Website Article Assignment

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l e a r n i n g O B J e C t i v e s

A policy is a temporary creed liable to be changed, but while it holds good, it has

got to be pursued with apostolic zeal.

—Mohandas Gandhi

One voice can change a room. And if one voice can change a room, then it can

change a city. And if it can change a city, it can change a state. And if it can change

a state, it can change a nation, and if it can change a nation, it can change the world.

Your voice can change the world.

—Barack Obama

C H A P T E R 3

H E A LT H P O L I C Y M A K I N G AT T H E S TAT E A N D L O C A L L E V E L S A N D I N T H E P R I VAT E S E C T O R

After completing this chapter, you should be able to

➤ describe features of the US state-level policymaking process and political system and provide examples of state healthcare legislation,

➤ discuss features of the US local government policymaking process and local political system and provide examples of local healthcare legislation,

➤ address the health policy–related activities of private health research institutes and foundations,

➤ understand the implications for the US healthcare system of private industry policies and practices, and

➤ appreciate the attributes of health policy development at the US state and local levels and in the private sector.

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C o p y r i g h t 2 0 1 9 . H e a l t h A d m i n i s t r a t i o n P r e s s .

A l l r i g h t s r e s e r v e d . M a y n o t b e r e p r o d u c e d i n a n y f o r m w i t h o u t p e r m i s s i o n f r o m t h e p u b l i s h e r , e x c e p t f a i r u s e s p e r m i t t e d u n d e r U . S . o r a p p l i c a b l e c o p y r i g h t l a w .

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7 1C h a p t e r 3 : H e a l t h P o l i c y m a k i n g a t t h e S t a t e a n d L o c a l L e v e l s a n d P r i v a t e S e c t o r

ma s s a C h u s e t t s he a lt h C a r e re f O r m

In 2006, Massachusetts enacted landmark legislation to provide health insurance coverage to nearly all state residents (KFF 2012). The legislation led to the creation of the Commonwealth Care health insurance program to provide subsidized coverage for individuals whose income is below 300 percent of the federal poverty level. It also developed a health insurance exchange for individuals and small businesses to purchase insurance at more affordable rates than could be obtained on the open market. The state’s Medicaid program was expanded and merged with the Children’s Health Insurance Program (CHIP) to form MassHealth. Children from a family whose income is up to 300 percent of the federal poverty level are covered by this program.

As part of this legislation, Massachusetts mandated that residents purchase health insurance coverage or be charged a penalty of up to $912. In addition, employers with 11 or more employees are required to contribute to health insurance coverage for their employees or pay an annual fair-share contribution of up to $295 per employee.

As of 2012, the percentage of residents without insurance in Massachusetts had declined to 6.3 percent, in comparison to the 2006 level of 10.9 percent uninsured (KFF 2012). Uninsur- ance in Massachusetts was about one-third that of the rest of the United States (18.4 percent). Employer health coverage remains the most common type of insurance, but MassHealth (the public insurance plan) and Commonwealth Care (which provides subsidies for families and individuals to purchase private coverage) have grown substantially (KFF 2012; Saluja et al. 2016).

Community health centers and safety net hospitals play a dominant role in caring for those Massachusetts residents who now have health insurance as a result of the state healthcare reform legislation. In addition, they continue to provide care for those who remain uninsured.

The Massachusetts experience with healthcare reform legislation provides a real-world case study demonstrating the potential to significantly reduce the number of uninsured through an individual mandate combined with affordable health coverage options. It illustrates the state’s role in bringing about real healthcare reform affecting healthcare access and delivery.

CO n n e C t i C u t OP i O i d re s P O n s e in i t i at i v e

According to the Connecticut Department of Mental Health and Addiction Services, admission for heroin addiction has increased since 2011, and heroin has replaced alcohol as the primary drug reported at admission for substance abuse treatment within the state, with heroin and other opiates accounting for 42 percent of admissions in fiscal year 2016 (Giard 2017). Connecticut

C a s e s t u d y 2

C a s e s t u d y 1

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Governor Dannel P. Malloy charged the Alcohol and Drug Policy Council (ADPC), a statewide stakeholder group, with comprehensively addressing Connecticut’s opioid crisis. The Connecti- cut Opioid REsponse (CORE) team—a partnership among academic, medical, and public health organizations and state agencies—supports the work of the ADPC by using evidence-based strategies to achieve measurable outcomes that have a prompt impact on the number of opioid overdose deaths in Connecticut (Fiellin et al. 2016). The CORE initiative has two main functions: (1) to serve as a means to convey strategies and methods likely to immediately treat opioid use disorder and reduce overdose events, and (2) to provide metrics and measures that may be used to monitor and track progress over time (Fiellin et al. 2016). Namely, CORE identifies strategies and associated metrics to address the opioid crisis in Connecticut.

The strategic plan involved a multistage process of data gathering from Connecticut stakeholders, evaluation of evidence-based practices, and stakeholder engagement (Fiellin et al. 2016). First, a three-month data-collection process led by Yale University’s Schools of Medicine and Public Health sought recommendations from stakeholders throughout the state. In addition, the team evaluated evidence-based practices from other states and countries. Review and integration of these data helped identify Connecticut’s specific data needs and key questions. Recommendations were further reviewed with regard to scientific strength, potential three-year impact on overdose mortality, and availability of a measurable outcome that could be monitored to determine strategic priority.

These efforts resulted in the following six strategies (Fiellin et al. 2016):

1. Increase access to high-quality treatment with methadone and buprenorphine. 2. Reduce overdose risk, especially among those individuals at the highest risk. 3. Increase adherence to opioid prescribing guidelines among providers, especially those

providing prescriptions associated with an increased risk of overdose and death. 4. Increase access to and track use of naloxone. 5. Increase data sharing across relevant agencies and organizations to monitor and

facilitate responses, including rapid responses to outbreaks of overdoses and other opioid-related events.

6. Increase community understanding of the scale of opioid use disorder, the nature of the disorder, and the most effective evidence-based responses to promote treatment uptake and decrease stigma.

Based on the evolving nature of the opioid epidemic, and an evolving evidence base, the CORE initiative team plans to evaluate its strategies, tactics, and metrics annually and adjust as needed.

