DynamicInfluencesonHealthCarePolicyupdated1.pptxDynamic Influences on Health Care Policy
Dr. Carla Nye
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Quality and Safety
1999 – when to err is human came out – errors 5th leading cause of death
2011 – errors 3rd leading cause of death
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ACA and Value Based Care
Looking at each of these dimensions
Improving the patient experience of care (including quality and satisfaction);
Improving the health of populations; and
Reducing the per capita cost of health care.
For every action there is an equal and opposite reaction
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Quadruple Aim
Create value
Coordinate care
Payment reform
Improve access to coverage
Aca has rules –
Community benefit – hospitals must do community health assessment, make a plan and partner with communities
Hospitals penalized for readmissions, but paid for developing transition to care programs.
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US HEALTH CARE POLICY
Public
Private
CHARACTERISTICS OF US HEALTH POLICY: TIMELINE OF GOVERNMENT INVOLVEMENT IN HEALTHCARE
Self pay, barter Pre-Industrial
Insurance policies early 1900’s
Social Security 1935
Medicare and Medicaid 1965
Children’s Health Insurance program 1997
Affordable Care Act 2010
Government as a subsidiary to private sector – in most developed countries – health care is seen as a right and the government is fully involved to ensure citizens have access to HC. Not the case in the US. Private sector is dominant. Right to health care has led to ACA. Citizen distrust of govt, Government intrusion on personal liberty is foundational to Declaration of independence. Govt has traditionally filled gaps where private sector cannot or wont address.
Insurance policies for workers
Social security for those with retirement savings wiped out due to depression
Medicare and Medicaid – insurance only there for working middle class and wealthy - poor left to own devices, charity
Children's health insurance - States are given flexibility in designing their CHIP eligibility requirements and policies within broad federal guidelines.
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CHARACTERISTICS OF US HEALTH POLICY
Fragmented policies
Incremental and piecemeal policies
Pluralistic Suppliers of Policy
Decentralized roles of the states
Impact of presidential leadership
Politics of the ACA
Fragmented policies - fragmented policies between federal, state, and local governments – came from checks and balances. Multiple combinations of public and private management of HC, and different in every state.
Incremental and piecemeal policies – Multiple compromises over the years between parties have led to smaller, incremental changes – nothing full bore until ACA. Within programs, changes are made incrementally – no big overhaul.
Interest groups as demanders of policies – each group fights hard to protect its interests – end result some type of compromise, where no one is truly happy. AMA, AARP, AHA, PharmA, labor unions, insurers.
Pluralistic Suppliers of Policy – executive, legislative and judicial branches can influence policy at fed, state, and local levels
Decentralized roles of the states – State is the primary controller of regulating managed care, care of disabled, oversight of professions. Very hard to coordinate a national strategy.
Impact of presidential leadership – and unintended consequences - Truman passed the Hill Burton act in 1946 that gave grants for building adequate hospital rooms for population. 1965 Johnson passed Medicare and Medicare. By 1980 – reached the level of hospital beds set out in Hill Burton and at same time Medicare and Medicaid reached gigantic expansion and expense. Ronald Reagan authorized PPS method of payment to reduce hospital utilization, which created a downward trend in inpatient stay and a glut of hospital beds.
Politics of the ACA – Democrats had control of house (Nancy Pelosi) and senate (Harry Reid). Obama had huge support from populace as well as party. Details of the ACA were largely kept secret from the public. (compared to when Clinton introduced his plan in 1993, which was very public). ACA passed with little contributions from the republicans, little input from the public. It won through the stakeholders with pledges to the stakeholders that they would get many new insured people – particularly the young healthy population.
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CHARACTERISTICS OF US HEALTH POLICY: INTEREST GROUPS AS DEMANDERS OF POLICY
| Key Health Care Concerns of Selected Interest Groups | |
| Federal and State Governments | Cost Containment Access to Care Quality of care |
| Employers | Cost Containment Workplace health and safety Minimum regulation |
| Consumers | Access to care Quality of care Lower out-Characteristics of US Health Policy of-pocket costs |
| Insurers | Administrative simplification Elimination of cost shifting |
| Practitioners | Income Maintenance Professional autonomy Malpractice reforms |
| Provider Organizations | Profitability Administrative simplification Bad debt reduction |
| Technology Producers | Tax Treatment Regulatory environment Research funding |
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Political Climate
Politics is the use of relationships and power to gain ascendency among competing stakeholders to influence policy and the allocation of resources
Politics is a noun/a process/a system
Wide range of political philosophies – answer the question of the state and its moral and ethical responsibilities to the people and to those outside of the state.
The idea behind the state is people cannot rule on their own – that there needs to be an organizing structure to maintain balance, control, moral and ethical duties and obligations.
Early Liberalism – (Hobbes, Locke, Mill) – individuals participate in political decision making and express their views freely: intellectual freedom, limited government in economic activities and personal life, govt protections against abuse of power,
Current Liberalism – Support expanded government, holding onto the status quo (medicare and Medicaid), government makes the regulations that control
Early Conservatism – stability and structure, government had the power and duty to protect the weak
Current conservatism – oppose rapid change, decrease in federal responsibility for health and social issues to state governments, a reduced tax burden so citizens can have $$ to control the economy, decreased federal involvement in life – individual freedom to choose
Socialism (marx) equality of all, classless society, economy that contributes to the welfare of all, , lack of individual ownership, lack of privatization of property – property is owned by central government that controls economy.
Communism –revolution to achieve socialism (soviet block)
Social Democrats – willing to work within system to achieve fairness (Scandinavian countries) , welfare state – lawyer and barista making similar salaries, shorter work hours.
Nation
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Social Libertarian (left): Jefferson (Democratic-Republican). Favoring a socialist democratic republic with limited power.
Social Liberal (left): Johnson (Democrat) and Lincoln (Republican). Favoring authoritative Democracy for the benefit of the collective.
Conservative Libertarian (right): Reagan (Republican). Favoring authoritative conservatism for individual liberty.
Liberal Conservative (right): Hamilton (Federalist). Favoring authoritative conservatism for the collective.
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US (Canada, and Australia) are also liberal welfare states
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Ethics
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Social Determinants of Health
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Crises ??
Opioid crisis – USA death rates
The U.S. falls between #36, Qatar, and #38, Poland, in this analysis, below lower-income nations like South Korea (#12), Malta (#16), Chile (#18), and Slovenia (#29). (Washington Post)
Gallup’s November 2017 poll on health care costs found that about one-third of Americans put off medical treatment due to costs, and more women (37%) than men (22%) do. This may be due to the fact that women’s healthcare costs are typically higher than men’s. What’s most somber about this statistic is that nearly two-thirds of people who forego care due to cost say they have a serious condition. Self-rationing of care due to cost can lead to earlier, avoidable, disability and death.
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Estimates of Death rates above normal
https://www.nytimes.com/2023/07/17/briefing/covid.html
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Now what?
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