, and Schubert, 2007; McFadden, Stock & Gowen, 2006; Uribe et al., 2002). The main governing body driving this quality initiative is the Joint Commission International (JCI) Accreditation under the International Standards for Hospitals (JCI, 2010, p. 35). The Institute of Medicine has also adopted the goals from the JCI to find ways to reduce medical errors. However, both governmental and private healthcare institutions are encouraged to develop QPS approaches to help improve hospitals to be safer, reduce medicals errors, be more effective, patient-centered, timely, more efficient and in addition, equitable (JCI, 2010; Laureate Education, Inc., 2008; Longo et al., 2007, p. 189). QPS supports healthcare organizations such as hospitals, for example, the Capital Medical Center in Olympia, WA, where medical errors and problems were identified and corrected and the quality of care and services was improved (JCI, 2010, p. 12; Rivara and Floersheim, 2004). One critic of a research article stated, Patient safety must be an integral part of the mission of every hospital in the U.S. (Longo et al., 2007, p. 205). The measurable elements for this QPS initiative are assessed, for instance, by


U.S. Public Health Policy

JCIA and scored as met, partially met or not met (JCI, 2010, p. 4). A Strategic Improvement Plan is needed in response to the not met findings identified by the JCI Official Surveys Findings Report (JCI, 2010, p. 4). U.S. agencies such as the Joint Commission on Accreditation of Healthcare Organizations, Leapfrog Group, National Registry of Myocardial Infarction, American Hospital Association, and Centers for Medicare and Medicaid Services have launched their own patient safety initiatives (Rivara and Floersheim, 2004). Furthermore, at large, the paramount role of these U.S. agencies is to provide licensure, which is a legal right that is granted by a government agency in compliance with a statute governing an occupation (such as physicians, dentists, nurses, psychiatry, or clinical social work, or the operation of a health care facility) (JCI, 2010, p. 250). Healthcare quality can be defined in terms of the resources input which is later measured through its processes in terms of the actual delivery of healthcare services, and this quality care can be reported based on the outcome in terms of patient satisfaction and speedy recovery. Both the government and private entities are required to protect healthcare quality adequately and, therefore, there needs to be more collaboration and involvement between the government and private entities for improving healthcare quality. This can be a joint operation and approach where it is neither voluntary nor government-mandated, but more of an integrated regulatory relationship approach and more widespread across the U.S. Let us take, for instance, the measurement of the patient identification accuracy across the healthcare institutions. The U.S. governmental agencies, in accordance with JCI standards, have stipulated that patients are identified using two patient identifiers, excluding the use of the patient room number or location. At the Capital Medical Center (CMC) in Olympia, WA, they have worked onpatient identification by using at least two discrete identifiers such as a patients name, identification number, birth date or bar-coded wristband (Rivara and Floersheim, 2004). CMC has also published a list of never-use abbreviations to which all medical staff are required to adhere (Rivara and Floersheim, 2004). This type of best practice can be implemented across other U.S. healthcare institutions, in order to improve effectiveness and efficiency. In a further example, implemented at Multicare, Tacoma (Rivara and Floersheim, 2004) patients are identified before giving medications, blood, or blood products, before taking blood and other specimens for clinical testing, or before providing any other treatments or procedures, in order to prevent wrong side/wrong site/wrong surgery. Policies and procedures support consistent practice in all situations and locations through a collaborative process (JCI, 2010, p. 36). For instance, Multicare is engaged

Quality Challenges and Policies


in collaborative work with the Washington Patient Safety Coalition to implement standard procedures and policies to address all possible identification situations (Rivara & Floersheim, 2004). However, many more collaborative initiatives are needed.