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A lthough US health policies are developed primarily at the federal level, state and local governments and industries in the private sector (nonfederal arenas) also engage in health policymaking. This chapter focuses on health policymaking in

these arenas. First, state-level health policymaking is presented; that discussion is followed by sections covering local government and private-sector health-related policy influencers. The attributes of health policymaking in these sectors are also summarized.

stat e gO v e r n m e n t st r u C t u r e

The federal and state sectors share a common government structure composed of the legis- lative, executive, and judiciary branches. However, each state also has its own constitution and bill of rights, which together define the structure and function of the state government and the local governments within the state’s boundary (Longest 2016). Following is a brief discussion of the typical state political system.

PO l i t i C a l sy s t e m

State governments are modeled after the US federal government in that each is composed of executive, legislative, and judicial branches (exhibit 3.1). States are bound by the US (federal) Constitution to maintain a republican form of government, although they are not specifically required to adhere to the three-branch system. The executive branch of the state government is headed by the governor and other state executives, such as the lieutenant governor, the attorney general, the secretary of state, auditors, and commissioners. All state

republican A type of democratic government in which the head of state is not a monarch; governmental activities and affairs are open to all interested citizens.

state executives Officials in the executive branch of state government. Examples include the governor, who is the chief executive of a state or territory, and the attorney general, who serves as the main legal adviser to the state government and has executive responsibility for law enforcement.

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exhiBit 3.1 The US State Political System

State government

Executive branch Governor Lieutenant governor Attorney general Secretary of state Auditors Commissioners

Legislative branch Senate House of representatives/ assembly/house of delegates

Judicial branch Supreme Court

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governors are directly elected by the people, as are most other positions in their executive branch. The exact structure of the executive branch varies from state to state.

The state legislative branch is the main lawmaking body of the government; it also approves the state budget and fulfills other functions of government. As in the federal gov- ernment, the state legislature consists of two chambers: a house of representatives—known in some states as the assembly or house of delegates—and a senate (except Nebraska, which has only one chamber in its legislature). In most states, senators are elected by the state’s voters to four-year terms, and members of the house are elected to two-year terms.

A state’s judiciary is generally headed by its version of the US Supreme Court (with exceptions; for example, New York’s Supreme Court is actually the trial-level court, and the state’s highest court is referred to as the Court of Appeals). This highest state court hears appeal cases from lower-level state courts; no trials are held in state supreme courts. Decisions made by a state supreme court are binding unless they do not adhere to the US Constitution, in which case its decisions may be appealed in the US Supreme Court. The exact structure of the courts and the rules governing judicial appointments and elections are determined on a state-by-state basis, either through state legislation or by the state constitution.

PO l i C y m a k i n g Pr O C e s s at t h e stat e le v e l

The policymaking process at the state level can vary substantially from state to state. In general, however, states apply the same legislative system as the federal government does (see, e.g., Maryland General Assembly 2006; State Legislature of Alaska 2018; West Virginia Legislature 2018). The idea for a new law can come from an elected representative, a group of elected representatives, the governor, or any other concerned citizen or interest group. The proposed law is drafted into a bill, which is then sponsored by an elected member of either the state’s senate chamber or its lower chamber (e.g., house of representatives, general assembly). Although a bill must be introduced into the legislature by a representative or senator, both legislators and interest groups draft significant amounts of legislation.

Bills can be introduced in either chamber of the legislature, where they are reviewed by committees. Many states require that the bill also be accompanied by a financial projec- tion showing the budgetary impact of the potential law. The bill goes through three readings before being voted on by the elected representatives. Often, amendments are made after each reading, and the merits of the bill are debated among the members.

After it passes one chamber, the bill proceeds to three readings in the other chamber. The same process of debates and amendments is followed. After both houses have agreed on and passed a final version of the bill, it goes to the governor to be signed into law. In many states, the governor has the authority to veto a bill that is passed by both chambers so that it does not become law. In other states, the governor’s veto can be overridden by a favorable vote of two-thirds or more of the members in both houses so that the bill becomes law even without the governor’s support.

state legislature The legislative body of a US state, also called the general assembly or legislative assembly.

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ex a m P l e s O f stat e he a lt h C a r e le g i s l at i O n

The power and responsibility of states to establish laws that protect the public’s health and welfare derive from the US Constitution. The focus of healthcare legislation can range from promoting health (including environmental protection, occupational health, safe food services, and injury prevention) to providing health services (such as public health nursing, communicable disease control, family planning and prenatal care, and nutritional counsel- ing). See exhibit 3.2 for examples of state health policies, review the Learning Point box titled “Illustration of State Involvement in Health Policy Development” for a description of health policy activity in Oregon, and read the Learning Point box titled “State Initiatives on Health Promotion and Disease Prevention” to understand state involvement in health promotion and disease prevention activity as well as efforts to address the healthcare needs of its vulnerable citizens.

exhiBit 3.2 Examples of State Responsibilities Through Health Policy

• Serve as a major payer of healthcare services; an average of 28.2 percent of all state expenditures were Medicaid related in 2015 (Medicaid and CHIP Payment and Access Commission 2016).

• Fund CHIP, health insurance benefits for state employees and other public-sector workers, and stand-alone state programs that provide health services to the uninsured.

• Regulate the state healthcare system (e.g., licensing and monitoring health professionals and health-related organizations, regulating the state private health insurance industry).

• Establish and monitor compliance with quality standards for environmental protection.

• Provide safety net facilities through support of local health departments and community-based healthcare organizations and through programs that provide charity care to low-income populations.

• Provide subsidies for graduate medical education and support large-scale educational campaigns.

LEARNING POINT Illustration of State Involvement in Health Policy Development

Known as a leader in state healthcare reform (Health Care for All Oregon 2017), Oregon’s Legislative Assembly passed House Bill 2009 in 2009, which established the Oregon Health Authority (OregonLive 2018). The legislation created an insurance exchange—a federal subsidy– eligible set of standardized healthcare plans regulated by the state from which individuals

( c o n t i n u e d )

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LEARNING POINT Illustration of State Involvement in Health Policy Development (continued)

may purchase health insurance—through the Oregon Health Authority for individuals and small businesses that do not have group health insurance (Oregon Legislative Assembly 2009).

The law also expanded the Oregon Health Plan to cover low-income working families and allocated an additional $5 billion to the Medicaid plan over the following ten years. The Oregon Health Plan is the Medicaid program for Oregon and is overseen by the Oregon Health Author- ity. Its purpose was to make healthcare more accessible to the working poor while rationing insurance benefits. President Bill Clinton approved the plan in 1993 but required a revision to ensure access for people with disabilities. In 2011, Oregon House Bill 3650, which contained the proposed revision, was passed by the state legislature, and Oregon Senate Bill 1580 was signed into law, establishing Coordinated Care Organizations (CCOs). A CCO is a network of all types of healthcare providers who care for people covered under the Oregon Health Plan. CCOs integrate physical, mental, and dental care for better care and better health outcomes at lower costs. CCOs focus on preventing illness and disease, improving quality of care, and managing existing health conditions to keep patients healthy.

