Unit 1 Assignment - Examine Knowledge Framework. 1000w. due 9-10-22. 4 references

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EssentialsofHealthPolicyandLaw.pdf

Home >Nursing homework help >Unit 1 Assignment - Examine Knowledge Framework. 1000w. due 9-10-22. 4 references

Series Editor: Richard Riegelman ES

SE N

T IA

L P

U B

LI C

H EA

LT H Health Policy

and Law Sara E. Wilensky, JD, PhD Department of Health Policy and Management, Milken Institute School of Public Health, The George Washington University

Joel B. Teitelbaum, JD, LLM Department of Health Policy and Management, Milken Institute School of Public Health, The George Washington University

Essentials of

FOURTH EDITION

lifie cific

Th cific

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Thi

s fir ifier

sific

Prologue . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

About the Editor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xi

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xv

About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii

Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix

PART I Setting the Stage: An Overview of Health Policy and Law 1

Chapter 1 Understanding the Role of

and Conceptualizing Health

Policy and Law . . . . . . . . . . . . . . . . . . 3

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Role of Policy and Law in Health Care

and Public Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Conceptualizing Health Policy and Law . . . . . . . . . . . . . 5

The Three Broad Topical Domains of Health

Policy and Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Social, Political, and Economic Historical Context . . . . 6

Key Stakeholders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Chapter 2 Policy and the

Policymaking Process . . . . . . . . . . . 11

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Defining Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Identifying Public Problems . . . . . . . . . . . . . . . . . . . . . . . . 11

Structuring Policy Options . . . . . . . . . . . . . . . . . . . . . . . . . 12

Public Policymaking Structure and Process . . . . . . . . .13

State-Level Policymaking . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

The Federal Legislative Branch. . . . . . . . . . . . . . . . . . . . . . 14

The Federal Executive Branch . . . . . . . . . . . . . . . . . . . . . . 21

The Health Bureaucracy. . . . . . . . . . . . . . . . . . . . . . . . . . . .25

The Federal Government . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

State and Local Governments . . . . . . . . . . . . . . . . . . . . . . 28

Interest Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

Chapter 3 Law and the Legal System . . . . . . . 33

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

The Role of Law. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

The Definition and Sources of Law . . . . . . . . . . . . . . . . .35

Defining “Law” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Sources of Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Key Features of the Legal System . . . . . . . . . . . . . . . . . .39

Separation of Powers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Federalism: Allocation of Federal

and State Legal Authority . . . . . . . . . . . . . . . . . . . . . . . . 40

The Role of Courts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47

Chapter 4 Overview of the

United States Healthcare

System . . . . . . . . . . . . . . . . . . . . . . . 49

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49

Healthcare Finance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50

Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

Direct Services Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Healthcare Access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54

The Uninsured . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

The Underinsured . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

Insurance Coverage Limitations . . . . . . . . . . . . . . . . . . . . 61

Safety Net Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Workforce Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Healthcare Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68

Key Areas of Quality Improvement . . . . . . . . . . . . . . . . . 68

Assessment of Efforts to Improve Quality . . . . . . . . . . . 71

Contents

iii

Comparative Health Systems . . . . . . . . . . . . . . . . . . . . . .71

A National Health Insurance System: Canada . . . . . . . 71

A National Health System: Great Britain . . . . . . . . . . . . . 73

A Socialized Insurance System: Germany . . . . . . . . . . . 74

The Importance of Health Insurance Design . . . . . . . . 75

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

Chapter 5 Public Health Institutions

and Systems . . . . . . . . . . . . . . . . . . . 81

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81

What Are the Goals and Roles

of Governmental Public Health Agencies? . . . . . . .81

What Are the 10 Essential Public Health Services? . . .83

What Are the Roles of Local and State Public

Health Agencies? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85

What Are the Roles of Federal Public Health

Agencies? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87

What Are the Roles of Global Health

Organizations and Agencies? . . . . . . . . . . . . . . . . . . . .90

How Can Public Health Agencies Work Together? . . .91

What Other Government Agencies

Are Involved in Health Issues? . . . . . . . . . . . . . . . . . . . .91

What Roles Do NGOs Play in Public Health? . . . . . . . .92

Nongovernmental Organizations . . . . . . . . . . . . . . . . . . . 92

How Can Public Health Agencies Partner

With Health Care to Improve the Response

to Health Problems? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .93

How Can Public Health Take the Lead in

Mobilizing Community Partnerships

to Identify and Solve Health Problems? . . . . . . . . . .95

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96

Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109

Other Sources Consulted . . . . . . . . . . . . . . . . . . . . . . . . . . 109

Source for Political Affiliation of Senate . . . . . . . . . . . . 109

Source for Political Affiliation of the

House of Representatives . . . . . . . . . . . . . . . . . . . . . . . 109

PART II Essential Issues in Health Policy and Law 111

Chapter 6 Individual Rights in Health Care

and Public Health . . . . . . . . . . . . . 113

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113

Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114

Individual Rights and Health Care: A Global

Perspective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116

Individual Rights and the Healthcare System . . . . . 117

Rights Under Healthcare and Health

Financing Laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

Rights Related to Freedom of Choice and

Freedom From Government Interference . . . . . . . 119

The Right to Be Free From Wrongful

Discrimination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125

Individual Rights in a Public Health Context . . . . . . 128

Overview of Police Powers . . . . . . . . . . . . . . . . . . . . . . . . 128

The Jacobson v. Massachusetts Decision. . . . . . . . . . . . 129

The “Negative Constitution” . . . . . . . . . . . . . . . . . . . . . . . 130

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134

Chapter 7 Social Determinants of Health

and the Role of Law in

Optimizing Health . . . . . . . . . . . . . 137

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138

Social Determinants of Health . . . . . . . . . . . . . . . . . . . 139

Defining Social Determinants of Health . . . . . . . . . . . 139

Types of SDH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

The Link Between Social Determinants and

Health Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

Law as a Social Determinant of Health . . . . . . . . . . . 142

Right to Criminal Legal Representation

vs. Civil Legal Assistance . . . . . . . . . . . . . . . . . . . . . . . . 144

Combating Health-Harming Social Conditions

Through Medical-Legal Partnership . . . . . . . . . . . . 146

The Evolution of an “Upstream” Innovation . . . . . . . . 147

The Benefits of MLPs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151

Chapter 8 Understanding Health

Insurance . . . . . . . . . . . . . . . . . . . . 153

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

A Brief History of the Rise of Health

Insurance in the United States . . . . . . . . . . . . . . . . . 154

How Health Insurance Operates . . . . . . . . . . . . . . . . . 156

Basic Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156

Uncertainty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157

Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158

Setting Premiums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160

Medical Underwriting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161

iv Contents

Managed Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162

Cost Containment and Utilization Tools. . . . . . . . . . . . 163

Utilization Control Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

Common Managed Care Structures . . . . . . . . . . . . . . . 166

The Future of Managed Care . . . . . . . . . . . . . . . . . . . . . . 169

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171

Chapter 9 Health Economics in a

Health Policy Context . . . . . . . . . . 173

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

Health Economics Defined . . . . . . . . . . . . . . . . . . . . . . . 174

How Economists View Decision Making . . . . . . . . . . . 174

How Economists View Health Care . . . . . . . . . . . . . . . . 176

Economic Basics: Demand . . . . . . . . . . . . . . . . . . . . . . . 176

Demand Changers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176

Elasticity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178

Health Insurance and Demand . . . . . . . . . . . . . . . . . . . . 179

Economic Basics: Supply . . . . . . . . . . . . . . . . . . . . . . . . . 180

Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180

Supply Changers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180

Profit Maximization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 180

Health Insurance and Supply . . . . . . . . . . . . . . . . . . . . . . 181

Economic Basics: Markets . . . . . . . . . . . . . . . . . . . . . . . . 182

Health Insurance and Markets . . . . . . . . . . . . . . . . . . . . . 182

Market Structure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182

Market Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187

Chapter 10 Health Reform in the

United States . . . . . . . . . . . . . . . . 189

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189

Difficulty Achieving Health Reform

in the United States . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190

Culture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191

U.S. Political System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191

Interest Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

Path Dependency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193

Unsuccessful Attempts to Pass

National Health Insurance Reform . . . . . . . . . . . . . 194

The Stars Align (Barely): How the ACA

Became Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197

Commitment and Leadership . . . . . . . . . . . . . . . . . . . . . 197

Lessons From Failed Health Reform Efforts . . . . . . . . . 199

Political Pragmatism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201

Overview of the ACA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201

Individual Mandate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203

State Health Insurance Exchanges/

Marketplaces . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206

Employer Mandate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213

Changes to the Private Insurance Market . . . . . . . . . . 214

Financing Health Reform . . . . . . . . . . . . . . . . . . . . . . . . . . 215

Public Health, Workforce, Prevention,

and Quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216

The U.S. Supreme Court’s Decision in the

Case of National Federation of Independent

Business v. Sebelius . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

States and Health Reform . . . . . . . . . . . . . . . . . . . . . . . . 218

Key Issues Going Forward . . . . . . . . . . . . . . . . . . . . . . . . 219

Congressional Activity. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220

Insurance Plan Premium Rates . . . . . . . . . . . . . . . . . . . . 222

ACA Litigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225

Chapter 11 Government Health Insurance

Programs: Medicaid, CHIP,

and Medicare . . . . . . . . . . . . . . . . 231

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 232

Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233

Program Administration . . . . . . . . . . . . . . . . . . . . . . . . . . . 233

Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234

Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 238

Amount, Duration, and Scope,

and Reasonableness Requirements . . . . . . . . . . . . . 241

Medicaid Spending . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 242

Medicaid Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243

Medicaid Provider Reimbursement . . . . . . . . . . . . . . . . 244

Medicaid Waivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 247

The Future of Medicaid . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248

Children’s Health

Insurance Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248

CHIP Structure and Financing . . . . . . . . . . . . . . . . . . . . . 249

CHIP Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250

CHIP Benefits and Beneficiary Safeguards . . . . . . . . . . 251

CHIP and Private Insurance Coverage . . . . . . . . . . . . . . 252

CHIP Waivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252

The Future of CHIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252

Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253

Medicare Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253

Medicare Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255

Medicare Spending . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258

Medicare Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 258

Medicare Provider Reimbursement . . . . . . . . . . . . . . . . 262

The Future of Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265

Contents v

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268

Chapter 12 Healthcare Quality Policy

and Law . . . . . . . . . . . . . . . . . . . . 271

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271

Quality Control Through Licensure

and Accreditation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272

Medical Errors as a Public

Health Concern . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273

Promoting Healthcare Quality Through the

Standard of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275

The Origins of the Standard of Care. . . . . . . . . . . . . . . . 275

The Evolution of the Standard of Care . . . . . . . . . . . . . 276

Tort Liability of Hospitals, Insurers, and MCOs . . . . 278

Hospital Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278

Insurer Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279

Managed Care Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . 280

Federal Preemption of State Liability

Laws Under ERISA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281

Overview of ERISA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281

ERISA Preemption . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282

The Intersection of ERISA Preemption

and Managed Care Professional

Medical Liability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283

Measuring and Incentivizing Healthcare Quality . . . 284

Quality Measure Development . . . . . . . . . . . . . . . . . . . . 286

Quality Measurement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286

Public Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286

Value-Based Purchasing . . . . . . . . . . . . . . . . . . . . . . . . . . . 287

National Quality Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . 288

Private Payer Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289

Role of Health Information Technology . . . . . . . . . . . . 289

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 290

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291

Chapter 13 Public Health Preparedness

Policy . . . . . . . . . . . . . . . . . . . . . . 293

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293

Defining Public Health Preparedness . . . . . . . . . . . . . 294

Threats to Public Health . . . . . . . . . . . . . . . . . . . . . . . . . 295

CBRN Threats . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295

Naturally Occurring Disease Threats . . . . . . . . . . . . . . . 299

Natural Disasters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 300

Man-Made Environmental Disasters . . . . . . . . . . . . . . . 303

Public Health Preparedness Policy . . . . . . . . . . . . . . . 303

Federal Response Agencies and Offices . . . . . . . . . . . 303

Preparedness Statutes, Regulations,

and Policy Guidance . . . . . . . . . . . . . . . . . . . . . . . . . . . . 305

Presidential Directives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307

International Agreements . . . . . . . . . . . . . . . . . . . . . . . . . 308

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 310

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311

PART III Basic Skills in Health Policy Analysis 315

CHAPTER 14 The Art of Structuring

and Writing a Health Policy

Analysis . . . . . . . . . . . . . . . . . . . . 317

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317

Policy Analysis Overview . . . . . . . . . . . . . . . . . . . . . . . . . 317

Client-Oriented Advice . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317

Informed Advice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318

Public Policy Decision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318

Providing Options and a

Recommendation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 318

Your Client’s Power and Values . . . . . . . . . . . . . . . . . . . . 318

Multiple Purposes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 319

Structuring a Policy Analysis . . . . . . . . . . . . . . . . . . . . . 319

Problem Identification . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320

The Background Section . . . . . . . . . . . . . . . . . . . . . . . . . . 322

The Landscape Section. . . . . . . . . . . . . . . . . . . . . . . . . . . . 323

The Options Section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326

The Recommendation Section . . . . . . . . . . . . . . . . . . . . 330

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 330

Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 337

vi Contents

Prologue

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About the Editor

Preface

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▸ Implementation of the ACA

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▸ Shifts in Public Health Education

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▸ Addressing Health Policy Challenges

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▸ About the Fourth Edition

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Acknowledgments

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About the Authors

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xviii About the Authors

Contributors

▸ Chapter 5: Public Health Institutions and Systems

Richard Riegelman, MD, PhD, MPH

The

▸ Chapter 13: Public Health Preparedness Policy

Rebecca Katz, PhD, and Claire Standley, PhD

xix

PART I

Setting the Stage: An Overview of Health Policy and Law

CHAPTER 1

Understanding the Role of and Conceptualizing Health Policy and Law

LEARNING OBJECTIVES

By the end of this chapter you will be able to:

■ Describe generally the important role played by policy and law in the health of individuals and populations ■ Describe three ways to conceptualize health policy and law

By the end of this chapter you will be able to:

■ Describe generally the important role played by policy and law in the health of individuals and populations ■ Describe three ways to conceptualize health policy and law

▸ Introduction

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▸ Role of Policy and Law in Health Care and Public Health

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▸ Conceptualizing Health Policy and Law

BOX 1-1

The Three Broad Topical Domains of Health Policy and Law

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BOX 1-1 Three Conceptual Frameworks for Studying

Health Policy and Law

Study based on the broad topical

domains of:

a. Health care

b. Public health

c. Bioethics

Study based on historically dominant

social, political, and economic perspectives:

a. Professional autonomy

b. Social contract

c. Free market

Study based on the perspectives of

key stakeholders:

a. Individuals

b. The public

c. Healthcare professionals

d. Federal and state governments

e. Managed care and traditional insurance

companies

f. Employers

g. Healthcare industries (e.g., the pharmaceutical

industry)

h. The research community

i. Interest groups

j. Others

Healthcare Policy and Law

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CHAPTER 2

Policy and the Policymaking Process

LEARNING OBJECTIVES

By the end of this chapter you will be able to:

■ Describe the concepts of policy and policymaking ■ Describe the basic function, structure, and powers of the legislative branch of government ■ Describe the basic function, structure, and powers of the executive branch of government ■ Explain the role of federal and state governments in the policymaking process ■ Explain the role of interest groups in the policymaking process

By the end of this chapter you will be able to:

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Committee/Subcommittee Health-Related Jurisdiction

Senate Finance Committee

■ Subcommittee on Health Care ■ Department of Health and Human Services

Centers for Medicare and Medicaid Services (includes

Children’s Health Insurance Program [CHIP])

Administration for Children and Families ■ Department of the Treasury

Group health plans under the Employee Retirement

Income Security Act (ERISA)

Senate Appropriations Committee

■ Subcommittee on Labor, Health, Human

Services, Education, and Related Agencies

■ Department of Health and Human Services

All areas except Food and Drug Administration, Indian

Health, and construction activities

■ Subcommittee on Agriculture, Rural

Development, Food and Drug Administration,

and Related Agencies

■ U.S. Agricultural Department (except Forest Service)

Includes child nutrition programs; food safety and

inspections; nutrition program administration; special

supplemental nutrition program for Women, Infants,

Children (WIC); Supplemental Nutrition Assistance

Program (SNAP) ■ Food and Drug Administration

(continues)

TABLE 2-1 Key Health Committees and Subcommittees

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Committee/Subcommittee Health-Related Jurisdiction

■ Subcommittee on Interior, Environment, and

Related Agencies

■ Department of Health and Human Services

Indian Health Services

Agency for Toxic Substances and Disease Registry

Senate Health, Education, Labor, and Pensions Committee

■ Subcommittee on Children and Families

■ Subcommittee on Primary Health and

Retirement Security

■ Occupational safety and health, public health, Health

Resources Services Act, substance abuse and mental

health, oral health, healthcare disparities, ERISA

Senate Committee on Agriculture, Nutrition, and Forestry

■ Subcommittee on Nutrition, Specialty Crops,

and Agricultural Research

■ Food from fresh waters; SNAP; human nutrition; inspection

of livestock, meat, and agricultural products; pests and

pesticides; school nutrition programs; other matters related

to food, nutrition, and hunger

Senate Committee on Environment and Public Works

■ Subcommittee on Clean Air and Nuclear Safety ■ Air pollution, environmental policy, research and

development, noise pollution, water pollution, nonmilitary

control of nuclear energy, solid waste disposal and recycling

House Committee on Ways and Means

■ Subcommittee on Health ■ Programs providing payments for health care, health

delivery systems, and health research

■ Social Security Act

■ Maternal and Child Health Block Grant

■ Medicare

■ Medicaid

■ Peer review of utilization and quality control of healthcare

organizations

■ Tax credit and deduction provisions of the Internal Revenue

Service relating to health insurance premiums and

healthcare costs

■ Subcommittee on Human Resources ■ Social Security Act

Public assistance provisions

Supplemental Security Income provisions

Mental health grants to states

House Committee on Appropriations

■ Subcommittee on Labor, Health and Human

Services, Education, and Related Agencies

■ Department of Health and Human Services

Administration for Children and Families

Administration for Community Living

Agency for Healthcare Research and Quality

Centers for Disease Control and Prevention

Centers for Medicare and Medicaid Services

TABLE 2-1 Key Health Committees and Subcommittees

16 Chapter 2

(continued)

Health Resources Services Administration

National Institutes of Health

Substance Abuse and Mental Health Services

Federal Mine Safety and Health Review Commission

Medicaid and CHIP Payment and Access Commission

Medicare Payment Advisory Committee

National Council on Disability

Occupational Safety and Health Review Commission

Social Security Administration

■ Subcommittee on Agriculture, Rural

Development, Food and Drug Administration,

and Related Agencies

■ Food and Drug Administration

■ Department of Agriculture (except Forestry)

■ Subcommittee on Energy, Water Development,

and Related Agencies

■ Department of Energy

National Nuclear Strategy Administration

Federal Energy Regulatory Commission

■ Department of Interior

■ Bureau of Reclamation

■ Defense Nuclear Facilities Safety Board

■ Nuclear Regulatory Commission

■ Subcommittee on Interior, Environment, and

Related Agencies

■ Department of Interior

■ Environmental Protection Agency

■ Indian Health Service

■ National Institute of Environmental Health Sciences

■ Chemical Safety and Hazards Investigation Board

House Committee on Agriculture

■ Subcommittee on Nutrition ■ Nutrition programs, including SNAP

■ Subcommittee on Biotechnology, Horticulture,

and Research

■ Policies and statutes relating to horticulture, bees, organic

agriculture, pest and disease management, bioterrorism,

biotechnology

■ Subcommittee on Livestock and Foreign

Agriculture

■ Policies and statutes relating to inspections of livestock,

dairy, poultry, and seafood; aquaculture; animal welfare

Congressional Commissions and Staff Agencies

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How Laws Are Made

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FIGURE 2-1 How a Bill Becomes a Law

18 Chapter 2

Representative introduces bill in the House

Senator introduces bill in the Senate

Bill is read in the House and assigned to a committee by the

Speaker

Bill is read in the Senate and assigned to a committee by the

majority leader

Bill leaves committee, is scheduled for floor

consideration and debate, may be amended

Bill leaves committee, is scheduled for floor

consideration and debate, may be amended

House passes bill Senate passes bill

Bill is sent to Senate Bill is sent to House

A conference committee is created to resolve differences if both chambers do not pass an identical bill

Identical bill is passed by both House and Senate OR one branch agrees to the other branch's version OR bill is amended and both branches vote again and pass amended version

Bill is presented to the President, who has four options

Option 1: President signs bill into law

Option 2: During congressional

session, bill becomes law after 10 days without presidential signature

Option 3: When not in session, bill

does not become law without presidential

signature

Option 4: President vetoes bill.

Two-thirds vote in House and Senate can override veto

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Constituents of Legislative Branch

TABLE 2-2 Federal Budget Process Timeline

First Monday in February President submits budget proposal to Congress.

March House completes its budget resolution.

April Senate completes its budget resolution.

April 15 House and Senate complete concurrent budget resolution.

May Authorizing committees develop reconciliation language when necessary and report

legislation to budget committees. House and Senate develop conference report on

reconciliation, which is voted on by each chamber.

June 10 House concludes reporting annual House appropriations bills.

June 15 If necessary, Congress completes reconciliation legislation.

June 30 House completes its appropriations bills.

September 30 Senate completes its appropriations bills. House and Senate complete appropriations

conference reports and vote separately on the final bills.

October 1 Fiscal year begins.

Modified from House Committee on the Budget Majority Caucus, Basics of the Budget Process, 107th Cong. Briefing Paper, 2001.

20 Chapter 2

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BOX 2-1 Office of Management and Budget

The Office of Management and Budget (OMB) reports

directly to the president and plays an important role

in policy decisions. OMB is responsible for preparing

the presidential budget proposal, which includes

reviewing agency requests, coordinating agency

requests with presidential priorities, working with

Congress to draft appropriation and authorization bills,

and working with agencies to make budget cuts when

needed. In addition to these budgetary functions,

OMB provides an estimate of the cost of regulations,

approves agency requests to collect information,

plays a role in coordinating domestic policy, and

may act as a political intermediary on behalf of the

president. OMB also has an oversight and evaluation

function over select federal agencies as a result of

the Government Performance and Results Act, which

requires agencies to set performance goals and have

their performance evaluated.

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FIGURE 2-2 Executive Agency Policymaking Source: Courtesy of Jeff Levi, Professor of Health Policy, George Washington University.

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Should this be on the agenda? Agency Staff

What are the options?

Is there a problem?

What is recommended to decision-maker?

Congress

Media

White House

CONSUMERS, CITIZENS, & CONSTITUENCY GROUPS

Political Players

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▸ The Health Bureaucracy

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TABLE 2-3 Summary of Public Policymaking Entities

Congress President Administrative Agencies

Main function Legislative body Chief executive of the country Implement statutes through

rule making

Main tools/

powers

Support/oppose/pass

legislation

Appropriations

Oversight

Agenda setting

Persuasion

Propose solutions

Budget proposals

Executive orders

Sign legislation into law

Create regulations

Provide information

Constituents Voters in state or district

Voters in nation if in leadership

role or have national

aspirations

Party

President

Nation (all voters)

Public who voted for the

president

Party

Other nations

International organizations

President

Congress

Individuals and entities

regulated or served by the

agency

Department of Health and Human Services

FIGURE 2-3

Th TABLE 2-4

FIGURE 2-3 Department of Health and Human Services Organizational Chart Source: Reproduced from: the U.S. Department of Health and Human Services. HHS Organizational Chart. Retrieved from https://www.hhs.gov/about/agencies/orgchart/index.html#

26 Chapter 2

Secretary Deputy Secretary

Chief of Staff

The Executive Secretariat (ES)

Office of Health Reform (OHR)

Office of the Secretary

Office of the Assistant Secretary for Administration (ASA)

Administration for Children and Families (ACF)

Administration for Community Living (ACL)

Agency for Healthcare Research and Quality (AHRQ)

Agency for Toxic Substances and Disease Registry (ATSDR)

Centers for Disease Control and Prevention (CDC)*

Centers for Medicare & Medicaid Services (CMS)

Food and Drug Administration (FDA)*

Health Resources and Services Administration (HRSA)*

Indian Health Service (IHS)*

National Institutes of Health (NIH)*

Substance Abuse and Mental Health Services Administration (SAMHSA)*

Office of the Assistant Secretary for Financial Resources (ASFR)

Office of the Assistant Secretary for Health (OASH)

Office of the Assistant Secretary for Legislation (ASL)

Office of the Assistant Secretary for Planning and Evaluation (ASPE)

Office of the Assistant Secretary for Preparedness and Response (ASPR)*

Office of the Assistant Secretary for Public Affairs (ASPA)

Center for Faith-Based and Neighborhood Partnerships (CFBNP)

Office for Civil Rights (OCR)

Departmental Appeals Board (DAB)

Office of the General Counsel (OGC)

Office of Global Affairs (OGA)*

Office of Inspector General (OIG)

Office of Medicare Hearings and Appeals (OMHA)

Office of the National Coordinator for Health Information Technology (ONC)

*denotes the components of the Public Health Service

Operating Divisions

Office of Intergovenmental and External Affairs (IEA)

TABLE 2-4 Department of Health and Human Services Agencies

Agency Main Purpose of Agency

Administration for Children and

Families (ACF)

To promote economic and social well-being of families, children,

individuals, and communities through educational and supportive

programs

Administration for Community

Living (ACL)

To increase access to community support and resources for older adults

and people with disabilities

Agency for Healthcare Research and

Quality (AHRQ)

To produce evidence to make health care safer, high quality, more

accessible, and affordable, and to work with HHS and other partners to

make sure the evidence is understood and used

Agency for Toxic Substances and

Disease Registry (ATSDR)

To prevent exposure to toxic substances and reduce the adverse health

effects associated with such exposure

Centers for Disease Control and

Prevention (CDC)

To protect the nation’s health by providing leadership in the prevention and

control of diseases and other preventable conditions, and to respond the

public health emergencies

Center for Medicare and Medicaid

Services (CMS)

To provide oversight of Medicare, the federal portions of Medicaid and CHIP,

and the Health Insurance Marketplace, and to engage in quality assurance

activities

Food and Drug Administration (FDA) To assure the safety of human and veterinary drugs, biological products,

and medical devices, and to ensure the safety and security of the nation’s

food supply and products that emit radiation

Health Resources and Services

Administration (HRSA)

To provide health care to populations that are geographically isolated, or

economically or medically vulnerable

Indian Health Services (IHS) To provide American Indians and Alaska Natives with comprehensive health

services

National Institutes of Health (NIH) To support and conduct biomedical and behavioral research, to train

promising young researchers, and to promote collecting and sharing

knowledge

Substance Abuse and Mental Health

Services Administration (SAMHSA)

To improve access to and reduce barriers to high-quality, effective programs

for individuals who suffer from addictive or mental disorders, and for their

families and communities

Department of Health and Human Services (2015).

Source: Department of Health and Human Services. (2015). HHS agencies and offices. Retrieved from https://www.hhs.gov/about/agencies/hhs-agencies-and-offices/index.html

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Department of Veterans Affairs and Department of Defense

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Interest Groups

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Interest Group Powers

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30 Chapter 2

▸ Endnotes

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CHAPTER 3

Law and the Legal System

LEARNING OBJECTIVES

By the end of this chapter you will be able to:

■ Describe the role of law in everyday life ■ Define the term “law” ■ Identify the various sources of law ■ Describe key features of the legal system

“It is perfectly proper to regard and study the law simply as a great anthropological document.”

(1899, p. 444).

By the end of this chapter you will be able to:

■ Describe the role of law in everyday life ■ Define the term “law” ■ Identify the various sources of law ■ Describe key features of the legal system

▸ Introduction

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34 Chapter 3

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▸ The Definition and Sources of Law

Defining “Law”

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▸ Key Features of the Legal System

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TABLE 3-1 Summary of the Primary Sources of American Law

Source of Law Key Points

Constitutions ■ Establish governments and delineate fundamental rights and obligations of government

and individuals. ■ There is a federal constitution and separate constitutions in each state. ■ The federal constitution restrains government more than it confers individual rights;

however, the Bill of Rights specifically guarantees several important individual rights. ■ The Supreme Court has the final word on the constitutionality of laws created by the

political branches of government.

Statutes ■ Created by legislatures at all levels of government. ■ Two hallmarks: prospectivity and generality. ■ As broad policy statements, statutes are often ambiguous as applied to specific cases

or controversies, requiring courts to interpret them through the practice of statutory

construction. ■ State legislatures can use statutes to regulate across a broader range of issues than can

Congress; however, federal statutes have primacy over conflicting state statutes.

Regulations ■ Created by executive branch administrative agencies to implement statutes and clarify

their ambiguities. ■ Play a particularly critical role in health policy and law.

Common law ■ Court opinions interpreting and applying law to specific cases. ■ Also referred to as case law, judge-made law, or decisional law. ■ Based on the traditions and customs of society, yet heavily influenced by legal precedent

and the doctrine of stare decisis.

ffici

diff diff

Thr

efficien

Thr efle

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Federalism: Allocation of Federal and State Legal Authority

d eff

Thi

ffa

defin

ffa

40 Chapter 3

nflic

cifie

definin definin

fir

definin

Thi

definin

The Role of Courts

diff Th

Thi eff

fin

cific

eff cific

Thi

Th lfi

infl

42 Chapter 3

Enforcing Legal Rights

ft fir

Thi

efi

efici

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cific

fir Thi

nfin

Reviewing the Actions of the Political Branches

Th Th

fin

fi eff

eff ffice

ft eff

fficer

Th fir

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The ifie

Thi flo fi

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fir

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fir ft ft

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44 Chapter 3

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Th sfies

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Maintaining Stability in the Law

Thi

left

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References Th

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46 Chapter 3

: Th

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▸ Endnotes Th

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48 Chapter 3

CHAPTER 4

Overview of the United States Healthcare System

LEARNING OBJECTIVES

By the end of this chapter you will be able to:

■ Identify the key players who provide and finance health care in the United States ■ Identify common characteristics of the uninsured ■ Understand the effect of insurance on access to care and on health status ■ Identify barriers to accessing health care ■ Understand concerns regarding the quality of health care provided in the United States ■ Describe differences in how health care is delivered in various countries

By the end of this chapter you will be able to:

▸ Introduction Efficien t-eff

unifie

ff fir

Th efficien t-eff

(Office Th unifie

diffic

fin

■

fi ■

■

ific ■

■

fin

unifie

fin

Thi fin

▸ Healthcare Finance

FIGURE 4-1 Thi

FIGURE 4-1 National Health Expenditures as a Share of Gross Domestic Product, 1987–2016

50 Chapter 4

Source: Reproduced from: Centers for Medicare and Medicaid Services, Office of the Actuary. (n.d.). National Health Care Spending in 2016. Retrieved from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports

/NationalHealthExpendData/Downloads/NHE-Presentation-Slides.pdf

10.0

P er

ce nt

o f G

D P

Calendar Years

17.9%

19 87

19 88

19 89

19 90

19 91

19 92

19 93

19 94

19 95

19 96

19 97

19 98

19 99

20 00

20 01

20 02

20 03

20 04

20 05

20 06

20 07

20 08

20 09

20 10

20 11

20 12

20 13

20 14

20 15

20 16

12.0

14.0

16.0

18.0

July 1990– March 1991 recession

20.0

December 2007– June 2009 recession

March 2001– November 2001 recession

The Share of GDP Devoted to Health Expenditures Was 17.9% in 2016

ft Th

Thi

FIGURE 4-2

et a

et Thi

et diff e-fift

Thi FIGURE 4-3

Health Insurance fin

fin

Thir

Th eff

FIGURE 4-2 Factors Accounting for Growth in per Capita National Health Expenditures, Selected Calendar Years, 2004–2016

6.5% 6.0% 5.5% 5.0% 4.5% 4.0% 3.5% 3.0%

0.0%

2004–2007

A nn

ua l P

er ce

nt C

ha ng

Per Capita Health Spending Grew 3.5% in 2016

5.8%

3.0%

4.3%

5.0%

3.5%

2008–2013 2014 2015 2016

1.0% 0.5%

2.0% 1.5%

2.5%

Age and sex factors Medical prices Residual use and intensity

Notes: Medical price growth, which includes economy-wide and excess medical-specific price growth (or changes in medical-specific prices in excess of economy-wide inflation), is calculated using the chain-weighted national health expenditures (NHE) deflator for NHE. “Residual use and intensity” is calculated by removing the effects of population, age and sex factors, and price growth from the nominal expenditure level.