Pros and Cons of Pay-for-Performance

The purpose of this section is to assess the positive and negative effects of pay-for-performance polices on quality improvement. There are quality problems that impact upon many patients worldwide. Therefore, healthcare professionals and managed care organizations (MCOs) have been motivated through the financial incentive programs for offering high-quality care (Andersen, Rice & Kominski, 2007; Institute of Medicine, IOM, 2001). There is a strong significance with these payment policies, such as pay-for-performance (P4P), on the delivery of health care, on the patient selection of the healthcare institutions and also the perception of the care (Hillman, 1991). One of the main objectives of incentive programs such as P4P is to reward high-quality care, to allow for the continuing development of more effective ways of delivering care and services, and also to allow for the continuous improvement of the quality of care (Teitelbaum and Wilensky, 2007; IOM, 2001). Another vital objective of the P4P policy is to allow for the healthcare organizations actions taking into account the financial incentives, are the importance of maintaining alignment, consistency and being compliant with organizational values and ethics (JCI, 2010). The leaders create guiding documents to provide a consistent framework to carry out these responsibilities. Healthcare organization leaders need to consider the national and international norms related to human rights and professional ethics when creating this framework (Moonesar and Vel, 2012). In addition to: operating within such a framework to disclose ownership and any conflicts of interest; honestly portray its services to patients; provide clear admission, transfer, and discharge policies; accurately bill for its services; and resolve conflicts when financial incentives and payment arrangements could compromise patient care (JCI, 2010). The P4P program, a quality measure, was established by government in addition to privatized organizations and agencies in order to uphold and harness and hone performance of healthcare services (Young, Conrad & Fallot, 2007). There are over 150 incentive programs that are geared and focused upon preventive care (Young, Conrad & Fallot, 2007). The Centers for Medicare


U.S. Public Health Policy

and Medicaid Services (CMS) is one of the organizations which established the P4P programs (Andersen, Rice & Kominski, 2007; Teitelbaum & Wilensky, 2007). There is much evidence that the notion of the implementation of the P4P incentive program has undoubtedly improved the quality of health care delivery overall (Kuhmerker & Hartman, 2007; Young, Conrad & Fallot, 2007). Even though there is much evidence that quality improvement delivers dollar savings in the long term (Jarlier & Charvet-Protat, 2000; Clemmer et al., 1999; Classen et al., 1997; Conrad et al., 1996), there have been some concerns and barriers that impede quality improvement and hinder the development of stronger incentives for quality enhancement (Datz, 2012; Galvin, 2006; IOM, 2001). In addition, in the design stage of the P4P, there were some factors affecting the size of the incentive payment which would entail other incentives being in place: patient characteristics such as education, organizational capabilities such as IT, market factors such as the availability of diagnostic resources and, finally, provider characteristics such as the current level of performance (Young, Conrad & Fallot, 2007; Dudley and Rosenthal, 2006). Furthermore, some interest groups have expressed concerns about the barriers contributing to the ineffectiveness of the P4P incentive program, concerns about the lack of continuous improvement of the delivery of health care and irregularities of the implementation of the P4P through the various stakeholders involved (such as payers, employers, providers, government and other private agencies) (Young, Conrad & Fallot, 2007; Dudley and Rosenthal, 2006). Even though most payment methods have cost containment goals, they tend not to focus on making quality of care or even making possible quality improvement as a by-product of the cost containment objective (IOM, 2001). Therefore, there should be efforts to explore such a goal and to enhance the effects of the incentive payment on the delivery of high-quality health care in order to prevent further implications of cost containment (IOM, 2001). Overall, the effectiveness of the delivery of health care can undoubtedly be improved through the P4P incentive program; however, in order to sustain such effectiveness, there has to be continuous alignment, which rewards quality care efficiency. These alignments could include the provision of fair payment for good clinical management and implementation of the care processes in relation to financial incentives. Another way of ensuring that the P4P incentive program meets all the targeted goals is to have other main resources for identifying and assessing performance measures, such as the Joint Commission on Accreditation of Healthcare Organizations; National Committee for Quality Assurance;

Quality Challenges and Policies


National Quality Measures Clearinghouse; Hospital Quality Alliance; National Quality Forum; and Ambulatory Care Quality Alliance (Dudley and Rosenthal, 2006). In addition to promoting stricter regulation and standards for the continuous improvement and sustainability of the quality standards, through accreditation and licensure, this would add to the alignment of P4P.