Other provisions contained in House Bill 2009 called for expanding the use of electronic health records through the Oregon Health Authority, establishing quality standards for hospi- tals and healthcare providers, and mandating that health insurance companies disclose their administrative costs and executive salaries to maintain transparency and accountability. As with the federal reforms included in the Affordable Care Act (ACA) of 2010, lifetime maximum limits on health benefits were eliminated, insurers were prohibited from taking health coverage away from those already enrolled in a plan, and children who were unmarried could stay on their parents’ health insurance plan until age 26 (Oregon Legislative Assembly 2009). The ACA was also expected to provide some financial support for the reforms in Oregon’s House Bill 2009.

The state’s efforts were largely successful. A report by the Oregon Health Authority (2017) showed that by 2017, about 94 percent of people in Oregon had health insurance coverage.

LEARNING POINT State Initiatives on Health Promotion and Disease Prevention

All US states and the District of Columbia receive federal grants to initiate their own health promotion and disease prevention programs (CDC 2018a). These programs focus on a variety of health problems, such as promoting wellness culture in the workplace, increasing access to healthy food, and improving physical activity. These programs have the common goal of improving environments to make healthy living easier. Four examples of these programs are provided here.

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LEARNING POINT State Initiatives on Health Promotion and Disease Prevention (continued)

Exercise and Dietary Modification to Combat Obesity in Michigan Strong evidence indicates that physical inactivity and excess calorie intake are the primary causes of obesity, not only for adults but also for young children (CDC 2017b). To address this public health concern, Michigan has worked on various activities such as partnering with the local Farmer’s Market Association to accept Supplemental Nutrition Assistance Program cards (formerly known as food stamps) and providing funding to local health jurisdictions to promote physical activity with walking campaigns. One highly successful project involved working with school districts and community organizations to enhance physical activity standards and healthy eating habits in early care and education settings (i.e., licensed childcare centers and in-home childcare settings) across the state. As a result of this five-year project, 226 centers and homes improved children’s physical activity through activities such as 60 minutes of adult-led playtime every day, and 194 centers and homes made children’s diets healthier by adding more fruits and vegetables to meals or encouraging parents to bring healthy snacks for children. To sustain the program, Michigan is making efforts to expand these improvements in every childcare center and in-home childcare setting in the state (CDC 2016b).

Healthier Retail Environments in Rural Wisconsin A 2013 study found that In Wisconsin, about 38 percent of adults consumed fruits and 26 percent of adults ate vegetables less than once a day (Young et al. 2017). In addition, rural residents often have limited access to nutrient-dense, fresh produce because most corner stores—small retail shops that sell groceries and other household items—in rural Wisconsin lack a variety of fruits and vegetables. To make healthy options more convenient for local residents, the Wisconsin Division of Public Health (DPH) partnered with the University of Wisconsin Extension and 11 community-based organizations in 2015 to promote and expand the Wisconsin Corner Store Assessment tool for corner stores across the state. The tool guides corner stores through an assessment of areas for improvement, informing them on factors such as placement and shelf space of healthy foods in the store (Young et al. 2017).

This state program achieved the most desirable results in rural Lincoln County. Many corner stores in Lincoln County now offer much healthier food and drink options in their communities through multiple strategies, including coupons for healthy foods, point-of-purchase promo- tions, and displays of healthy products. To build on this success, the DPH decided to expand this program to gas stations in Lincoln County (CDC 2014; Young et al. 2017). Milwaukee County also launched a similar initiative to encourage corner stores to sell healthy foods by using such strate- gies as fresh produce signage, in-store demonstrations, and store redesign (Young et al. 2017).

Dietary Interventions in Philadelphia Healthcare Settings In the state of Pennsylvania, the Philadelphia Department of Public Health launched the Good Food, Healthy Hospitals (GFHH) initiative, a healthy food and beverage option promotion

( c o n t i n u e d )

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In some instances, an initiative instigated by a private-sector group to address an urgent public health problem may garner support from the state. For example, see the case in the Learning Point box titled “West Virginia’s Drug-Free Moms and Babies.”

LEARNING POINT State Initiatives on Health Promotion and Disease Prevention (continued)

targeting patients, staff, and visitors in local hospitals (Bartoli 2018). Providing hospital patients suffering from chronic diseases with a healthy diet is a key component of chronic disease management, the department found, and many of the hospitals in Philadelphia serve residents of low-income areas where few fresh and healthy food options are available. The Common Market (a nonprofit organization) and the American Heart Association partnered with the Philadelphia Department of Public Health in 2014 to implement the GFHH initiative. Specifi- cally, they encouraged hospitals to adopt five GFHH food standards that applied to purchased foods and beverages, cafeteria meals, patient meals, catering, and vending machines. Each standard came with specific guidelines. For example, the patient meal standard prohibited deep frying as a method of food preparation (Bartoli 2018).

As of June 2017, 15 hospitals had signed a pledge and committed to adopt GFHH standards. In their first year of implementation, all of these hospitals had met the minimum guidelines for at least one of the five GFHH standards, and half of them had achieved this goal for mul- tiple standards. Most hospitals reported increased sales of healthy items even in their first year of implementation. One local medical center’s cafeteria reported increased sales of unsweetened waters by 83 percent compared with the previous year, after following a GFHH price reduction guideline. Most important, these hospitals credited the GFHH standards with helping to shape hospital policies around healthier food and beverage options (Bartoli 2018).

Bike Share Program in California Considering that the obesity rate for adults in Sacramento County, California, increased dra- matically, by nearly 29 percent from 2001 to 2011, the California Department of Public Health (CDPH) collaborated with five state agencies to initiate a bike share program that motivated state employees to use free bicycles for business and personal trips during weekdays (Rosenhall 2018). The initial results were encouraging: From May 2015 to May 2016, 235 CDPH employees had enrolled and made more than 900 trips, biking a total of more than 3,000 miles (CDC 2016a; Rosenhall 2018). The program thus accomplished the dual benefits of improving employee fit- ness and decreasing environmental pollution from cars. City officials, taking notice of the CDPH program’s success, worked to establish a bike share program for the Sacramento metropolitan area. The new bike rental service, called Social Bicycles, debuted on May 17, 2018, with a fleet of several dozen bicycles available in downtown Sacramento and along the West Sacramento waterfront and with plans for an increase to about 900 bikes by the end of the year (Bizjak 2018).