/NationalHealthExpendData/Downloads/NHE-Presentation-Slides.pdf

eff Office

Thi

FIGURE 4-4

nific

FIGURE 4-5

Th cifics

efi

FIGURE 4-3 The Nation’s Health Dollar, Calendar Year 2016: Where it Went

FIGURE 4-4 Healthcare Coverage in the United States,

March 2016

52 Chapter 4

Note: “Other spending” includes dental services, other professional services, home health care, durable medical equipment, other nondurable medical products, government public health activities, and investment.

Hospital care, 32%

Physician and clinical services,

20%Nursing care facilities and continuing care

retirement communities, 5%

Prescription drugs, 10%

Government administration and net

cost of health insurance, 8%

Other health, residential, and personal care,

Other spending,

20%

/NationalHealthExpendData/Downloads/NHE-Presentation-Slides.pdf

Employer, 153 million

(47.3%)

Medicare, 55.5 (17.2%)

Medicaid, 49 (15.2%)

Medicaid/CHIP 23.6 (7.3%)

Affordable Care Act 9.1 (2.9%)

Other 4 (1.2%)

Total U.S. population 323.2 million

Uninsured 29 (9%)

Source: Hiltzik, M. (2016, March 29). Where America gets its health coverage: Everything you wanted to know in one handy chart. L.A.

Times. Retrieved June 11, 2018 from http://www.latimes.com/business/hiltzik/la-fi-hiltzik-gaba-20160329-snap-htmlstory.html

Direct Services Programs

■ lifi Th

■ Th

deficien deficien

fin Th

FIGURE 4-5 Insurance Company–Consumer–Provider Interaction

Insurance Company

Consumer

Accepts payment Accepts rules

Sets reimbursement rates Sets quality control requirements

Enroll in plan Pays plan Questions

Appeals

Sets plan rules Covers some consumer costs

Provider

Accepts patient Provides services May accept payment

Chooses provider Receives services May pay provider

■

▸ Healthcare Access

fie

infl

fie

fin ff

The Uninsured

Characteristics of the Uninsured Th

nific

fin FIGURES 4-6 4-7 Th

nific

tz et a

54 Chapter 4

FIGURE 4-8

nific

Th diff

et a

diffic

FIGURE 4-9

FIGURE 4-6 Percentage Point Change in Uninsured Rate Among the Nonelderly Population by Selected Characteristics,

2013–2016

FIGURE 4-7 Reasons for Being Uninsured Among Uninsured

Nonelderly Adults, 2016

<1 00

% F

PL 10

0 to

1 99

% F

PL ≥2

00 %

F PL

W hi

Bl ac

k H

is pa

ni c

As ia

n C

hi ld

re n

0– 17

N on

el de

rly

ad ul

ts 1

8– 64

Yo un

g ad

ul ts

19 –2

0.0%

–9.5%

–3.6%

–4.8%

–7.4% –7.3%

–1.4%

–8.2%

–12.8%

–11.1%–11.3%

–2.0%

–4.0%

–6.0%

–8.0%

–10.0%

–14.0%

Notes: Includes nonelderly individuals ages 0–64.

–12.0%

Poverty level Race/ethnicity Age

Source: Foutz et al., 2017, Figure 4; Kaiser Family Foundation analysis of the 2013 and 2016 National Health Interview Survey.

Share who say they are uninsured because:

Cos t is

to o

hig h

Lo st

job o

r c ha

ng ed

em plo

ye rs

Lo st

m ed

ica id

Em plo

ye r d

oe s n

ot o

ffe r o

ine lig

ibl e

for co

ve ra

Fa m

ily st

at us

ch an

No ne

ed fo

r h ea

lth

co ve

ra ge

45 %

23%

12% 10% 9%

Notes: Includes nonelderly adults ages 18–64. Respondents can select multiple reasons. Status change includes marital status change, death of spouse or parent, or ineligible due to age or leaving school.

Source: Kaiser Family Foundation. (n.d.). Key facts about the uninsured population. Retrieved from https://www.kff.org

/uninsured/fact-sheet/key-facts-about-the-uninsured-population/

FIGURE 4-10

fie

FIGURE 4-8 After 3 Years of the ACA, Uninsured Rates for Blacks, Latinos, and Whites Have Declined Significantly, but Large

Numbers of Immigrant Latinos Remain Uninsured

FIGURE 4-9 Cumulative Increase in Family Premiums, Worker Contribution to Premiums, and Worker Earnings, 1999–2017

56 Chapter 4

0 White

P er

ce nt

A du

lts A

ge s

19 –6

4 U

ni ns

ur ed

47 43

Black Latino (total)

Latino (U.S.-born)

Latino (foreign-born)

July-Sept. 2013

Feb.-April 2016

Source: Reproduced from Foutz et al., 2017; The Commonwealth Fund Affordable Care Act Tracking Surveys. July–September 2015 and February–April 2016.

Source: Kaiser/HRET Survey of Employer-Sponsered Health Benefits, 1999-2017; Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), 1999-2017; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current

Employment Statistics Survey, 1999-2017 (April to April).

1999

38%

38% 29%

24%

109%

113%

47%

172%

180%

270%

224%

64%

47% 38%

11%

50%

100%

150%

200%

250%

300%

C um

ul at

iv e

G ro

w th

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Overall inflation Worker earnings

Family premiums Worker contributions

fir ff

ff Th

ft Th

FIGURE 4-11

Th Th

diff

Thi

FIGURE 4-10 Characteristics of the Nonelderly Uninsured, 2016

100–199% FPL 25%

200–399% FPL 31%

400%+ FPL 20%

<100% FPL 24%

Total = 27.5 Million Nonelderly Uninsured

Family work status Family income (%FPL)

Race

One or more full-time workers

75%

No workers

15%11% Part-time workers White

44%

Black 15%

Hispanic 33%

Asian/Native Hawaiian or

Pacific Islander 5%

Other 3%

Notes: Includes nonelderly individuals ages 0–64. The U.S. Census Bureau’s poverty threshold for a family with two adults and one child was $19,318 in 2016. Data may not total 100% due to rounding. Persons of Hispanic origin may be of any race; all other race/ethnicity groups are non-Hispanic.

Source: Kaiser Family Foundation analysis of the March 2017 Current Population Survey, Annual Social and Economic Supplement.

The Importance of Health Insurance Coverage to Health Status

efi

ff efi

tz et a

et fie

FIGURE 4-12

ft diffic

FIGURE 4-11 Uninsured Rates Among the Nonelderly by State, 2016

Source: Reproduced from Centers for Disease Control and Prevention, MMWR 1996;45: 526–528.

58 Chapter 4

ND MN

MS AL GA

NJ DE MD DC

NCTN

INIL

WV VA

ME VT

NH MA

CT RI

NMAZ

UTNV

Notes: Includes nonelduals individuals ages 0–64.

<7% (11 states including DC)

7–12% (28 states)

>12% (12 states)

Source: Kaiser Family Foundation analysis of the March 2017 Current Population Survey, Annual Social and Economic Supplement.

BOX 4-1 Discussion Questions

From a policy perspective, are the characteristics just

described interrelated, or should they be addressed

separately? If you are trying to reduce the number

of uninsured, do you believe the focus should be on

altering insurance programs or changing the effect of

having one or more of these characteristics? Whose

responsibility is it to reduce the number of uninsured?

Government? The private sector? Individuals?

BOX 4-2 Discussion Questions

The ACA made it a priority to reduce the number of

uninsured. At what point, if any, should the government

step in to provide individuals with assistance to

purchase insurance coverage? Do you think such

assistance should be a federal or a state responsibility?

cific

eff

Ways to Assess the Cost of Being Uninsured Th

fin fin

fin

Th fin nific

et Th

FIGURE 4-13

fici et

FIGURE 4-12 Barriers to Health Care Among Nonelderly Adults by Insurance Status, 2016

0 No usual source

of care Postponed seeking

care due to cost

Note: Includes nonelderly adults ages 18–64. Includes barriers experienced in past 12 months. Respondents who said usual source of care was the emergency room were included among those not having a usual source of care. All differences between uninsured and insurance groups are statistically significant (p < 0.05).

49%

12% 12%

23%

9% 6%

20%

18%

14%

6% 3%

Went without needed care due to cost

Postponed or did not get needed prescription

drug due to cost

Uninsured

Medicaid/other public

Employer/other private

Source: Foutz et al., 2017; Kaiser Family Foundation analysis of the 2016 National Health Interview Survey.

Thi

eff

ffice sfie

Thi

uff

efi

ffice fi

uff

The Underinsured

fin

ft efici et Th

hift ff

FIGURE 4-13 Problems Paying Medical Bills by Insurance Status, 2016

60 Chapter 4

0 Problems paying or unable to pay

medical bills

Worried about being able to pay costs for normal care

Note: Includes nonelderly adults ages 18–64. All differences between uninsured and insured groups are statistically significant (p < 0.05).

29%

14%

63%

26%

76%

44%

30% 24%

Worried about paying medical bills if get sick

Medical bills being paid off over time

Uninsured

Insured

Source: Foutz et al., 2017; Kaiser Family Foundation analysis of the 2016 National Health Interview Survey.

Insurance Coverage Limitations

Th cific

Cost Sharing

ft Th

FIGURE 4-14

FIGURE 4-14 Average Annual Premiums for Single and Family Coverage, 1999–2017

19 99

20 00

20 01

20 02

20 03

20 04

20 05

20 06

20 07

20 08

20 09

20 10

20 11

20 12

20 13

20 14

20 15

20 16

20 17

$6,000

$8,000

$10,000

$12,000

$18,000

$20,000

$16,000

$14,000

$4,000

$2,000

$3 ,3

83 *

$9 ,0

68 *

$3 ,6

95 *

$9 ,9

50 *

$4 ,0

24 *

$1 0,

88 0*

$4 ,2

42 *

$1 1,

48 0*

$4 ,4

79 *

$1 2,

10 6*

$4 ,7

04 *

$1 2,

68 0*

$5 ,0

49 *

$1 3,

77 0*

$5 ,4

29 *

$1 5,

07 3*

$5 ,8

84 *

$1 6,

35 1*

$6 ,4

35 $1

8, 14

$6 ,6

90 *

$1 8,

76 4*

$6 ,2

51 *

$1 7,

54 5*

$6 ,0

25 $1

6, 83

$5 ,6

15 *

$1 5,

74 5*

$4 ,8

24 $1

3, 37

$2 ,6

89 *

$7 ,0

61 *

$2 ,4

71 *

$6 ,4

38 *

$2 ,1

96 $5

,7 91

$3 ,0

83 *

$8 ,0

03 *

Single coverage

Family coverage

*Estimate is statistically different from estimate for the previous year shown (p < 0.05).

Source: Kaiser/HRET Survey of Employer-Sponsered Health Benefits, 1999–2017.

infl

Th diff

cific

ffice

nific

fir

fir nific

FIGURE 4-15

cific

fir efici

fir Thi

Reimbursement and Visit Caps

cific

FIGURE 4-15 Percentage of Covered Workers Enrolled in a Plan With a General Annual Deductible of $1,000 or More for Single

Coverage, by Firm Size, 2009–2017

62 Chapter 4

80%

40%

30%

20%

10%

50%

P er

ce nt

ag e

of C

ov er

ed W

or ke

60%

70%

2012 2013 2014 2016 20172015201120102009

40%

46% 50% 49%

58%* 61% 63% 65%

58%

51%

48%

51%

45%

46%

39%*

41%

32%

38%

28%

34%

26%

31%

22%*

27%*

17%

22%

13%

*Estimate is statistically different from estimate for the previous year shown (p < 0.05).

Note: These estimates include workers enrolled in HDHP/SOs and other plan types. Average general annual health plan deductibles for PPOs, POS plans, and HDHP/SOs are for in-network services.

All small firms (3–199 Workers) ALL FIRMS

All large firms (200 or more workers)

Source: “2017 Employer Health Benefits Survey,” 2017.

Service Exclusions

cifie

Th efi

Safety Net Providers diffic

ft diffic fin

defin

nific

diffic

Th fi defini

lifie

ft et

ft cific

ft fin

diffic

infl

nific ff

diffic

64 Chapter 4

Workforce Issues

Thi ff

ft nific

h et a

ffices ffice-b Th

fie

et Th

ffice

FIGURES 4-16

4-18

defici

BOX 4-3 Discussion Questions

Safety net providers mostly serve uninsured and

publicly insured low-income patients. Many of the

safety net provider features you just read about are in

place to assist these patients in accessing health care.

Instead of pursuing universal coverage, would it be

an equally good strategy to expand the number of

safety net providers? Are there reasons for both safety

net providers and health insurance to exist? How does

having insurance relate to accessing care?

ND MN

MS AL GA

NCTN

INIL

WV VA

NYSD

NMAZ

UTNV

*Note: Estimates in states with an RSE > 20% should be used with caution because of large sampling error.

902–4,032

4,033–7,017

7,018–13,986

13,987–26,841

26,842–94,385

RSE 20–29%*

Total number

NJ DE MD

ME VT

NH MA

CT RIWY

FIGURE 4-16 Number of Physicians by State, 2008–2010 Source: See Figure 2 from The US Health Workforce Chartbook, HRSA, 2013, retrieved from https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/chartbookpart1.pdf

ND MN

MS AL GA

NCTN

INIL

WV VA

NYSD

NMAZAZ

UTNV

*Note: Estimates in states with an RSE > 20% should be used with caution because of large sampling error. **Data are not reported at the state level, because the RSE ≥ 30%; estimate does not meet standards of reliability.

597–763

764–1,394

1,394–2,204

Not reportable**

2,205–3,649

3,650–10,198

RSE 20–29%*

Total number

NJ DE MD

ME VT

NH MA

CT RI

KYKYKS

SCSC

FIGURE 4-17 Number of Physician Assistants by State, 2008–2010 Source: See Figure 7 from The US Health Workforce Chartbook, HRSA, 2013, retrieved from https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/chartbookpart1.pdf

66 Chapter 4

Thi

Th defin

fi fi

diffic

fie

Thi 110

■

ND MN

MS AL GA

NCTN

INIL

WV VA

NYSD

NMAZ

UTNV

4,296–22,260 Total number

22,261–50,861

50,842–90,663

90,664–167,476

167,477–274,722

NJ DE MD

ME VT

NH MA

CT RI

FIGURE 4-18 Number of Nurse Practitioners by State, 2008–2010 Source: See Figure 21 from The US Health Workforce Chartbook, HRSA, 2013, retrieved from https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/chartbookpart1.pdf

■

eff

■

▸ Healthcare Quality

fin

ff et

y et a

Key Areas of Quality Improvement

effic effi

Safety

diff

Efficacy ific

eff eff

Thi eff eff

68 Chapter 4

eff fin

Patient-Centeredness

nific

diff

diff defin

(Office

Timeliness

ffices,

ff diffic

efficien

Efficiency efficien

nific

efficien

diff

eff

BOX 4-4 Discussion Questions

Unfortunately, evidence is not available to support the

effectiveness or cost–benefit of every procedure or

drug. How should policymakers and providers make

decisions when faced with a dearth of evidence?

Do you prefer a more cautious approach that does

not approve procedures or drugs until evidence

is available or a more aggressive approach that

encourages experimentation and use of treatments

that appear to be effective? What about medical care

for children, who are generally excluded from clinical

and research trials for ethical reasons? When, if ever, is

it appropriate for insurers to cover or the government

to pay for treatments that are not proven effective?

diffic

FIGURE 4-19

Equity

efi

ufficien Th

ff ufficien

*Or nearest year; data from 2014 for Australia and Canada. No recent data for New Zealand (since 2007). Data reflect current spending on governance and health system and financing administration, in current prices, current PPPs. ‘OECD median’ reflects the median of 34 OECD countries.

34 89 90

123 141 206

255 272 286

787

100

200

300

400

500

600

700

800

900

Unit ed

S ta

te s

Switz er

lan d

Fra nc

Ger m

an y

Net he

rla nd

Can ad

Aus tra

lia

Unit ed

K ing

do m

Swed en

Nor way

Dollars ($US)

OECD

MEDIAN

Adjusted for Differences in Cost of Living

FIGURE 4-19 Spending on Health Insurance Administration per Capita, 2015 Source: Retrieved from https://www.commonwealthfund.org/publications/publication/2017/nov/multinational-comparisons-health-systems-data-2017

70 Chapter 4

diff

Assessment of Efforts to Improve Quality Th

nifi

nific

nflic

efficien

defi

▸ Comparative Health Systems

fl ft

FIGURE 4-20

Th ft

fin

s in diff TABLE 4-1

A National Health Insurance System: Canada

difie Th

1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014

P er

ce nt

ag e

United States (16.6%)

Switzerland (11.4%)

Sweden (11.2%)

France (11.1%)

Germany (11.0%)

Netherlands (10.9%)

Canada (10.0%)

United Kingdom (9.9%)

New Zealand (9.4%)

Norway (9.3%)

Australia (9.0%)

GDP refers to gross domestic product. Data in legend are for 2014.

FIGURE 4-20 Healthcare Spending as a Percentage of Gross Domestic Product, 1980–2014 Source: Retrieved from https://www.commonwealthfund.org/chart/2017/health-care-spending-percentage-gdp-1980-2014

TABLE 4-1 Comparison of Health Systems Across Four Countries

United States Canada Great Britain Germany

System type No unified system National health

insurance

National

health system

Socialized health insurance

Universal

coverage

Near universal if ACA

fully implemented

Yes Yes Yes

Role of private

insurance

Significant Supplemental to

Medicare, two-thirds

purchase

Minimal Minimal

Financing Private payments and

tax revenue

Mostly tax revenue

(federal, provincial,

territorial)

All federal

income tax

revenue

Mandatory employer and

employee contributions to

national health fund

Hospital

reimbursement

Varies by payer (DRGa,

FFSb, capitation,

per diem)

Global budget Global

budget

DRGa

Physician

reimbursement

Fee schedule or

capitation

Negotiated fees with

provinces/ territories

Salary or

capitation

Negotiated fees with funds

DRGa = diagnostic-related group (payment based on bundle of services needed for diagnosis). FFSb = fee for service (payment per service rendered).

72 Chapter 4

Th ff

Th cific

efi efi

fin

A National Health System: Great Britain

ft Th

Th nific

ff e (Th uffie Th fin

Thi

defici (Th et

t (Th y et a Th fin

n et a . 182; Th y et a

sifie

fin

fin et Th et

(Th et cific

ific

(Th et

et (Th y et a

A Socialized Insurance System: Germany fir

et a fi

efi

efi Th

ofit ofit

fin

74 Chapter 4

diff FIGURES 4-21 4-25

BOX 4-5 Discussion Questions

Do you prefer one of these health systems to the

others? Why or why not? Are there features that you

think should be incorporated into the U.S. healthcare

system? Are there reasons why certain features might be

difficult to incorporate into the U.S. healthcare system?

FIGURE 4-21 Cost-Related Access Barriers in the Past Year Source: Retrieved from https://www.commonwealthfund.org/publications/surveys/2016/nov/2016-commonwealth-fund-international-health-policy-survey-adults

et a

The Importance of Health Insurance Design

Diff

fin

cific fin

7 7 8 8 10 14

16 17 18 22

Unit ed

K ing

do m

Ger m

an y

Net he

rla nd

Swed en

Nor way

Aus tra

lia

Can ad

Fra nc

New Z

ea lan

Switz er

lan d

Unit ed

S ta

te s

P er

ce nt

ag e*

*Had a medical problem but did not visit doctor; skipped medical test, treatment, or follow-up recommended by doctor; and/or did not fill prescription or skipped doses

▸ Conclusion Thi

fin

efficien

cific

FIGURE 4-23 Waited 2 Months or Longer for a Specialist Appointment Source: Retrieved from https://www.commonwealthfund.org/publications/surveys/2016/nov/2016-commonwealth-fund-international-health-policy-survey-adults

FIGURE 4-22 Did Not Get Same or Next-Day Appointment Last Time You Needed Care Source: Retrieved from https://www.commonwealthfund.org/publications/surveys/2016/nov/2016-commonwealth-fund-international-health-policy-survey-adults

76 Chapter 4

19 22

41 41 42 43 44 47 50 53

100

P er

ce nt

Base: Excludes adults who did not need to make an appointment to see a doctor or nurse

Unit ed

K ing

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FIGURE 4-24 Used the ED in the Last 2 Years Source: Retrieved from https://www.commonwealthfund.org/publications/surveys/2016/nov/2016-commonwealth-fund-international-health-policy-survey-adults

16 16 20 23 24

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FIGURE 4-25 Cost-Related Access Barriers in the Past Year, By Income Source: Retrieved from https://www.commonwealthfund.org/publications/surveys/2016/nov/2016-commonwealth-fund-international-health-policy-survey-adults

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80 Chapter 4

CHAPTER 5

Public Health Institutions and Systems

LEARNING OBJECTIVES

By the end of this chapter you will be able to:

■ Identify goals of governmental public health ■ Identify the 10 essential services of public health ■ Describe basic features of local, state, and federal public health agencies in the United States ■ Identify global public health organizations and agencies and describe their basic roles ■ Identify roles in public health for federal agencies not identified as health agencies ■ Illustrate the need for collaboration by governmental public health agencies with other governmental and

nongovernmental organizations ■ Describe approaches to connecting public health and the healthcare system

By the end of this chapter you will be able to:

nongovernmental organizations ■ Describe approaches to connecting public health and the healthcare system

▸ Introduction BOX 5-1 efle

▸ What Are the Goals and Roles of Governmental Public Health Agencies?

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82 Chapter 5 nstitutions and S

BOX 5-1 Vignette

A young man in your dormitory is diagnosed with tuberculosis. The health department works with the student health

service to test everyone in the dorm, as well as in his classes, with a tuberculosis skin test. Those who are positive for the

first time are advised to take a course of a medicine called INH. You ask, is this standard operating procedure?

You go to a public health meeting and learn that many of the speakers are not from public health agencies, but from the

Departments of Labor, Commerce, Housing, and Education. You ask, what do these departments have to do with health?

You hear that a new childhood vaccine was developed by the National Institutes of Health (NIH), approved by

the Food and Drug Administration (FDA), endorsed for federal payment by the Centers for Disease Control and

Prevention (CDC), and recommended for use by the American Academy of Pediatrics. You ask, do all these agencies and

organizations always work so well together?

A major flood in Asia leads to disease and starvation. Some say it is due to global warming, others to bad luck.

Coordinated efforts by global health agencies, assisted by nongovernmental organizations (NGOs) and individual

donors, help get the country back on its feet. You ask, what types of cooperation are needed to make all of this happen?

A local community health center identifies childhood obesity as a problem in the community. The center collects

data demonstrating that the problem begins as early as elementary school. They develop a plan that includes clinical

interventions at the health center and also at the elementary school. They ask the health department to help them

organize an educational campaign and assist in evaluating the results. Working together, they are able to reduce the

obesity rate among elementary school children by 50%. This seems like a new way to practice public health, you

conclude. What type of approach is this?

Source: © maxstockphoto/ShutterStock, Inc.

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TABLE 5-1 10 Essential Public Health Services

Essential Service Meaning of Essential Service Examples

Core function: assessment

1. Monitor health

status to identify

and solve

community health

problems

This service includes accurate diagnosis of the community’s

health status; identification of threats to health and assessment of

health service needs; timely collection, analysis, and publication

of information on access, utilization, costs, and outcomes of

personal health services; attention to the vital statistics and health

status of specific groups that are at a higher risk than the total

population; and collaboration to manage integrated information

systems with private providers and health benefit plans.

Vital statistics Health

surveys Surveillance,

including reportable

diseases

2. Diagnose and

investigate health

problems and

health hazards in

the community

This service includes epidemiologic identification of emerging

health threats; public health laboratory capability using modern

technology to conduct rapid screening and high-volume testing;

active communicable disease epidemiology programs; and

technical capacity for epidemiologic investigation of disease

outbreaks and patterns of chronic disease and injury.

Epidemic

investigations

CDC–Epidemic

Intelligence Service

State public health

laboratories

Core function: policy development

3. Inform, educate,

and empower

people about

health issues

This service includes social marketing and media

communications; providing accessible health information

resources at community levels; active collaboration with personal

healthcare providers to reinforce health promotion messages

and programs; and joint health education programs with schools,

churches, and worksites.

Health education

campaigns, such

as comprehensive

state tobacco

programs

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▸ What Are the 10 Essential Public Health Services?

TABLE 5-1

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(continues)

84 Chapter 5 nstitutions and S

Essential Service Meaning of Essential Service Examples

4. Mobilize

community

partnerships and

action to identify

and solve health

problems

This service includes convening and facilitating community

groups and associations, including those not typically considered

to be health-related, in undertaking defined preventive,

screening, rehabilitation, and support programs; and skilled

coalition-building to draw upon the full range of potential human

and material resources in the cause of community health.

Lead control

programs: testing

and follow-up of

children, reduction

of lead exposure,

educational

follow-up, and

addressing

underlying causes

5. Develop policies

and plans that

support individual

and community

health efforts

This service requires leadership development at all levels of

public health; systematic community and state-level planning for

health improvement in all jurisdictions; tracking of measurable

health objectives as a part of continuous quality improvement

strategies; joint evaluation with the medical/healthcare system

to define consistent policy regarding prevention and treatment

services; and development of codes, regulations, and legislation

to guide public health practice.

Newborn screening

and follow-up

programs for PKU

and other genetic

and congenital

diseases

Core function: assurance

6. Enforce laws and

regulations that

protect health and

ensure safety

This service involves full enforcement of sanitary codes, especially

in the food industry; full protection of drinking water supplies;

enforcement of clean air standards; timely follow-up of hazards,

preventable injuries, and exposure-related diseases identified

in occupational and community settings; monitoring quality of

medical services (e.g., laboratory, nursing home, home health

care); and timely review of new drug, biologic, and medical

device applications.

Local: Fluoridation

and chlorination

of water State:

Regulation of

nursing homes

Federal: FDA drug

approval and food

safety

7. Link people to

needed personal

health services

and ensure

the provision

of health care

when otherwise

unavailable

This service (often referred to as “outreach” or “enabling” services)

includes ensuring effective entry for socially disadvantaged

people into a coordinated system of clinical care; culturally

and linguistically appropriate materials and staff to ensure

linkage to services for special population groups; ongoing “care

management”; and transportation.

Community health

centers

8. Ensure the

provision of a

competent public

and personal

healthcare

workforce

This service includes education and training for personnel to

meet the needs of public and personal health services; efficient

processes for licensure of professionals and certification of

facilities with regular verification and inspection follow-up;

adoption of continuous quality improvement and lifelong

learning within all licensure and certification programs; active

partnerships with professional training programs to ensure

community-relevant learning experiences for all students;

and continuing education in management and leadership

development programs for those charged with administrative/

executive roles.

Licensure of

physicians, nurses,

and other health

professionals

TABLE 5-1 10 Essential Public Health Services (continued)

Monitor Health

Evaluate

Assure Competent Workforce

Diagnose and

Investigate

Inform, Educate, Empower

Link to / Provide

Care

Enforce Laws

Develop Policies

Mobilize Community

Partnerships

ResearchResearch

A S

S U

R A

N C

ASSESSM

ENT

S ys

te m Managem

ent

POLICY DEVELO PM

E N

FIGURE 5-1 Essential Public Health Services and Institute of

Medicine’s Core Functions Source: Centers for Disease Control and Prevention. (2017). The public health system & the 10 essential public health services.

Retrieved from https://www.cdc.gov/stltpublichealth/publichealthservices/essentialhealthservices.html

Governmental

Public Health

Agencies

Other Government

Agencies

Local

State

Federal

Global

Healthcare Delivery System

Community and Private Organizations

FIGURE 5-2 Framework for Viewing Governmental Public

Health Agencies and Their Complicated Connections

FIGURE 5-1

FIGURE 5-2

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▸ What Are the Roles of Local and State Public Health Agencies?

9. Evaluate

effectiveness,

accessibility, and

quality of personal

and population-

based health

services

This service calls for ongoing evaluation of health programs,

based on analysis of health status and service utilization data,

to assess program effectiveness and to provide information

necessary for allocating resources and reshaping programs.

Development of

evidence-based

recommendations

All three IOM core functions

10. Research for

new insights

and innovative

solutions to health

problems

This service includes continuous linkage with appropriate

institutions of higher learning and research and an internal

capacity to mount timely epidemiologic and economic analyses

and conduct needed health services research.

NIH, CDC, AHRQ,

other federal

agencies

Abbreviations: Agency for Healthcare Research and Quality = AHRQ; Centers for Disease Control and Prevention = CDC; Food and Drug Administration = FDA; National Institutes of Health = NIH;

phenylketonuria = PKU.

Source: Data from Public Health in America. Essential public health services. Retrieved from http://www.cdc.gov/nphpsp/ essentialservices.html. Accessed October 26, 2015.

86 Chapter 5 nstitutions and S

BOX 5-2 Brief History of Public Health Agencies in the United States

An understanding of the history of U.S. public health institutions requires an understanding of the response of local,

state, and federal governments to public health crises and the complex interactions among these levels of government.

