Intro final paper

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Hi,

Please read all instructions all that is needed is Introduction to a paper following the following guidelines:

Introduction (discussing the global, national, state and local implications of the group policy change and explaining how and why the group selected to focus on this particular policy change. At the end of this section the group should set forth the Group’s policy change in brief)

Must Contain and discuss a single specific and detailed change to an existing law.

APA Style in-text citations using “external authoritative sources” are required

At least one source citation substantively used in each paragraph.

Proper English is required throughout the entire paper.

Must be TWO pages.

LAW to discuss:

EMTALA – Emergency Medical Treatment and Active Labor Act

“Hard to imagine a world without the Emergency Medical Treatment and Active Labor Act (EMTALA), which went into effect in 1986. This law guarantees emergency health care by requiring healthcare providers to deliver medical services regardless of the patient’s ability to pay. The law requires caregivers to stabilize the patient and provide treatment until a point that the patient remains stable, such as with injury or during child birth. If the care provider is unable or unwilling to provide such service, the provider must transfer the patient to a capable facility.”

If this law were to be changed, we as a group think that instead of transferring a patient to a different facility where care providers are willing to provide a service, all providers must be willing to provide service even though a patient may not be able to pay. As medical care providers, healthcare for all should be the most important aspect of healthcare so the policy change should be to provider medical service regardless of the ability to pay when all the financial dealings can be done at a later time. 

I think that the law policy should be changed so that hospitals should give 100% care to anyone who has life threatening conditions and not just to stabilize a patient to be transported. She said that To require private for profit hospitals to keep patients who walk into their emergency room past stabilizing them will cut into their obligation to their shareholders. The change would only require a hospital to give care past stabilization only if it is 100% required.

I have added the book as well for help.

Links to help:  

https://www.mdlinx.com/article/10-medical-laws-all-doctors-sho

https://www.acep.org/life-as-a-physician/ethics–legal/emtala/emtala-fact-sheet/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1305897/

https://journalofethics.ama-assn.org/article/emtala-bad/2010-06

https://pubmed.ncbi.nlm.nih.gov/29116661/

L E I Y U S H I

00_Shi (2374) Book.indb 1 11/21/18 10:55 AM

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Mayo Clinic

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L E I Y U S H I

00_Shi (2374) Book.indb 2 11/21/18 10:55 AM

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Library of Congress Cataloging-in-Publication Data

Names: Shi, Leiyu, author.
Title: Introduction to health policy / Leiyu Shi, Gateway to Healthcare Management.
Description: Second edition. | Chicago, Illinois : Health Administration Press, HAP ; Washington, D.C. :

Association of University Programs in Health Administration, AUPHA, [2019] | Includes bibliographical
references and index.

Identifiers: LCCN 2018040567 (print) | LCCN 2018041419 (ebook) | ISBN 9781640550261 (ebook) |
ISBN 9781640550278 (xml) | ISBN 9781640550285 (epub) | ISBN 9781640550292 (mobi) | ISBN
9781640550254 (print : alk. paper)

Subjects: LCSH: Medical policy—History. | Health care reform. | Public health—International cooperation.
Classification: LCC RA393 (ebook) | LCC RA393 .S473 2019 (print) | DDC 362.1—dc23
LC record available at https://lccn.loc.gov/2018040567

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in Health Administration

1730 M Street, NW
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00_Shi (2374) Book.indb 4 11/21/18 10:55 AM

I dedicate this book to my wife, Ruoxian,
and my children, Sylvia, Jennifer, and Victor Shi.

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v i i

B R I E F C O N T E N T S

Preface ………………………………………………………………………………………………………. xiii

PART I Introduction

Chapter 1 Overview of Health Policy ………………………………………………………………3

PART II Health Policymaking

Chapter 2 Federal Health Policymaking …………………………………………………………37

Chapter 3 Health Policymaking at the State and Local Levels
and in the Private Sector ………………………………………………………..70

Chapter 4 International Health Policymaking ……………………………………………….102

PART III Health Policy Issues

Chapter 5 Health Policy Related to Financing and Delivery …………………………….131

Chapter 6 Health Policy for Diverse Populations …………………………………………..155

Chapter 7 International Health Policy Issues …………………………………………………202

PART IV Health Policy Research

Chapter 8 Overview of Health Policy Research ……………………………………………..255

Chapter 9 Health Policy Research Methods ………………………………………………….292

Chapter 10 An Example of Health Policy Research ………………………………………….339

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v i i i B r i e f C o n t e n t s

Glossary …………………………………………………………………………………………………….375

Index ………………………………………………………………………………………………………….383

About the Author ……………………………………………………………………………………..407

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i x

Preface ………………………………………………………………………………………………………. xiii

PART I Introduction

Chapter 1 Overview of Health Policy ………………………………………………………………3
Learning Objectives ……………………………………………………………………….3
Case Study 1: Healthcare Reform: Hillary Clinton

and Barack Obama …………………………………………………………………4
Case Study 2: Healthcare Reform After the ACA ………………………………..5
Health Defined……………………………………………………………………………..6
Public Health Defined ……………………………………………………………………9
What Are the Determinants of Health? …………………………………………..10
Policy Defined …………………………………………………………………………….18
Health Policy Defined ………………………………………………………………….19
What Are the Determinants of Health Policy? ………………………………….21
Stakeholders of Health Policy ………………………………………………………..25
Why Is It Important to Study Health Policy? ……………………………………27
Key Points ………………………………………………………………………………….28
Case Study Questions …………………………………………………………………..29
For Discussion …………………………………………………………………………….29
References ………………………………………………………………………………….30