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lO C a l gO v e r n m e n t st r u C t u r e

Local US governments typically fall into one of two levels: county or municipality (e.g., cities, towns, villages). Counties—called boroughs in Alaska and parishes in Louisiana—may

LEARNING POINT West Virginia’s Drug-Free Moms and Babies

In 2015, West Virginia led the nation in drug overdose mortality among US states, with a rate of 41.5 deaths per 100,000 people (Mullins 2017). High rates of drug addiction, including but not limited to opiates, were also believed to affect neonatal outcomes and child health. To address this growing problem, a group of West Virginia neonatologists and pediatricians met with members of the Perinatal Partnership and coders in 2014 to address neonatal outcomes for infants being born to opioid-addicted mothers (Mullins 2017). Specifically, the group sought to “develop a standardized definition for neonatal withdrawal and guidance on documenting exposure and withdrawal among newborns” (Mullins 2017).

The group examined how the Drug Free Moms and Babies Project—a medical and behavioral health program for women during and after pregnancy—leveraged collaborative relationships to achieve positive outcomes for mothers and babies through a comprehensive, integrated approach including prevention, early intervention, addiction treatment, and recovery sup- port services (Mullins 2017; West Virginia Department of Health and Human Services 2018). The three-year project was supported through funding from the West Virginia Department of Health and Human Resources; the Division of Behavioral Health and Health Facilities; the West Virginia Office of Maternal, Child and Family Health; and the Claude Worthington Benedum Foundation (West Virginia Department of Health and Human Services 2018). Four pilot sites were selected for the project to represent a cross-section of types and services—rural and urban, large and small, public and private—from which 354 women completed the program (West Virginia Department of Health and Human Services 2018; Towner 2017).

Overall, the program resulted in improved identification, increased collaboration among partners, greater availability of case management, and an increase in self-referrals (Mullins 2017). Urine tests screened for the presence of illegal drugs throughout the process, and the percentage of those testing positive markedly decreased over the nine months of the program participants’ pregnancies (Towner 2017). Between 72 percent and 95 percent of the mothers tested negative for illicit substances at the time of delivery (Mullins 2017). Representatives from the West Virginia Department of Health and Human Resources noted the following les- sons learned: (1) this kind of initiative requires time, flexibility, and patience; (2) client trust takes time to develop and affects early enrollment; (3) transportation and child care present significant barriers to enrollment; (4) comorbidities are common and complicate the treatment process; (5) coordination of care with physicians in private practice is difficult; (6) postpartum follow-up is challenging; (7) recovery coaching services can be difficult to locate and manage; and (8) plans for sustainability should be incorporated early in the program (Mullins 2017).

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be further divided into townships. Service districts, such as school districts and police and fire protection districts, may be congruent with county or municipal boundaries or set their own borders.

The structures of county and municipal governments vary greatly, but they all follow the democratic model. States assign powers to the local governments rather than to indi- viduals; however, mayors, city council members, and members of other governing bodies are usually elected directly by local residents. Laws are typically passed by majority votes at local council sessions.

The powers granted to a given county or municipality often depend on the size of its population. New York City, for example, has millions of residents and controls its own fire, police, and emergency medical services as well as libraries, parks and recreation, public transportation, and public works services. Smaller communities, on the other hand, may rely on county or state governments to provide these services.

PO l i C y m a k i n g Pr O C e s s at t h e lO C a l gO v e r n m e n t le v e l

As with state policymaking, the legislative process can vary significantly between counties and cities or towns (see, e.g., Erie County Legislature 2018; Metropolitan Government of Nash- ville and Davidson County, Tennessee 2018; Monroe County 2017b). However, in general, local government structures follow the same democratic process to make laws as that used by federal and state legislatures. The exception is that local legislatures and councils typically have only one chamber, unlike the federal and state legislatures. Proposals for new laws are written into resolutions—also referred to as referrals, ordinances, or bills. They are brought in front of the county legislature, city council, or other local governing body to be considered.

Resolutions can be introduced by the local government or elected representatives. In some counties, concerned citizens can write a resolution for presentation at the local govern- ment meeting. Resolutions are usually reviewed by committees in larger counties or cities and by the entire council or legislature in smaller local governments. The resolution then proceeds through multiple readings—with amendments to the legislation often introduced after each reading—and its merits debated before being voted on by the elected representatives. Some resolutions, such as tax laws, may require a greater than 50 percent majority vote to pass.

After the resolution has passed, it may need to be signed into law by the mayor or council executive. Once they become law, resolutions may continue to be called resolutions or become known as bylaws, local laws, or ordinances.

ex a m P l e s O f lO C a l he a lt h C a r e le g i s l at i O n

The public health departments of county and city governments enforce laws that comple- ment state-level healthcare legislation. One of the most common areas for health legislation at the local level is the regulation of tobacco products and smoking in public environments.

democratic Processes carried out in the representative tradition of government by the people, as through free elections.

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To protect children from exposure to secondhand smoke, ten states have enacted laws since 2006 to prevent smoking in cars when children are present (Public Health Law Center 2017a, 2017b). In Monroe County, New York, the local government instituted a general smoking code and a law to prevent adolescent tobacco use (Monroe County 2005, 2017a). Monroe County’s smoking laws are part of a wider public health campaign in the state of New York to curb tobacco use and reduce exposure to secondhand and environmental smoke.

In addition, public health campaigns in many US municipalities urge adults and children to be more active and engage in outdoor activities to curb obesity. Examples of such measures include offering healthy lunches and limiting soft drinks in schools and providing portion-control and nutrition information in restaurants, the latter of which is mandatory in some states (Burgermaster et al. 2017; Finch et al. 2016; Sisson et al. 2016).

Pr i vat e he a lt h re s e a r C h in s t i t u t e s

As with federal, state, and local governments, the private sector has contributed to health policy development. Here, the role of private research institutes—also known as think tanks— in influencing health policy is demonstrated through the work of the RAND Corporation.

RAND conducts research and analysis to improve and inform policymaking in the areas of health, education, and national security. With headquarters located in Santa Monica, California, RAND strives to provide objective analysis and operates independently of com- mercial or partisan ties (RAND Corporation 2018).