The colonial period in the United States saw repeated epidemics of smallpox, cholera, and yellow fever, primarily

focused in the port cities. These epidemics brought fear and disruption of commerce, along with accompanying disease

and death. One epidemic in 1793 in Philadelphia, which was then the nation’s capital, nearly shut down the federal

government. These early public health crises brought about the first municipal boards of health, made up of respected

citizens authorized to act in the community’s interest to implement quarantine, evacuation, and other public health

interventions of the day. The federal government’s early role in combating epidemics led to the establishment in 1798

of what later became known as the U.S. Public Health Service.

Major changes in public health occurred in the last half of the 1800s, with the great expansion of the understanding

of disease and the ability to control it through community actions. The Shattuck Commission in Massachusetts in 1850

outlined the roles of state health departments as responsible for sanitary inspections, communicable disease control,

food sanitation, vital statistics, and services for infants and children. Over the next 50 years, the states gradually took the

lead in developing public health institutions based on delivery of these services.

Local health departments did not exist outside of the largest cities until the 1900s. The Rockefeller Foundation

stimulated and helped fund early local health departments and campaigns, in part to combat specific diseases, such as

hookworm. There was no standard model for local health departments; they developed in different ways in the various

states and were chronically underfunded.

The federal government played a very small role in public health throughout the 1800s and well into the 20th

century. However, an occasional public health crisis stimulated federal action, often as a result of media attention. The

founding of the FDA in 1906 resulted in large part from the journalistic activity known as “muckraking,” which exposed

the status of food and drug safety. The early years of the 1900s set the stage for expansion of the federal government’s

role in public health through the passage of the 16th Amendment to the Constitution, which authorized federal income

tax as a major source of federal government funding.

The Great Depression, in general, and the Social Security Act of 1935, in particular, brought about a new era in which

federal funding became a major source of financial resources for state and local public health departments and NGOs.

The founding of the CDC (which at that time stood for Communicable Disease Center) in 1946 led to a national (and

eventually international) leadership role for the CDC, which attempts to connect and hold together the complex local,

state, and federal public health efforts and integrate them into global public health efforts.

The Johnson administration’s War on Poverty, as well as the Medicare and Medicaid programs, brought about

greatly expanded funding for healthcare services and led many health departments to provide direct healthcare

services, especially for those without other sources of care. The late 1980s and 1990s saw a redefinition of the roles of

governmental public health, including the IOM definition of core functions and the development of the 10 essential

public health services. These documents have guided the development of a broad population focus for public health

and a move away from the direct provision of healthcare services by health departments.

The terrorism of September 11, 2001, and the subsequent anthrax scare moved public health institutions to

the center of efforts to protect the public’s health through emergency response and disaster preparedness. The

development of flexible efforts to respond to expected and unexpected hazards is now a central feature of public

health institutions’ roles and funding. The success of these efforts has led to new levels of coordination of local,

state, federal, and global public health agencies using state-of-the-art surveillance, laboratory technology, and

communications systems.

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▸ What Are the Roles of Federal Public Health Agencies?

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88 Chapter 5 nstitutions and S

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TABLE 5-2 Key Federal Health Agencies of the Department of Health and Human Services

Agency Roles/Authority Examples of Structures/Activities

Centers for Disease

Control and

Prevention (CDC)

and the Agency for

Toxic Substances

and Disease Registry

(ATSDR)

The CDC is the lead agency for prevention,

health data, epidemic investigation, and

public health measures aimed at disease

control and prevention.

The CDC administers the ATSDR, which works

with the Environmental Protection Agency to

provide guidance on health hazards of toxic

exposures.

The CDC and ATSDR work extensively with

state and local health departments.

The CDC’s Epidemic Intelligence Service

functions domestically and internationally

at the request of governments.

National Institutes of

Health (NIH)

Serves as lead research agency; also funds

training programs and communication

of health information to the professional

community and the public.

NIH comprises 17 institutes in all—the

largest being the National Cancer Institute.

The National Library of Medicine is part of

NIH Centers, which also include the John E.

Fogarty International Center for Advanced

Study in the Health Sciences.

NIH is the world’s largest biomedical

research enterprise, with intramural

research at NIH and extramural research

grants throughout the world.

Food and Drug

Administration (FDA)

Acts as consumer protection agency with

authority for safety of foods and safety and

efficacy of drugs, vaccines, and other medical

and public health interventions.

Divisions of FDA are responsible for food

safety, medical devices, drug efficacy, and

safety pre- and post-approval.

Health Resources

and Services

Administration (HRSA)

Seeks to ensure equitable access to

comprehensive quality health care.

HRSA funds community health centers,

HIV/AIDS services, and scholarships for

health professional students.

Agency for Healthcare

Research and Quality

(AHRQ)

Sets research agenda to improve the

outcomes and quality of health care,

including patient safety and access to

services.

AHRQ supports U.S. Preventive Services

Task Force, evidence-based medicine

research, and Guidelines Clearinghouse.

Substance Abuse

and Mental

Health Services

Administration

(SAMHSA)

Works to improve quality and availability of

prevention, treatment, and rehabilitation for

substance abuse and mental illness.

SAMHSA provides research, data collection,

and funding of local services.

Indian Health Service

(IHS)

Provides direct health care and public health

services to federally recognized tribes.

IHS provides services to approximately 550

federally recognized tribes in 35 states.

It is the only comprehensive federal

agency responsibility for health care plus

public health services.

Source: Reproduced from Centers for Disease Control and Prevention, MMWR 1996;45: 526–528.

BOX 5-3 History of the CDC

The following is reprinted as it originally appeared in 1996 in the Morbidity and Mortality Weekly Report (CDC, 1996):

The Communicable Disease Center was organized in Atlanta, Georgia, on July 1, 1946; its founder, Dr. Joseph W. Mountin,

was a visionary public health leader who had high hopes for this small and comparatively insignificant branch of the

Public Health Service (PHS). It occupied only one floor of the Volunteer Building on Peachtree Street and had fewer than

400 employees, most of whom were engineers and entomologists. Until the previous day, they had worked for Malaria

Control in War Areas, the predecessor of CDC, which had successfully kept the southeastern states malaria-free during

World War II and, for approximately 1 year, from murine typhus fever. The new institution would expand its interests to

include all communicable diseases and would be the servant of the states, providing practical help whenever called.

Distinguished scientists soon filled CDC’s laboratories, and many states and foreign countries sent their public

health staffs to Atlanta for training. Medical epidemiologists were scarce, and it was not until 1949 that Dr. Alexander

Langmuir arrived to head the epidemiology branch. Within months, he launched the first-ever disease surveillance

program, which confirmed his suspicion that malaria, on which CDC spent the largest portion of its budget, had long

since disappeared. Subsequently, disease surveillance became the cornerstone on which CDC’s mission of service to the

states was built and, in time, changed the practice of public health.

The outbreak of the Korean War in 1950 was the impetus for creating CDC’s Epidemic Intelligence Service (EIS).

The threat of biological warfare loomed, and Dr. Langmuir, the most knowledgeable person in PHS about this then-

arcane subject, saw an opportunity to train epidemiologists who would guard against ordinary threats to public health

while watching out for alien germs. The first class of EIS officers arrived in Atlanta for training in 1951 and pledged to

go wherever they were called for the next 2 years. These “disease detectives” quickly gained fame for “shoe-leather

epidemiology,” through which they ferreted out the cause of disease outbreaks.

The survival of CDC as an institution was not at all certain in the 1950s. In 1947, Emory University gave land on Clifton

Road for a headquarters, but construction did not begin for more than a decade. PHS was so intent on research and the

rapid growth of the National Institutes of Health that it showed little interest in what happened in Atlanta. Congress,

despite the long delay in appropriating money for new buildings, was much more receptive to CDC’s pleas for support

than either PHS or the Bureau of the Budget.

Two major health crises in the mid-1950s established CDC’s credibility and ensured its survival. In 1955, when

poliomyelitis appeared in children who had received the recently approved Salk vaccine, the national inoculation

program was stopped. The cases were traced to contaminated vaccine from a laboratory in California; the problem was

corrected, and the inoculation program, at least for first and second graders, was resumed. The resistance of these

6- and 7-year-olds to polio, compared with that of older children, proved the effectiveness of the vaccine. Two years

later, surveillance was used again to trace the course of a massive influenza epidemic. From the data gathered in 1957

and subsequent years, the national guidelines for influenza vaccine were developed.

CDC grew by acquisition. When CDC joined the international malaria-eradication program and accepted

responsibility for protecting the earth from moon germs and vice versa, CDC’s mission stretched overseas and into space.

CDC then played a key role in one of the greatest triumphs of public health: the eradication of smallpox. In 1962 it

established a smallpox surveillance unit, and a year later tested a newly developed jet gun and vaccine in the Pacific island

nation of Tonga. CDC also achieved notable success at home tracking new and mysterious disease outbreaks. In the mid-

1970s and early 1980s, it found the cause of Legionnaires disease and toxic-shock syndrome. A fatal disease, subsequently

named acquired immunodeficiency syndrome (AIDS), was first mentioned in the June 5, 1981, issue of MMWR.

Although CDC succeeded more often than it failed, it did not escape criticism. For example, television and press

reports about the Tuskegee study on long-term effects of untreated syphilis in black men created a storm of protest in

1972. This study had been initiated by PHS and other organizations in 1932 and was transferred to CDC in 1957. Although

the effectiveness of penicillin as a therapy for syphilis had been established during the late 1940s, participants in this

study remained untreated until the study was brought to public attention. CDC was also criticized because of the 1976

effort to vaccinate the U.S. population against swine flu, the infamous killer of 1918–1919. When some recipients of the

vaccines developed Guillain-Barre syndrome, the campaign was stopped immediately; the epidemic never occurred.

As the scope of CDC’s activities expanded far beyond communicable diseases, its name had to be changed. In 1970 it

became the Center for Disease Control and in 1981, after extensive reorganization, Center became Centers. The words “and

Prevention” were added in 1992 but, by law, the well-known three-letter acronym was retained. In health emergencies, CDC

means an answer to SOS calls from anywhere in the world, such as the recent one from Zaire where Ebola fever raged.

Fifty years ago, CDC’s agenda was non-controversial (hardly anyone objected to the pursuit of germs), and Atlanta

was a backwater. In 1996, CDC’s programs are often tied to economic, political, and social issues, and Atlanta is as near

to Washington as the tap of a keyboard.

90 Chapter 5 nstitutions and S

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▸ What Are the Roles of Global Health Organizations and Agencies?

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TABLE 5-3

TABLE 5-3 Global Public Health Organizations

Type of Agency Structure/Governance Role(s) Limitations

World Health

Organization

United Nations Organization

Seven “regional” semi-

independent components

(e.g., Pan American Health

Organization covers North

and South America)

Policy development

(e.g., tobacco treaty, epidemic

control policies)

Coordination of services

(e.g., SARS control)

Vaccine development

Data collection and

standardization (e.g., measures

of healthcare quality, measures

of health status)

Limited ability to enforce

global recommendations,

limited funding, and

complex international

administration

Other UN

agencies with

focused agenda

UNICEF

UNAIDS

Focus on childhood

vaccinations

Focus on AIDS

Limited agendas and

limited financing

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International

financing

organizations

The World Bank

Other multilateral regional

banks (e.g., InterAmerican and

Asian Development Banks)

World Bank is largest

international funder.

Increasingly supports “human

capital” projects and reform of

healthcare delivery systems

and population and nutrition

efforts

Provides funding and technical

assistance, primarily as loans

Criticized for standardized

approach with few local

modifications

Bilateral

governmental aid

organizations

USAID

Many other developed

countries have their own

organizations and contribute

a higher percentage of their

gross domestic product to

those agencies than does the

United States

Often focused on specific

countries and specific types

of programs (e.g., the focus on

HIV/AIDS in the United States),

and maternal and child health

May be tied to domestic

politics and global

economic, political, or

military agendas

AIDS = acquired immunodeficiency syndrome; HIV = human immunodeficiency virus; SARS = severe acute respiratory syndrome; UN = United Nations; UNAIDS = Joint United

Nations Programme on HIV/AIDS; UNICEF = United Nations International Children’s Emergency Fund; USAID = U.S. Agency for International Development.

92 Chapter 5 nstitutions and S

BOX 5-4 SARS and the Public Health Response

The SARS epidemic of 2003 began with little notice, most likely somewhere in the heartland of China, and then spread

to other areas of Asia. The world took notice following televised reports of public health researchers who were sent to

Asia to investigate the illness subsequently contracting and dying from the disease. Not an easily transmissible disease

except for between those in very close contact, such as investigators, family members, and healthcare providers, the

disease spread slowly but steadily through areas of China. Among those infected, the case-fatality rate was very high,

especially without the benefits of modern intensive care facilities.

The disease did not respond to antibiotics and was thought to be a viral disease by its epidemiologic pattern of

spread and transmission, but at first, no cause was known. The outside world soon felt the impact of the brewing

epidemic when cases appeared in Hong Kong that could be traced to a traveler from mainland China. Fear spread when

cases were recognized that could not be explained by close personal contact with a SARS victim.

The epidemic continued to spread, jumping thousands of miles to Toronto, Canada, where the second-greatest

concentration of disease appeared. Soon, the whole world was on high alert, if not quite on the verge of panic. At least

8,000 people worldwide became sick, and nearly 10% of them died. Fortunately, progress came quite quickly. Researchers

coordinated by WHO were able to put together the epidemiologic information and laboratory data and establish a

presumed cause—a new form of the coronavirus never before seen in humans—leading to the rapid introduction of testing.

WHO and the CDC put forth recommendations for isolation, travel restrictions, and intensive monitoring that rapidly

controlled the disease, even in the absence of an effective treatment aimed at a cure. SARS disappeared as rapidly as it

emerged, especially after systematic efforts to control spread were put in place in China. Not eliminated, but no longer a

worldwide threat, SARS left a lasting global impact. WHO established new approaches for reporting and responding to

epidemics, which now have the widespread formal acceptance of most governments.

Once the world could step back and evaluate what happened, it was recognized that the potential burden of disease

posed by the SARS epidemic had worldwide implications and raised the threat of interruption of travel and trade. Local,

national, and global public health agencies collaborated quickly and effectively. Infection control recommendations made

at the global level were rapidly translated into efforts to identify disease at the local level and manage individual patients

in hospitals throughout the world. It is a model of communicable disease control that will be needed in the future.

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▸ What Roles Do NGOs Play in Public Health?

Nongovernmental Organizations

BOX 5-5 National Vaccine Plan

In 1994, a National Vaccine Plan was developed as part of a coordinated effort to accomplish the following goals:

1. Develop new and improved vaccines.

2. Ensure the optimal safety and effectiveness of vaccines and immunizations.

3. Better educate the public and members of the health profession on the benefits and risks of immunizations.

A recent IOM report evaluated progress since 1994 on achieving these goals and made recommendations for the

development of a revised National Vaccine Plan (IOM, 2008). The IOM highlighted a number of successes since 1994

in achieving each of the goals of the plan. These successes illustrate the potential for improved collaboration between

public health systems and healthcare systems.

In terms of the development of new and improved vaccines since 1994, over 20 new vaccine products resulting

from the collaborative efforts of the NIH, academicians, and industry researchers were approved by the FDA. Novel

vaccines introduced include vaccines against pediatric pneumococcal disease, meningococcal disease, and the human

papillomavirus—a cause of cervical cancer.

In terms of safety, vaccines and vaccination approaches with improved safety have been developed since 1994,

including those directed against rotavirus, pertussis (whooping cough), and polio. The FDA Center for Biologics

Evaluation and Research, which regulates vaccines, now has an expanded array of regulatory tools to facilitate the

review and approval of safe and efficacious vaccines. The FDA and the CDC have collaborated on surveillance for and

evaluation of adverse events. Efforts have also been made to increase collaboration with the Centers for Medicare and

Medicaid Services, the Department of Defense, and the Department of Veterans Affairs to improve surveillance and

reporting of adverse events following immunization in the adult populations these agencies serve.

In terms of better education of health professionals and the public, progress has also been made. The American

Academy of Pediatrics collaborates with the CDC for its childhood immunization support. The American Medical

(continues)

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eff

eff Th

eff

eff Th

eff eff

▸ How Can Public Health Agencies Partner With Health Care to Improve the Response to Health Problems?

t-eff nfiden Th

BOX 5-5

94 Chapter 5 nstitutions and S

Association cosponsors the annual National Influenza Vaccine Summit, a group that represents 100 public and private

organizations interested in preventing influenza.

Despite the growing collaboration and success in vaccine development and use, new issues have appeared in

recent years. Vaccines are now correctly viewed by health professionals and the broader public as having both benefits

and harms. In recent years, the public has grown more concerned about the safety of vaccines, including the issue of

the use of large numbers of vaccines in children. The limitations of vaccines to address problems, such as HIV/AIDS, have

also been increasingly recognized. Hopefully, the continued efforts to develop and implement national vaccine plans

will build upon these recent successes and address the new realities and opportunities.

BOX 5-5 National Vaccine Plan

BOX 5-6 Community-Oriented Primary Care

Community-oriented primary care (COPC) is a structured effort to expand the delivery of health services from a focus

on the individual to include an additional focus on the needs of communities. Serving the needs of communities brings

healthcare and public health efforts together. COPC can be seen as an effort on the part of healthcare delivery sites,

such as community health centers, to reach out to their community and to governmental public health institutions.

TABLE 5-4 outlines the six steps in the COPC process and presents a question to ask when addressing each of these

steps. Notice the parallels between COPC and the evidence-based approach.

A series of principles underlies COPC:

■ Healthcare needs are defined by examining the community as a whole, not just those who seek care. ■ Needed healthcare services are provided to everyone within a defined population or community. ■ Preventive, curative, and rehabilitative care are integrated within a coordinated delivery system. ■ Members of the community directly participate in all stages of the COPC process.

The concept of COPC, if not the specific structure, has been widely accepted as an approach for connecting

the organized delivery of primary health care with public health. It implies that public health issues can and should

be addressed, when possible, at the level of the community with the involvement of healthcare providers and the

community members themselves.

TABLE 5-4 The Six Sequential Steps of Community-Oriented Primary Care

Steps in the COPC Process Questions to Ask

1. Community

definition

How is the community defined based on geography, institutional affiliation, or

other common characteristics (e.g., use of an Internet site)?

2. Community

characterization

What are the demographic and health characteristics of the community, and what

are its health issues?

3. Prioritization What are the most important health issues facing the community, and how should

they be prioritized based on objective data and perceived need?

4. Detailed assessment

of the selected

health problem

What are the most effective and efficient interventions for addressing the selected

health problem based on an evidence-based assessment?

5. Intervention What strategies will be used to implement the intervention?

6. Evaluation How can the success of the intervention be evaluated?

Data from Mullan, F., & Epstein, L. (2002). Community-oriented primary care: New relevance in a changing world. American Journal of Public Health, 92(11), 1748–1755.

(continued)

BOX 5-7 Child Oral Health and Community-Oriented Public Health

The problem of childhood dental disease illustrates the potential for COPH. A lack of regular dental care remains a major

problem for children in developed, as well as developing, countries. Oral health is often high on the agenda of parents,

teachers, and even the children themselves.

The history of public health interventions in childhood oral health is a story of great hope and partial success. Public

health efforts to improve oral health go back to the late 1800s and early 1900s, when toothbrushes and toothpaste were

new and improved technologies. The public health campaigns of the early 1900s were very instrumental in making

(continues)

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BOX 5-6

fin fin, 2011).

eff

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▸ How Can Public Health Take the Lead in Mobilizing Community Partnerships to Identify and Solve Health Problems?

Th eff

Thr

Th eff

Eff

eff ifie

eff

eff BOX 5-7

eff

96 Chapter 5 nstitutions and S

BOX 5-7 Child Oral Health and Community-Oriented Public Health (continued)

toothbrushing a routine part of life in the United States. Unfortunately, the fluoridization of drinking water, despite the

well-grounded evidence of its benefits, has not been so readily accepted. The American Dental Association and the

American Medical Association have supported this intervention for over half a century. Resistance from those who view

it as an intrusion of governmental authority, however, has prevented universal use of fluoridation in this country. After

over a half century of effort, fluoridation has reached less than 66% of Americans through the water supply.

Today, new technologies, from dental sealants to more cost-effective methods for treating cavities, have again

made oral health a public health priority. However, the number of dentists has not grown in recent years to keep up

with the growing population. In addition, dental care for those without the resources to pay for it is often inadequate

and inaccessible. Thus, a new approach is needed to bring dental care to those in need. Perhaps a new strategy using a

COPH approach can make this happen.

COPH can reach beyond the institutional and geographical constraints that COPC faces when based in a community

health center or other institutions serving a geographically defined population or community. COPH as a government-

led effort allows a greater range of options for intervention, including those that require changes in laws, incentives,

and governmental procedures. Interventions may include authorizing new types of clinicians, providing services in

nontraditional settings such as schools, funding innovations to put new technologies into practice, and addressing the

regulatory barriers to rapid and cost-effective delivery of services.

▸ Conclusion ff Th

References

uffin,

fin, fin,

ffic

▸ Endnotes Thi

Thi Th

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P A

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rr is

o n

( 1

8 8

9 –

1 8

9 3

);

G ro

ve r

C le

ve la

n d

( 1

8 9

3 –

1 8

9 7

); W

ill ia

M cK

in le

y (1

8 9

7 –

1 9

0 1

)

T h

e o

d o

re R

o o

se ve

lt (

1 9

0 1

– 1

9 0

9 )

U .S

. H o

u se

o f

R e

p re

se n

ta ti

ve s

R e

p u

b lic

a n

( 1

8 8

9 –

1 8

9 1

); D

e m

o cr

a t

(1 8

9 1

– 1

8 9

5 );

R e

p u

b lic

a n

( 1

8 9

5 –

1 9

1 1

)

U .S

. S e

n a

te D

e m

o cr

a t

(1 8

9 3

– 1

8 9

5 )

(5 3

rd );

R e

p u

b lic

a n

( 1

8 9

5 –

1 9

1 3

) (5

4 th

– 6

2 n

d )

R e

p u

b lic

a n

(1 9

0 0

– 1

9 2

0 ):

C h

a ra

c te

ri ze

d b

y p

o p

u la

r su

p p

o rt

f o

r so

ci a

l r e

fo rm

, p a

o f

w h

ic h

in cl

u d

e d

c o

m p

u ls

o ry

h e

a lt

h in

su ra

n ce

; R o

o se

ve lt

c a

m p

a ig

n e

d o

n a

s o

ci a

in su

ra n

ce p

la tf

o rm

in 1

9 1

2 .

P ro

h ib

it s

in te

rs ta

te t

ru st

s so

e co

n o

m ic

p o

w e

r w

o u

ld n

o t

b e

c o

n ce

n tr

a te

d in

fe w

c o

rp o

ra ti

o n

dd in gfi el d,

5 9

N .E

. 1 0

5 8

( In

d . 1

9 0

1 ):

P h

ys ic

ia n

s a

re u

n d

e r

n o

d u

ty t

o t

re a

a n

d a

p h

ys ic

ia n

is n

o t

lia b

le f

o r

a rb

it ra

ri ly

r e

fu si

n g

t o

r e

n d

e r

m e

d ic

a l a

ss is

ta n

ce ;

e n

a m

e d

t h

a s

it s

ro le

in d

is e

a se

c o

n tr

o l a

c ti

v it

ie s

e xp

a n

d s;

R e

g u

la te

s sa

fe ty

a n

d e

ff e

c ti

ve n

e ss

o f

v a

cc in

e s,

s e

ru m

s, e

tc .;

1 9

7 U

.S . 1

1 (

1 9

0 5

): S

ta te

s ta

tu te

r e

q u

ir in

g c

o m

p u

ls o

ry v

a cc

in a

ti o

n a

g a

in st

s m

a llp

o x

a c

o n

st it

u ti

o n

a l e

xe rc

is e

o f

p o

lic e

p o

w e

( W

ile y

A c

t) : G

iv e

re g

u la

to ry

p o

w e

r to

m o

n it

o r

fo o

d m

a n

u fa

c tu

ri n

g , l

a b

e lin

g , a

n d

s a

le s

to F

D A

p re

d e

ce ss

o r;

F e

d e

ra l E

m p

lo ye

rs L

ia b

ili ty

A c

t: C

re a

te s

w o

rk e

rs c

o m

p e

n sa

ti o

n p

ro g

ra m

f o

r se

le c

fe d

e ra

l e m

p lo

ye e

A M

A r

e o

rg a

n iz

e s

a t

lo ca

l/ st

a te

le ve

l a n

d g

a in

s st

re n

g th

, b e

g in

n in

g e

ra o

f “ o

rg a

n iz

e d

m e

d ic

in e

” a s

p h

ys ic

ia n

s a

g ro

u p

b e

co m

e a

m o

re c

o h

e si

ve a

n d

in cr

e a

si n

g ly

p ro

fe ss

io n

a l

a u

th o

ri ty

101

19 10

s 19

20 s

P re

si d

e n

t R

e p

u b

lic a

n D

e m

o cr

a t

R e

p u

b lic

a n

R e

p u

b lic

a n

W ill

ia m

H . T

a ft

( 1

9 0

9 –

1 9

1 3

) W

o o

d ro

w W

ils o

n (

1 9

1 3

– 1

9 2

1 )

W a

rr e

n G

. H a

rd in

(1 9

2 1

– 1

9 2

3 )

C a

lv in

C o

o lid

g e

(1 9

2 3

– 1

9 2

9 )

U .S

. H o

u se

o f

R e

p re

se n

ta ti

ve s

D e

m o

cr a

t (1

9 1

1 –

1 9

) (6

2 n

d –

6 5

th )

D e

m o

cr a

t (1

9 1

3 –

1 9

) (6

3 rd

– 6

5 th

);

R e

p u

b lic

a n

( 1

9 1

9 –

1 9

3 3

) (6

6 th

– 7

2 n

d )

R e

p u

b lic

a n

(1 9

1 9

– 1

9 3

1 )

(6 6

th –

7 1

st )

R e

p u

b lic

a n

U .S

. S e

n a

te R

e p

u b

lic a

n D

e m

o cr

a t

(1 9

1 3

– 1

9 1

9 )

(6 3

rd –

6 5

th );

R e

p u

b lic

a n

( 1

9 1

9 –

1 9

3 3

) (6

6 th

– 7

2 n

d )

R e

p u

b lic

a n

R e

p u

b lic

a n

( 1

9 1

4 –

1 9

; U n

it e

d S

ta te

e n

te rs

in 1

9 1

7 )

e st

a b

lis h

e d

D e

p a

rt m

e n

t o

f C

o m

m e

rc e

( la

te r

m o

ve d

t o

D e

p a

rt m

e n

o f

La b

o r)

; is r

e n

a m

e d

t h

e a

n d

a u

th o

ri ze

d t

o in

ve st

ig a

te h

u m

a n

d is

e a

se a

n d

s a

n it

a ti

o n

;

C la

ri fi

e s

th e

S h

e rm

a n

A n

ti tr

u st

A c

t a

n d

in cl

u d

e s

a d

d it

io n

a l p

ro h

ib it

io n

F ir

st s

ta te

w o

rk e

rs c

o m

p e

n sa

ti o

n la

w e

n a

c te

d ;

P ro

v id

e s

fi rs

t fe

d e

ra l g

ra n

ts t

o s

ta te

s fo

r p

u b

lic h

e a

lt h

s e

rv ic

e s;

st a

b lis

h e

th e

V e

te ra

n s

A d

m in

is tr

a ti

o n

; P

ro v

id e

s g

ra n

ts f

o r

th e

C h

ild re

n ’s

B u

re a

u a

n d

s ta

te m

a te

rn a

l a n

d c

h ild

h e

a lt

h p

ro g

ra m

s, a

n d

is t

h e

fi rs

t d

ir e

c t

fe d

e ra

l f u

n d

in g

o f

h e

a lt

h s

e rv

ic e

s fo

r in

d iv

id u

a ls

F le

xn e

r R

e p

o rt

o n

M e

d ic

a l E

d u

ca ti

o n

c re

a te

m e

d ic

a l s

ch o

o l s

ta n

d a

rd s;

“s ic

kn e

ss ” i

n su

ra n

e st

a b

lis h

e d

b y

B ri

ta in

in 1

9 1

1 a

n d

R u

ss ia

in 1

9 1

2 ;

S o

ci a

lis t

a n

d P

ro g

re ss

iv e

p a

rt ie

s in

t h

e U

n it

e d

S ta

te s

su p

p o

rt s

im ila

r “ si

ck n

e ss

” i n

su ra

n ce

f o

u n

d e

d ;

A C

S b

e g

in s

a cc

re d

it a

ti o

o f

h o

sp it

a ls

; 1 91

8– 19

19 p

an de

m ic

fl u

ki lls

o ve

r 6

0 0

,0 0

0 p

e o

p le

in t

h e

U n

it e

d S

ta te

A M

A p

a ss

e s

re so

lu ti

o n

a g

a in

st c

o m

p u

ls o

ry h

e a

lt h

in su

ra n

ce ; A

M A

o p

p o

si ti

o n

c o

m b

in e

w it

h e

n tr

y in

to W

o rl

d W

a r

I ( a

n d

t h

e a

n ti

-G e

rm a

n s

e n

ti m

e n

ts a

ro u

se d

), u

n d

e rm

in e

s su

p p

o rt

fo r

n a

ti o

n a

l h e

a lt

h r

e fo

rm a

n d

g o

ve rn

m e

n t

in su

ra n

ce ;

e st

a b

lis h

e d

it s

fi rs

h o

sp it

a l i

n su

ra n

ce p

la n

a t

B ay

lo r

U n

iv e

rs it

y ; C

h ro

n ic

il ln

e ss

e s

b e

g in

t o

r e

p la

ce in

fe c

ti o

u s

d is

e a

se s

a s

m o

st s

ig n

ifi ca

n t

h e

a lt

h t

h re

a t;

W it

h in

n o

v a

ti o

n s

in m

e d

ic a

l c a

re , h

e a

lt h

ca re

c o

st s

b e

g in

t o

r is

e .