Cost Challenges and Policies

Challenges in Containing Health Care Costs

The purpose of this discussion essay is to describe a significant challenge affecting healthcare costs in the U.S. and to identify a cost-containment strategy including data that was developed to address it. Additionally, some challenges in gaining timely and accurate information to inform policymaking will be highlighted. The interest group that will be impacted most as well as possible ramifications if the status quo is maintained will be noted. Also, highlighting the lessons to be learned from managed care or other efforts that could be applied to maximize current or future cost containment strategies successfully will be discussed. Cost containment is a leading problem in the health care field, but it has not been addressed from a comprehensive management perspective (Smith, Fottler & Saxberg, 1981). In 2007, the U.S. spent $2.2 trillion on health services, an average of $7,421 per person (Barton, 2010). As compared to the expenditures in 1960, the expenditures in 2007 grew nearly 83-fold in the 47-year period, where these expenditures for health service usually constitute the second largest category of governmental expenditures (Barton, 2010; USDOC, 2008; Orszag and Ellis, 2007; Ross, Ratner & Fein, 1991). Firstly, it is important to consider that health care spending for a given population might be roughly defined as a function of five basic factors: population needs or morbidity; access to services; propensity to seek services; volume, nature, or intensity of services supplied or ordered, and unit cost or price of services (Seshamani, Lambrew & Anotos, 2008). One approach to cost containment which was developed was reducing the need


U.S. Public Health Policy

for physician services, in terms of the provision of primary and secondary prevention, health promotion and education, health behavior-based premiums, and patient safety and reduced medical errors (Cutler, 2010; Joint Commission International, Inc., 2010; Merlis, 2009). Consequently, both the supply and demand will be affected in this approach. In terms of supply, the services of physicians would remain almost the same, where their services could be tailored to other services. On the other hand, in terms of demand, these physician services will be less than the usual according to Graph 1 (Dewar, 2010). This cost containment model may have implications for management research in several areas, such as, organization structures, cost/quality trade-offs, incentive systems, cost containment baselines and constraints (Smith, Fottler & Saxberg, 1981). Graph 1 Demand Curve Shift (Dewar, 2010)

Demand Curve Shift

Decrease in D

Quantity of Physician services

Cost Challenges and Policies


The interest groups such as government policy administrators, insurers, payers and providers would benefit from reducing the need for physician services where this will encompass under the preventive services, health promotion and coverage policies (Orszag and Emanuel, 2010; Merlis, 2009). Under the preventative services, the interest groups and providers could be given incentives to promote the use of the preventive services through a pay-for-performance system (Merlis, 2009). Another impact of benefit is through health promotion activities, for instance, smoking cessation or weight reduction as one of the measures as an incentive for efficiency without placing the providers at excessive risks (Pham and Ginsburg, 2007). A third impact of benefit is that under any of the coverage models, payers would continue to take decisions about what services will or will not be covered only under specified circumstances or with prior authorization (Merlis, 2009). Therefore, consumers could then sort themselves out based on their price-sensitivity and their willingness to accept the plan rather than a physician as the arbiter of their care (Pauly, 2005). This will also be a better way to prevent adverse selection (Pauly, 2007). The overall healthcare costs are driven to a significant extent by the behavior and lifestyle choices of individuals (GFOA, 2004). One ramification is that the participants economic incentive to use health care in terms of having the typical health insurance model provides an incentive to overuse health care services because there is not a very direct connection between participants out-of-pocket costs and the actual cost of services (Neeleman, 2005). Health care cost containment covering active and, where applicable, retired employees, is a critical component of long-term financial planning and budgeting (GFOA, 2011). Cost containment is necessary to maintain the provision of government service levels, particularly in jurisdictions subject to tax limitations (GFOA, 2011). Therefore, it is vital to reduce the need for physician services as a strategy (GFOA, 2011; Barton, 2010; Dewar, 2010). There are some potential unintended consequences of this cost-containment effort. There is a possible risk selection problem that would need to be addressed and it is not clear that this consumer-choice model would take all the politics out of coverage decision-making: consumers who accept a hypothetically limited plan when they are well might not be stoical about the plans limits once they become sick (Merlis, 2009). Still, plan competition on this basis is not inherently less reasonable than competition assuming the tightness of network restrictions (Merlis, 2009). It seems more likely that such a market would emerge under the non-group and play-or-pay options than under the connector model (Merlis, 2009).