The RAND Health division conducts studies on public policy issues related to healthcare reform, health insurance coverage, and the use of information technology in healthcare. Obesity, post-traumatic stress disorder, and complementary and alternative medicine are RAND’s public health focus areas. As a well-regarded participant in policymaking circles, RAND is highly influ- ential through its studies and reports. For an example of RAND’s work, see the Research from the Field box titled “RAND Health Policy Research: An Assessment of High-Deductible Health Plans.”

RESEARCH FROM THE FIELD RAND Health Policy Research: An Assessment of High-Deductible Health Plans

High-deductible health plans (HDHPs), also known as consumer-directed health plans (CDHPs), have increased in popularity in the twenty-first century as methods for controlling healthcare costs. By shifting more of the cost to the patient through increased deductibles, it is believed that consumers will use less care, especially unnecessary care.

In 2011, researchers at the RAND Corporation conducted a cost assessment of HDHPs (Beeuw- kes Buntin et al. 2011). The researchers for this retrospective study looked at data previously

( c o n t i n u e d )

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Pr i vat e he a lt h fO u n d at i O n s

In addition to conducting health policy research, private health foundations work to advance policies through grant programs that fund promising social experiments. The Pew Charitable Trusts is an example of one such foundation.

The Pew Charitable Trusts conducts research and public policy work to address the challenges facing the United States and global community. Areas of study include the envi- ronment, early education, and public health. The Pew trusts also conduct public opinion polls to study trends in specific issues relevant to Americans. Pew’s mission is to advance solutions to these issues (Pew Charitable Trusts 2018a).

The Pew trusts support health research in six main broad policy areas: communities, governing, environment, health, families, and trends. These main topics are subdivided into

RESEARCH FROM THE FIELD RAND Health Policy Research: An Assessment of High-Deductible Health Plans (continued)

collected from the healthcare plan claims and enrollment information reported for 808,707 households by 53 major employers in the United States. Of these employers, 28 offered HDHPs (or CDHPs) to their employees. The increase in healthcare costs for those who enrolled in one of these types of plans for the first time from 2004 to 2005 was compared to the cost increases for those enrolled in traditional healthcare plans during the same period. Similar comparisons were made for the rates of use of preventive care services between the two groups.

Overall, the RAND researchers found that, although healthcare costs increased during the study for both those with HDHPs and those with traditional plans, costs grew at a lower rate for the HDHP group. Similarly, expenditures for families with HDHPs were lower for inpatient and outpatient care and prescription drugs than for families enrolled in traditional health plans; spending on urgent care did not differ between the two groups. The RAND study also found that families who enrolled in HDHPs reduced their use of preventive care services, including childhood immunizations, the rates of which increased among traditional plan users; mammog- raphy; cervical cancer screening; and colorectal cancer screening (Beeuwkes Buntin et al. 2011).

Studies such as those conducted by RAND can inform policymakers assessing the effec- tiveness of government health programs. Under the ACA, for example, deductibles must be waived for preventive healthcare services. Thus, one implication of the RAND study is that communicating information clearly to families enrolled in HDHPs and to employers offer- ing these plans about this provision of the ACA must be a priority if the goal of increasing preventive care is to be met. Moreover, amending regulations to expand the “safe harbor” by allowing HDHP coverage of high-value services and medications for chronic diseases would provide Americans with a plan option that better meets their clinical and financial needs (Fendrick and Soonavala 2017).

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more focused areas of study. For example, the health topic encompasses antibiotics, biomedi- cal research, drug safety, food safety, healthcare costs, and medical ethics (Pew Charitable Trusts 2018b). Solutions to problems identified in these areas are policy-oriented, such as supporting mandatory food safety standards (see the Research from the Field box titled

“An Example of Pew Health Policy Research: The Kids’ Safe and Healthful Foods Project”) and organizing informational campaigns to curb the overuse of antibiotics in livestock (Pew Charitable Trusts 2018b).

RESEARCH FROM THE FIELD An Example of Pew Health Policy Research: The Kids’ Safe and Healthful Foods Project

The Kids’ Safe and Healthful Foods Project (2013), funded by the Pew Health Group in partner- ship with other private foundations, aims to improve the food choices available in schools to curb childhood obesity and reform food safety policies in schools to stop the spread of foodborne illnesses. As part of the project, the Pew Health Group works with the US Depart- ment of Agriculture (USDA) by providing the agency with evidence-based analysis and policy recommendations.

The three major goals of the Kids’ Safe and Healthful Foods Project (2013) are to (1) ensure that the nutrition standards established by the USDA for foods and beverages available in schools are based on scientific evidence, (2) make sure schools have sufficient resources to properly train cafeteria employees and keep cafeteria equipment in good working order, and (3) help the USDA establish and enforce stringent food safety policies for schools. (Prior to the launch of the Kids’ Safe and Healthful Foods Project, the USDA nutritional standards for school meals had not been updated in more than 15 years.)

As a result of the project, which is also closely aligned with the White House Task Force on Childhood Obesity, food safety has improved. Under the new school food safety policies that arose from the Healthy, Hunger-Free Kids Act and were guided by the Kids’ Safe and Healthful Foods Project, the USDA is required to enhance its communication with other government agencies, including its hold and recall procedures, so that schools are notified of food recalls in a timely manner. The agency must also ensure that food served outside the cafeteria—in classrooms or elsewhere—meets the same safety standards. These additional requirements will help schools to avoid outbreaks of foodborne illness, such as in 2009 when schools may have served students peanut products contaminated with Salmonella because they did not receive the recall notices in time (Kids’ Safe and Healthful Foods Project 2013). In 2017, researchers examining 1.7 million meals in an urban school district in the state of Washington found that the overall nutritional quality of meals had increased by 29 percent since the standards took effect. According to a poll conducted by Pew, the Robert Wood Johnson Foundation (RWJF), and the American Heart Association, more than 70 percent of parents surveyed said they supported the updated nutrition standards (Ratliff 2017).

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Pr i vat e in d u s t ry

Corporate America influences health and health policy primarily through its services or products and its lobbying activities. The fast-food and tobacco industries, for example, have extensive business interests in the United States and around the world, and their products are key influencers of the population’s health status. Corporate America can also take a leadership role in promoting better health for employees in the workplace (see the For Your Consid- eration box titled “Importance of Workplace Health Promotion”), thus setting an example for smaller businesses. Some private enterprises in the United States are even developing their own initiatives to address the delivery of cost-effective, integrated healthcare services.

fa s t-fO O d in d u s t ry

According to an annual Gallup poll, nearly 50 percent of American adults eat fast food at least once a week, and 80 percent eat it at least once a month (Dugan 2013). In 2017, Americans spent nearly $291 billion on fast food, a huge increase compared with 1970, when they spent $6 billion (Statista 2018a). In addition to those with drive-through access, fast-food restaurants (also called quick-service restaurants) can be found in airports, hospi- tals, schools and universities, stadiums, cruise ships, and many other gathering places (CBS News 2002; Statista 2018a; Walker 2001).