102

19 30

s 19

40 s

P re

si d

e n

t R

e p

u b

lic a

n D

e m

o cr

a t

H e

rb e

rt H

o o

ve r

(1 9

2 9

– 1

9 3

3 )

Fr a

n kl

in D

. R o

o se

ve lt

( 1

9 3

3 –

1 9

4 5

)

U .S

. H o

u se

o f

R e

p re

se n

ta ti

ve s

D e

m o

cr a

t (1

9 3

1 –

1 9

4 7

) (7

2 n

d –

7 9

th )

D e

m o

cr a

U .S

. S e

n a

te D

e m

o cr

a t

(1 9

3 3

– 1

9 4

7 )

(7 3

rd –

7 9

th )

D e

m o

cr a

( 1

9 2

9 t

h ro

u g

h 1

9 3

0 s)

; (

1 9

3 3

– 1

9 3

9 )

( 1

9 3

9 –

1 9

4 5

), P

e a

rl H

a rb

o r

1 9

4 1

)

e st

a b

lis h

e d

;

p ro

v id

e s

lim it

e d

m e

d ic

a l s

e rv

ic e

fo r

th e

m e

d ic

a lly

in d

ig e

n t;

ro v

id e

s fe

d e

ra l

g ra

n t-

in -a

id f

u n

d in

g f

o r

st a

te s

to c

re a

te a

n d

m a

in ta

in p

u b

lic h

e a

lt h

s e

rv ic

e s

a n

d t

ra in

in g

, e xp

a n

d s

re sp

o n

si b

ili ti

e s

fo r

th e

C h

ild re

n ’s

H e

a lt

h B

u re

a u

a n

d e

st a

b lis

h e

s A

id t

o F

a m

ili e

s w

it h

D e

p e

n d

e n

t C

h ild

re n

( A

F D

C )

w e

lf a

p ro

g ra

m ;

is c

re a

te d

, i n

cl u

d in

p ro

je c

ts t

o b

u ild

a n

d im

p ro

ve h

o sp

it a

ls ;

E xp

a n

d s

re g

u la

to ry

s co

p e

o f

F D

A t

o r

e q

u ir

e p

re m

a rk

e t

a p

p ro

v a

l ( in

re sp

o n

se t

o d

e a

th s

fr o

m a

n u

n te

st e

d p

ro d

u c

t) ;

P u

b lic

H e

a lt

h S

e rv

ic e

is t

ra n

sf e

rr e

d f

ro m

t h

e T

re a

su ry

D e

p a

rt m

e n

t to

t h

e n

e w

F e

d e

ra l S

e cu

ri ty

A g

e n

c y.

F u

n d

s w

a rt

im e

e m

e rg

e n

c y

b u

ild in

g o

f h

o sp

it a

ls ;

r u

le s

th a

t th

e p

ro v

is io

n o

f b

e n

e fi

ts , i

n cl

u d

in g

h e

a lt

h in

su ra

n ce

, d o

e s

n o

t v

io la

te w

a g

e f

re e

ze ;

C o

n so

lid a

te s

th e

la w

s re

la te

d t

o t

h e

f u

n c

ti o

n s

o f

th e

P H

S ;

F u

n d

s h

o sp

it a

l c o

n st

ru c

ti o

n t

o im

p ro

ve a

cc e

ss t

o h

o sp

it a

l- b

a se

m e

d ic

a l c

a re

; o

p e

n s

a s

p a

o f

th e

P u

b lic

H e

a lt

h S

e rv

ic e

; T

ru m

a n

’s n

a ti

o n

a l h

e a

lt h

in su

ra n

ce p

ro p

o sa

is d

e fe

a te

d .

T h

e G

re a

t D

e p

re ss

io n

t h

re a

te n

s fi

n a

n ci

a l s

e cu

ri ty

o f

p h

ys ic

ia n

s, h

o sp

it a

ls ,

a n

d in

d iv

id u

a ls

; C o

m m

e rc

ia l i

n su

ra n

ce in

d u

st ry

r is

e s

in t

h e

a b

se n

ce o

g o

ve rn

m e

n t-

sp o

n so

re d

in su

ra n

ce p

la n

s; In

t h

h e

B lu

e C

ro ss

(h o

sp it

a l s

e rv

ic e

s) a

n d

B lu

e S

h ie

ld (

p h

ys ic

ia n

s e

rv ic

e s)

h e

a lt

h in

su ra

n ce

p la

cr e

a te

d ; P

re p

a id

g ro

u p

h e

a lt

h p

la n

s/ m

e d

ic a

l c o

o p

e ra

ti ve

s g

a in

p o

p u

la ri

w it

h s

o m

e p

ro v

id e

rs a

n d

c o

n su

m e

rs , b

u t

a re

o p

p o

se d

b y

A M

A .

N o

b e

l P ri

ze in

M e

d ic

in e

a w

a rd

e d

f o

r d

e ve

lo p

m e

n t

o f

p e

n ic

ill in

t re

a tm

e n

fo r

h u

m a

n s,

w h

ic h

is u

se d

e xt

e n

si ve

ly in

t h

e w

a r;

a is

e r

P e

rm a

n e

n te

, a

la rg

e p

re p

a id

, i n

te g

ra te

d h

e a

lt h

p la

n is

o p

e n

e d

t o

t h

e p

u b

lic ; 1

9 4

6 t

h e

E m

e rs

o n

R e

p o

rt r

e le

a se

d p

ro p

o si

n g

o ve

ra ll

p la

n f

o r

p u

b lic

h e

a lt

h in

t h

e U

n it

e d

S ta

te s;

A M

A o

p p

o se

s Tr

u m

a n

’s p

la n

f o

r n

a ti

o n

a l h

e a

lt h

in su

ra n

ce a

n d

s e

n ti

m e

n ts

a g

a in

st n

a ti

o n

a l h

e a

lt h

r e

fo rm

a ls

o f

u e

le d

b y

th e

C o

ld W

a r;

E m

p lo

ye r-

b a

se d

h e

a lt

h in

su ra

n ce

g ro

w s

ra p

id ly

w it

h n

o n

a ti

o n

a l h

e a

lt h

in su

ra n

ce p

ro g

ra m

a n

a s

e m

p lo

ye rs

c o

m p

e te

f o

r a

s h

o rt

s u

p p

ly o

f e

m p

lo ye

e s

d u

e t

o t

h e

w a

r a

n d

b e

ca u

se h

e a

lt h

b e

n e

fi ts

a re

e xe

m p

te d

f ro

m t

h e

w a

g e

f re

e ze

; A ft

e r

W W

II, la

b o

u n

io n

s g

a in

e d

t h

e r

ig h

t to

b a

rg a

in c

o lle

c ti

ve ly

, l e

a d

in g

t o

a n

o th

e r

e xp

a n

si o

n in

e m

p lo

ye e

h e

a lt

h p

la n

s; C

o m

m e

rc ia

l i n

su ra

n ce

h a

s ta

ke n

o ve

r 4

0 %

o f

th e

m a

rk e

fr o

m B

lu e

C ro

ss .

103

19 50

s 19

60 s

P re

si d

e n

t D

e m

o cr

a t

R e

p u

b lic

a n

D e

m o

cr a

t D

e m

o cr

a t

H a

rr y

S . T

ru m

a n

( 1

9 4

5 –

1 9

5 3

) D

w ig

h t

D . E

is e

n h

o w

e r

(1 9

5 3

– 1

9 6

1 )

Jo h

n F

. K e

n n

e d

(1 9

6 1

– 1

9 6

3 )

Ly n

d o

n B

. J o

h n

so n

( 1

9 6

3 –

1 9

6 9

)

U .S

. H o

u se

o f

R e

p re

se n

ta ti

ve s

R e

p u

b lic

a n

( 1

9 4

7 –

1 9

4 9

) (8

0 th

);

D e

m o

cr a

t (1

9 4

9 –

1 9

5 3

) (8

1 st

– 8

2 d

)

R e

p u

b lic

a n

( 1

9 5

2 –

1 9

5 5

) (8

3 rd

);

D e

m o

cr a

t (1

9 5

5 –

1 9

9 4

) (8

4 th

– 1

0 3

rd )

D e

m o

cr a

t D

e m

o cr

a t

U .S

. S e

n a

te R

e p

u b

lic a

n (

1 9

4 7

– 1

9 4

9 )

(8 0

th );

D e

m o

cr a

t (1

9 4

9 –

1 9

5 3

)

(8 1

st –

8 2

n d

)

R e

p u

b lic

a n

( 1

9 5

3 –

1 9

5 5

) (8

3 rd

);

D e

m o

cr a

t (1

9 5

5 –

1 9

8 1

) (8

4 th

– 9

6 th

)

D e

m o

cr a

t D

e m

o cr

a t

C o

ld W

a r

id e

o lo

g y

a n

d M

cC a

rt h

yi sm

( 1

9 5

0 –

1 9

5 4

); (

1 9

5 0

– 1

9 5

3 )

E co

n o

m ic

d o

w n

tu rn

c re

a te

fr o

m t

h e

F e

d e

ra l S

e cu

ri ty

A g

e n

c y,

a n

d t

h e

P u

b lic

H e

a lt

h S

e rv

ic e

is t

ra n

sf e

rr e

to H

E W

; In

te rn

a l R

e ve

n u

e S

e rv

ic e

d e

cl a

re s

th a

t e

m p

lo ye

rs c

a n

p ay

h e

a lt

h in

su ra

n ce

p re

m iu

m s

fo r

th e

ir e

m p

lo ye

e s

w it

h p

re -t

a x

d o

lla rs

;

3 4

7 U

.S . 4

8 3

( 1

9 5

4 ):

R a

ci a

l s e

g re

g a

ti o

n in

p u

b lic

e d

u ca

ti o

n v

io la

te s

th e

E q

u a

l P ro

te c

ti o

n C

la u

se o

f 1

4 th

A m

e n

d m

e n

C re

a te

s g

o ve

rn m

e n

t m

e d

ic a

l c a

re p

ro g

ra m

fo r

m ili

ta ry

a n

d d

e p

e n

d e

n ts

o u

ts id

e t

h e

V e

te ra

n s

A ff

a ir

s sy

st e

m ;

is a

m e

n d

e d

t o

p ro

v id

e S

o ci

a l S

e cu

ri ty

D is

a b

ili ty

In su

ra n

ce .

re q

u ir

e t

h a

t n

e w

d ru

g s

b e

“e ff

e c

ti ve

.”

p ro

v id

e s

fe d

e ra

l f u

n d

in g

t h

ro u

g h

ve n

d o

r p

ay m

e n

ts t

o s

ta te

s fo

r m

e d

ic a

lly in

d ig

e n

t e

ld e

rl y

;

3 2

3 F

.2 d

9 5

(4 th

C ir

. 1 9

6 3

): R

a ci

a l s

e g

re g

a ti

o n

in p

ri v

a te

h o

sp it

a ls

r e

ce iv

in g

fe d

e ra

l H ill

-B u

rt o

n f

u n

d s

v io

la te

s th

e E

q u

a l P

ro te

c ti

o n

C la

u se

o f

th e

1 4

th A

m e

n d

m e

n t;

a ss

e d

;

p ro

g ra

m s

cr e

a te

d t

h ro

u g

S o

ci a

l S e

cu ri

ty A

m e

n d

m e

n ts

; 3

8 1

U .S

. 4 7

9 (

1 9

6 5

): T

h e

C o

n st

it u

ti o

n p

ro te

c ts

a r

ig h

t to

p ri

v a

c y,

st a

te la

w f

o rb

id d

in g

t h

e u

se o

f co

n tr

a ce

p ti

ve s

o r

p ro

v is

io n

o f

th e

m t

o m

a rr

ie d

c o

u p

le s

v io

la te

s a

c o

n st

it u

ti o

n a

l r ig

h t

m a

ri ta

l p ri

v a

c y

;

( C

H A

M P

U S

) cr

e a

te d

is c

re at

e d

to p

ro vi

d e

v o

lu n

ta ry

a cc

re d

it at

io n

; S

al k

cr e

at e

s p

o lio

v ac

ci n

e ;

fi rs

o rg

an t

ra n

sp la

n t

is p

e rf

o rm

e d

; C o

n ti

n u

e d

p ro

g re

ss io

n in

m e

d ic

al s

ci e

n ce

a n

te ch

n o

lo g

y le

ad s

to in

cr e

as e

d c

o st

s; P

o lit

ic al

fo cu

s tu

rn s

to K

o re

an W

ar a

n d

a w

fr o

m m

e d

ic al

c ar

e r

e fo

rm .

M e

d ic

a re

a n

d M

e d

ic a

id c

re a

te d

; fi

rs t

h u

m a

n h

e a

rt t

ra n

sp la

n t.

104

19 70

s 19

80 s

P re

si d

e n

t R

e p

u b

lic a

n R

e p

u b

lic a

n D

e m

o cr

a t

R e

p u

b lic

a n

R ic

h a

rd M

. N ix

o n

(1 9

6 9

– 1

9 7

4 )

G e

ra ld

R . F

o rd

( 1

9 7

4 –

1 9

7 7

) Ji

m m

y C

a rt

e r

(1 9

7 7

– 1

9 8

1 )

R o

n a

ld R

e a

g a

n (

1 9

8 1

– 1

9 8

9 )

U .S

. H o

u se

o f

R e

p re

se n

ta ti

ve s

D e

m o

cr a

t D

e m

o cr

a t

D e

m o

cr a

t D

e m

o cr

a t

U .S

. S e

n a

te D

e m

o cr

a t

D e

m o

cr a

t D

e m

o cr

a t

R e

p u

b lic

a n

( 1

9 8

1 –

1 9

8 7

) (9

7 th

– 9

9 th

); D

e m

o cr

a t

(1 9

8 7

– 1

9 9

5 )

(1 0

0 th

– 1

0 3

rd )

“N e

w F

e d

e ra

lis m

” o f

th e

R e

a g

a n

a d

m in

is tr

a ti

o n

;

B e

rl in

W a

ll fa

lls

P re

si d

e n

t N

ix o

n ’s

p ro

p o

se d

c o

m p

re h

e n

si ve

h e

a lt

h in

su ra

n ce

p la

n f

a ils

;

p ro

p o

se d

H e

a lt

h S

e cu

ri ty

A c

t fr

o m

S e

n a

to r

E d

w a

rd K

e n

n e

d y

(D -M

A )

fa ils

; C

o m

m u

n ic

a b

le D

is e

a se

C e

n te

r is

r e

n a

m e

d t

h e

e xt

e n

d M

e d

ic a

re e

lig ib

ili ty

a n

d c

re a

te S

u p

p le

m e

n ta

l S e

cu ri

ty In

co m

(S S

I) p

ro g

ra m

; 4

6 4

F .2

d 7

7 2

( D

.C . C

ir . 1

9 7

2 ):

E st

a b

lis h

e d

m o

d e

rn la

w o

f in

fo rm

e d

c o

n se

n t

b a

se d

o n

a r

e a

so n

a b

p a

ti e

n t

st a

n d

a rd

; 4

1 0

U .S

. 1 1

3 (

1 9

7 3

): C

o n

st it

u ti

o n

a l r

ig h

to p

ri v

a c

y e

n co

m p

a ss

e s

a w

o m

a n

’s d

e ci

si o

n t

o t

e rm

in a

te h

e r

p re

g n

a n

c y

;

S u

p p

o rt

s g

ro w

th o

h e

a lt

h m

a in

te n

a n

ce o

rg a

n iz

a ti

o n

p a

ss e

d ;

is c

re a

te d

t o

a d

m in

is te

r th

e M

e d

ic a

re a

n d

M e

d ic

a id

p ro

g ra

m s.

C a

rt e

in tr

o d

u ce

s a

N a

ti o

n a

l H e

a lt

h P

la n

to C

o n

g re

ss ;

is c

re a

te d

f ro

m a

re o

rg a

n iz

e d

H E

W .

M e

d ic

a re

im p

le m

e n

ts p

ro sp

e c

ti ve

p ay

m e

n t

sy st

e m

fo r

re im

b u

rs in

g h

o sp

it a

ls ;

E n

su re

a cc

e ss

t o

e m

e rg

e n

c y

se rv

ic e

s in

M e

d ic

a re

-p a

rt ic

ip a

ti n

h o

sp it

a ls

r e

g a

rd le

ss o

f a

b ili

ty t

o p

ay ; C re

a te

s th

e N

a ti

o n

a l

P ra

c ti

ti o

n e

r D

a ta

b a

n k;

In cl

u d

e s

h e

a lt

h b

e n

e fi

t p

ro v

is io

n s

th a

t e

st a

b lis

h c

o n

ti n

u a

ti o

o f

e m

p lo

ye r-

sp o

n so

re d

g ro

u p

h e

a lt

h c

o ve

ra g

e ;

In cl

u d

e s

o u

tp a

ti e

n t

p re

sc ri

p ti

o n

d ru

g b

e n

e fi

t a

n d

o th

e r

ch a

n g

e s

in M

e d

ic a

re (

re p

e a

le d

1 9

8 9

H e

al th

ca re

c o

st s

co n

ti n

u e

t o

r is

e d

ra m

at ic

al ly

, d u

e t

o a

d va

n ce

s in

m e

d ic

al t

e ch

n o

lo g

y, h

ig h

-t e

h o

sp it

al c

ar e

, t h

e n

e w

p o

o l o

f p

ay in

g p

at ie

n ts

f ro

m M

e d

ic ai

d a

n d

M e

d ic

ar e

, i n

cr e

as e

d u

ti liz

at io

n o

se rv

ic e

s, a

n d

in cr

e as

e d

p h

ys ic

ia n

s p

e ci

al iz

at io

n ;

c o

m p

u te

d t

o m

o g

ra p

h y

(C T

) sc

an fi

rs t

u se

d ;

fi rs

t b

ab y

co n

ce iv

e d

t h

ro u

g h

in v

it ro

fe rt

ili za

ti o

n is

b o

rn .

W o

rl d

H e

a lt

h A

ss e

m b

ly d

e cl

a re

s sm

a llp

o x

e ra

d ic

a te

d ;

S ci

e n

ti st

s id

e n

ti fy

A ID

S ;

t h

e J

o in

C o

m m

is si

o n

A cc

re d

it a

ti o

n o

f H

o sp

it a

ls c

h a

n g

e s

n a

m e

to t

h e

J o

in t

C o

m m

is si

o n

A cc

re d

it a

ti o

n o

f H

e a

lt h

ca re

O rg

a n

iz a

ti o

n s

(J C

A H

O );

S h

if t

aw ay

f ro

m t

ra d

it io

n a

l f e

e -f

o r-

se rv

ic e

in su

ra n

ce p

la n

s a

n d

t o

w a

rd m

a n

a g

e d

c a

re .

105

19 90

P re

si d

e n

t R

e p

u b

lic a

n D

e m

o cr

a t

G e

o rg

e B

u sh

( 1

9 8

9 –

1 9

9 3

) W

ill ia

m J

. C lin

to n

( 1

9 9

3 –

2 0

0 1

)

U .S

. H o

u se

o f

R e

p re

se n

ta ti

ve s

D e

m o

cr a

t *F

ir st

t im

e si

n ce

1 9

5 5

t h

a t

b o

th h

o u

se s

a re

R ep

u b

lic a

n ; R

e p

u b

lic a

n (

1 9

9 5

– 2

0 0

5 )

(1 0

4 th

– 1

0 8

th )

U .S

. S e

n a

te D

e m

o cr

a t

R e

p u

b lic

a n

( 1

9 9

5 –

2 0

0 5

) (1

0 4

th –

1 0

8 th

[ Ja

n . 3

– 2

0 , 2

0 0

1 , a

n d

J u

n e

6 , 2

0 0

1 –

N o

v. 1

2 , 2

0 0

2 D

e m

o cr

a t]

)

G u

lf W

a r

Fo re

ig n

c ri

se s

in H

a it

i a n

d B

o sn

ia ;

N o

rt h

A m

e ri

ca n

F re

e T

ra d

e A

g re

e m

e n

t (N

A F

TA );

W h

it e

w a

te r

in ve

st ig

a ti

o n

; O

kl a

h o

m a

C it

y b

o m

b in

g ;

P re

si d

e n

t C

lin to

n im

p e

a ch

e d

cr e

a te

d ;

P ro

v id

e s

p ro

te c

ti o

n a

g a

in st

d is

a b

ili ty

d is

cr im

in a

ti o

n ;

C re

a te

s fe

d e

ra l s

u p

p o

rt f

o r

A ID

S -

re la

te d

s e

rv ic

e s;

4 9

7 U

.S . 2

6 1

( 1

9 9

0 ):

Fi rs

t “ ri

g h

t to

d ie

” c a

se b

e fo

S u

p re

m e

C o

u rt

, i n

w h

ic h

t h

e C

o u

rt h

e ld

t h

a t

a c

o m

p e

te n

p e

rs o

n h

a s

a c

o n

st it

u ti

o n

a lly

p ro

te c

te d

li b

e rt

y in

te re

st in

re fu

si n

g m

e d

ic a

l t re

a tm

e n

P re

si d

e n

t C

lin to

n ’s

p ro

p o

se d

is d

e fe

a te

d ;

P H

S r

e o

rg a

n iz

e d

t o

re p

o rt

d ir

e c

tl y

to t

h e

S e

cr e

ta ry

o f

H H

S ;

In cl

u d

e s

p ri

v a

c y

ru le

s to

p ro

te c

t p

e rs

o n

a l h

e a

lt h

in fo

rm a

ti o

n , a

tt e

m p

ts t

o s

im p

lif y

co d

in g

f o

h e

a lt

h b

ill s,

m a

ke s

it d

iffi cu

lt t

o e

xc lu

d e

p a

ti e

n ts

f ro

m in

su ra

n ce

p la

n s

d u

e t

o p

re e

xi st

in g

c o

n d

it io

n s;

re p

la ce

s A

F D

w it

h t

h e

T e

m p

o ra

ry A

ss is

ta n

ce f

o r

N e

e d

y Fa

m ili

e s

(T A

N F

) p

ro g

ra m

;

R e

q u

ir e

s in

su ra

n ce

c a

rr ie

rs t

h a

t o

ff e

r m

e n

ta l h

e a

lt h

b e

n e

fi ts

t o

p ro

v id

e t

h e

s a

m e

a n

n u

a l a

n d

lif e

ti m

e d

o lla

r lim

it s

fo r

m e

n ta

l a n

d p

h ys

ic a

l h e

a lt

h b

e n

e fi

ts ;

R e

la xe

s re

st ri

c ti

o n

s o

n d

ir e

c t-

to -c

o n

su m

e r

a d

ve rt

is e

m e

n ts

o f

p re

sc ri

p ti

o n

d ru

g s;

d d

s M

e d

ic a

re p

a rt

C , t

h e

M e

d ic

a re

m a

n a

g e

d c

a re

p ro

g ra

m , a

n d

cr e

a te

s th

e S

ta te

H e

a lt

h In

su ra

n ce

P ro

g ra

m , w

h ic

h a

llo w

s st

a te

s to

e xt

e n

d h

e a

lt h

in su

ra n

ce c

o ve

ra g

to a

d d

it io

n a

l l o

w -i

n co

m e

c h

ild re

n ;

C re

a te

s a

n e

w s

ta te

o p

ti o

n t

o h

e lp

in d

iv id

u a

ls w

it h

d is

a b

ili ti

e s

st ay

e n

ro lle

d in

M e

d ic

a id

o r

M e

d ic

a re

c o

ve ra

g e

w h

ile r

e tu

rn in

g t

o w

o rk

E n

ro llm

e n

t in

m a

n a

g e

d c

a re

d o

u b

le s;

G re

a te

r u

se o

f o

u tp

a ti

e n

t se

rv ic

e s;

R a

te o

f h

e a

lt h

s p

e n

d in

g is

re la

ti ve

ly s

ta b

le a

t ro

u g

h ly

1 2

% t

o 1

3 %

o f

g ro

ss d

o m

e st

ic p

ro d

u c

t; D

ir e

c t-

to -c

o n

su m

e r

a d

ve rt

is in

g o

p h

a rm

a ce

u ti

ca ls

in cr

e a

se s

d ra

m a

ti ca

lly a

n d

t h

e In

te rn

e t

is u

se d

a s

o u

rc e

o f

m e

d ic

a l i

n fo

rm a

ti o

n ;

O re

g o

n H

e a

lt h

P la

n r

a ti

o n

s M

e d

ic a

id s

e rv

ic e

s th

ro u

g h

a p

ri o

ri ti

ze d

li st

o f

m e

d ic

a l t

re a

tm e

n ts

a n

co n

d it

io n

Ia n

W ilm

u t

cl o

n e

s a

s h

e e

p f

ro m

a d

u lt

h u

m a

n c

e lls

106

20 00

P re

si d

e n

t R

e p

u b

lic a

n D

e m

o cr

a t

G e

o rg

e W

. B u

sh (

2 0

0 1

– 2

0 0

9 )

B a

ra ck

O b

a m

a (

2 0

0 9

– 2

0 1

7 )

U .S

. H o

u se

o f

R e

p re

se n

ta ti

ve s

R e

p u

b lic

a n

( 2

0 0

5 –

2 0

0 7

) (1

0 9

th );

D e

m o

cr a

t (2

0 0

7 –

2 0

0 9

) (1

1 0

th )

D e

m o

cr a

t (2

0 0

9 –

2 0

1 1

) (1

1 1

th );

R e

p u

b lic

a n

2 0

1 1

– (

1 1

2 th

)

U .S

. S e

n a

te R

e p

u b

lic a

n (

2 0

0 5

– 2

0 0

7 )

(1 0

9 th

); D

e m

o cr

a t

(2 0

0 7

– 2

0 0

9 )

(1 1

0 th

) D

e m

o cr

a t

(2 0

0 9

– 2

0 1

5 )

(1 1

1 th

– 1

1 3

th )

t e

rr o

ri st

a tt

a ck

s o

n W

o rl

d T

ra d

e C

e n

te r

in N

e w

Y o

rk a

n d

t h

e P

e n

ta g

o n

;

U .S

. m ili

ta ry

a c

ti o

n in

A fg

h a

n is

ta n

; Ir

a q

W a

r b

e g

in s

G re

a t

R e

ce ss

io n

( b

e g

a n

in D

e ce

m b

e r

2 0

0 7

), in

cl u

d in

g fi

n a

n ci

a l

cr is

is a

n d

c o

lla p

se o

f h

o u

si n

g m

a rk

e t;

P a

ss a

g e

o f

th e

2 0

1 0

P a

ti e

n t

P ro

te c

ti o

n a

n d

A ff

o rd

a b

le C

a re

A c

C o

n g

re ss

io n

a l a

tt e

n ti

o n

a n

d s

p e

n d

in g

t u

rn s

to in

te rn

a ti

o n

a l a

n d

s e

cu ri

ty c

o n

ce rn

s, li

tt le

d is

cu ss

io n

o f

h e

a lt

h r

e fo

rm ;

t ra

n sf

e rs

s o

m e

H H

S f

u n

c ti

o n

in cl

u d

in g

t h

e S

tr a

te g

ic N

a ti

o n

a l S

to ck

p ile

o f

e m

e rg

e n

c y

p h

a rm

a ce

u ti

ca l s

u p

p lie

s a

n d

t h

N a

ti o

n a

l D is

a st

e r

M e

d ic

a l S

e rv

ic e

, t o

t h

e n

e w

D e

p a

rt m

e n

t o

f H

o m

e la

n d

S e

cu ri

ty ;

A d

d s

a p

re sc

ri p

ti o

n d

ru g

b e

n e

fi t

to M

e d

ic a

re b

e g

in n

in g

in 2

0 0

6 ;

P ro

v id

e s

fu n

d in

g f

o r

v a

cc in

e s

a n

d m

e d

ic a

ti o

n s

fo r

b io

d e

fe n

se a

n d

a llo

w s

e xp

e d

it e

d F

D A

r e

v ie

w o

f tr

e a

tm e

n ts

in r

e sp

o n

se t

o a

tt a

ck s;

2 00

5 D

efi ci

t M

a ke

s ch

a n

g e

s to

M e

d ic

a id

c o

st s

h a

ri n

g , p

re m

iu m

s, b

e n

e fi

ts , a

n d

a ss

e t

tr a

n sf

e rs

; g

o e

s in

to e

ff e

c t;

a m

e n

d e

d t

o r

e q

u ir

e in

su re

rs t

o t

re a

t m

e n

ta l h

e a

lt h

c o

n d

it io

n s

o n

t h

e s

a m

b a

si s

a s

p h

ys ic

a l c

o n

d it

io n

C o

n g

re ss

io n

a l f

o cu

s o

n h

e a

lt h

r e

fo rm

, s p

e n

d in

g c

u ts

; P re

si d

e n

O b

a m

a e

st a

b lis

h e

s th

ffi c

;

c re

a te

in ce

n ti

ve s

to h

e lp

d e

ve lo

p h

e a

lt h

in fo

rm a

ti o

n t

e ch

n o

lo g

y a

n d

e xp

a n

d t

h e

p ri

m a

ry c

a re

w o

rk fo

rc e

, a m

o n

g o

th e

r th

in g

e xt

e n

d in

g (

fo r

4 .5

y e

a rs

) a

n d

e xp

a n

d in

g t

h e

p ro

g ra

m ;

C o

m p

re h

e n

si ve

h e

a lt

h r

e fo

rm in

cl u

d in

g a

n “i

n d

iv id

u a

l m a

n d

a te

”

to p

u rc

h a

se in

su ra

n ce

c o

ve ra

g e

, M e

d ic

a id

e xp

a n

si o

n , c

re a

ti o

n o

st a

te h

e a

lt h

in su

ra n

ce e

xc h

a n

g e

s, a

n d

m u

ch m

o re

A ft

e r

th e

S e

p te

m b

e r

1 1

, 2 0

0 1

, a tt

a ck

s, p

u b

lic h

e a

lt h

b e

co m

e s

fo cu

se d

o n

e m

e rg

e n

c y

p re

p a

re d

n e

ss ;

S e

q u

e n

ci n

g o

f h

u m

a n

g e

n o

m e

c o

m p

le te

d ;

S A

R S

e p

id e

m ic

a n

d 2

0 0

4 fl

u v

a cc

in e

s h

o rt

a g

e r

a is

e s

co n

ce rn

s a

b o

u t

p u

b lic

h e

a lt

h r

e a

d in

e ss

; W o

rl d

w id

co n

ce rn

a b

o u

t a

p o

ss ib

le A

v ia

n fl

u e

p id

e m

ic ; H

ig h

le ve

l o f

co n

ce rn

in t

h e

U n

it e

d S

ta te

a b

o u

t th

e r

is in

g r

a te

o f

o b

e si

ty ;

G a

rd a

si l v

a cc

in e

p ro

te c

ti n

g a

in st

t w

o s

tr a

in s

o f

th e

h u

m a

n p

a p

ill o

m a

v ir

u s,

w h

ic h

is a

ss o

ci a

te d

w it

h c

e rv

ic a

l c a

n ce

r, a

p p

ro ve

d b

y th

e F

D A

;

I n

te rn

a ti

o n

a l H

e a

lt h

R e

g u

la ti

o n

s, p

a ss

e d

b y

th e

W o

rl d

H e

a lt

h O

rg a

n iz

a ti

o n

in 2

0 0

5 , a

im p

le m

e n

te d

b y

m e

m b

e r

st a

te s.