PART II Health Policymaking

Chapter 2 Federal Health Policymaking …………………………………………………………37
Learning Objectives ……………………………………………………………………..37

D E TA I L E D C O N T E N T S

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x D e t a i l e d C o n t e n t s

Case Study 1: The Development of Medicare and Medicaid ……………….38
Case Study 2: The Health Insurance Portability and Accountability

Act of 1996 …………………………………………………………………………39
The US Political System………………………………………………………………..40
Policymaking Process at the Federal Level ………………………………………..42
Attributes of Health Policymaking in the United States ……………………..54
Role of Interest Groups in US Health Policymaking ………………………….58
Key Points ………………………………………………………………………………….62
Case Study Questions …………………………………………………………………..62
For Discussion …………………………………………………………………………….63
References ………………………………………………………………………………….63
Additional Resources ……………………………………………………………………68

Chapter 3 Health Policymaking at the State and Local Levels
and in the Private Sector ………………………………………………………..70

Learning Objectives ……………………………………………………………………..70
Case Study 1: Massachusetts Healthcare Reform ………………………………71
Case Study 2: Connecticut Opioid Response Initiative ………………………71
State Government Structure ………………………………………………………….73
Local Government Structure …………………………………………………………79
Private Health Research Institutes…………………………………………………..81
Private Health Foundations …………………………………………………………..82
Private Industry …………………………………………………………………………..84
Attributes of Health Policy Development in Nonfederal Sectors ………….89
Key Points ………………………………………………………………………………….91
Case Study Questions …………………………………………………………………..92
For Discussion …………………………………………………………………………….92
References ………………………………………………………………………………….93

Chapter 4 International Health Policymaking ……………………………………………….102
Learning Objectives ……………………………………………………………………102
Case Study 1: WHO Healthy Cities Initiative ………………………………..103
Case Study 2: Primary Care Workforce Around the World ……………….104
The World Health Organization …………………………………………………..105
Health Policymaking in Selected Countries ……………………………………109
Key Points ………………………………………………………………………………..121
Case Study Questions …………………………………………………………………121
For Discussion …………………………………………………………………………..122
References ………………………………………………………………………………..122
Additional Resources ………………………………………………………………….128

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D e t a i l e d C o n t e n t s x i

PART III Health Policy Issues

Chapter 5 Health Policy Related to Financing and Delivery …………………………….131
Learning Objectives ……………………………………………………………………131
Case Study 1: The Federally Funded Health Center Program:

Providing Access, Overcoming Disparities ………………………………132
Case Study 2: Precision Medicine …………………………………………………133
Financing US Healthcare …………………………………………………………….134
US Healthcare Delivery ………………………………………………………………139
Policy Issues in Healthcare Financing and Delivery …………………………145
Key Points ………………………………………………………………………………..149
Case Study Questions …………………………………………………………………150
For Discussion …………………………………………………………………………..150
References ………………………………………………………………………………..151

Chapter 6 Health Policy for Diverse Populations …………………………………………..155
Learning Objectives ……………………………………………………………………155
Case Study 1: The Health Center Program …………………………………….156
Case Study 2: My Health GPS Program for Patients

with Multiple Chronic Conditions ………………………………………..157
Defining Vulnerability ………………………………………………………………..158
Health Policy Issues for Diverse Populations …………………………………..159
Health Policy Issues for Vulnerable Subpopulations …………………………168
Key Points ………………………………………………………………………………..184
Case Study Questions …………………………………………………………………184
For Discussion …………………………………………………………………………..185
References ………………………………………………………………………………..185

Chapter 7 International Health Policy Issues …………………………………………………202
Learning Objectives ……………………………………………………………………202
Case Study 1: Climate Change and Public Health …………………………..203
Case Study 2: Primary Care Around the World ………………………………204
Health Policy Issues in Developed Countries ………………………………….207
Health Policy Issues in Developing Countries …………………………………217
Key Points ………………………………………………………………………………..236
Case Study Questions …………………………………………………………………237
For Discussion …………………………………………………………………………..237
References ………………………………………………………………………………..237
Additional Resources ………………………………………………………………….250

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x i i D e t a i l e d C o n t e n t s

PART IV Health Policy Research

Chapter 8 Overview of Health Policy Research ……………………………………………..255
Learning Objectives ……………………………………………………………………255
Case Study 1: The RAND Health Insurance Experiment ………………….256
Case Study 2: Idaho’s Preventive Health Assistance Program ……………..257
Defining Health Policy Research ………………………………………………….258
The Process of Health Policy Research …………………………………………..265
Communicating Health Policy Research ………………………………………..276
Implementing Health Policy Research …………………………………………..279
Key Points ………………………………………………………………………………..285
Case Study Questions …………………………………………………………………286
For Discussion …………………………………………………………………………..286
References ………………………………………………………………………………..287