U.S. Public Health Policy

In addition, there is a need to consider the factors that may influence the shift of the supply. These are the changes in costs for suppliers, changes in medical technology and changes in number of physicians in the healthcare industry. On the other hand, the factors that may influence the shift of the demand are change in population or market size, change in patient preferences, change in price of substitutes or complements, and even change in patient disposable income. This shift can be brought about, for instance, in preventative services. Some Medicaid programs are experimenting with contracts with beneficiaries, under which full benefits are contingent on the beneficiaries compliance with specified utilization rules (Barton, 2010; Merlis, 2009). An employer might also require employees to obtain some preventive services as part of a behaviour-based premium scheme (Barton, 2010; Dewar, 2010). The overall healthcare costs are driven, to a significant extent, by the behavior and lifestyle choices of individuals (GFOA, 2004). Research has indicated that participants economic incentives to use health care in terms of the typical health insurance model, provides an incentive to overuse health care services, because there is no direct connection between participants out-of-pocket costs and the actual cost of services (Neeleman, 2005). For example, if participants only cost is $30 co-pay, there is no incentive to choose a physician who charges $100 for an office visit over one who charges $150. In fact, total overuse of service in the healthcare system has been estimated at between 30% and 50% (Neeleman, 2005). A long-term plan also makes it easier to take smaller steps toward a larger ultimate goal. An incremental approach limits the upfront investment and allows managers to assess the impacts of relatively small changes, and then make adjustments before proceeding further (GFOA, 2011). The proposed strategy can help reduce costs by approximately 5% to 20% (GFOA, 2011). Furthermore, this provides economies of scale and access to best practices that might not otherwise be available (GFOA, 2011).

Legislation on Cost Containment

The purpose of this section is to provide an example of a memo to a legislator on cost containment ideas, particularly cost shifting and the Iowa State in relation to a policy analysis. This section will also look at the strategies for the healthcare cost containment in cost shifting, in relation to the current social, political and economic climate and furthermore, highlighting potential oppositions.

Cost Challenges and Policies


In modern times, containing healthcare costs has become a necessary topic for discussion. Firstly, cost containment can be best defined as the process of managing healthcare cost through policy debates and the implementation of initiatives in order to keep such costs from getting out of control and prevent misuse. (Merlis, 2009; Shi & Singh, 2008). Cost shifting is one of the many tools, which are used for containing costs (Purcell, 2009). Cost shifting, often known as cross-subsidizing, is the shifting of costs from one entity to another. This is seen as a way of making up the losses in one area by charging more in other areas (Barton, 2010, p. 599). A typically example is when the uninsured is provided with health care, the healthcare provider recovers its costs by charging more to the insured (Barton, 2010, p. 236). The question that pops to mind is, Is cost shifting really an ethical cost containment tool? The state strategies of healthcare cost containment, particularly cost shifting, is characterized either through or a combination of government regulation or market-based competition (Purcell, 2009; Shi and Singh, 2008). The main goal of these cost-shifting strategies of the healthcare providers overall, is to have comprehensive supply-side controls, price controls and utilizations controls (Merlis, 2009; Shi and Singh, 2008). The first strategy of cost shifting as a cost-containment tool is by reducing Medicaid cross-subsidization by increasing the Medicaid reimbursement to healthcare providers to cover and make up for lost revenues (Shi and Singh, 2008; National Conference of State Legislatures, 2003). Cost shifting has diminished considerably in the last few years, chiefly because of Medicare has begun to pay its hospital costs obligations, and Medicaid payments have improved as well (Andersen, Rice & Kominski, 2007, p. 140). In this option, the problem statement is very much focused and entails several options for coming up with a solution. This could be in terms of the occurrence of more malpractice claims, therefore, could result in more resources being devoted to keeping such malpractice under control (Fuchs, 2009). Another example of how the government could incur supplementary costs due to cost-shifting could be in terms of the federal government shifting the costs to the local, state and private plans, causing and prompting the setting up of the Medicaid and Medicare reimbursement levels below market costs (Government Finance Officers Association, 2004). In terms of the social factors, the providers are happier that their loss of revenues are being recovered some way or the other (Purcell, 2009) and the access to healthcare is improved (GFOA, 2011; NCSL, 2003). In the economic context, the physicians are more likely to treat Medicaid patients who in turn prevent unnecessary costs in