R a

te o

f h

e a

lt h

s p

e n

d in

g c

o n

ti n

u e

s to

s ky

ro ck

e t,

a cc

o u

n ti

n g

2 0

0 9

f o

r 1

7 %

o f

th e

g ro

ss d

o m

e st

ic p

ro d

u c

H 1

N 1

s w

in e

fl u

v ir

u s

p a

n d

e m

ic .

107

10 s

P re

si d

e n

t D

e m

o cr

a t

R e

p u

b lic

a n

B a

ra ck

O b

a m

a (

2 0

0 9

– 2

0 1

7 )

D o

n a

ld T

ru m

p (

2 0

1 7

– )

U .S

. H o

u se

o f

R e

p re

se n

ta ti

ve s

R e

p u

b lic

a n

2 0

1 1

– P

re se

n t

(1 1

2 th

– 1

1 5

th )

U .S

. S e

n a

te R

e p

u b

lic a

n 2

0 1

5 (

1 1

4 th

– 1

1 5

th )

u t

m a

n y

n o

t p

ro sp

e ri

n g

d u

ri n

g t

h e

r e

co ve

ry ;

, i n

cl u

d in

g d

e b

a te

s in

n e

a rl

h a

lf t

h e

s ta

te s

co n

ce rn

in g

w h

e th

e r

to a

d o

p t

th e

A C

A ’s

M e

d ic

a id

e xp

a n

si o

n ; S

e ve

ra l

st a

te s

co n

ti n

u e

t o

e xp

e ri

e n

ce fi

n a

n ci

a l a

n d

/o r

te ch

n ic

a l i

ss u

e s

in t

h e

e st

a b

lis h

m e

n t

a n

d o

p e

ra ti

o n

o f

A C

A in

su ra

n ce

e xc

h a

n g

e s;

In cr

e a

si n

g p

o lit

ic a

l a n

d le

g a

a cc

e p

ta n

ce o

f sa

m e

-s e

x m

a rr

ia g

e li

ke ly

t o

im p

a c

t u

se a

n d

c o

st o

f h

e a

lt h

in su

ra n

a n

d p

u b

lic h

e a

lt h

p ro

g ra

m s;

G ro

w th

o f

IS IS

a s

a t

e rr

o ri

st t

h re

a t;

s u

d d

e n

ly in

F e

b ru

a ry

2 0

1 6

, a ft

e r

w h

ic h

th e

U .S

. S e

n a

te , u

n d

e r

R e

p u

b lic

a n

p o

w e

r, re

fu se

s to

c o

n si

d e

r P

re si

d e

n t

O b

a m

a’ s

re p

la ce

m e

n t

n o

m in

a ti

o n

u n

ti l a

ft e

r th

e 2

0 1

6 e

le c

ti o

n .

M a

in ly

a ti

o n

a l e

le c

ti o

n r

e su

lt s

in a

b ru

p t

sh if

t in

f e

d e

ra l p

o lic

ym a

ki n

g , v

ie w

s a

b o

u t

e n

ti tl

e m

e n

t a

n d

w e

lf a

re p

ro g

ra m

a n

d r

e v

is e

d im

m ig

ra ti

o n

p o

lic ie

s, a

m o

n g

o th

e r

ke y

n a

ti o

n a

l p o

lit ic

a l a

n d

s o

ci a

is su

e s;

;

in 2

0 1

7 t

o in

ve st

ig a

te t

h e

a lle

g e

d r

o le

o f

R u

ss ia

n in

te rf

e re

n ce

in t

h e

2 0

1 6

n a

ti o

n a

l e le

c ti

o n

; on

fir m

ed to

t a

ke J

u st

ic e

S ca

lia ’s

s e

a t

o n

t h

e U

.S . S

u p

re m

e C

o u

rt ;

a t

th e

e n

d o

f th

e 2

0 1

7 –

2 0

1 8

t e

rm , i

s re

p la

ce d

b y

th e

s m

a lle

st m

a rg

in f

o r

a S

u p

re m

e C

o u

rt J

u st

ic e

s in

ce 1

8 8

1 a

n d

a ft

e r

d e

e p

ly t

ro u

b lin

g a

n d

p o

la ri

zi n

g n

o m

in a

ti o

n p

ro ce

ss ; N

a ti

o n

a l e

co n

o m

y m

a in

re co

ve rs

f ro

m G

re a

t R

e ce

ss io

n ,

o n

g re

ss io

n al

f o

cu s

co n

ti n

u e

s to

b e

o n

d e

b at

in g

t h

e A

C A

a s

w e

ll as

in te

rn at

io n

se cu

ri ty

is su

e s;

n d

e d

t h

e d

is cr

im in

at o

m ili

ta ry

p o

lic y

re g

ar d

in g

g ay

s e

rv ic

e m

b e

rs ;

S u

p re

m e

C o

u rt

h e

ld t

h at

t h

e A

C A

’s in

d iv

id u

al in

su ra

n ce

r e

q u

ir e

m e

n t

w as

c o

n st

it u

ti o

n al

b u

t al

so r

u le

d t

h at

t h

e A

C A

’s r

e q

u ir

e m

e n

t th

at a

ll st

at e

s e

xp an

d M

e d

ic ai

d w

u n

d u

ly c

o e

rc iv

e ;

th e

S u

p re

m e

C o

u rt

h e

ld t

h at

o n

p ro

vi si

o n

o f

th e

A C

A v

io la

te d

f e

d e

ra l l

aw b

y re

q u

ir in

g c

lo se

ly h

e ld

c o

rp o

ra ti

o n

s to

p ay

f o

r in

su ra

n ce

c o

ve ra

g e

f o

r ce

rt ai

n t

yp e

s o

f co

n tr

ac e

p ti

o n

;

r e

p la

ce d

t h

e S

u st

ai n

ab le

G ro

w th

R at

e f

o rm

u la

u se

fo r

p h

ys ic

ia n

p ay

m e

n t

an d

f u

n d

e d

C H

IP t

h ro

u g

h 2

0 1

7 ;

th e

S u

p re

m e

C o

u rt

h e

ld t

h at

t h

e f

u n

d am

e n

ta l r

ig h

t to

m ar

ri ag

e is

g u

ar an

te e

d t

sa m

e -s

e x

co u

p le

s; In

h e

S u

p re

m e

C o

u rt

u p

h e

ld t

h e

A C

A ’s

st at

u to

ry a

n d

r e

g u

la to

ry s

ch e

m e

p e

rm it

ti n

g f

e d

e ra

l s u

b si

d ie

s to

fl o

w t

h ro

u g

h b

o th

st at

e -r

u n

a n

d f

e d

e ra

lly f

ac ili

ta te

d in

su ra

n ce

e xc

h an

g e

s; T

h e

au th

o ri

ze d

a c

o m

p re

h e

n si

ve , s

tr at

e g

ic a

p p

ro ac

h f

o r

U .S

. f o

re ig

as si

st an

ce t

o d

e ve

lo p

in g

c o

u n

tr ie

s to

r e

d u

ce g

lo b

al p

o ve

rt y

an d

h u

n g

e r,

ac h

ie ve

fo o

d s

e cu

ri ty

, p ro

m o

te s

u st

ai n

ab le

a g

ri cu

lt u

ra l-

le d

e co

n o

m ic

g ro

w th

, a n

d im

p ro

n u

tr it

io n

al o

u tc

o m

e s,

p ar

ti cu

la rl

y fo

r w

o m

e n

a n

d c

h ild

re n

; T h

b e

ca m

e la

w in

2 0

1 6

a n

d w

as d

e si

g n

e d

t o

h e

lp a

cc e

le ra

te m

e d

ic al

p ro

d u

c t

d e

ve lo

p m

e n

t an

d b

ri n

g n

e w

in n

o va

ti o

n s

an d

a d

va n

ce s

to p

at ie

n ts

w h

o n

e e

d t

h e

fa st

e r

an d

m o

re e

ffi ci

e n

tl y

; I n

W h

o le

(

2 0

1 6

), th

S u

p re

m e

C o

u rt

s tr

u ck

d o

w n

s tr

ic t

Te xa

s ab

o rt

io n

r e

g u

la ti

o n

s, r

u lin

g t

h at

a b

o rt

io n

p ro

vi d

e r

re g

u la

ti o

n s

m u

st b

e b

as e

d o

n c

o n

vi n

ci n

g m

e d

ic al

e vi

d e

n ce

a n

d c

an n

o t

u n

d u

ly b

u rd

e n

a w

o m

an ’s

r ig

h t

to a

b o

rt io

n .

A ft

e r

P re

si d

e n

t Tr

u m

p ’s

in a

u g

u ra

ti o

n , m

u lt

ip le

R e

p u

b lic

a n

e ff

ff (

th o

u g

h s

e ve

ra l e

xe cu

ti ve

re g

u la

to ry

a c

ti o

n s

h a

lt o

r lim

it t

h e

r e

a ch

o f

th e

A C

A );

a n

d f

u n

d e

d t

h ro

u g

h 2

0 2

7 ; T

h e

e p

re se

n ts

th e

b ig

g e

st f

e d

e ra

l t a

x o

ve rh

a u

l i n

3 0

y e

a rs

— a

m o

n g

o th

e r

th in

g s,

it c

u t

th e

m a

xi m

u m

c o

rp o

ra te

in co

m e

t a

x ra

te t

o 2

1 %

, e lim

in a

te d

t h

e t

a x

o n

p e

o p

w h

o d

o n

o t

o b

ta in

a d

e q

u a

te h

e a

lt h

in su

ra n

ce c

o ve

ra g

e , a

n d

in cr

e a

se d

t h

st a

n d

a rd

d e

d u

c ti

o n

a n

d t

h e

e st

a te

t a

x e

xe m

p ti

o n

, w h

ic h

t o

g e

th e

r w

ill r

e d

u ce

fe d

e ra

l r e

ve n

u e

s b

y si

g n

ifi ca

n t

a m

o u

n ts

a n

d li

ke ly

m a

ke t

h e

d is

tr ib

u ti

o n

o f

a ft

e r-

ta x

in co

m e

m o

re u

n e

q u

a l.

( 2

0 1

7 ),

th e

S u

p re

m e

C o

u rt

r u

le d

t h

a t

ra ci

a l g

e rr

ym a

n d

e ri

n g

v io

la te

d t

h e

r ig

h ts

o f

vo te

rs t

o e

q u

a l

p ro

te c

ti o

n o

f th

e la

w s;

T h

e S

u p

re m

e C

o u

rt r

u le

d 5

– 4

t h

a t

P re

si d

e n

t Tr

u m

p h

a d

th e

le g

a l a

u th

o ri

ty t

o r

e st

ri c

t tr

a ve

l f ro

m s

e ve

ra l m

o st

ly M

u sl

im c

o u

n tr

ie s

in t

h e

2 0

1 8

c a

se o

f ; I

( 2

0 1

8 ),

th e

S u

p re

m e

C o

u rt

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Other Sources Consulted

Source for Political Affiliation of Senate

Source for Political Affiliation of the House of Representatives

Further Reading

fin

References

111

PART II

Essential Issues in Health Policy and Law

113

CHAPTER 6

Individual Rights in Health Care and Public Health

LEARNING OBJECTIVES

By the end of this chapter you will be able to:

■ Describe the meaning and importance of the “no-duty to treat” principle ■ Explain generally how the U.S. approach to health rights differs from that of other developed countries ■ Describe the types and limitations of individual legal rights associated with health care ■ Describe the balancing approach taken when weighing individual rights against the public’s health

By the end of this chapter you will be able to:

▸ Introduction BOX 6-1

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▸ Background

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BOX 6-1 Vignette

At the turn of the 20th century, an Indiana physician

named George Eddingfield repeatedly refused to

come to the aid of Charlotte Burk, who was in labor,

even though he was Mrs. Burk’s family physician.

Doctor Eddingfield conceded at trial that he made this

decision for no particular reason and despite the facts

that he had been offered monetary compensation

in advance of his performing any medical services

and that he was aware that no other physician was

available to provide care to Mrs. Burk. Unattended by

any medical providers, Mrs. Burk eventually fell gravely

ill, and both she and her unborn child died. It was

determined upon trial and subsequent appeals that

Dr. Eddingfield did not wrongfully cause either death.

Around the same time as the scenario just described,

the Cambridge, Massachusetts, Board of Health ordered

everyone within city limits to be vaccinated against the

smallpox disease under a state law granting local boards

of health the power, under certain circumstances, to

require the vaccination of individuals. After refusing

to abide by the Cambridge Board’s order, Henning

Jacobson was convicted by a state trial court and

sentenced to pay a $5 fine. Remarkably, Mr. Jacobson’s

case not only made its way to the U.S. Supreme Court,

it resulted in one of the court’s most important public

health rulings and a sweeping statement about

limitations to fundamental individual rights in the face

of threats to the public’s health.

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BOX 6-2 Discussion Question

Depending on one’s personal experience in obtaining

health care, or one’s view of the role of physicians in

society, of law as a tool for social change, of the scope

of medical ethics, or of the United States’ place in the

broader global community, the no-duty principle

might seem appropriate, irresponsible, or downright

wrong. Imagine you are traveling in a country where

socialized medicine is the legal norm, and your

discussion with a citizen of that country turns to the

topic of your countries’ respective health systems.

When asked, how will you account for the fact that

health care is far from being a fundamental right

rooted in American law?

118 Chapter 6 ublic Health

Rights Under Healthcare and Health Financing Laws

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BOX 6-3 Discussion Questions

Go back to the first legal principle drawn from the

Canterbury decision: namely, that physicians have

a duty of reasonable disclosure to include therapy

options and the dangers potentially involved with

each. Do you agree with the court that this duty is

both a logical and modest extension of physicians’

“traditional” obligation to their patients? Why or why

not? Depending on your answer, are you surprised

to learn that some states have opted not to follow

the Canterbury court’s patient-oriented standard

of informed consent, relying instead on the more

conventional approach of measuring the legality

of physician disclosure based on what a reasonable

physician would have disclosed?

122 Chapter 6 ublic Health

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If you were asked to distill, down to their most

essential parts, the constitutional right to privacy and

the right to privacy as it applies to abortion, what

elements would you include?

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Jacobson v. Massachusetts is a product of the early

20th century, and the public health law principles

supporting it are vestiges of an even earlier time.

This, coupled with a century of subsequent civil

liberties jurisprudence and societal advancement,

has led some commentators to question whether

Jacobson should retain its paradigmatic role in terms

of the scope of government police powers. At the

same time, other public health law experts call

for Jacobson’s continued vitality, arguing that it is

settled doctrine and a still-appropriate answer to the

private interest/collective good question. What do

you think?

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BOX 6-6 Discussion Questions

The “negative constitution” is a concept over

which reasonable people can easily disagree.

Notwithstanding the “defensive” manner of some of

the Constitution’s key provisions, there are several

arguments in support of more affirmative action

on the part of government health and welfare

officials than current Supreme Court jurisprudence

requires. For example, the dissent in DeShaney argues

persuasively that Wisconsin’s implementation of a child

protection program effectively created a constitutional

duty to actually protect children from seemingly

obvious danger. As one leading scholar put it,

If an agency represents itself to the public as a

defender of health, and citizens justifiably rely on

that protection, is government “responsible” when

it knows that a substantial risk exists, fails to inform

citizens so they might initiate action, and passively

avoids a state response to that risk? (Gostin, 2000)

What do you think of this argument? Can you think of

other arguments that call into question the soundness

of the negative theory of constitutional law?

133

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CHAPTER 7

Social Determinants of Health and the Role of Law in Optimizing Health

LEARNING OBJECTIVES

By the end of this chapter you will be able to:

■ Describe the meaning of social determinants of health and the significance of social factors on individual

and population health ■ Describe how law can create or perpetuate health-harming social conditions ■ Explain how law can be used to ameliorate health-harming social conditions ■ Understand how innovative interventions to improve health, such as medical-legal partnership, can help

address health-harming social conditions at the individual and population levels

By the end of this chapter you will be able to:

■ Describe the meaning of social determinants of health and the significance of social factors on individual

address health-harming social conditions at the individual and population levels

BOX 7-1 Vignette

Living through brief periods without heat or electricity is a fact of life for most of us, perhaps as a result of a powerful

weather system or a blown generator. But have you thought about what it would be like to be without heat or

electricity more chronically, due to homelessness, inadequate housing, or an unscrupulous landlord who neglects

a property without concern for tenants? Even for the healthiest among us, this social factor would be incredibly

challenging; for those with chronic illness, it can mean increased asthma attacks, severe pain associated with sickle cell

disease, an inability to refrigerate needed medicine, and much more, including death. The social factors just noted—

homelessness, dilapidated homes, slum landlords—and many others have nothing to do with biology, genetics,

personal choice, or access to healthcare services, but have a great deal to do with individual and public health.

138 Chapter 7

▸ Introduction

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BOX 7-2 Discussion Questions

Do you think trying to achieve wide-scale health

equity is a laudable goal? Why or why not? If yes,

what do you think are the keys to achieving it? And

what about people who are given the opportunity to

achieve optimal health but do not take advantage of

it; should they face consequences of some sort?

139

▸ Social Determinants of Health

Defining Social Determinants of Health

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BOX 7-3 Group Activity

Each student should begin by rank-ordering a list of

the half-dozen social determinants (from those listed

in this chapter or otherwise; broad or specific) that

he or she believes most significantly affect individual

health. Then get together in groups of three or four

people to compare lists, discussing disagreements and

making the case for some determinants over others.

142 Chapter 7

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Get together in groups of three or four people.

As a group, take 20 minutes to make a list of all the

specific ways you can think of that the law has been

used to directly respond to health-harming social

needs (examples exist in category 5 in this section).

When time is up, compare lists across groups, discuss

disagreements, and see which group thought of the

greatest number of legal interventions.

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What do you think about the differences that exist

between rights that attach in the area of criminal legal

representation versus those that exist in the realm of

civil legal assistance? Does it seem fair to you? Why or

why not? Even if you believe it is fair, do you think all

individuals should have access to at least a baseline

level of civil legal assistance?

147

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Housing &

Utilities

Education &

Employment

Legal Status

Income

Personal &

Family Stability

1. Less violence at home means less need for costly emergency healthcare services. 2. Stable family relationship significantly reduce stress and allow for better decision-making, including decisions related to health care.

1. Clearing a person’s criminal history or helping a veteran change their discharge status helps make consistent employment and access to public benefits possible. 2. Consistent employment provides money for food and safe housing, which helps people avoid costly emergency healthcare services.

1. A quality education is the single greatest predicator of a person’s adult health. 2. Consistent employment helps provide money for food and safe housing, which also helps avoid costly emergency healthcare services. 3. Access to health insurance is often linked to employment.

1. A stable, decent, affordable home helps a person avoid costly emergency room visits related to homelessness. 2. Consistent housing, heat and electricity helps people follow their medical treatment plans.

1. Increasing someone’s income means s/he makes fewer trade-offs between affording food and health care, including medications. 2. Being able to afford enough healthy food helps people manage chronic diseases and helps children grow and develop.

Education & Employment

Units: Secure specialized education services; Prevent and remedy employment discrimination and enforce workplace rights

Benefits Unit: Appeal denials of food stamps, health insurance, cash benefits, and disability benefits

Housing Unit: Secure housing subsidies; Improve substandard conditions; Prevent eviction; Protect against utility shut-off

Family Law Unit: Secure restraining order for do- mestic violence; Secure adoption, custody and guardianship for children

Veterans & Immigration

Units: Resolve veteran discharge status; Clear criminal/credit histories; Assist with asylum applications

Civil Legal Aid

Interventions That

Help

Availability of resource to meet daily basic needs

Access to the opportunity to learn

and work

Healthy physical environments

Access to the opportunity to work

Expose to violence

Common Social

Determinant of

Health

Impact of Civil Legal Aid Intervention on

Health /Health Care

I-HELP ® Issue

JOB

FIGURE 7-1 Framing Legal Care as Health Care Source: Reproduced from: Marple, K. Framing Legal Care as Health Care. National Center for Medical-Legal Partnership. http://medical-legalpartnership.org/new-messaging-guide-helps-frame-legal-care-health-care/. Published January 21, 2015. Accessed August 27, 2015.

Train &

Identify Need

Treat

Patients with direct legal assistance

Transform

Clinic

Practice through enhanced screening, toolkits, and EHR template letters

Improve

Population

Health through joint policy advocacy

FIGURE 7-2 The Medical-Legal Partnership Approach to the

Social Determinants of Health Source: Reproduced from: The MLP Approach to the Social Determinants of Health. National Center for Medical-Legal

Partnership. 2013.

149

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CHAPTER 8

Understanding Health Insurance

LEARNING OBJECTIVES

By the end of this chapter you will be able to:

■ Understand the role of risk and uncertainty in insurance ■ Define the basic elements of health insurance ■ Differentiate various insurance products ■ Discuss incentives created for providers and patients in various types of insurance arrangements ■ Discuss health policy issues relating to health insurance

By the end of this chapter you will be able to:

▸ Introduction

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BOX 8-1 Vignette

William owns a small business that sells all kinds of

wheels and gears. He has nine employees and has

always made it a priority to offer competitive benefits,

including health insurance. Unfortunately, last year

one of his employees was diagnosed with cancer,

which he continues to fight. Due to the sharp increase

in use of health services by his employee group, the

insurance company doubled his group premiums

for the upcoming year. When William contacted

other carriers, several of them would not consider

insuring his group, and most of the others gave

him quotes as expensive as his current carrier. One

company gave him a lower quote, but it covered only

catastrophic care; his employees would have to pay

for the first $5,000 of care out of their own pockets.

After reviewing his company’s finances, William is left

with several unattractive options: stop offering health

insurance; offer comprehensive health insurance but

pass on the cost increase to his employees, which

would make it unaffordable for most of them; offer

the bare-bones catastrophic plan only; or significantly

lower wages and other benefits to defray the rising

health insurance costs. In addition to wanting to

offer competitive benefits, William is concerned

that adopting any of these options will cause his

employees to leave and make it hard to attract others,

threatening the sustainability of his company.

The 2010 health reform law, the Patient Protection

and Affordable Care Act (ACA), attempts to help

small businesses like William’s by creating state health

insurance exchanges. Starting in 2014, these exchanges

were intended to offer a variety of plans to individuals

and small businesses that otherwise might not be

able to afford health insurance coverage. By creating

large groups of purchasers through the exchanges,

it is possible to pool risk and keep prices lower than

if individuals or small businesses were attempting to

purchase insurance coverage on their own.

154 Chapter 8 Understanding Health I

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BOX 8-2 Discussion Questions

Most people in this country obtain health insurance

through employer-sponsored plans. Although the

historical background you just read explains how this

system came about, it does not discuss whether it

is a good or bad thing. Is our reliance on employer-

sponsored health insurance ideal for individuals?

Providers? Employers? Society? What are the benefits

and drawbacks to having employers as the primary

source of health insurance? How different are the

benefits and drawbacks when considered from various

stakeholder perspectives? Would it be better to have

more federal government involvement in providing

health insurance? What primary policy goal would you

use to decide how to answer these questions?

155

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▸ How Health Insurance Operates

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Basic Terminology

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156 Chapter 8 Understanding Health I

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Uncertainty

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BOX 8-3 Discussion Questions

As a general matter, all types of insurance under

traditional economic models cover expensive and

unforeseen events, not events that have small

financial risk or little uncertainty (Council of Economic

Advisors, 2004, p. 195). For example, auto insurance

does not cover regular maintenance such as an

oil change, and home insurance does not protect

against normal wear and tear, such as the need to

replace an old carpet. Accordingly, many economists

argue that health insurance should not cover regular,

foreseeable events such as physical exams or low-cost

occurrences such as vaccinations. Other economists

support a different school of thought. An alternative

economic view is that health insurance should

insure one’s health, not just offer protection against

the financial consequences of major adverse health

events. Because people without health insurance

are less likely to obtain preventive care such as

physical exams or vaccinations, these economists

believe it is in everyone’s best interest, ethically and

financially, to promote preventive care. Therefore, it is

appropriate for insurance to cover both unpredictable

and expensive events as well as predictable and less

expensive events. Which theory do you support?

What do you think is the best use of insurance? If

insurance does not cover low-cost and predictable

events, should another resource be available to assist

individuals, or should people pay out of their own

pockets for these healthcare needs? BOX 8-4 Discussion Questions

As discussed earlier, risk and uncertainty are important

concepts in health insurance. Individuals purchase

health insurance policies to protect themselves

financially against healthcare costs, and insurance

carriers try to set premiums that will cover the

cost of the services used by their beneficiaries.

Currently (when allowed by law), insurance carriers

may consider factors such as medical history,

demographics, type of occupation, size of the

beneficiary pool, and similar criteria when setting the

terms of an insurance policy. Should health insurance

carriers also have access to and be able to use genetic

testing results when deciding whether to insure an

individual, what premiums to charge, or which services

to cover? If you think the answer to that question

should be “no,” why is genetic information different

from all of the other kinds of information insurance

carriers may take into account when making those

decisions? Conversely, what is the strongest argument

you can make in favor of allowing insurance carriers

to consider an applicant’s genetic information? How

would allowing genetic testing alter an individual’s or

a provider’s diagnosis and treatment decisions? What

is the primary policy goal that affects your view?

157

Risk

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158 Chapter 8 Understanding Health I

40%

30%

20%

10%

0% 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

3% 3%

7%* 3%

6% 6%

9% 7%*

9%* 12% 11%

8% 9%

20% 21%

14% 15%

24%

28% 28%

9% 9%

19%19%*

13%*

17%*

20%

3%2% 2% 4%*

* Estimate is statistically different from estimate for the previous year shown (p < 0.05). Note: Covered workers enrolled in an HDHP/SO are enrolled in either an HDHP/HRA or a HSA-Qualified HDHP.

HDHP/HRA HSA-qualified HDHP

70%

60%

50%

40%

30%

20%

10%

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

16%* 18%

21%

26%*

32%

41%* 40% 43%

45%

52%*

57% 58%

13%*

18%

26%

39% 38% 38%

49%* 52%

33%

21%

15%

7% 10%

22%

27% 25%

27% 23%

31%

23%

15% 11%

13%

* Estimate is statistically different from estimate for the previous year shown (p < 0.05).

3–199 Workers 1,000 or more workers

200–999 Workers

Source: Reproduced from: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2017 https://www.kff.org/report-section/ehbs-2017-section-8-high-deductible-health-plans-with-savings-option/

Source: Reproduced from: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2017. https://www.kff.org/report-section/ehbs-2017-section-8-high-deductible-health-plans-with-savings-option/

lifie

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BOX 8-5

FIGURE 8-1 Percentage of Covered Workers Enrolled in a High-Deductible Health Plan (HDHP) or Health Reimbursement

Arrangement, or in a Health Savings Account–Qualified HDHP, 2006–2017

FIGURE 8-2 Among Firms Offering Health Benefits, Percentage That Offer a High-Deductible Health Plan With a Savings

Option, 2005–2017

159

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BOX 8-5 Discussion Questions

A literature review of studies relating to consumer

behavior with HDHPs found that these plans reduced

the use of both appropriate care, such as preventive

screenings, and inappropriate care, such as unnecessary

emergency department visits (Argwal, Mazurenko, &

Menachemi, 2017). To date, research generally has not

focused on health outcomes of HDHP users. Some

recent studies have shown consumers rarely engaging

in price-conscious behavior, instead achieving savings

through use of fewer services (Kullgren, Cliff, & Krenz,

2018; Sinaiko, Mehrotra, & Sood, 2016; Sood, Wagner,

Huckfeldt, & Haviland, 2013).

Do HDHPs achieve the right balance of providing

insurance coverage while incentivizing consumers to use

resources prudently? Or are they simply a way to lower

employer healthcare costs while making it unaffordable

for many consumers to obtain the health care they

need? How easy is it for consumers to compare costs

for healthcare providers and services? What additional

challenges might an HDHP present for individuals who

are low-income, live in rural areas, speak a primary

language other than English, or have low health literacy?

BOX 8-6 Discussion Questions

In general, people with low incomes or no health

insurance (or both) tend to be less healthy than those

who are financially better off or insured (or both). As

a result, policy proposals that suggest including poor,

uninsured individuals in already-existing insurance

plans are met with resistance by individuals in those

plans and by carriers or employers who operate them.

Yet, if an insurance plan is created that subscribes only

a less-healthy, poor, or uninsured population, it is likely

to be an unattractive business opportunity because

beneficiaries are likely to need a high quantity of

health care that will be costly to provide. Given what

you know about adverse selection and risk, what, in

your opinion, is the best way to provide insurance

coverage to the poor and uninsured? Should they be

included in current plans? Should the government

provide financial incentives for private carriers to

insure them? Should a separate plan or program be

created to serve them? In these various scenarios,

what incentives are created for plans, current plan

members, government, and so on?

160 Chapter 8 Understanding Health I

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BOX 8-7 Discussion Questions

What populations or types of people pay more under

experience rating? Does experience rating create

any incentives for individuals to act in a certain way?

What populations or types of people pay more under

community rating? Does community rating create any

incentives for individuals to act in a certain way? Which

rating system seems preferable to you? What trade-offs

are most important to you? Should the focus be on the

good of the individual or the good of the community?

Are these mutually exclusive concerns?

161

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▸ Managed Care Th

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162 Chapter 8 Understanding Health I

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Cost Containment and Utilization Tools

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TABLE 8-1 Provider Payment Cost Containment Strategies

Strategy Provider Payment Method How Costs Are Controlled

Who Assumes

Financial Risk

Salary and bonuses/

withholdings

Provider receives a salary as an

employee of an MCO

Incentive for provider to perform

fewer and/or less-costly services

MCO and

provider

Discounted fee

schedule

Provider receives a lower fee

than under FFS for each service

to members

Pays provider less per service

rendered than under FFS

MCO (but also

has lower costs)

Capitation Provider receives a set payment

per month for each member

regardless of services provided

Incentive for provider to perform

fewer and/or less-costly services

Provider

Abbreviations: FFS = fee for service; MCO = managed care organization.

163

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Utilization Control Tools

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164 Chapter 8 Understanding Health I

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TABLE 8-2 Service Utilization Control Strategies

Strategy Description Potential Concerns

Gatekeeper Uses a primary care provider to make sure only

necessary and appropriate care is provided

Gatekeepers may have financial incentive to

approve fewer services or less-costly care

Utilization

review

Uses MCO personnel to review and approve or

deny services requested by a provider to make sure

only necessary and appropriate care is provided

Interferes with patient–provider relationship;

someone other than the patient’s provider

decides whether treatment is appropriate

Case

management

Uses MCO personnel to manage and coordinate

patient care to make sure care is provided in

the most cost-effective manner

May act as a barrier to receiving care if the

case manager does not approve a desired

service or service provider

Abbreviation: MCO = managed care organization.