In general, fast food is inexpensive, conve- nient, filling, and prepared quickly for the con- sumer. Fast food does not require dishes or utensils for eating, is often deep fried, and comes in large portions with uniform specifications. Few fresh vegetables are used because they are difficult to store long term.

The fast-food industry consists mainly of multimillion-dollar national restaurant chains. McDonald’s Corporation alone franchised 36,899 restaurants worldwide in 2016 and continues to expand each year (Statista 2018b). It hires more people per year than does any other American organization and is the country’s largest purchaser

of beef, pork, and potatoes. McDonald’s is also the largest owner of retail property in the world and the leading fast-food restaurant chain in the United States, with retail sales of about $36.39 billion in 2016 (Statista 2018b).

In addition to its vast marketing campaigns, the fast-food industry and its suppliers spend large sums lobbying the US government to promote or oppose legislation according

corporate America An informal term referring to the corporations based and operating in the United States; they are not under direct governmental control.

fast food Ready-to-eat, often portable, and inexpensive food available through many outlets in the United States. This type of food tends to be less healthy than homemade food and has been criticized for contributing to the obesity epidemic in the United States.

FOR YOUR CONSIDERATION Importance of Workplace Health Promotion

About 160 million people in the United States spend half of their waking hours at work, which makes the workplace an essential setting for health promotion and disease prevention. In addition, scientific evidence proves that well-designed workplace health promotion programs can improve population health, reduce healthcare costs, increase worker productivity, and even achieve a desirable return on investment (Baxter et al. 2016; Soler et al. 2010).

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to the industry’s interests. Worker safety, food safety, and minimum wage laws have histori- cally been opposed by the fast-food industry.

The increased consumption of fast food has contributed to obesity among American adults and children (CBS News 2002; WHO 2017). In addition to the commonly cited factors linking fast-food consumption to obesity (e.g., large amounts of fat, highly processed ingredients), studies have shown that proximity to fast-food outlets is a factor (e.g., Currie et al. 2009; Elliston et al. 2017; Mejia et al. 2015; Rabin 2009; Svastisalee et al. 2016). For example, Currie and colleagues (2009) found that when a fast-food restaurant was located within a tenth of a mile of a school, the obesity rates for children attending the school increased 5.2 percent more than for children who attended a school with a fast-food restaurant at least a quarter of a mile away.

In 2002, a group of obese and overweight children filed a class-action lawsuit against McDonald’s, asking the court to award compensation for their obesity-related health prob- lems and requesting that it force McDonald’s to improve its nutritional labeling and provide funding for a health education campaign on the dangers of fast food. The lawsuit was dis- missed a year later, but it raised important questions about legal accountability for the poor nutritional standards of most fast-food menu items. Mello, Rimm, and Studdert (2003) draw parallels between the fast-food industry’s intention to process and manufacture food to be addictive and the tobacco industry’s aim to manufacture addictive cigarettes.

Ci g a r e t t e a n d tO B a C C O in d u s t ry

The tobacco industry is composed mainly of large, multinational corporate tobacco growers and cigarette manufacturers. The industry carries historical significance in the United States, as tobacco was an important commodity in colonial times. The United States was the world’s fourth largest producer of tobacco (following China, India, and Brazil) in 2016 (Statista 2018c). According to the USDA (2016), US farmers harvested about 700 million pounds of tobacco in 2015, and the leading state in tobacco production was North Carolina. About 249 billion cigarettes were sold in the United States in 2017 (CDC 2018b).

Tobacco products are the most heavily taxed consumer product in the United States, when measured by percentage of retail price. The industry is also highly regulated, with quotas set for each farmer’s land and the end product graded by USDA inspectors. The sale of tobacco to dealers and warehouses is monitored by the USDA’s Agricultural Stabilization and Conservation Service.

According to the American Lung Association (2018a) and the Centers for Disease Control and Prevention (CDC 2018c), smoking cigarettes is the number one preventable cause of morbidity and mortality worldwide. More than 480,000 Americans and 7 million people worldwide die from tobacco smoking–related diseases annually (CDC 2018c; WHO 2018). Smoking causes more deaths in the United States each year than the following causes

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combined: HIV, illegal drug use, alcohol use, motor vehicle injuries, and firearm-related incidents (CDC 2013, 2017a; HHS 2014). Secondhand smoke contains more than 7,000 chemicals, including hundreds of toxic substances and at least 70 that can cause cancer (CDC 2017c). Chronic lung disease, including lung cancer and chronic obstructive pulmonary disease, accounts for 80 to 90 percent of smoking-related morbidity (CDC 2017a). Every year, smoking-related deaths and diseases cost the United States more than $300 billion, including $170 billion from direct healthcare expenditures and more than $156 billion from lost productivity due to premature death and exposure to secondhand smoke (CDC 2018c).

Despite such statistics illustrating the widely known health risks associated with tobacco products, however, the tobacco industry is highly concentrated—only four companies together accounted for 92 percent of US cigarette sales in 2017 (CDC 2018b)—and has a strong economic incentive to continue to sell its products. In 2016, US tobacco companies spent about $9.5 billion marketing cigarettes and smokeless tobacco in the United States (CDC 2018b, 2018c). Most promotional efforts came in the form of price discounts to wholesalers and retailers (American Lung Association 2018b; CDC 2018b, 2018c). It has been shown that lowering the price of cigarettes increases youth consumption; conversely, with each 10 percent increase in the price of cigarettes, youth consumption drops by 6 to 7 percent (American Lung Association 2018b; Boonn 2017).

Pr i vat e in i t i at i v e s t O ad d r e s s he a lt h C a r e de l i v e ry

Largely disillusioned with the slow pace in healthcare reform and saddled with ever-increasing healthcare expenses for their employees, US private enterprises are experimenting with their own reform initiatives to bring healthcare costs down and develop a more integrated approach toward care delivery.