U.S. Public Health Policy

the long term, for instance, if a patient was denied medical treatment in the initial stages, this could result in making the patients condition worsen, necessitating a visit to the emergency room (GFOA, 2011; NCSL, 2003). Physicians may be caught between the desire to provide quality care and the desire for cost control on the part of the payers, including PPOs, Medicare and Medicaid (Henry J. Kaiser Family Foundation, 2009). The second cost shifting state strategy would include shifting costs to private entities such as insurance companies and private payers (Shi and Singh, 2008; NCSL, 2003). When the government implements cost-control measures, providers may establish charging higher prices to private payers and private insurances for the services attained (GFOA, 2011; Shi and Singh, 2008, p. 498). In the social context, the private entities are affected directly in terms of having higher bills to pay and it being morally and ethically wrong (GFOA, 2011). Another group of interest that would benefit from this strategy is the State Childrens Health Insurance Program (SCHIP). If states influence the federal government to channel funds to expanding the coverage of SCHIP, then this can result in reducing uncompensated care and thus shifting the cost to the private entities (Emanuel and Fuchs, 2008; NCSL, 2003). In the economic sense, the shifting of costs to the private entities actually increases the health insurance premiums and, therefore, influences the increases in governmental cost of employee insurance (Fuchs, 2009; NCSL, 2003). Lets take, for instance, the prices of prescribed medications, which are higher due to price discrimination and price regulation (Fuchs, 2009; NSCL, 2003). This practice in its sense is quite difficult to stop since the budget and its revenue for the research and development of drugs continue to rise (Fuchs, 2009; Emanuel & Fuchs, 2008). Another point to consider is the notion that if certain services are not covered under health insurance, then groups of patients requiring these services are denied access to healthcare (GFOA, 2011; NCSL, 2003). In the political context, the interest group which is quite likely to favour this strategy would be the healthcare providers with their hidden taxes and agendas; at least, the lost revenues are being recovered (NCSL, 2003). The third cost shifting state strategy would entail improving the enforcement of mandatory insurance laws for motor vehicle owners and drivers (NCSL, 2003). From a political standpoint, the actuality of cost shifting is not reducing the cost of health care (Fuch, 2009). However, it would be noteworthy to highlight that this could be in terms of such a strategy being most likely to have higher administrative costs, as a result, more resources will be devoted to keeping track and records of all the