165

Source: Reproduced from: Kaiser/HRET Employer Health Benefits Survey, 2017. Retrieved from https://www.kff.org/health-costs/report/2017-employer-health-benefits-survey/

Common Managed Care Structures Th

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FIGURE 8-3

Health Maintenance Organizations fir

0% 10%

2017

2016

2015

2014

2013

2012

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

2000

1999

1996

1993

1988 73%

46% 21% 26%

28%

39%

42%

46%

52%

54%

55%

61%

60%

57%

58%

60%

58%

55%

56%

57%

58%

52%

48%

48%14%

15%

14%

13%

14%

16%

17%

19%

20%

21%

20%

21%

25%

24%

27%

24%

29%

28%

31%27%

10%

14%

24%

21%

23%

18%

17%

15%

13%

17%

19%

20%

24%

29%

28%10%

10%

12%

13%

16% 11%

20% 30% 40% 50% 60% 70% 80% 90% 100%

Note: Information was not obtained for POS plans in 1988 or for HDHP/SO plans until 2006. A portion of the change in plan type enrollment for 2005

is likely attributable to incorporating more recent Census Bureau estimates of the number of state and local government workers and removing federal

workers from the weights. See the Survey Design and Methods section from the 2005 Kaiser/HRET Survey of Employer-Sponsored Health Benefits for

additional information.

Conventional POSHMO PPO HDHP/SO

FIGURE 8-3 Distribution of Health Plan Enrollment for Covered Workers by Plan Type, 1988–2017

166 Chapter 8 Understanding Health I

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TABLE 8-3

Preferred Provider Organizations

TABLE 8-3 Key Characteristics of Common HMO Models

HMO Model

HMO-Provider

Relationship and

Payment Type

Provider

Employment

Arrangement

Must

Members

Seek Care

From

Network?

May Providers

Care for

Nonmembers? General Comments

Staff model/

closed-panel

HMO employs

providers and

pays a salary that

often includes

bonuses or

withholdings.

Employed by

HMO.

Yes No Provides services only in

HMO’s office and affiliated

hospitals. Relatively

speaking, HMO has the

most control over providers

and service utilization,

but has fixed costs of

building and staff. HMO

may contract with outside

providers if necessary.

Providers and consumers

often do not like restrictions

imposed by HMO. Providers

do not need to solicit

patients. Consumers may

find it to be the most cost-

effective option.

Group HMO contracts

with one

multispecialty

group for a

capitated rate.

Employed by

own provider

group.

Yes Depends

on terms of

contract

HMO has less control

over utilization. HMO

contracts for hospital care

on a prepaid or FFS basis.

Providers may prefer this

model because they remain

independent as opposed to

becoming an employee of

the HMO and because they

may serve nonmembers if

their contract permits.

(continues)

167

HMO Model

HMO-Provider

Relationship and

Payment Type

Provider

Employment

Arrangement

Must

Members

Seek Care

From

Network?

May Providers

Care for

Nonmembers? General Comments

Network HMO contracts

with several

group practices

(often primary

care practices)

for a capitated

rate.

Employed by

own provider

group.

Yes Depends

on terms of

contract

The group practices may

make referrals but are

financially responsible

for reimbursing outside

providers. HMO has less

control over utilization

due to greater number

of contracts and ability of

providers to subcontract.

Providers may prefer

additional autonomy, but

also take on financial risk

of providing primary and

specialty care. Members

may have a relatively

greater choice of providers.

IPA HMO contracts

with IPA for a

capitated rate.

IPA is

intermediary

between

HMO

and solo

practitioners

and groups.

IPA pays

providers a

capitated

rate.

Yes Depends

on terms of

contract

HMO has reduced control

over providers but may

have less malpractice

liability because IPA is an

intermediary. HMO may

contract with specialty

physicians as needed

and for hospital care on

a prepaid or FFS basis.

Providers may prefer

contracting with IPA instead

of HMO to retain more

autonomy. Members may

have greater choice of

providers.

Direct-

contract

HMO contracts

directly with

individual

providers for a

capitated rate.

Self-

employed.

Yes Depends

on terms of

contract

HMO has more leverage

over providers because

it contracts with them

as individuals, but its

administrative costs

are much higher than

having one contract or

a few contracts with

groups. Providers have

less leverage regarding

practice restrictions when

contracting on an individual

basis.

Abbreviations: fee for service = FFS; HMO = health maintenance organization; IPA = individual practice association.

TABLE 8-3 Key Characteristics of Common HMO Models (continued)

168 Chapter 8 Understanding Health I

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The Future of Managed Care

BOX 8-8 Discussion Questions

Cost containment strategies embraced by MCOs

were a direct result of the FFS experience with

ever-increasing utilization and healthcare costs.

However, many consumers and providers chafe at

the restrictions imposed by MCOs and are concerned

that someone other than the provider is making

treatment decisions. Are these restrictions appropriate

and necessary? Do you favor some of the restrictions

over others? Is it appropriate for one entity to be

responsible for both paying for and providing care?

Should someone other than an MCO—say the federal

or state governments—have primary responsibility for

making determinations about service utilization?

BOX 8-9 Discussion Questions

In terms of containing healthcare costs and improving

healthcare quality, do you think healthcare consumers

and professionals need even more restrictions than are

currently used in managed care? Are there any reasons

to revert back to the FFS system, even knowing its

inflationary qualities? If you think that managed care is

not the answer to our still-rising healthcare costs and

quality concerns, what other tools might help lower

costs and improve the quality of care? Should any

tools be imposed by government regulation or agreed

to voluntarily by insurers and the insured?

169

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170 Chapter 8 Understanding Health I

▸ Endnotes

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173

CHAPTER 9

Health Economics in a Health Policy Context

LEARNING OBJECTIVES

By the end of this chapter you will be able to:

■ Understand why it is important for health policymakers to be familiar with basic economic concepts ■ Understand how economists view decision making and options analysis ■ Describe the basic tenets of supply, demand, and markets ■ Understand how health insurance affects economic conditions ■ Apply economic concepts to health policy problems

By the end of this chapter you will be able to:

▸ Introduction

Thi

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174 Chapter 9 onomics in a Health P

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How Economists View Decision Making

Thi

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Utility Analysis

BOX 9-1 Vignette

Jaia is Governor Jara’s chief health policy analyst.

Governor Jara is interested in improving the health

status of residents in the state but is concerned about

the impact any new initiative will have on the state’s

economy. She asks Jaia to compare the economic

consequences of three options: tax incentives for

individuals to purchase exercise equipment or gym

memberships, tax incentives for employers to offer

wellness programs, and a mandate requiring that

all stores selling food in the state provide fresh food

and other healthy options. Fortunately, Jaia has a

background in economics and knows that she needs

to be concerned with basic principles of supply,

demand, and market functions to help her governor

make the best choice. This knowledge will lead her

to ask questions such as: How big of a tax incentive

is necessary to compel individuals or employers to

act? Will tax incentives encourage behaviors, such as

people joining a gym or employers offering wellness

programs, that would not occur otherwise, or will

the government simply be subsidizing transactions

that would take place anyway? Is the problem that

exercise options and healthy foods are not available

and affordable, or are individuals simply making the

choice not to engage in healthy behavior because

they prefer to spend their time and money on other

goods and activities? Will a mandate lead to the

proliferation of healthy food stores or encourage stores

to leave the state? The answers to these questions will

help Jaia supply the governor with informed policy

recommendations.

efined 175

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176 Chapter 9 onomics in a Health P

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How Economists View Health Care

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▸ Economic Basics: Demand fir

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Demand Changers

177

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BOX 9-2 Discussion Questions

Consider each of the following issues and discuss whether you support Theory X, Theory Y, neither theory, or some

combination of them.

Issue Theory X Theory Y

Your view about how

an individual’s health is

determined

Whether a person is healthy or sick is

determined randomly.

Whether a person is healthy or sick depends

on lifestyle choices such as whether a

person smokes, drinks, or wears a seatbelt.

Your view of medical

practice

Medicine is a science, and experts will

ultimately discover the best means

for treating every illness.

Medicine is an art and there will never be

one best way to treat every illness because

illnesses are often patient-specific and

because there will always be a demand for

lower-cost and less painful treatments.

Your view of medical

care

Medical care is a unique commodity. Medical care is similar to any other good or

service.

Your view of the

government’s role in

health care

Government regulations are

necessary to protect this unique

commodity, to control profiteering

at the cost of patient care, to control

resources spent on health care, and

to improve information sharing.

Government regulations are not necessary,

technological advances and more services

are desirable, and competition, not

regulation, should drive the market.

Source: From Musgrave, GL. Health economics outlook: two theories of health economics. Bus Econ. 1995;30:7–13.

178 Chapter 9 onomics in a Health P

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Elasticity

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Price Elasticity of Demand

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179

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Income Elasticity of Demand

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Health Insurance and Demand

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180 Chapter 9 onomics in a Health P

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Profit Maximization

181

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▸ Economic Basics: Markets

hifts hifts

Health Insurance and Markets

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Market Structure

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TABLE 9-1

183

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Market Failure

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TABLE 9-1 Characteristics of Key Market Structures

Perfectly Competitive Monopoly Monopolistically Competitive

Number of firms Many One (in a pure monopoly) Many

Market share No dominant firms One firm has all market share and

price and output.

There may be many firms

with market share and or a

few dominant firms. Firms can

set price because of product

differentiation.

Barriers to entry

for new firms into

market

No Yes—absolute barriers; no new

firms may enter market.

Some barriers, due to

differentiation of product,

licensure, etc.

Product

differentiation

No. Products are for

each other.

No. Only one product; no

substitutes are available.

Yes. Many products; they are not

substitutes for each other (brand

loyalty).

Access to

information and

resources

Consumers and

producers have

perfect information.

One firm controls all information

(asymmetric information).

All firms have equal access to

resources and technology unless

there are a few dominant firms

with more access to resources.

Cost of

transaction

Consumers bear cost

of consumption, and

producers bear cost

of production.

Higher price to consumer

because firm has ability to reduce

quantity, retain excess profits.

Blend of costs in perfectly

competitive market and

monopoly market.

184 Chapter 9 onomics in a Health P

Public Goods

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Externalities

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Government Intervention

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186 Chapter 9 onomics in a Health P

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Redistribution of Income

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BOX 9-3 Discussion Questions

Some people argue that the government should not

intervene in the case of a market failure because the

government itself is inefficient and will simply create

new problems to replace the ones it is trying to fix.

In addition, critics contend that the government is

usually less efficient than private sectors. Do you

think the government is less efficient than the private

sector? Does it depend on the issue involved? If

you think it is inefficient in a particular area, does

that lead you to recommend against government

intervention, or is there a reason that you would still

support government intervention? If you think the

government should intervene, which intervention

options do you prefer and why?

187

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mific

References

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▸ Endnotes

fin

189

CHAPTER 10

Health Reform in the United States

LEARNING OBJECTIVES

By the end of this chapter you will be able to:

■ Describe previous national health reform attempts ■ Understand why national health reform has been difficult to achieve in the United States ■ Analyze why national health reform succeeded in 2010 when so many previous attempts had failed ■ Understand the key components of the Patient Protection and Affordable Care Act ■ Understand the core rulings of multiple U.S. Supreme Court decisions related to the Affordable Care Act ■ Evaluate the political climate regarding repealing and replacing the Affordable Care Act, and understand the

main features of legislation drafted toward that end ■ Describe key issues going forward related to implementation of the Affordable Care Act

By the end of this chapter you will be able to:

main features of legislation drafted toward that end ■ Describe key issues going forward related to implementation of the Affordable Care Act

▸ Introduction ff

ffs

eff

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190 Chapter 10 ed S

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▸ Difficulty Achieving Health Reform in the United States

Th diff

BOX 10-1 Vignette

A group of friends were talking about the ACA,

illustrating the wide-ranging viewpoints about the

law. Katherine, whose friend Sophia is struggling to

make a living as an artist, is pleased that Sophia has

health insurance for the first time since graduating

from college. Although Sophia cannot stay on her

parents’ insurance because she just turned 27 years

old, she can now afford a good health insurance plan

that she found on her state’s health exchange. While

Katherine has not noticed much of a change in her

own health insurance coverage, which she obtains

through her government employer, her cousin Mia

is upset about health reform. She does not want

the government forcing her to purchase health

insurance (although she always chose to be insured

in the past), and she recently found out that her old

plan was cancelled because it did not meet the law’s

requirements. Mia found several new plan options to

choose from, but none had her former plan’s exact

combination of benefits, providers, and price. In

addition, Katherine’s uncle, Ethan, is 55 years old and

self-employed. He purchases his health insurance on

his state’s exchange and because he has preexisting

conditions, he is grateful to be able to find a plan. Even

so, Ethan’s premiums will increase by 15% this year and

his deductible is $5,000, making health care difficult

to afford even with insurance. Katherine’s husband,

Calvin, thinks we should all be willing to pay a little

more or change some aspects of our plans to help the

millions of people who can now afford insurance for

the first time as a result of the ACA. After witnessing

her uncle’s experience, however, Katherine is doubtful

that the government will be able to keep its promises.

ifficult 191

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U.S. Political System Th diffic

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Source: Center on Budget and Policy Priorities, 2018.

BOX 10-2 Select Trump Administration Executive Actions Relating to the ACA

■ Issued Executive Order ordering federal agencies to begin dismantling the ACA “to the maximum extent permitted

by law” and to grant exemptions or delay implementation of ACA provisions that impose a tax, fee, or other costs

(January 2017) ■ Issued an insurance regulation that made it more difficult for individuals to sign up for insurance during a special

enrollment period, shortened the length of the enrollment period, lowered premium tax credits, made it easier for

insurers to collect back premiums, and provided states more flexibility to define Essential Health Benefits (April 2017) ■ Ended contracts to navigators that provided one-on-one enrollment assistance to consumers, slashed funding for

enrollment outreach efforts, and limited weekend access to online enrollment functions (July–August 2017) ■ Created an expanded option for employers who choose not to provide contraceptive coverage due to religious or

moral reasons (October 2017) ■ Ceased cost-sharing reduction payments to insurers (October 2017) ■ Signed the Tax Cut and Jobs Act, which eliminated individual mandate penalties (December 2017) ■ Proposed Association Health Plan (AHP) rules that would allow these plans to offer insurance products that are

exempt from many ACA provisions, such as the Essential Health Benefits provision and another one that limits the

charging of higher premiums based on one’s age, gender, or occupation (January 2018) ■ Issued guidance allowing work requirements to be applied to Medicaid recipients. Approved Kentucky’s Medicaid

waiver that includes work requirements, higher premiums, and coverage lockouts (January 2018) (Note that

this waiver was subsequently vacated by a federal court and the question of whether states can mandate work

requirements for Medicaid recipients is the subject of ongoing litigation.) ■ Proposed rules to extend short-term limited duration health plans (that do not need to meet many of the ACA’s

requirements) from 3 months to 1 year (February 2018) ■ Filed a brief in Texas v. United States declining to defend the constitutionality of the ACA (June 2018) ■ Delayed risk-adjustment transfers that provide payments from insurers with low-risk pools to insurers with high-risk

pools (July 2018) ■ Slashed the budget (again) for enrollment outreach and navigation efforts (July 2018)

204 Chapter 10 ed S

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Are there alternatives to the individual mandate that

accomplish the same goals without engendering

so much political turmoil? Could policymakers have

designed an incentive system that would be as

effective as a mandate? What are the pros and cons

of using a mandate versus an incentive? Can you

think of incentives to encourage enrollment that have

occurred in other parts of the healthcare system?

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Source: Data from: McDermott Will & Emery. Challenges facing “narrow” provider networks on the ACA health insurance exchanges. http://www.mwe.com /files/Uploads/Documents/News

/Challengs-Facing-Narrow-Provider-Networks.pdf. Published April 20, 2015. Accessed July 7, 2015.

BOX 10-4 Provider Networks

An emerging policy and care delivery issue has been the question of whether provider networks available in plans

offered in the exchanges are adequate. Prior to the ACA, insurers could control costs through a variety of mechanisms,

including limiting benefits, excluding consumers with preexisting conditions, and using medical underwriting to charge

higher premiums to higher-risk individuals and groups. Plans would compete with each other based on price, benefits,

cost-sharing, and other features. The ACA includes a variety of rules that eliminate these options, such as prohibition of

exclusions based on preexisting conditions, guaranteed issue requirements, community rating requirements, essential

health benefit requirements, and actuarial tiering of plans. As a result of ACA restrictions, many plans are trying to

control costs by limiting provider networks and/or provider reimbursement. Of course, some providers may choose not

to participate in exchange plans if the reimbursement is not sufficient.

Many consumers who purchase plans in an exchange choose plans based on the premium price and indicate they

would prefer cheaper plans with narrow networks as opposed to expensive plans with broader networks. On the other

hand, consumers who purchase plans through employer-sponsored insurance often prefer broader networks, even

if the coverage is more expensive. Complaints about narrow networks range from consumers being disappointed

that their usual doctor or local hospital is not in network, to questions about access to care, network transparency,

and quality of care. Several lawsuits have been filed against plans regarding network transparency and provider

terminations. In 2014 the Office of the Insurance Commissioner issued federal rules regarding network adequacy in

individual and small-group plans, and CMS continues to issue guidance regarding network adequacy for qualified

health plans. State responses to network adequacy concerns have spanned the gamut, from Massachusetts requiring

plans to develop tiered and narrow networks to promote cost savings, to several failed attempts by state legislatures to

pass “any willing provider” laws that require insurers to include any provider willing to accept the insurers’ terms.

BOX 10-5 Essential Health Benefits

All plans in the state exchanges must offer the following benefits:

■ Ambulatory patient services ■ Emergency services ■ Hospitalization ■ Maternity and newborn care ■ Mental health services and substance use disorder services, including behavioral health treatment ■ Prescription drugs ■ Rehabilitative and habilitative services and devices (rehabilitative therapies improve, maintain, or prevent

deterioration of functions that have been acquired [e.g., after an adult has surgery], whereas habilitative therapies

are provided to achieve functions and skills never acquired [e.g., as with a developmentally disabled child]) ■ Laboratory services ■ Prevention and wellness services and chronic disease management services ■ Pediatric services, including vision and dental services

209

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BOX 10-6 Discussion Questions

There was a lengthy debate about whether to include

a public option in health reform. A public option is

some type of government-run health plan that would

be available to compete with private plans. A public

option could exist within the health exchange model

or outside of it. Instead of a public option, Congress

voted to require the Office of Personnel Management,

which runs the Federal Employees Health Benefit

Program, to contract with at least two multistate plans

in every state health insurance exchange.

What are the pros and cons of having a public

option? Does the Office of Personnel Management

compromise achieve all or some of the goals of having

a public option? Why do you believe the Office of

Personnel Management compromise was acceptable

to legislators but the public option was not?

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Income Level by Federal

Poverty Level (FPL)

Premium as a

Percentage of Income

100–133% FPL 2% of income

133–150% FPL 3–4% of income

150–200% FPL 4–6.3% of income

200–250% FPL 6.3–8.05% of income

250–300% FPL 8.05–9.5% of income

300–400% FPL 9.5% of income

TABLE 10-2 Cost-Sharing Subsidy Schedule

Income Level by Federal Poverty

Level (FPL) Actuarial Value

100–150% FPL 94%

150–200% FPL 87%

200–250% FPL 73%

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Income Level by Federal

Poverty Level (FPL) Out-of-Pocket Limit

100–200% FPL 2/3 of maximum

200–300% FPL 1/2 of maximum

300–400% FPL 1/3 of maximum

BOX 10-7 Discussion Questions

CBO estimates that premium subsidies and CSRs will

cost the federal government $760 billion over the

years 2019–2028 (CBO, 2018). Is this a good use of

resources? Are these subsidies well designed? Are

they sufficient to make health insurance affordable?

Do they cover people with incomes that are too high?

Should they cover more people?

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BOX 10-8 Discussion Questions

The ACA includes a tax on insurers for more generous

health plans. Because it is likely insurers will pass on

the cost of the tax to consumers, the idea behind

the tax is to provide incentives for people to choose

lower-cost plans. In theory, the less money employers

spend on healthcare costs (and other fringe benefits),

the more they will spend on wages. The income

tax paid for by workers on their higher wages will

provide revenue that can be used to pay for health

reform. In addition, people may be less likely to obtain

unnecessary care if fewer services are covered by their

plan or if cost-sharing is higher.

Is it likely that employers will trade lower benefits

for higher wages? Are there times or industries where

this trade-off is more or less likely to occur?

In 2017 the average cost of premiums for an

employer plan was $6,690 for single coverage and

$18,764 for family coverage (KFF & HRET, 2017,

Section 1). Beginning in 2020, plans that exceed

$10,800 for individual coverage and $29,050 for family

coverage are taxed. Congress rejected lower thresholds

for the tax ($8,500/$23,000) that would have raised

an estimated $149 billion. Did Congress pick the right

thresholds for the tax? Should they be higher or lower?

Why did Congress delay implementation of the tax

until 2020? What are the pros and cons to having the

tax start well after the main provisions of health reform

are in place?

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Sources: United States Preventive Services Taskforce. (2016, January). Breast cancer:

Screening. Retrieved from https://www.uspreventiveservicestaskforce.org/Page

/Document/UpdateSummaryFinal/breast-cancer-screening1?ds=1&s=breast%20cancer;

American College of Obstetricians and Gynecologists. (2016, January 11). ACOG statement

on breast cancer screening guidelines. Retrieved from https://www.acog.org/About

-ACOG/News-Room/Statements/2016/ACOG-Statement-on-Breast-Cancer-Screening

-Guidelines; American Cancer Society (n.d.). American Cancer Society guidelines for the

early detection of cancer. Retrieved July 19, 2018 from https://www.cancer.org/healthy

/find-cancer-early/cancer-screening-guidelines/american-cancer-society-guidelines-for

-the-early-detection-of-cancer.html

BOX 10-9 Discussion Questions

There is a debate about the proper age at which to

start regular mammogram screenings to detect breast

cancer in women who do not have specific risk factors

for the disease. As of 2009, the U.S. Preventive Services

Task Force recommends waiting until age 50 years to

begin mammogram screening for breast cancer and

further recommends that screening should occur every

2 years. It also stated, however, that the final decision

about the initial timing and frequency of breast cancer

screening should be made by the patient and her

physician. In making its recommendations, the Task

Force found that physicians would need to screen

1,000 women to save 1 woman’s life and concluded

that earlier and/or more frequent screening was

not worth the harm associated with false positives

(anxiety, unnecessary biopsies, overtreatment). Other

organizations disagree with the U.S. Preventive Services

Task Force and conclude that the lifesaving effects of

more routine mammogram screening outweigh the

potential harm. Thus, the American Cancer Society

recommends having routine annual mammograms

from age 45 to 54 years (or 40 if the patient so chooses)

and then every 2 years thereafter. The American College

of Obstetricians and Gynecologists recommends

starting annual mammograms at age 40 years.

The idea of comparative effectiveness research is

to provide information about the value of different

tools. Once that information is available, however, who

should make the decisions about whether to provide

coverage and reimbursement for a particular good

or service? Can one objectively assess the potential

harms and benefits associated with mammograms or

other services or medications? Should decisions be

made solely by the patient and treating provider? Does

it matter if decisions affect taxpayers (for example, if a

patient is covered by a government program such as

Medicare or the Veterans Administration)?

218 Chapter 10 ed S

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TABLE 10-4 Comparison of U.S. House and Senate Bills Designed to Replace the Affordable Care Act

American Health Care Act (House) Better Care Reconciliation Act (Senate)

Premium tax credits Replaces with tax credits based on age

only, not income or geographic area

Keeps tax credits, lowers eligibility to 350%

FPL, includes those under 100% FPL, tied to

less expensive benchmark, changes individual

contribution levels so older consumers pay more

Individual mandate Eliminates penalties, replaces with 1-year

30% premium surcharge if lapse in

coverage

Eliminates penalties, replaces with 6-month

waiting period if lapse in coverage

Employer mandate Eliminates penalties Eliminates penalties

Medicaid expansion Phases out at end of 2019 Phases out by end of 2024

ACA taxes Eliminates most key taxes Eliminates many key taxes, keeps Medicare

surtax and investment tax on high-income

earners

Essential health

benefits

Allows state waivers to redefine Allows state waivers to redefine

Medicaid program Changes to block grant or per-

capita allotment in 2020, allows work

requirements

Changes to block grant or per-capita allotment

in 2020, allows work requirements

CSR funds Funds through 2019, repeals in 2020 Funds through 2019, repeals in 2020

Women’s health

services

Defunds Planned Parenthood for 1 year;

redefines qualified plan to exclude plans

that provide abortion services except for

rape, incest, or life of mother in danger

Defunds Planned Parenthood for 1 year;

redefines qualified plan to exclude plans that

provide abortion services except for rape, incest,

or life of mother in danger

Private market rules Keeps guaranteed issue, dependent

coverage until 26; keeps preexisting

condition protection

Keeps guaranteed issue, dependent coverage

until 26; keeps preexisting condition protection;

permits sale of noncompliant plans as long as

selling one ACA-compliant plan

State stabilization

pool

Provides $123 billion over 9 years Provides $182 billion over 9 years

Public health

prevention fund

Eliminates Eliminates

Age rating band Changes to 5-to-1 but allows for state

variation

Changes to 5-to-1 but allows for state variation

CBO

estimate—uninsured

23 million more uninsured by 2026 22 million more uninsured by 2026

CBO estimate—

federal savings

$119 billion $321 billion

ACA = Affordable Care Act; CBO = Congressional Budget Office; FPL = federal poverty level.

222 Chapter 10 ed S

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CHAPTER 11

Government Health Insurance Programs: Medicaid, CHIP, and Medicare

LEARNING OBJECTIVES

By the end of this chapter you will be able to:

■ Describe the basic structure, administration, financing, and eligibility rules for: Medicaid The Children’s Health Insurance Program (CHIP) Medicare

■ Understand how the Patient Protection and Affordable Care Act alters Medicaid, CHIP, and Medicare ■ Discuss key health policy questions and themes relating to each of these public programs

By the end of this chapter you will be able to:

■ Describe the basic structure, administration, financing, and eligibility rules for:

Medicaid

The Children’s Health Insurance Program (CHIP)

Medicare ■ Understand how the Patient Protection and Affordable Care Act alters Medicaid, CHIP, and Medicare ■ Discuss key health policy questions and themes relating to each of these public programs

BOX 11-1 Vignette

Governor Jadyn is in a quandary. She believes everyone should have access to health care and would like to support

state policies that make care accessible and affordable. While she supported President Obama’s goal of reducing the

number of uninsured, she is concerned that some of the provisions in the Patient Protection and Affordable Care Act

are too burdensome on the states, particularly in a fragile economy. The governor wonders how her state can afford

the mandated Medicaid expansion when the recent trend has been to cut services across the board. How will state

agencies cope with their new responsibilities when positions are being defunded and employees are being furloughed?

Should she spend her state’s time and resources to establish a health insurance exchange when the federal government

will step in if she does not act? At the same time, does she want to leave decisions about how the exchange will be

operated in her state to bureaucrats in Washington, DC?

231

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BOX 11-2 Discussion Questions

Do you think it makes more sense to structure

government healthcare programs as entitlements or

block grants? What are the economic and healthcare

risks and benefits of each approach? Does your

answer depend on who is paying for the program?

Who the program serves? What kinds of benefits the

program provides? Do you think various stakeholders

would answer these questions differently? How

might the answers change if you ask a member of the

federal government, a governor, a state legislator, an

advocate, or a tax-paying citizen who is not eligible for

benefits under the program?

233

Kaiser Family Foundation, Distribution of the non-elderly with Medicaid by Race/Ethnicity, 2016.

Total Medicaid enrollees: 58.9 million

White 43%

Hispanic 30%

Black 18%

Other 9%

Source: Kaiser Family Foundation, Distribution of the non-elderly with Medicaid by race/ethnicity, 2016. Retrieved from https://

www.kff.org/medicaid/state-indicator/distribution-by-raceethnicity-4/?currentTimeframe=0&selectedDistributions

=white--black--hispanic--other&selectedRows=%7B%22wrapups%22:%7B%22united-states%22:%7B%7D%7D%7D&sort

Model=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D

Nonelderly below 100% FPL 55%

40%

38%

76%

17%

49%

20%

45%

42%

62%

Percentage with Medicaid Coverage

Nonelderly between 100% and 199% FPL

All children

Children below 100% FPL

Parents

Births (pregnant women)

Medicare beneficiaries

Elderly and people with disabilities

Families

Nonelderly adults with a disability

Nonelderly adults with HIV in regular care

Nursing home residents

Note: FPL = Federal Poverty Level. The U.S. Census Bureau’s poverty threshold for a family with two adults and one child was $19,318 in 2016.

Source: KFF Analysis of 2017 Current Population Survey, Annual Social and Economic Supplement; Birth data - Implementing Coverage and Payment Initiatives: results from a 50-State Medicaid Budget Survey for State Fiscal Years 2016 and 2017, KFF, October 2016.;

Medicare data - Medicare Payment Advisory Commission, Data Book: Beneficiaries Dually Eligible for Medicare and Medicaid (January 2018); 2013 data. Disability - KFF Analysis of 2016 ACS; Nonelderly with HIV - 2014 CDC MMP; Nursing Home Residents - 2015 OSCAR/

CASPER data. Retrieved from https://kaiserfamilyfoundation.files.wordpress.com/2015/05/medicaid_s-role-for-selected-populations.png

Eligibility

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BOX 11-3 Discussion Questions

What are the benefits and drawbacks of having a

health program that varies by state versus having one

that is uniform across the country? Do you find that

the positives of state flexibility outweigh the negatives,

or vice versa? Does your analysis change depending

on what populations are served? Does your analysis

change depending on whose point of view you

consider? Is it fair that similarly situated individuals

may be treated differently in different states? Does this

occur in other aspects of society?

FIGURE 11-1 Medicaid Beneficiaries by Race/Ethnicity, 2016

FIGURE 11-2 Medicaid Plays a Key Role for Selected Populations, 2017

234 Chapter 11

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BOX 11-4 Federal Poverty Level

Federal poverty guidelines are determined annually

and calculated based on the number of individuals in a

family. The guidelines are commonly referred to as the

federal poverty level, but the U.S. Department of Health

and Human Services (HHS) discourages the use of this

term because the Census Bureau also calculates, using

different methods, a figure referred to as the federal

poverty thresholds. However, because the term federal

poverty level is still commonly used when discussing

eligibility for federal and state programs, we use it here.

The poverty guidelines are somewhat higher for Alaska

and Hawaii due to administrative procedures adopted

by the Office of Economic Opportunity.