Independent Healthcare Through Corporate Giants: Amazon, Berkshire Hathaway, and JPMorgan Chase Coalition In January 2018, Amazon, Berkshire Hathaway, and JPMorgan Chase announced that they would combine their efforts to improve healthcare and lower its cost for the three companies’ US employees—more than 900,000 workers in all (Bomey and Weise 2018; Business Wire 2018; Chappell 2018; Snider 2018)—by forming “an independent company that is free from profit-making incentives and constraints” (Business Wire 2018). Executives from each of the three companies were named to lead the initial formation and early planning stages of the new healthcare company, and a CEO search was launched in March 2018 (Business Wire 2018; Chappell 2018; Farr 2018). It was unclear how greatly the three corporate partners would change their employees’ existing health coverage as a result of the new plan—whether

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they would simply help employees find a local doctor, guide employees to online medical advice, or use their influence to negotiate lower prices for drugs and medical procedures.

Although the new healthcare company would serve only the three founding companies’ employees, these large corporations were expected to be closely watched so that any success- ful efforts could serve as a model for other businesses (Snider 2018). Early reactions to the announcement suggested that Amazon’s involvement in the new company could make the pharmacy market more competitive, given Amazon’s proven ability to lower shipping costs and make delivery more efficient for a variety of other products (Bomey and Weise 2018).

Expansion of Geographic Coverage: Advocate Health Care and Aurora Health Care Merger In April 2018, Illinois-based Advocate Health Care and Wisconsin-based Aurora Health Care merged to become Advocate Aurora Health, the tenth-largest not-for-profit health- care system in the United States (Boulton 2018; Schencker 2018). The merger agreement included a single board of directors with equal numbers of directors from each of the two companies; the Advocate and Aurora CEOs serving as co-CEOs of the new company; and dual headquarters retaining the two original headquarters in Downers Grove, Illinois, and Milwaukee, Wisconsin (Boulton 2017, 2018; Burke 2017; Schencker 2018).

Prior to the merger, Advocate Health Care was the largest health system in Illinois and one of the largest healthcare providers in the Midwest, and Aurora Health Care was Wisconsin’s largest private employer (Advocate Health Care 2017). The new Advocate Aurora Health operates 27 hospitals as well as several hundred other sites of care and employs about 70,000 people (Advocate Health Care 2017; Boulton 2018; Schencker 2018). The potential advantages of such an increase in size include making full use of advances in information technology, such as analytics, to better manage the care of patients and creating economies of scale for providing increasingly complex care to patients, such as treatments based on patients’ genetic makeup (Boulton 2017) as well as improving access to physicians and communication with healthcare providers through services such as telehealth (Schencker 2018). The co-CEOs expressed hope that their merger would not only improve healthcare quality but also slow the ongoing increase in healthcare costs (Boulton 2018).

Vertical Integration: Humana, TPG Capital, and Welsh, Carson, Anderson, and Stowe Acquisition of Kindred Healthcare In April 2018, the shareholders of Kindred Healthcare, a provider of post-acute care services, agreed to a takeover by national insurer Humana and two private equity firms—TPG Capital and Welsh, Carson, Anderson and Stowe (WCAS)—for $4.1 billion (Sweeney 2018). The acquisition, announced in December 2017, was completed in July 2018 (Gulden 2018;

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Livingston 2017; Stankiewicz 2018; Sweeney 2018). The three acquiring companies split off and will jointly operate Kindred at Home (Kindred’s provider of home health, hospice, and community care) as a stand-alone company; and TPG Capital and WCAS took over Kindred Hospitals (Kindred’s long-term acute care hospitals) and ReHab Care (Kindred’s inpatient rehabilitation facilities) to be operated together under the Kindred Healthcare name as a specialty hospital company (Gulden 2018; Livingston 2017; Stankiewicz 2018).

The acquisition of Kindred at Home gives Humana greater control of home health providers that offer the kinds of services needed by about 10 percent of Humana’s 3.3 mil- lion Medicare Advantage members, which could lead to cost savings for those members and Humana (Gulden 2018). At the time of the acquisition, Humana would own 40 percent of Kindred at Home but have the option to buy out the other 60 percent owned by TPG Capital and WCAS in the future (Gulden 2018; Stankiewicz 2018; Sweeney 2018).

Pharmacy–Insurance Combination: CVS Acquisition of Aetna CVS is a pharmacy chain with more than 9,700 retail pharmacies across the United States—about 1,100 of them also containing walk-in clinics (Japsen 2018). Aetna is a large insurer, offering health plans for Medicare beneficiaries and serving the employer market. Both firms sponsor Medicare prescription drug plans. CVS paid $69 billion to acquire Aetna in an agreement that was expected to receive the necessary federal and state approval by the end of 2018 (Japsen 2018).

The CVS–Aetna merger joins a health insurance company with healthcare provid- ers—in this case, with retail clinics (Frakt and Garthwaite 2018). By more closely integrating pharmacy benefit management with nondrug coverage, the CVS acquisition of Aetna could benefit consumers, as suggested by studies of Medicare and Medicaid (Dranove and Starc 2017; Lavetti and Simon 2016; Starc and Town 2015). Combining CVS retail clinics with Aetna could improve coordination of care if there were value-increasing investments, which neither company made because they would have financially benefitted only the other firm (Ashwood et al. 2016).

It remains to be seen whether cost savings will materialize, and if so, whether they will they be shared with consumers. It is also unclear whether the coordinated benefits that the combined CVS–Aetna could offer would lead to lower healthcare costs.

Insurer Purchase of Large Doctors Group: UnitedHealth Group and DaVita Medical Group Following the announcement of the CVS acquisition of Aetna, the large insurance com- pany UnitedHealth Group made a move to buy DaVita Medical Group, a large group of doctors (Abelson 2017; Tech2.org 2018). The acquisition was to be made through Unit- edHealth’s Optum unit and was expected to pass regulatory review and be completed by the end of 2018 (Seeking Alpha 2018). It would give UnitedHealth control of more than

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250 DaVita-operated urgent care clinics and a number of medical practices in California, Florida, and several other states, allowing it to offer consumers a lower-cost alternative to hospital care for some emergency services and certain chronic conditions such as asthma and diabetes (Abelson 2017; Tech2.org 2018).