Cost Challenges and Policies


mandated laws (Fuchs, 2009; Kennedy, 2009). From a social point of view, the patients involved in motor-vehicular accidents are usually of a lowerincome status and uninsured (Mahan, & Escott-Stump, 2004). With reference to Table 1, which illustrates the comparison of the Iowa (IA) State with the National U.S. data, Accidents are in 5th position among the top leading causes of deaths and diseases in the U.S. (Trust for Americas Health, 2011; Xu, Kochanek, Murphy & Tejada-Vera, 2010). It is, therefore, of paramount importance to lower these death rates and thus enforce mandatory healthcare insurance for driversor even their passengers (Mahan and Escott-Stump, 2004). Consequently, this has a social aspect, in terms of reducing the long term leading causes of death and diseases, which would be much more beneficial, since it would fall under preventive services, acting as health promotion and coverage policies, and thus reducing the death rates, not only in Iowa State, but also across the entire U.S. (Merlis, 2009). This is very similar to the health promotion activities for reducing smoking, for instance, smoking cessation or weight reduction conditions as one of the incentive measures for efficiency, without placing the providers at excessive risks (Pham and Ginsburg, 2007). The overall healthcare costs are driven to a significant extent by the behavior and lifestyle choices of individuals (GFOA, 2004). The fourth strategy is to determine the pros and cons of cost shifting, in particular, for instance using the State of Iowa (NCSL, 2003) as an example in conducting a Strengths-Weakness-Threats-Opportunities (SWOT) analysis. The risk factors associated with Diabetes Mellitus (DM) that is prevalent in the Iowa State as an example in relation to cost-shifting. DM is a group of metabolic diseases characterized by high blood-glucose concentrations (hyperglycemia) resulting from defects in insulin secretion, insulin action or both (Mahan and Escott-Stump, 2004, p. 794). It is not known why the insulin producing cell fails in adult diabetes (Ballinger and Patchett, 2007; Mahan and Escott-Stump, 2004, p. 795). It seems that some of the stresses of aging, weight gain, decreasing physical activity and decreasing muscle mass, amongst other medical problems, contribute to the onset of DM and intake of excessive calories (Mahan and Escott-Stump, 2004). In the social context, those patients who are uninsured are usually denied access to health care for treatment, but it is important to provide access for patients for the treatment of DM. In an economical context, cost shifting could be sufficient and successful, if the funds were allocated according to aid in addressing the States issues and problems. Currently, IA State sends and receives electronic health information to healthcare providers and community health centers (Trust


U.S. Public Health Policy

Table 1: The US Top 10 leading causes of death and diseasesa

National Dataa 10 leading causes of death and diseasesa # of deaths % of death Iowa (IA) State Data # of IA % of IA deathsa death VS Nationalb 27,221 6,880 6,376 1,686 1.12% 1.12% 1.13% 1.24% % of death for IAc 100.0% 25.27% 23.42% 6.19%

All causes 1. Diseases of heart (heart disease) 2. Malignant neoplasms (cancer) 3. Cerebrovascular diseases (stroke) 4. Chronic lower respiratory (diseases) 5. Accidents (unintentional injuries) 6. Alzheimers disease 7. Diabetes mellitus (diabetes) 8. Influenza and pneumonia 9. Nephritis, nephrotic syndrome and nephritis (kidney disease) 10. Septicemia

2,423,712 100.0% 616,067 25.40% 562,875 23.20% 135,952 5.60%






123,706 74,632 71,382 52,717

5.10% 3.10% 2.90% 2.20%

1,252 1,202 767 749

1.01% 1.61% 1.07% 1.42%

4.60% 4.42% 2.82% 2.75%











a: extract from Xu, et al., 2010. b: # of IA deaths divide by # national death c: Leading cause IA death divide by total # of IA death

N/A: data not available

for Americas Health, 2011). On the other hand, IA State does not have a health department equipped with an electronic syndromic surveillance system that can report and exchange information on health insurance (Trust for Americas Health, 2011). There should be a surveillance system

Cost Challenges and Policies


in place to identify DM early, before diagnoses are confirmed and reported to public health agencies, and to mobilize a rapid response, thereby reducing morbidity and mortality (Henning, 2004). In addition, the U.S. Government should continue to provide funding for public health services within IA State with an increase for 2011 (Trust for Americas Health, 2011). In 2010, $59,664,208 was given to IA State, of which $224,612 was given to address the DM issues, which represent only 0.38% of the entire budget. DM as a cause of death and disease could be further reduced by increasing the budgets for addressing this health problem, which is prevalent across IA State. This increased budget can be used to educate physicians on the updates of DM, for instance, and employ more dietitians. Both the medical management and nutritional management of DM would benefit from an increase budget. Under medical management, DM patients can be advised and given proper diagnosis, monitoring, medication and exercise. As advised by a Dietitian, the nutritional management would include lifestyle strategies (food/eating and physical activity) that improve the blood-glucose levels. This would also include nutrition education, health promotion and energy restriction to promote 510% weight loss (Barton, 2010, p. 320; Mahan and Escott-Stump, 2004, p. 798). Though, it is vital to note that in March 2010, Congress passed legislation that specifically addressed diabetes prevention through H.R. 3590 the Patient Protection and Affordable Care Act, SEC. 399V-3-National Diabetes Prevention Program, in Iowa (CDC, 2011). In the political context, disease and its impact on the healthcare delivery system within IA State and U.S. has been an edifying and enriching research for comparison of death and disease information. Though the top leading causes were the same for Iowa and U.S. at large, other diseases in IA needed to be addressed. For instance, there were also deaths resulting from Parkinsons disease, chronic liver disease and cirrhosis, hypertensive disease, intentional-harm (suicide), drug-induced causes and infant and neonatal deaths (Xu, et al., 2010). The efforts implemented at each state level would impact upon the U.S. healthcare delivery system through its reformation and development of policies, rules, regulations and legislation; re-looking at the allocation of funding to each state; and, in particular, in spite of reinstating the idea of having a national health insurance, cost-shifting. In conclusion, Table 2 below summarizes the cost shifting strategies which are more likely to be passed and work.