235

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TABLE 11-1 Select Medicaid Mandatory and Optional Eligibility Groups and Income Requirements Prior to ACA

Eligibility Category Mandatory Coverage Optional Coverage

Infants <1 year ≤133% FPL ≤185% FPL

Children 1–5 years ≤133% FPL >133% FPL

Children 6–19 years ≤100% FPL >100% FPL

Pregnant women ≤133% FPL ≤185% FPL

Parents Below state’s 1996 AFDC limit May use income level above

state’s 1996 AFDC limit

Parents in welfare-to-work families ≤185% FPL

Older adults and disabled SSI beneficiaries SSI limits Above SSI limits, below 100% FPL

Certain working disabled May not exceed specified

amount

Variable, SSI level to 250% FPL

Older adults—Medicare assistance onlya Variable, up to 175% FPL Variable up to 175% FPL

Nursing home residents Above SSI limits, below 300% SSI

Medically needy “Spend down” medical expenses

to state-set income level

aMedicare assistance only = payment for Medicare cost-sharing requirements.

Abbreviations: AFDC = Aid to Families With Dependent Children; FPL = federal poverty level; SSI = Supplemental Security Income (a federal program that provides cash assistance to older adults

and individuals who are blind or disabled who meet certain income and resource requirements).

236 Chapter 11

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BOX 11-5 Discussion Questions

Does the medically needy category make sense to

you? Do you think it is a good idea to discount medical

expenses of high-need individuals so they can access

the healthcare services they need through Medicaid?

If so, is the process described above cumbersome and

likely to result in people being on and off Medicaid

(and therefore likely on and off treatment) because

their eligibility is based on their spending patterns?

Why should individuals with high medical needs have

an avenue to Medicaid eligibility that is not available

to other low-income people who have other high

expenses, such as child care or transportation costs?

Would it make more sense to simply raise the eligibility

level for Medicaid so more low-income people are

eligible for the program? Politically, which option

would likely have more support? Does your view

about the medically needy category vary depending

on your primary decision-making goal (e.g., fiscal

restraint, equity, improved health outcomes)?

237

flexi

fie

Benefits efi

efi

Traditional Medicaid Benefits ff

efi

BOX 11-6 Discussion Questions

Looking at Medicaid’s traditional eligibility rules, you

notice numerous value/policy judgments: pregnant

women and children are favored over childless adults,

the medically needy are favored over other low-

income individuals with high costs, non-immigrants

are favored over immigrants. Under the ACA expansion,

these distinctions mostly disappear and eligibility

depends purely on income level in the case of the

biggest expansion group. Which approach do you

prefer? If the ACA approach were expanded beyond

133% of FPL, the costs of the Medicaid program would

soar. Given limited resources, do you think it would be

better to cover more people at a higher poverty level

across the board or continue to favor some groups

over others through the categorical requirement?

Should we decide that, for some populations, the

government should step in and provide coverage

regardless of the cost? In other words, is there a point

where equity trumps financial constraints?

BOX 11-7 Discussion Questions

What are the implications of a two-tiered Medicaid

system? Is there justification for offering some

beneficiaries a less generous benefit package than

others? Is it fair to impose additional requirements

(categorical, asset test) on only some beneficiaries? Why

do you think policymakers created these distinctions?

Do you think they will remain in place over time?

238 Chapter 11

left TABLE 11-2

defin

TABLE 11-2 Traditional Medicaid Benefits

Mandatory Optional

Acute Care Benefits

Physician services

Laboratory and X-ray services

Inpatient hospital services

Outpatient hospital services

Early and periodic screening, diagnostic, and treatment

services (EPSDT) for beneficiaries <21 years

Family planning services and supplies

Federally qualified health center (FQHC) services

Rural health clinic services

Nurse–midwife services

Certified pediatric and family nurse practitioner services

Non-emergency transportation to medical care

Prescription drugs

Medical care or remedial care furnished by nonphysician

licensed practitioners

Rehabilitation and other therapies

Clinic services

Dental services, including dentures

Prosthetic devices, eyeglasses, and durable medical

equipment

Primary care case management

Tuberculosis-related services

Other specified medical or remedial care

Long-Term Care Benefits

Nursing facility services for individuals ≥21 years

Home healthcare services for individuals entitled to

nursing facility care

Intermediate care facility services for the mentally retarded

(ICF/MR)

Inpatient/nursing facility services for individuals ≥65 years

in an institution for mental disease

Inpatient psychiatric hospital services for individuals

<21 years

Home- and community-based waiver services

Other home health care

Targeted case management

Respiratory care services for ventilator-dependent individuals

Personal care services

Hospice services

Services furnished under a Program of All-Inclusive Care for

the Elderly (PACE)

New Benefits in ACA

Tobacco cessation program for pregnant women

Freestanding birth centers

New state option for community-based care

New state option for home health care

New state option for family planning services

Source: 42 U.S.C. 1396d; 42 CFR Parts 430–498.

239

efici

efi ff

efi

The diff

cific

Benefits for Expansion Population Under the ACA

efi efi Th efici

BOX 11-8

ifie Th

n (eff

efi fici ifie

ff Th

BOX 11-8 Benchmark Benefit Options

Federal Employee Health Benefits Plan

State employee health plan

Largest commercial non-Medicaid HMO in the state

HHS secretary-approved plan

Full actuarial value for the following services:

■ Inpatient and outpatient hospital ■ Physician (surgical and medical) ■ Laboratory and X-ray ■ Well-baby and well-child ■ Other appropriate preventive services (defined

by HHS secretary)

75% actuarial value for the following services:

■ Prescription drugs ■ Mental heath ■ Vision ■ Hearing

ff The 2017 essential health benefit (EHB) benchmark

plan from any state

An existing state benchmark with one or more EHB

categories replaced by a benchmark from another

state

A new benchmark that meets the “typical employer

plan” requirement

Note: States must wrap around EPSDT coverage as

necessary.

240 Chapter 11

diffic efi

Th efi

efi

efici

efi

ff Th

efi

lifie

nific

efici efici

efi BOX 11-9

efi

et a

Amount, Duration, and Scope, and Reasonableness Requirements

flexi efi

efici

fin

BOX 11-9 Alternative Benefit Plan

(Section 1973 Plan) Requirements

■ Align with an approved benchmark or benchmark

equivalent ■ Provide EHBs ■ Include EPSDT to children up to age 21 years ■ Cover federally qualified health center/rural

healthcare services ■ Cover non-emergency transportation to medical care ■ Cover family planning services and supplies ■ Comply with mental health parity law ■ Comply with traditional Medicaid cost-sharing rules ■ Do not cover care for beneficiaries in institutions

for mental diseases ■ Exempt certain medically frail populations from

benefit limits

241

TABLE 11-3 ifies

Medicaid Spending

FIGURE 11-3

TABLE 11-3 “Reasonableness” and “Amount, Duration, and Scope” Requirements in Medicaid

Requirement Requirement Purpose Section 1937 Changes to the Requirement

Reasonableness State must provide all services to categorically

needy beneficiaries in sufficient amount,

duration, and scope to achieve its purpose.

States have to meet only amount,

duration, and scope requirements found

in the named benchmark or benchmark-

equivalent plan.

Comparability All categorically needy beneficiaries in the state

are entitled to receive the same benefit package

in content, amount, duration, and scope.

States may apply benchmark or

benchmark-equivalent packages to some,

but not all, populations.

Statewideness In most cases, states must provide same benefit

package in all parts of the state.

States may apply benchmark or

benchmark-equivalent packages to some,

but not all, populations.

Nondiscrimination States may not discriminate against a

beneficiary based on diagnosis, illness, or type

of condition by limiting or denying a mandatory

service.

DRA does not include language changing

Medicaid nondiscrimination rules, and ACA

includes nondiscrimination protections

regarding age, expected life span,

diagnosis, disability, medical dependency,

quality of life, or other health condition (42

CFR 440.347(e)).

BOX 11-10 Discussion Questions

The DRA also included new rules on citizenship verification. Prior to the DRA, all but four states allowed beneficiaries to

self-attest to their citizenship status. Under the DRA, Medicaid and CHIP applicants now have to prove their citizenship

status by providing original or certified copies of citizenship documents, such as a U.S. passport, state-issued driver’s

license, or birth certificate. The exact requirements depend on what type of document is submitted. Subsequent

laws eased this burden by giving states the option to conduct a data match with the Social Security Administration’s

database to verify citizenship. Under the ACA, the matching system must be used to verify citizenship for individuals

purchasing insurance in an exchange. These rules were intended to ensure that only eligible beneficiaries received

Medicaid benefits. Many individuals have had difficulty obtaining access to these documents and as a result were

dropped from the program despite being eligible.

Do you think these rules are a good idea? Do you think this requirement is a reasonable burden? Does it matter that

evidence was not available to support the claim that noncitizens or ineligible immigrants were accessing Medicaid

benefits? Or, is the possibility that ineligible immigrants might enroll in Medicaid concerning enough to warrant the

new documentation requirements?

242 Chapter 11

Source: Spending and enrollment estimates for FY2015 from the Congressional Budget Office’s March 2016 Medicaid baseline. Center on Budget and Policy Priorities. Retrieved from cbpp.org.

Source: Data from Medicaid and CHIP Payment and Access Commission. (2017, December). MACSTATS: Medicaid and CHIP data book.

Retrieved from https://www.macpac.gov/wp-content/uploads/2015/12/MACStats-Medicaid-CHIP-Data-Book-December-2017.pdf

Medicaid enrollment Medicaid spending

Aged 8%

Adults 36%

Blind and disabled

13%

Aged 14%

Adults 32%

Blind and disabled

34%Children 43%

Children 19%

To ta

ex pe

nd itu

re s

Hos pit

al ca

Phy sic

ian /

cli nic

al se

rv ice

Hom e

he alt

h ca

Nur sin

g ho

m e

Pre sc

rip tio

dr ug

17% 17.9%77

11%

36.1%

31.7%

9.8%

efici e-fift

FIGURE 11-4 nific

efi

Medicaid Financing Th fin

fie

fin

FIGURE 11-3 Enrollment and Spending in Medicaid

FIGURE 11-4 Medicaid Percentage of National Spending by

Type of Service, 2016

243

fin fici

efici

efi

fin

Th f-eff

Thi

Th nific

defici

Medicaid Provider Reimbursement

BOX 11-11 Discussion Questions

States have enormous flexibility in designing

their Medicaid programs. States spend significant

resources on optional services or mandatory services

for optional populations. Yet, states complain that

Medicaid expenditures are unsustainable and that

significant reform, such as the DRA and expanded

waiver options, are needed. If states have the ability to

reduce Medicaid spending without any reforms, why

do you think state politicians are focused on reforming

the program? Why might states choose not to reduce

their Medicaid program to cover only mandatory

services and populations? Politically, what do you

think is the most feasible way for states to reduce their

Medicaid budgets?

BOX 11-12 Discussion Questions

What do you think of the MOE requirements? Is

it fair for the federal government to impose new

eligibility rules on states when the states are ultimately

responsible for the cost of providing services? Does

such a requirement violate a fundamental element of

Medicaid to permit state flexibility? On the other hand,

without an MOE requirement, wouldn’t many states

simply reduce their eligibility rules, thwarting the

intent of Congress to reduce the number of uninsured

by expanding Medicaid coverage? Does the budget

deficit exception undermine the rule?

244 Chapter 11

FFS Reimbursement

ufficien

diff

ifie

eff eff

nific ft

efficien

cifie

diffic

diff

nific fie

nific Th eff

Managed Care Reimbursement

efici

FIGURE 11-5

Th efici

efici

fin

245

ND MN

MS AL GA

FL PR

NJ DE MD DC

NCTN

INIL

WV VA

ME VT

NH MA

CT RI

NMAZ

UTNV

Note: Comprehensive managed care includes risk-based managed care organizations (MCOs) and Programs of All-inclusive Care for the Elderly (PACE).

0 (5 states)

51–65% (5 states)

81–100% (16 states, including PR)

>0–50% (11 states)

66–80% (15 states, including DC)

U.S Overall = 68.1%

Source: Medicaid.gov. (2018). Medicaid managed care enrollment and program characteristics, 2016. Retrieved from https://www.medicaid.gov/medicaid/managed-care/downloads/enrollment/2016-medicaid-managed-care-enrollment-report.pdf

efici

defin

diffic

efici

FIGURE 11-5 State Comprehensive Managed Care Penetration as of July 1, 2016

BOX 11-13 Discussion Questions

Is higher Medicaid cost sharing a good idea? What are

the strongest arguments you can make for and against

higher cost sharing? Should Medicaid beneficiaries have

the same cost-sharing responsibilities as privately insured

individuals, or should the government bear more of the

cost because Medicaid beneficiaries are low-income

individuals? What is the primary decision-making goal

that led to the exclusion of so many populations and

services from the new cost-sharing options?

BOX 11-14 Discussion Questions

Who should determine Medicaid provider

reimbursement rates, and how should they compare

to other insurance programs or plans? Should the

federal government play a stronger role in setting

provider rates? Is this an area where it is better to

have state variation or national uniformity? Should

the federal or state governments be required to

ensure that Medicaid reimbursement rates match

private insurance reimbursement rates? What might

occur if poorer states were required to provide

higher reimbursement rates? What is the risk if

reimbursement rates are very low?

246 Chapter 11

Medicaid Waivers

flexi

flexi Th diff

Thi defin

efici

efficien efici

Th definin

The

efici

ff Th

BOX 11-15 Discussion Questions

Should states be allowed to impose work requirements

as a condition for receiving Medicaid benefits? Do

work requirements promote independence and

upward mobility, and, if so, are those two goals

legitimate objectives of the Medicaid program? Are

work requirements unnecessary barriers to care?

Those who oppose work requirements argue that

they do not further the objective of the program,

which is to provide coverage to those who cannot

afford it. As a practical matter, most beneficiaries

are already working, and most of those who are not

working are in poor health or disabled, are acting as

caregivers, or are students. Many of the nonworkers

would be exempt even under the recently approved

waivers. In addition, work requirements create

extensive administrative obligations for beneficiaries

and administrators alike. Of the 1 to 4 million

beneficiaries estimated to lose coverage if work

requirements are imposed broadly, most would be

disenrolled due to lack of reporting.

Those who support requirements contend that

everyone who can work should be working, both to

reduce the burden on the Medicaid program and to

support personal upward mobility. According to this

view, the ultimate goal should be to wean people off

of Medicaid and promote work requirements. Some

states with Republican legislatures, such as Virginia,

would not support expanding Medicaid under the

ACA without work requirements.

Do you support work requirements? Even if you

oppose work requirements, is it better to expand

coverage with work requirements than to not expand

coverage at all?

247

cific

Th diff

efi

efi ft ff

The Future of Medicaid

defici diff

nifi

eff eff

diff

efi cific

efi

fie Th

▸ Children’s Health Insurance Program

difie

BOX 11-16 Discussion Questions

What type of Medicaid reform, if any, do you support?

Should Medicaid beneficiaries be treated like privately

insured individuals, meaning increased cost-sharing

requirements, fewer legal protections, and fewer

guaranteed benefits than in the current Medicaid

program? Is it fair to provide a more generous package

of benefits to publicly insured individuals than most

privately insured people receive? Can the country

afford a more generous Medicaid program? Can it

afford not to provide adequate health insurance and

access to care for the poor and near poor? Is it best

to let states experiment with new ideas? If you could

design a new Medicaid program, what would be your

primary decision-making goal?

248 Chapter 11

fir ffice

Th fi

2 ft

2018.

CHIP Structure and Financing

Th nific

cific

efle

Thi fig

flo Th

TABLE 11-4 diff

diff

efi efici

249

CHIP Eligibility

Th Th

TABLE 11-4 Comparing Key Features of Medicaid and CHIP

Feature Medicaid CHIP

Structure Entitlement Block grant

Financing Federal–state match Federal–state match at higher rate than

Medicaid

Use of funds for

premium assistance

No (without a waiver) Yes

Benefits Federally defined, with option to use benchmark

or benchmark-equivalent benefits package;

broad EPSDT services for children

Benefits undefined; use benchmark

package; limited “basic” services required

Cost sharing Limited or prohibited for some populations

and services, higher amounts allowed for some

populations and services

Cost sharing permitted within limits, but

prohibited for well-baby and well-child

exams

Antidiscrimination

provision

Yes No

Abbreviations: CHIP = Children’s Health Insurance Program; EPSDT = early and periodic screening, diagnosis, and treatment.

BOX 11-17 Discussion Questions

Why do you think that Medicaid was created as

an entitlement program but CHIP was established

as a block grant? Both programs are federal–state

insurance programs for low-income individuals, so

does the distinction make sense? Does it matter that

one program is for children and the other is broader?

Should one program be changed so they are both

either entitlements or block grants? Which structure

do you prefer?

250 Chapter 11

Thi

ific

fin lific

CHIP Benefits and Beneficiary Safeguards efi

efi

ff efi

efi

efi Th

■ Th ff

■ Th

■

efi

BOX 11-18 Discussion Questions

When designing CHIP, policymakers chose to follow

the private insurance model instead of the Medicaid

model. Although states have the choice to create a

generous Medicaid expansion program for their CHIP

beneficiaries, they also have the choice to implement a

more limited insurance program with fewer protections.

Similar choices were made when the DRA options were

created for Medicaid. These decisions raise essential

questions about the role of government in public

insurance programs. Does the government (federal

or state) have a responsibility to provide additional

benefits and protection to its low-income residents?

Or, is the government satisfying any responsibility it

has by providing insurance coverage that is equivalent

to major private insurance plans? What if the standard

for private insurance plans becomes lower—does

that change your analysis? Is it fair for low-income

individuals to receive more comprehensive health

insurance coverage than other individuals? Is there

a point where fiscal constraints trump equity or

the likelihood of improved health outcomes when

designing a public insurance program?

251

efi

flexi efici

efi defini

CHIP and Private Insurance Coverage

CHIP Waivers

efi

efici

The Future of CHIP Th

efici eff

252 Chapter 11

Source: Reproduced from 2013 Annual report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical insurance Trust Funds. Retrieved from https://www.kff.org/medicare/slide/projected-change-in-medicare-enrollment-2000-2050/

3.0% 2.4%

0.9% 0.4%

10%92.4 88.9

81.5

64.3

47.7 39.7

1.9%

205020402030202020102000 0

100

Average annual growth in enrollment

Medicare enrollment (in millions)

ff Th

fir

▸ Medicare

fin diff Thi

efi fin

Medicare Eligibility

Th figur

FIGURE 11-6

FIGURE 11-6 Projected Change in Medicare Enrollment, 2000–2050

BOX 11-19 Discussion Questions

Although many Medicare beneficiaries are poor,

there is no means test (income- or resource-specific

eligibility level) to determine eligibility as there is

with Medicaid and CHIP. Is there a good public policy

reason for this difference? What would be the basis for

making this distinction? Does the government have a

different role to play in providing health care based on

the population involved?

253

Source: Kaiser Family Foundation analysis of the Centers for Medicare & Medicaid Services Medicare Current Beneficiary 2013 Cost and Use file; Urban Institute/Kaiser Family Foundation analysis of DYNASIM data, 2017 (for income and savings). Retrieved from https://

www.kff.org/medicare/issue-brief/an-overview-of-medicare/

Note: ADL = activity of daily living.

Percent of total Medicare population

Age 85+

Long-term care facility resident

Fair/poor health

5+ Chronic conditions

Savings below $74,450

Income below $26,200

Cognitive/mental impairment

Functional implairment (1+ ADL limitations)

Under age 65 with permanent disabilities

50%

36%

34%

13%

17%

27%

30%

Th Th

efici efici

nific efici FIGURE 11-7

efici

efici fi

efici

efici nific

efici uff

FIGURE 11-8

FIGURE 11-7 Characteristics of the Medicare Program

254 Chapter 11

Source: Kaiser Family Foundation analysis of CMS Medicarte Current Beneficiary Survey Cost & Use File, 2012.

65%

61%

33%

58%

29%

49%

21%

39%

11%

13%

72%

In fair or poor health

Cognitive or mental impairment

Require assistance with 1+ self-care tasks

3+ Chronic conditions

Under 65 and disabled

Long-term care facility resident

Medicare beneficiaries who receive Medicaid Other Medicare beneficiaries

efici

Office Office)

Medicare Benefits

cifie efici

efici efici efi

efi TABLE 11-5 efi FIGURE 11-9

efi nific

efi

et a Th

nific efi

FIGURE 11-10

n et a

FIGURE 11-8 Health and Functioning of Medicare Beneficiaries Who Receive Medicaid Compared to Other Medicare

Beneficiaries

255

Skilled nursing facilities

Home health 3%

Hospital outpatient services

Physician payments

10%

Part D prescription drugs

14%

Note: *Consists of Medicare benefit spending on hospice, durable medical equipment, Part B drugs, outpatient dialysis, outpatient therapy, ambulance, lab, community mental health center, rural health clinic, federally qualified health center, and other Part B services.

Total Medicare Benefit Payments, 2016: $675 billion

Hospital impatient services

21%

Other services*

11%

Medicare Advantage

30%

Source: Congressional Budget Office, June 2017 Medicare Baseline.

efici et

TABLE 11-5 Medicare Benefits

Part Services Covered

A Inpatient hospital, 100 days at skilled nursing facility, limited home health following stay at a hospital or skilled

nursing facility, and hospice care.

B Physician, outpatient hospital, outpatient mental health, X-ray, laboratory, emergency department, and other

ambulatory services; medical equipment; limited preventive services, including one preventive physical exam,

mammography, pelvic exam, prostrate exam, colorectal cancer screening, glaucoma screening for high-

risk patients, prostrate cancer screening, and cardiovascular screening blood test; diabetes screening and

outpatient self-management; bone-mass measurement for high-risk patients; hepatitis B vaccine for high-risk

patients; pap smear; and pneumococcal and flu vaccinations. New ACA benefits: cost sharing eliminated

for select preventive services; coverage for personalized prevention plan, including comprehensive health

assessment.

C Managed care plans, private fee-for-service plans, special needs plans, and medical savings accounts. The

plans provide all services in Part A and Part B and generally must offer additional benefits or services as well.

D Prescription drug benefit.

FIGURE 11-9 Medicare Benefit Payments by Type of Service, 2016

256 Chapter 11

Source: Reproduced from Jacobson, G., Damico, A., Neuman, T., & Gold, M. (2017, June 6). Medicare Advantage 2017 spotlight: Enrollment market update. Retrieved from https://www.kff.org/medicare/issue-brief/medicare-advantage-2017-spotlight-enrollment

-market-update/

Share of Medicare Beneficiaries Enrolled in Medicare Private Health Plans, by State, 2017

45%%45%45%

30%

31%

20%

37%

17% 56%

18%

31%

21%

33%

16% 36% 34%

42%42%

21% 11% 11% 15%

24%

32% 36%

28%

26%21%

39%

34%%

35%

41%

25%%% 17%

38%

%27%% 8%

10% 21%

28% 37%

20%

12%

15%

18%

33%

33%39%

35%35%

44%

40%

Note: Includes Medicare Medical Savings Accounts (MSAs) cost plans and demonstrations. Includes special needs plans as well asother Medicare Advantage plans. Excludes beneficiaries with unknown county addresses and beneficiaries in territories other than Puerto Rico.

< 10% (3 states)

10%–19% (10 states + D.C.)

30%–39% (19 states) 20%–29% (12 states)

≥40% (6 states)

National average, 2017 = 33%

efi efici

Th efi Th efi

efici

Thr fir

et flexi

fi et

efi

et a

efici

ff efi ff efi

efici

efi Th efici

efici

FIGURE 11-10 Enrollment in Medicare Advantage Plans Varies Across States

257

Source: KFF Analysis of Medicare spending data from 2008 and 2018 Annual Report of the Board of Trustees of the Federal

Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds. Table II.B1.

11% – $49 billion

2007 2017

41% – $176 billion

47% – $200 billion

42% – $293 billion

$702 billion

44% – $309 billion

14% – $100 billion

$425 billion

Part A

Part B Includes traditional Medicaii re and Medicare Advantagtt e

Part D

Medicare Spending

FIGURE 11-11

efi

efici

efici ksi et a

cifie Th

efi Thi

Medicare Financing

fin fin

fin FIGURE 11-12

efici

o fin efi

efici

efi Thi

FIGURE 11-11 Medicare Payments for Parts A, B, and D,

2007–2017

258 Chapter 11

Source: Reproduced from Cubanski, J. & Neuman, T. (2018, June 22). The facts on Medicare spending and financing. Retrieved from https://www.kff.org/medicare/issue-brief/the-facts-on-medicare-spending-and-financing/

45%

87% 75%

23%

78%

36%

13%

3%3%3%

Total

$710.2 billion

Note: Data are for the calendar year.

$290.8 billion $313.2 billion $106.2 billion Part A Part B Part D

1% 1%

<1%

1% 1%

13%

General revenue

Payroll taxes

Premiums

Transfers from states

Taxation of social security benefits

Interest

Other

3%3%3%3%3%

FIGURE 11-13

fin

efici efici

efici

efici efi efici

efici

FIGURE 11-12 Sources of Medicare Revenue, 2016

BOX 11-20 Discussion Questions

Lawmakers were concerned that adding a prescription

drug benefit to Medicare would encourage

employers to drop prescription drug coverage to the

beneficiaries who receive prescription drugs through

retiree health plans. In an effort to avoid a shift in

older people who rely on public insurance instead of

private insurance for their prescription drug coverage,

Congress included in the MMA a tax-free subsidy

to encourage employers to maintain prescription

drug coverage. While the ACA eliminates the tax

deduction, the subsidy remains in place. The amount

of the subsidy is based on the prescription drug costs

of individuals who remain with the employer’s plan

and do not enroll in Part D. In 2017, approximately

2 million beneficiaries purchased coverage through

employer retiree plans and employers received a

subsidy of 28% of their costs between $405 and

$8,350 per retiree (KFF, 2017b).

Is this subsidy a good idea? Is the proper role of

government to pay private companies to maintain

insurance coverage? If so, should it occur for other

benefits? Do you have a preference regarding giving

incentives for private entities to provide insurance

coverage versus the government financing the

coverage directly?

259

Source: Kaiser Family Foundation based on the 2014 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplementary Medical Insurance Trust Funds.

Source: Kaiser Family Foundation. (2017a). An overview of Medicare. Retrieved on July 25, 2018 from https://www.kff.org/medicare/issue-brief/an-overview-of-medicare/

39.7 47.7

64.4

81.8 89.2

92.8

4.0

3.4

2.8

2.3 2.2 2.3

0.5

1.5

2.5

3.5

4.5

100

2000 2010 2020 2030 2040 2050

Number of beneficiaries (in millions)

Number of workers per beneficiary

In m

ill io

Total Medicare Enrollment, 2013: 49 million

Note: Analysis excludes beneficiaries enrolled in Part A or Part B only.

Share of Traditional Medicare Enrollees, by Type of Supplemental Coverage:

Employer- Sponsored

34%

Medicaid 22%

Medigap 23%

Other – 2% None 19%

Traditional Medicare

66%

Medicare Advantage

34%

efici Th

ff efi

FIGURE 11-14

FIGURE 11-15

efici

efi Th efici

FIGURE 11-13 Number of Medicare Beneficiaries and Number of Workers per Beneficiary, 2000–2050

FIGURE 11-14 Distribution of Medicare Advantage and Traditional Medicare Enrollment and Types of Supplemental Coverage

Among Medicare Beneficiaries, 2013

260 Chapter 11

Source: Kaiser Family Foundation. (2017a). An overview of Medicare. Retrieved on July 25, 2018 from https://www.kff.org/medicare/issue-brief/an-overview-of-medicare/

Source: Kaiser Family Foundation. (2017b). The Medicare Part D prescription drug benefit. Retrieved from https://www.kff.org/medicare/fact-sheet/the-medicare-prescription-drug-benefit-fact-sheet/

Average Total Out-of-Pocket Spending on Services and Premiums, 2013: $6,150

Note: Analysis excludes beneficiaries enrolled in Medicare Advantage plans those enrolled in Part A or Part B only.

Share of spending by type of service:

18%

12%

4% 4%

Services 53%

$3,257

Premiums 47%

$2,893

Long-term care facility

Medical providers/supplies

Prescription drugs

Dental services

Hospital services

Skilled nursing facility and home health services

Note: Some amounts rounded to nearest doller. 1Amount corresponds to the estimated catastrophic coverage limit for non-Low- Income Subsidy (LIS) enrollees ($7,509 for LIS enrollees), which corresponds to True Out-of-Pocket (TrOOP) spending of $5,000, the amount used to determine when an enrollee reaches the catastrophic coverage threshold in 2018.

$8,000

Enrollee pays 5% Plan pays 15%; Medicare pays 80%

Total drug spending:Benefit phase:

Coverage gap

Catastrophic

coverage

Initial coverage

period

Deductible

$7,000

Catastrophic coverage threshold =

$8,418 in estimated total

drug costs1

($5,000 in true-out- of-pocket spending)

Initial coverage limit = $3,750 in total drug costs

Deductible = $405

Plan pays 75%

Generic drugs

Enrollee pays 44% Plan pays 56%

Enrollee pays 25%

Brand-name drugs

Enrollee pays 35% Plan pays 15%

50% manufacturer discount$6,000

$5,000

$4,000

$3,000

$2,000

$1,000

et a efi

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FIGURE 11-16 efici

FIGURE 11-15 Average Out-of-Pocket Spending on Services and Premiums by Medicare Beneficiaries, 2013

FIGURE 11-16 Standard Medicare Prescription Drug Benefit, 2018

261

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TABLE 11-6

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Medicare Provider Reimbursement

Physician Reimbursement

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TABLE 11-6 Medicare Financing by Part

Medicare Part

Government Financing

Scheme

Annual

Deductible Monthly Premium Cost Sharing

A Trust fund through mandated

employer and employee

payroll taxes

Yes No, if Social Security

work requirements are

met

Yes

B General federal tax revenue Yes Yes—tiered by income Yes

D General federal tax revenue

and state clawback payments

for dual enrollees

Yes—except

some low-

income

beneficiaries

Yes—tiered by income

(some low-income

beneficiaries do not pay

premiums)

Yes—except

some low-income

beneficiaries

262 Chapter 11

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BOX 11-21 Discussion Questions

The clawback provision is controversial and highlights

some of the tensions about state flexibility and

national uniformity that policymakers face when

designing public programs. The clawback seems to

contradict the prior decision to provide states with

flexibility and program design responsibilities under

Medicaid. In addition, it changes the decision to use

only federal funds to pay for Medicare. Given decisions

made by states prior to the MMA, there are many

variations among state prescription drug benefits that

will be “frozen” in place with the clawback provision. At

the same time, the MMA creates a uniform rule about

how all states finance prescription drug funding in the

future, which could impact state-level decisions about

dual enrollee coverage.

Is the clawback provision a good idea? Should

states help pay for federal prescription drug coverage?

Is there a better design? Should states or the federal

government control Medicaid prescription drug

coverage that is provided to dual enrollees? Should

dual enrollees be treated differently than other

Medicaid beneficiaries?