UnitedHealth had already acquired a chain of outpatient surgical centers in January 2017, and the DaVita purchase was seen by industry observers as an effort to broaden its business model to include direct delivery of medical care (Abelson 2017; Tech2.org 2018). The move was viewed as potentially beneficial to consumers in lowering healthcare costs; however, it could also limit the choice of doctors available in the insured’s health plan to those affiliated with UnitedHealth, although the company claimed that Optum currently works with more than 80 health plans (Abelson 2017).

at t r i B u t e s O f he a lt h PO l i C y de v e l O P m e n t i n nO n f e d e r a l se C t O r s

Health policymaking in nonfederal sectors—state and local governments and the private sector—is characterized by several factors:

◆ The constraints imposed by the broader policy landscape

◆ The relationship between politics and policy

◆ The level of public health funding available

◆ The ways in which the private sector shapes policy direction

◆ Policy entrepreneurship at the grassroots level

CO n s t r a i n t s un d e r fe d e r a l PO l i C y

Health policymaking at the state and local levels is limited by broader federal policy. Although regulation is primarily the states’ responsibility, federal laws can preempt state legislation. For example, states cannot require firms to offer insurance to their employees because federal law—in the form of the Employee Retirement Income Security Act—would override any attempt by the state to do so.

The private sector is also influenced and constrained by federal regulations, in areas such as practitioner licensing, security and privacy of patient information, and reimbursement. For example, the Medicare and Medicaid programs periodically adjust their reimbursement methodologies—the methods by which they calculate how much money to pay providers for services rendered—which has prompted healthcare organizations to make changes in the way services are delivered.

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re l at i O n s h i P Be t w e e n PO l i t i C s a n d PO l i C y

Legislation is most likely to pass if the governor and the majority of the legislature carry the same political party affiliation. Similarly, legislation often is stalled or diluted when the policymakers consid- ering it represent different parties (see the For Your Consideration box titled “Traditional Republican and Democratic Stances”).

Another link between politics and policy, which applies to all sectors involved in policymak- ing, is the election cycle. In the time preceding an election, politicians running for reelection often emphasize legislation that is expected to garner immediate results, thus benefiting their reelection bids. Difficult problems that take a long time to solve are often left for future congressional sessions. As a result, many problems facing US residents are

cumulative, but the policies meant to address them are symptomatic—addressing not the root cause but rather its symptoms—and piecemeal. The underlying problems, left unresolved, tend to worsen over time and exact an even heavier toll on all those affected than an earlier, more comprehensive solution would have.

le v e l O f Pu B l i C he a lt h fu n d i n g

The US market-oriented economy attracts private entrepreneurs to carry out key functions of healthcare delivery at a profit, leaving the public sector to assume a secondary role when the market alone cannot address all healthcare needs, particularly for members of vulnerable populations who cannot afford expensive care. The resulting healthcare system is function- ally fragmented, with little standardization, resulting in the duplication of certain services and inadequacy of others.

Funding for public health in the United States is relatively low. In 2009, of all the money spent on health (nearly $2.5 trillion), only 3.1 percent of it ($77.2 billion) was spent on government public health activities (IOM 2012). By comparison, Canada spent 5.5 percent of its total health expenditure on public health in 2005 (Canadian Institute for Health Information 2005). Little public investment is made in health technology, workforce training and recruitment, or facility construction or renovation in the United States. In addition, the fact that spending on public health varies widely across communities raises

FOR YOUR CONSIDERATION Traditional Republican and Democratic Stances

The 2016 election cycle highlighted a number of policy positions (known as planks in their platform) favored by each major party. Republicans have traditionally sought “small” government—gov- ernment that practices limited use of regulation, as opposed to

“big,” centralized government—and limited taxation and supported business interests, whereas Democrats have historically favored social programs, assistance for vulnerable populations, and a larger tax share from the wealthy than from the middle and lower classes. How do you view these positions in light of the comments made by party leaders during the 2016 presidential and congressional elections as reported by the mainstream media? Do the comments consistently reflect these traditional stances? Why or why not?

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concerns about whether and how these differences might affect the availability of essential public health services.

sh a P i n g PO l i C y di r e C t i O n

The private sector shapes policy direction more than state and local governments do. As described earlier in this chapter, the topics addressed by private research institutes and the projects funded by private foundations lead to findings that contribute to a better under- standing of health problems, their underlying causes, and potential solutions, thus paving the way for policy development. Another way that private research institutes and founda- tions drive policy is in their evaluations of existing policies, the results of which are often incorporated in policy modifications or new policies.

PO l i C y en t r e P r e n e u r s h i P at t h e gr a s s r O O t s le v e l

Grassroots efforts by policy entrepreneurs involve community stakeholders and may be funded by private foundations. Such efforts are critical to adapting successful experiences to other environments and identifying innovative approaches to solving health-related issues.

Typically, community-based projects stress participation and empowerment; engaging community members in these projects helps the initiative be accepted and helps promote sustainability of the intervention. Community members plan and manage initiatives, and— through community mobilization, skill building, and resource sharing—communities are empowered to identify and meet their own needs, making them stronger advocates for the vulnerable populations within and across their community boundaries.

➤ Although the policymaking process can vary substantially from state to state, states generally apply the same legislative system as the federal government does.

➤ Local government structures follow the same democratic process for making laws as federal and state legislatures do, except that local legislatures and councils typically have only one legislative chamber.

➤ The private sector, including private research institutes, foundations, and industry, contributes to health policy development.

➤ The major attributes of health policymaking in the public nonfederal sector include the constraints imposed by the broader federal policy landscape, influence of politics, availability of funding, level of entrepreneurship at the local level, and lack of integration and coordination among policymaking groups.

policy entrepreneurs Public innovators who, from outside the formal positions of government, introduce, translate, and implement new ideas into public practice.

k e y P O i n t s

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Ca s e st u d y 1

Research the events leading to and following the enactment of the Massachusetts healthcare reform legislation introduced in the case study, and answer the following questions:

1. Why was Massachusetts able to enact state-level healthcare reform whereas most other states were not?

2. What are the positive and negative consequences of the Massachusetts healthcare reform?

3. What consequences would you anticipate if similar reform were enacted nationally?

Ca s e st u d y 2

Research the prevalence of mental health problems in the United States, and answer the fol- lowing questions:

1. As mental health becomes a public health issue in the United States and elsewhere, what are the major mental health challenges?

2. What are the determinants of mental health problems in the United States and elsewhere?

3. Using the Connecticut example, how can the state address its mental health challenges from both public health and healthcare perspectives?

1. Describe, and provide an example of, the policymaking process at the US state level. 2. Describe, and provide an example of, the policymaking process at the US local level. 3. What are the health policy–related activities of private health research institutes? Of

private health foundations? 4. What kinds of public health information and initiatives are contributed by private

industry? 5. What impact would the private business sector have on the development of healthcare

financing and delivery in the United States? 6. List three characteristics of health policy development in the US state government,

local government, and private sectors.

C a s e s t u d y Q u e s t i O n s

f O r d i s C u s s i O n

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r e f e r e n C e s

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