U.S. Public Health Policy

Table 2: Health Care Cost Containment: Cost Shifting Strategies

More Likely To Pass & Work State Strategies: Cost Shifting Social 1. Increase Medicaid reimbursement to providers 2. Shifting costs to private entities 3. Mandatory insurance laws 4. Conduct a SWOT analysis State-wise

Political X




: Yes; X: No

Disease and Emergency-Related Health Policy

The purpose of this section is to discuss the Ryan White CARE Act, which was passed in 1990 after Whites death; the events leading to this policy proposal and efforts that were necessary to enact it. Additionally, the current terms of this policy and its impact on various stakeholders locally, nationally, and internationally will also be discussed. It is crucial to note that the social-political context is connected to the development and implementation of health policy for individuals living with Human Immunodeficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS). Therefore, advancement in the treatment of AIDS as a result of HIV has improved overtime and the number of deaths due to the disease has decreased. However, in the early 1980s and 1990s many were not as fortunate; by 1990, 150,000 people reportedly were diagnosed and over 100,000 had died (Health Resources and Services Administration, HRSA, 2012; Teitelbaum and Wilensky, 2007) Little was known about the disease and only few could afford treatment. The Ryan White Comprehensive AIDS Resource Emergency Act (CARE), a federal discretionary program, was enacted to urgently provide care to the impoverished, to improve the quality and availability of care of those infected with the disease, as well as their families (Anderson, Rice & Kominski, 2007, p. 386). It was named after an infected teenager who courageously fought and strove to educate people about the disease before succumbing to it in 1990. This Act is comprised of five parts, and is designed especially for low-income patients and families, those uninsured, and the underinsured. Part A provides funding to those in metropolitan areas; Part B aids states and territories in increasing access, support services and improving the quality of services, including medication availability; Part C provides aid for early interventions; Part D provides funding for


U.S. Public Health Policy

family-centered care for women, children, and youths, while Part F funds innovation, education and training of service providers as well as dental care (Buchanan and Hatcher, 2007, p. 2013). As research, innovation, education, and treatment changed, Congress had to enforce reauthorizations of the Act in years 1996, 2000, 2006, and 2009. In addition, the face of the disease changed; the trends in the treatment regimen have changed and improved, especially in its social acceptance and drug therapy (Barton, 2010). This current legislation is due for reauthorization in 2013 (HRSA). Funding for the program has been fairly constant, initiating appropriations at under $500 million in 1990 to over $2 billion in 2010 (HRSA, 2012). The HRSA also noted that the program was funded in all 50 states, DC, Guam, the U.S. Virgin Islands, Puerto Rico, and five U.S. Pacific territories and jurisdictions (U.S. Department of Health and Human Services, 1995). As it is not a guaranteed entitlement, once the allocated funds are utilized, states have to wait until the next federal budget cycle to be reallocated. The Ryan White Comprehensive AIDS Resources Emergency (CARE) Act has been highly instrumental in reducing the incidence of morbidity and mortality rate in the U.S., especially among the impoverished and minority groups (Shi and Singh, 2008; Thielemann, Scotch & Bielefeld, 1999). Its stipulations of indiscriminate appropriation of funds have enabled service providers to strategically serve the communities and income groups that would otherwise suffer from this destructive disease.