263

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Hospital Reimbursement

diff

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43–44).

diff

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MA Reimbursement

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BOX 11-22 Discussion Questions

Controlling Medicare spending is a difficult task.

Even if provider reimbursement rates are reduced,

physicians and hospitals may increase volume and

intensity of services to make up for lost revenue.

The ACA included a number of pilot programs and

demonstration projects to experiment with reforming

the way health care is financed and delivered, and

MACRA increased the incentives for physicians to

participate in these experiments. Some of these

projects include bundling payment for acute care

services; using value-based purchasing, which

ties payments to quality outcomes; and creating

accountable care organizations that bring together

providers across the healthcare spectrum and reward

organizations with better outcomes. The ACA created

the CMS Innovation Center to oversee these and other

reform projects.

What approach to reducing costs and improving

quality do you prefer? What are the advantages and

disadvantages of these ideas?

264 Chapter 11

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The Future of Medicare

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References

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268 Chapter 11

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271

CHAPTER 12

Healthcare Quality Policy and Law

LEARNING OBJECTIVES

By the end of this chapter you will be able to:

■ Discuss licensure and accreditation in the context of healthcare quality ■ Describe the scope and causes of medical errors ■ Describe the meaning and evolution of the medical professional standard of care ■ Identify and explain certain state-level legal theories under which healthcare professionals and

entities can be held liable for medical negligence ■ Explain how federal employee benefits law often preempts medical negligence lawsuits against

insurers and managed care organizations ■ Describe efforts to measure and incentivize high-quality health care

By the end of this chapter you will be able to:

entities can be held liable for medical negligence ■ Explain how federal employee benefits law often preempts medical negligence lawsuits against

insurers and managed care organizations ■ Describe efforts to measure and incentivize high-quality health care

▸ Introduction

infl

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272 Chapter 12

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▸ Quality Control Through Licensure and Accreditation

defin lific

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BOX 12-1 Vignette

Michelina Bauman was born on May 16, 1995, in

New Jersey. The managed care organization (MCO)

through which her parents received healthcare

coverage had precertified coverage for 1 day in

the hospital postbirth, and both Michelina and her

mother were discharged from the hospital 24 hours

after Michelina was born. The day after the discharge,

Michelina became ill. Her parents telephoned the

MCO, but they were neither advised to take Michelina

back to the hospital nor provided an in-home visit

by a pediatric nurse as promised under the MCO’s

“L’il Appleseed” infant care program. Michelina died

that same day from meningitis stemming from an

undiagnosed strep infection.

273

ufficien eff

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defin fie

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▸ Medical Errors as a Public Health Concern

fin

274 Chapter 12

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▸ Promoting Healthcare Quality Through the Standard of Care

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BOX 12-2 Discussion Questions

What do you think of the term medical error as a

descriptor of adverse medical outcomes? After all,

there are many medical procedures (e.g., invasive

surgeries) and treatments (e.g., chemotherapy) that

not only are inherently risky, but also cause painful

and dangerous (and often unpreventable) side

effects (i.e., that lead to “adverse” medical results).

Given this fact, is it conceivable that the healthcare

delivery system could ever operate free of “error”? Can

you think of other terms that better (or more fairly)

convey the range of adverse outcomes attending

healthcare practice?

276 Chapter 12

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The Evolution of the Standard of Care

The Professional Custom Rule

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278 Chapter 12

▸ Tort Liability of Hospitals, Insurers, and MCOs

Hospital Liability

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Vicarious Liability Th

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BOX 12-3 Discussion Questions

Give some thought to the term national standard

of care. What do you think it means, from both

a healthcare quality and legal (i.e., evidentiary)

perspective? Are you aware of any national body—

governmental or otherwise—that determines the

efficacy of new diagnostic protocols or treatment

modalities? In the absence of such an entity, how are

health professionals put on notice that a new medical

care standard for a particular procedure or treatment

has emerged?

279

Corporate Liability

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Insurer Liability

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280 Chapter 12

Managed Care Liability

definin

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▸ Federal Preemption of State Liability Laws Under ERISA

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Overview of ERISA

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BOX 12-4 Discussion Questions

What do you think about the role and success of tort

law in promoting high-quality health care? Does it

help to deter errors? If not, why?

282 Chapter 12

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ERISA Preemption

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▸ Measuring and Incentivizing Healthcare Qualityi

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BOX 12-5 Discussion Questions

The critical intersection between health care and

health insurance as exemplified by the Davila decision

leads to an important question: is it reasonable to treat

a healthcare coverage decision as having nothing

to do with health care itself? Put another way, given

the expense of health care today, do you believe that

individuals and families can afford necessary health

care if there is no third party responsible for covering

at least some of the cost?

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288 Chapter 12

National Quality Strategy

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Role of Health Information Technology

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292 Chapter 12

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CHAPTER 13

Public Health Preparedness Policy

LEARNING OBJECTIVES

By the end of this chapter you will be able to:

■ Describe what public health preparedness is and understand the scope of events that can lead to a public health

emergency ■ Understand the threats from and history of the use of weapons of mass destruction ■ Define public health threats from biologic agents and naturally occurring diseases ■ Describe key policies and laws that support public health preparedness and the infrastructure that has been built

to support preparedness activities at the federal, state, and local levels

By the end of this chapter you will be able to:

■ Describe what public health preparedness is and understand the scope of events that can lead to a public health

to support preparedness activities at the federal, state, and local levels

▸ Introduction

eff fir

293

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▸ Defining Public Health Preparedness

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294 Chapter 13

Eff Thi

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■ eff

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▸ Threats to Public Health

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CBRN Threats Th

Chemical Threats Th

BOXES 13-2 13-3

BOX 13-1 Discussion Questions

What is public health preparedness? How do you

define it? What is the role of the public health

professional in detecting, responding to, and

recovering from a public health emergency?

295

Source: Ganesan et al. (2010).

BOX 13-2 Types of Chemical Agents

■ primarily act on the nervous system, causing seizures and death. Examples of this category include

sarin, VX, tabun, and soman. This category also includes fourth-generation chemical weapons, known as novichok

agents, which are thought to be much more lethal than VX. ■ primarily cause irritation of the skin and mucous membrane. Examples of this category

include mustard gas and arsenical lewisite. ■ primarily cause damage to the lungs, including pulmonary edema and

hemorrhage. Examples include phosgene, diphosgene, and chlorine. ■ primarily cause seizures and respiratory and cardiac failure in high doses. Examples include hydrogen

cyanide and cyanogen cyanide. ■ cause incapacitation due to irritation of eyes and respiratory system. Examples include CN, CS,

PS, and CR. ■ , in low doses, cause psychiatric effects. An example is lysergic acid diethylamide (LSD). ■ cause symptoms that range from death to incapacitation, depending on the agent. Examples include ricin

and saxitoxin.

Sources: BBC (2018a, 2018b), Brunning (2018), Holmes and Solomon (2013), United Nations (2013), Vale, Mars, and Maynard (2018).

BOX 13-3 Examples of Chemical Agents Impacting Public Health

On March 19, 2013, a rocket landed in the village of Khan al-Assal, in the Aleppo region of Syria. Upon impact, a gas

was released, ultimately leading to over 20 fatalities and wounding many dozens more. Samples analyzed by both

Russia and the United States identified the agent as sarin. The Syrian government and the opposition faction were

quick to trade accusations of responsibility, and the Syrian government requested that the United Nations investigate

the incident further. After lengthy delays due to a lack of access and disagreement over the scope of the investigation,

a United Nations team finally arrived in August 2013, only to have their mandate quickly overshadowed by a second

sarin attack at Ghouda. The team eventually concluded that the perpetrators “likely” had access to the Syrian military’s

chemical weapons stockpile but the “evidentiary threshold” for assigning responsibility was not met. At the time of the

attack, Syria was not a signatory to the Chemical Weapons Convention. This example demonstrates the challenges of

preparing for, responding to, and attributing responsibility for chemical incidents in the midst of a conflict situation.

On March 4, 2018, Sergei Skripal, a former Russian military intelligence officer and double agent for the United Kingdom,

and his daughter Yulia collapsed while sitting on a public bench in Salisbury, England. It was quickly determined by the local

hospital that they had been poisoned by a toxic agent. Testing at the United Kingdom’s Defence Science and Technology

Laboratory at Porton Down identified the cause as a novichok nerve agent, a potent organophosphate believed to have

been developed by the Soviet Union during the Cold War. This finding was further confirmed by the Organization for the

Prohibition of Chemical Weapons. A police officer involved in the initial response on March 4 was also exposed and required

hospitalization. All three victims eventually recovered fully. After trace elements of the agent were found at public sites

visited by the Skripals earlier in the day, Public Health England was forced to reassure the public of the “very low risk” of

exposure and restricted access to nine locations for decontamination. On April 13, the United Kingdom’s National Security

Advisor, Sir Mark Sedwill, stated the government’s assertion that only Russia possessed the technical and operational means,

as well as motive, to carry out the attack. On June 30, a British couple without known links to the Skripals fell ill at their house

and were also determined to have been exposed to novichok. Police believed they had possibly handled a contaminated

item, highlighting the challenges of controlling even a small, likely targeted, poisoning attack with a lethal nerve agent.

296 Chapter 13

■

■ n eff ■

■

eff

Nuclear Threats fi

Radiologic Threats

Th Th

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Th nific

■

Biologic Threats

ff ff

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BOXES 13-4 13-5

BOX 13-4 Biologic Agents in Nature

Free-living unicellular organisms

Core of DNA or RNA surrounded by a coat of

protein; require host cell in order to replicate; much

smaller than bacteria

Toxic substances produced by living organisms

297

sific

Thi fir sific

(Th d defin

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Thi

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Source: CDC (2018a).

BOX 13-5 Major Biologic Threat Agents

Anthrax (Bacillus anthracis)

Botulism (Clostridium botulinum toxin)

Brucellosis (Brucella species)

Food safety threats (e.g., Salmonella species,

Escherichia coli O157:H7, Shigella)

Glanders (Burkholderia mallei)

Melioidosis (Burkholderia pseudomallei)

Plague (Yersinia pestis)

Psittacosis (Chlamydia psittaci)

Q fever (Coxiella burnetii)

Ricin toxin

Smallpox (Variola major)

Staphylococcal enterotoxin B

Tularemia (Francisella tularensis)

Typhoid fever (Salmonella Typhi)

Typhus fever (Rickettsia prowazekii)

Viral encephalitis (alphaviruses [e.g., Venezuelan

equine encephalitis, eastern equine encephalitis,

western equine encephalitis])

Viral hemorrhagic fevers (filoviruses [e.g., Ebola,

Marburg] and arenaviruses [e.g., Lassa, Machupo])

Water safety threats (e.g., cholera [Vibrio cholera],

Cryptosporidium parvum)

Emerging infectious diseases such as Zika virus,

Nipah virus, and hantaviruses

298 Chapter 13

figur fin

fi Th ffice ff

ff Th

Naturally Occurring Disease Threats

BOX 13-6 Th

cific

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Sources: CDC (2014a, 2014b, 2014d), Kaiser (2014), Maron (2014), Sun (2014).

BOX 13-6 U.S. Biosafety Incidents in 2014

Over the summer of 2014, three significant biosafety

incidents occurred involving U.S. government facilities.

The first incident took place in early June at the

Centers for Disease Control and Prevention’s (CDC’s)

Roybal Campus in Atlanta. On June 5, a laboratory

worker used an improper method to deactivate

anthrax spores that were being transferred to several

lower biocontainment laboratories on the same

campus. The mistake was discovered over a week

later, when culture plates left in the original laboratory

showed signs of bacterial growth. Thirty-five staff

and 67 visitors were considered at risk of exposure to

anthrax as a result of the error.

The second incident also involved the CDC. On

July 9, it was discovered that a sample of low-

pathogenic avian influenza shipped to the U.S.

Department of Agriculture from the CDC was

contaminated with highly pathogenic H5N1. Because

the sample was assumed to be of low risk, safety

and security precautions required for shipping of

select agents were not carried out. All handling of

the sample at both institutions took place under

BSL-3 conditions, minimizing the risk of accidental

exposure. The contamination was determined to have

taken place at the CDC influenza laboratory, and the

discovery was made by the USDA on May 23. However,

the incident was not reported for another 6 weeks.

The third incident occurred in mid-July, when

several vials labeled as smallpox were discovered

on the National Institutes of Health (NIH) campus in

Bethesda, Maryland. The vials dated from the 1950s,

when smallpox was still widespread, and are believed

to have been part of a previous Food and Drug

Administration (FDA) facility on the site. While some

of the viral contents were shown to still be viable, the

vials were well sealed and the risk of exposure was

deemed to be very low.

While no casualties resulted from any of these

incidents, they highlight the potential risks of

accidental exposure to dangerous biologic agents

as a result of poor bio-risk management practices. In

January 2016 an expert review, commissioned by the

CDC, found that while the agency had made some

progress, “considerable work” remained to be done to

achieve a culture of safety.

299

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Natural Disasters

fir flo BOX 13-8

TABLE 13-1

Th ffici

BOX 13-7 Discussion Question

How can a naturally occurring disease event lead to a

public health emergency? Describe how disease can

impact national, regional, or international security.

300 Chapter 13

Sources: Barron (2017), Einbinder (2018), Greenough and Kirsch (2005), Greshko (2017), Lister (2005), Philipps (2017), The White House (2006).

BOX 13-8 Recent U.S. Response to Hurricanes

On August 29, 2005, Hurricane Katrina landed on the Gulf Coast of the United States, reaching Mississippi, Louisiana,

and Alabama. It came ashore with winds of 115 to 130 miles per hour and brought with it a water surge that in some

locations rose as high as 27 feet. The surge pushed 6–12 miles inland and flooded approximately 80% of the city of

New Orleans. Some 93,000 square miles were affected, resulting in 1,300 fatalities, 2 million displaced persons, 300,000

destroyed homes, and almost $100 billion in property damage.

Katrina was the worst domestic natural disaster in recent history, but the consequences of the event were made

worse by a faltering levee system designed by the U.S. Army Corps of Engineers and a failure of government at all

levels to properly prepare for and respond to the disaster. First, long-term warnings went unheeded. It was clear that a

hurricane of this type would eventually hit the region, yet local and state officials, even after running exercises based on

such a scenario, failed to properly prepare. Local and state officials were unable to evacuate all of the citizens, struggled

with logistics, and did not make proper preparations for dealing with vulnerable populations, including nursing home

residents. The federal government failed to adequately anticipate the needs of the state and local authorities, and the

insufficient coordination resulted in a lack of resources and a too-slow response.

The public health and medical response coordinated by the federal government followed the traditional response

to a flood or hurricane: focus on sanitation and hygiene, water safety, surveillance and infection control, environmental

health, and access to care. Katrina, though, also presented unique challenges, such as the inability of displaced persons

to manage chronic disease conditions and access medications, death and illness from dehydration, and mental health

problems, all associated with the widespread devastation among those affected.

Almost all offices and branches of the federal Department of Health and Human Services (of which the CDC is a part)

eventually became involved in the response to Katrina. The CDC sent staff to the affected areas, deployed the Strategic

National Stockpile to provide drugs and medical supplies, and developed public health and occupational health

guidance. The FDA issued recommendations for handling drugs that might have been affected by the flood. The NIH

set up a phone-based medical consultation service for providers in the region. The Substance Abuse and Mental Health

Services Administration set up crisis counseling assistance and provided emergency response grants.

In addition, the National Disaster Medical System deployed 50 Disaster Medical Assistance Teams to try to

accommodate and treat hurricane victims. Disaster Mortuary Operational Response Teams also deployed to help process

bodies. The Department of Defense set up field hospitals at the New Orleans International Airport and aboard naval

vessels. The Department of Veterans Affairs evacuated both of its local hospitals—one prior to the storm, one afterward.

A combination of climatic conditions, including warmer-than-usual sea temperatures in the tropical Atlantic, led the

2017 Atlantic hurricane season to be the most devastating since 2005, and the fifth most active since recordkeeping

began in the 1930s. In particular, three storms—Hurricanes Harvey, Irma, and Maria—had a substantial impact on the

U.S. mainland and Puerto Rico. Along the Gulf Coast of Texas, Louisiana, and Florida, Hurricanes Harvey and Irma hit

within 2 weeks of each other, causing an estimated $175 billion of damage. Ten days later, Hurricane Maria slammed

directly into Puerto Rico, which had already been heavily impacted by Irma. The federal response was rapid, with

President Trump immediately approving disaster declarations for all three storms.

However, there were significant differences between the impact of the three storms, as well as the federal responses.

The Federal Emergency Management Agency (FEMA) already had supplies and personnel stationed in Texas before

Hurricane Harvey made landfall, and leveraged existing memoranda of understanding with local and state authorities,

as well as the National Guard, to coordinate response efforts closely. Local and federal responders had even previously

trained together, under the $2 billion invested by FEMA in training of local authorities since 2005. Similarly, within

4 days of Hurricane Irma’s landfall in Florida, FEMA had deployed more than 2,650 staff (out of a total of more than

40,000 federal response personnel) to support response efforts.

In contrast, the federal response to Hurricane Maria in Puerto Rico was criticized by the United Nations and other observers

for being sluggish and inadequate. Already stretched thin by the Harvey and Irma responses, only 10,000 federal response

personnel were initially deployed, many of whom were trainees or lacked previous response experience. Few supplies were

in place ahead of time, and being an island, FEMA faced considerable logistical challenges in sending provisions, tarpaulins,

and other key supplies to Puerto Rico, leading to major shortages of food and shelter, particularly as Maria had destroyed

more than one-third of homes on the island. The Army Corps of Engineers, deployed to help repair homes destroyed by the

hurricane, managed to put up just over 400 roofs in the month following the storm, whereas they had repaired more than 10

times that many in Florida in the same time frame after Irma. The hurricane also crippled Puerto Rico’s electricity grid; as late as

May 2018, over 100,000 residents were still without power, highlighting the slow recovery faced by the island.

301

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cific

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TABLE 13-1 Major Natural Disasters, 1900 to Present

Date Event Location Approximate Death Toll

June–November, 2017 Hurricanes Caribbean Basin Up to 8,750

April 25, 2015 Earthquake Gorkha, Nepal 9,000

March 11, 2011 Earthquake/tsunami Tohoku, Japan 15,800–18,500

January 12, 2010 Earthquake Port-au-Prince, Haiti 170,000–230,000

May 2, 2008 Cyclone Myanmar 138,000

December 26, 2004 Tsunami (Indian Ocean) Indonesia, Thailand, Sri Lanka,

India, and more

220,000 (+)

July 28, 1976 Earthquake Tangshan, China 242,000–655,000

November 13, 1970 Cyclone Bangladesh 500,000

May–August 1931 Yellow River and Yangtze

River floods

China 1–3.7 million

May 22, 1927 Earthquake Xining, China 200,000

September 1, 1923 Earthquake and fires Tokyo, Japan 143,000

December 16, 1920 Earthquake Haiyuan, China 200,000

Sources: Associated Press (2010), CBC News (2010), Kishore et al., (2018), Noji (1997), Office of U.S. Foreign Disaster Assistance (1993), U.S. Geological Survey (2004).

BOX 13-9 Discussion Questions

How did the public health community respond to Hurricane Katrina? What lessons can be learned to better prepare for

future response efforts?

To what extent did the response to the 2017 hurricane season reveal improvements to public health preparedness

for natural disasters, versus gaps still remaining?

302 Chapter 13

Man-Made Environmental Disasters Th

BOX 13-10

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Federal Response Agencies and Offices

Department of Health and Human Services (HHS)

ffices Sources: Kaufmann and Penciakova (2011), Secretariat of the Investigation Committee on

the Accidents at the Fukushima Nuclear Power Station (2012), Tanter (2013), Wheatley,

Sovacool, and Sornette (2017).

BOX 13-10 Fukushima Nuclear Disaster

The most serious radiation accidents have been

associated with nuclear power plants. While the total

number of accidents occurring at nuclear power plants

is a matter of debate, at least 33 significant accidents

are believed to have taken place since the 1950s. The

most recent serious incident occurred at Fukushima

Nuclear Power Plant in Japan, starting on March 11,

2011. The incident began when the facility was struck

by a tsunami, itself caused by the magnitude 9.0 Tohoku

earthquake. Seawater flooding the nuclear facility

caused the plant’s power (including backup generators)

to fail. With no mechanism for continued cooling, the

reactors began to heat up; eventually, three out of

the facility’s six nuclear reactors melted, resulting in a

massive release of radioactive material, and the largest

nuclear incident since Chernobyl in 1986. Investigations

into the Fukushima disaster concluded the catastrophe

must be considered “man-made”: the findings of a

2008 tsunami risk assessment had been ignored by

the facility’s management; there was institutionalized

“corruption, collusion, and nepotism” between the

nuclear industry and regulatory authorities; and the

Japanese government’s eventual response to the

disaster was thoroughly criticized for its poor crisis

command, inadequate legal structure for nuclear

crisis management, and lack of communication and

transparency. While there were no immediate casualties

from the incident, more than 100,000 people were

evacuated from their homes and an estimated 1,000

died as a result of maintaining the evacuation. Concerns

over the long-term impact of radiation exposure remain.

303

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Federal Bureau of Investigation (FBI) Th

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304 Chapter 13

Department of Defense (DoD) Th

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Preparedness Statutes, Regulations, and Policy Guidance

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Public Health Improvement Act of 2000 (Public Law 106-505) Th

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Public Health Security and Bioterrorism Preparedness and Response Act of 2002 (Public Law 107-188)

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Smallpox Emergency Personnel Protection Act of 2003 (Public Law 108-20)

The Project Bioshield Act of 2004 (Public Law 108-276)

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Presidential Directives

Biodefense for the 21st Century: National Security Presidential Directive 33/ Homeland Security Presidential Directive 10, April 2004

BOX 13-11 Discussion Questions

The PAHPRA of 2013 included changes to each of the

four main titles of the previous PAHPA law. Looking

back at PAHPA (2006), how significant do you think

these changes were, and what might have been the

rationale behind the revisions? How does this act

compare to the current reauthorization?

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International Agreements

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BOX 13-12 Discussion Questions

Describe the federal preparedness infrastructure

that evolved after 9/11. Are there things about

the departments, agencies, and offices that to

you represent improvements over the pre-9/11

infrastructure? Are there aspects that seem redundant

or misplaced?

BOX 13-13 Policy Case Study: Domestic Response to the 2014–2016 Ebola Outbreak

Several of the federal preparedness laws and regulations of the early 2000s focused on the need to develop and

stockpile a ready supply of medical countermeasures to be deployed in the event of a public health emergency.

However, many pathogens of concern are relatively rare, or occur endemically only in lower-income or resource-

constrained countries. As such, there was reluctance from the pharmaceutical and drug manufacturing industries to

commit significant research and development dollars to products that might not have a commercially viable market.

The Project Bioshield Act of 2004 sought to change that by establishing a government-funded market for such

countermeasures, and thus incentivize the development of vaccines and therapeutics that would not otherwise be

cost-effective. Subsequent legislation changed how the development of medical countermeasures were funded to

better incentivize private sector companies to remain committed and financially viable during the lengthy process

between initial development of a product and final approval by the FDA.

Given the length of time required for a product to come to market, the Project Bioshield Act also allowed for HHS to

authorize the emergency use of countermeasures even if they had not yet been approved by the FDA. Of course, FDA

approval processes are critical for determining safety and efficacy, so the concern was raised about liability in the event

that a non-FDA-approved countermeasure, used for a legitimate public health emergency, produced a severe side effect

or failed as a treatment. Manufacturers feared that liability in these situations would fall on them, leading to a reticence

to even engage in the development of the product. In response, Congress passed the PREP Act, which provides

immunity from liability for any claims resulting from the use of a medical countermeasure approved for use during a

public health emergency. There have been eight PREP Act Declarations since its inception, addressing countermeasures

for smallpox, pandemic influenza, botulinum toxin, and anthrax, as well as for nonbiologic threats such as radiation.

Starting in late 2013, erupting in 2014, and continuing into 2015 and 2016, Ebola virus disease spread through

Guinea, Sierra Leone, and Liberia, infecting and killing thousands more people than any previous Ebola outbreak. The

virus spread to countries outside of West Africa, including the United States, through global travel and the return of

infected medical volunteers. The scale of the outbreak prompted several pharmaceutical companies to accelerate

research and development of Ebola vaccines and therapeutics; despite such products being incentivized under the

(continues)

309

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Project Bioshield Act, virtually no companies had focused on Ebola virus, and few countermeasures were at an advanced

stage of testing. There was tremendous public fear and pressure mounted on public health and medical officials to

ensure that U.S. patients with Ebola were given every available treatment, even if experimental. In August 2014, the

media widely reported on the remarkable recovery of two American Ebola patients in Liberia, who had been given

doses of an experimental drug called ZMapp. It is not clear if and what liability protections were waived for the initial

use of this and other experimental Ebola therapeutics on U.S. patients, though the provision of these treatments were

sanctioned under the auspices of the FDA’s “compassionate use exemption” whereby a patient may receive unapproved

treatment outside of already-approved clinical trials. However, HHS subsequently issued a PREP Act declaration

providing immunity from liability for the manufacturing, administration, and use of Ebola-related vaccines, including

several Ebola vaccines under development, and later issued a declaration for therapeutics such as ZMapp.

This example demonstrates the importance of establishing a legal framework for preparedness to ensure the

appropriate and timely use of medical countermeasures in the event of a public health emergency. Having a process

in place to protect manufacturers allowed them to move forward with getting potentially lifesaving products to a

frightened, at-risk population.

Sources: FDA (2018b), HHS (2017), Health Resources and Services Administration (2017), Kadlec (2013), Monahan and Halabi (2015).

BOX 13-13 Policy Case Study: Domestic Response to the 2014–2016 Ebola Outbreak (continued)

310 Chapter 13

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References

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BOX 13-14 Discussion Question

What are the distinct roles of local, state, federal,

and international governments and organizations in

managing a public health emergency of international

concern?

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PART III

Basic Skills in Health Policy Analysis

317

CHAPTER 14

The Art of Structuring and Writing a Health Policy Analysis

LEARNING OBJECTIVES

By the end of this chapter you will be able to:

■ Understand the concept of policy analysis ■ Analyze a health policy issue ■ Write a health policy analysis ■ Develop descriptive and analytic side-by-side tables

By the end of this chapter you will be able to:

■ Understand the concept of policy analysis ■ Analyze a health policy issue ■ Write a health policy analysis ■ Develop descriptive and analytic side-by-side tables

▸ Introduction

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320 CHAPTER 14

Problem Identification

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Identifying Key Factors

BOX 14-1 Possible Factors to Include in a Landscape Section

What is the political salience of the issue?

Is this a front-burner issue?

Is this a controversial issue?

Are your client, legislators, and the general public interested in addressing this issue?

Has this or a similar healthcare issue been addressed recently?

Do key constituents, opponents, interest groups, or other stakeholders have an opinion about the issue? Who is likely to

support or oppose change?

Is there bipartisan support for the issue?

Is there a reason to act now?

Is there a reason to delay action?

Who is affected by this problem?

According to the client who assigned the analysis, are influential or valued people or groups affected by this problem?

Is there a fairness concern relating to this issue?

Is there a stigma associated with this issue?

What is the economic impact of addressing this problem? Of not addressing it?

Are various people or groups impacted differently?

Are there competing demands for resources that relate to this issue?

What is the economic situation of the state or nation? How does this affect the politics relating to this issue?

How will addressing this issue affect healthcare costs/healthcare spending?

Is it realistic to try to solve this problem?

Do others need to be involved to be able to solve this problem?

Is the technology available to solve this problem?

Would it be more practical to solve this problem later?

Are other people in a better position to solve this problem?

What do we know about solutions that do or do not work?

If this problem cannot be solved, is it still necessary (politically, socially) to act in some way to address the problem?

Is evidence available to support potential solutions?

Are there legal restrictions affecting this problem?

Is there a need to balance public health concerns and individual legal rights?

Are there legal requirements that impact the analysis?

Is new legislative authority necessary to solve the problem?

Is there legal uncertainty relating to this problem?

Is future litigation a concern if action is taken?

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Does this problem address quality-of-care issues?

Do some solutions focus on quality of care more than others?

Do quality-of-care concerns vary based on which provider is involved?

Is evidence available about the best ways to improve quality of care?

Has the client already taken any actions to improve quality of care?

326 CHAPTER 14

The Options Section fini

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BOX 14-2 Sample Options Criteria

How much does this option cost? (You may

have to break this down: how much does it

cost the federal government, state government,

individuals, etc.?)

enefit: How much “bang for the buck” does

this option provide? (This is a difficult criterion to

assess in shorter, less complicated policy analyses

because you often do not have the information

necessary to make this determination.)

Is this option politically viable?

Is it likely to become law? Even if it is not likely

to become law, is it likely to help your client

politically?

Is this option legal? If so, are there any

restrictions?

Does this option have steep

implementation hurdles?

Are people affected by this option treated

fairly/equally?

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improve quality of care, lower healthcare spending,

reduce the incidence of a particular disease, etc.?

328 CHAPTER 14

Side-by-Side Tables

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TABLE 14-1 Descriptive Side-by-Side Table

Increasing Access to Care for Immigrants—Options Description

Public Education Campaign Grants to States Health Center Funding

General

description

Campaign on radio,

television, and public areas

Federal government provides funds

to states to increase access to care

for immigrants

Federal government provides

funding to health centers for

services

Populations

affected

All will hear, focus on

immigrants in community

Only immigrants in the state All health center patients,

including immigrants

Length of

option

1 year 5 years, subject to annual

appropriations

2 years

Payer Federal Federal Federal

329

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TABLE 14-2 Analytic Side-by-Side Table

Increasing Access to Care for Immigrants—Options Assessment

Options Criteria

Public Education

Campaign Grants to States

Health Center

Funding

Cost to federal government Low Medium High

Political feasibility Medium Low High

Increase in access for immigrants Low High Medium

BOX 14-3 Checklist for Writing a Policy Analysis

tific Is my problem written as one sentence in the form of a question?

Can I identify the focus of my problem ?

Can I identify several options (but not many) for solving the problem?

Does my background include all necessary factual information?

Have I eliminated information that is not directly relevant to the analysis?

Is the tone of my background appropriate?

Does the landscape identify all of the key stakeholders?

Are the stakeholders’ views described clearly and accurately?

Is the structure of the landscape consistent and easy to follow?

Is the tone of the landscape appropriate?

Does the reader have all the information necessary to assess the options?

Do my options directly address the issue identified in the problem identification?

Did I assess the pros and cons of each option?

Did I apply all of the criteria to each option’s assessment?

Are the options sufficiently different from each other to give the client a real choice?

Are all of the options within the power of my client?

Is my recommendation one of the options assessed?

Did I recommend only one of my options?

Did I explain why this recommendation is the best option, despite its flaws?

330 CHAPTER 14

References

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