Getting Involved in Health Policy In conclusion, the American Public Health Association (APHA) was established in 1872 as an organization made up of various healthcare professionals, all collaborating to protect society from communicable diseases and to promote health and wellness (APHA, 2012). This organization furthermore, works closely with Congress, Regulatory Agencies, and some public organizations to promote public health in the legislative and policy-making processes (APHA, 2012). As it is in the interest of APHA to see the paradigm of the focus on an individuals health change to a corporative focus on community and the publics health, the members were indeed pleased with the reforms of the Affordable Care Act (ACA) expanding health insurance to the particular sector of the uninsured and underinsured in America (Stenrud, 2012). This legislation will enable more people to have access to healthcare in that businesses with greater than 50 employees will be required to offer benefits, otherwise be faced with a penalty, and Medicaid access will be extended to those with income up to 133% of the federal poverty level. Furthermore, there has been the expansion of the childrens health insurance program and children may be covered up to age 26 under their parents health insurance (Wallen, 2012; The Henry J. Kaiser Family Foundation, 2011). Such initiatives certainly increase more of the populations access to healthcare. In addition, the ACA also promotes increases in payments to primary care, investment in primary care training and expansion of community health centres (Davis, 2010). The APHA offers its support and advocacy through various measures, for instance, the organization collaborates with other agencies such as the American Healthcare Association


U.S. Public Health Policy

(AHA), National Association of Community Health Centres, and Association of Clinicians for the Underserved, to name a few, in writing to Congress revoking cuts to agencies like Medicaid and other community or public organizations. In order to be an effective healthcare administrator and/or professional, the responsibility is on him/her to get involved in organizational movements that support these values within the healthcare arena. Lets take, for instance, that peoples mindset has to change on being able to highlight the importance of health and have some compassion about people being able to have access to healthcare. In order to promote access however, people can let their voice be heard and encourage their fellow U.S. citizens to vote. People can write letters to Congress and encourage other community and professional organizations to do the same. It is important that people get involved to make a difference, in order to help create positive changes in the community, even the counties, cities and the country at large. Often, changes leading to legislatures start with the idea or initiative of one individual who has been heard, forms coalitions, and subsequently influences the masses. As healthcare professionals and emerging doctoral scholars, we have to contribute to the continuing work of developing tools in order to be able to make that difference, influencing the development of policies and the reformation of legislatures, so as to promote a more efficient healthcare system and a healthier country.


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U.S. Public Health Policy examines health policy in the United States, which reflects authoritative decisions and the process of decision-making, carried out at the federal, state, and local levels, which affect personal health and access to and delivery of health services. The publication provides an analysis of health policy making in the U.S., including how health policy proposals move through the policy process. It also assesses the key challenges with regards to addressing cost, access, and quality issues in health care and an evaluation of the existing policies in these arenas. In addition, it contains an analysis of the diversity of perspectives held by policy makers, interest groups, health care professionals, and other stakeholders regarding existing and proposed health policy; in addition to the identification of the ways in which health care professionals can participate in and influence health policy development.

Immanuel Azaad Moonesar is the Managing Director at I AM Consulting. He was formerly the Institutional Research Ofcer at the University of Wollongong in Dubai (UOWD) and now heads the Institutional Effectiveness & Accreditation department at Mohammed Bin Rashid School of Government (MBRSG). He is also the Vice President (Database Marketing & Outreach) and Executive Board member of the Academy of International Business Middle East North Africa (AIB-MENA) Chapter. His qualications include a Master of Quality Management (Distinction), a Postgraduate Diploma in Institutional Community Nutrition & Dietetics and a Bachelor of Science in Human Ecology. He has published over 28 publications in peer-reviewed journal articles, peer-reviewed international conferences, co-authored books and book chapters thus far. He is currently pursuing a Doctor of Philosophy (PhD) in Health Services: Leadership.

Introduction Access challenges and policies Quality challenges and policies Cost challenges and policies Disease and emergency-related health policy Conclusion

ISBN 978-1-909287-86-0

9 781909 287860

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