Chapter 9 Health Policy Research Methods ………………………………………………….292
Learning Objectives ……………………………………………………………………292
Case Study 1: Health Centers and the Fight

Against Health Disparities in the United States ……………………….293
Case Study 2: Vermont’s Accountable Communities

for Health Learning Lab ………………………………………………………294
Quantitative Methods ………………………………………………………………..295
Qualitative Methods …………………………………………………………………..314
Key Points ………………………………………………………………………………..326
Case Study Questions …………………………………………………………………326
Case Study Assignment ………………………………………………………………327
For Discussion …………………………………………………………………………..327
References ………………………………………………………………………………..327
Additional Resources ………………………………………………………………….338

Chapter 10 An Example of Health Policy Research ………………………………………….339
by Sarika Rane Parasuraman

Learning Objectives ……………………………………………………………………339
Questions for Policy Analysis ……………………………………………………….340
Policy Analysis: Responses to Exam Questions ……………………………….341
Key Points ………………………………………………………………………………..366
For Discussion …………………………………………………………………………..366
References ………………………………………………………………………………..367

Glossary …………………………………………………………………………………………………….375

Index ………………………………………………………………………………………………………….383

About the Author ……………………………………………………………………………………..407

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x i i i

P R E FA C E

U
S policymakers have been struggling for years to find solutions to our healthcare
challenges. Thus, healthcare reform is among the top priorities of almost every
administration. This introductory textbook on US health policy covers the related

areas of health policymaking, critical health policy issues, health policy research, and an
international perspective on health policy and policymaking. The book offers the following
features:

◆ Real-world cases to exemplify the theories and concepts presented from a
variety of perspectives, including the hospital setting, public health, managed
care, ambulatory care, and extended care

◆ Exhibits and extra feature boxes (Learning Points, For Your Consideration,
Key Legislation, Research from the Field, International Policymaking, Global
Health Impact, and others) that present background information on concepts,
examples, and up-to-date information

◆ Learning objectives and key points

◆ Discussion questions

Or g a n i z at i O n O f t h e BO O k

This book is organized in four parts: an introduction, an overview of health policymaking, a
health policy issues section, and a discussion of health policy research and analysis. Chapter 1,
the sole chapter in part I, introduces key terms related to, and the determinants of, health

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x i v P r e f a c e

and health policy. It lists the key stakeholders in health policymaking and presents important
reasons for studying health policy. The chapter lays the foundation for the rest of the book.

Part II—containing chapters 2, 3, and 4—examines the policymaking process at the
federal, state, and local levels; in the private sector; and in international settings. Chapter 2
focuses on the policymaking process at the federal level of the US government. Important
activities within the three policymaking stages—policy formulation, policy implementation,
and policy modification—are described. The key characteristics of health policymaking in
the United States are analyzed, and the role of interest groups in making policy is discussed.

Chapter 3 focuses on the US policymaking process at the state and local levels and in
the private sector, which includes the research community, foundations, and private industry.
Examples of policy-related research by private research institutes and foundations are described.
The impact of the private sector’s services and products on health and policy is illustrated
using the fast-food industry as well as tobacco and pharmaceutical companies as examples.

Chapter 4 discusses international health policymaking. The World Health Organiza-
tion (WHO) is presented as an example of an international agency involved in policymak-
ing related to health and major health initiatives. Three countries—Canada, Sweden, and
China—are highlighted to illustrate diverse policymaking processes in distinct geographic
regions. The experiences of these countries show that different political systems and policy-
making processes lead to diverse approaches to population health and healthcare delivery.

Part III—encompassing chapters 5, 6, and 7—examines the policy issues related to
social, behavioral, and medical care health determinants; to people from diverse or medi-
cally or socially vulnerable populations; and to international health. Chapter 5 describes
how US healthcare is financed and delivered. Private and public health insurance programs
are summarized, and the subsystems of healthcare delivery—managed care plans, safety net
providers, public health programs, long-term care services, and military-operated health-
care—are introduced. After summarizing the major characteristics of US healthcare delivery,
the chapter provides examples of health policy issues related to financing (cost containment)
and delivery (healthcare workforce, professional accreditation, antitrust regulations, patient
access to care, and patient rights).

Chapter 6 defines medically and socially vulnerable populations and discusses the
dominant healthcare policy issues related to those populations. People from diverse popu-
lations include members of racial or ethnic minorities, the uninsured, people with low
socioeconomic status, the elderly, people with chronic illness, people with mental illness,
women and children, people with disabilities, the homeless, and people with HIV/AIDS.
In each segment, the magnitude of the problem is summarized and a detailed discussion of
the policies and strategies meant to address the problem is presented.

In chapter 7, dominant health policy issues in the international community are
discussed, with examples given for select countries, to help students understand not only
international health policy applications but also the field of global health. The chapter begins

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P r e f a c e x v

by examining issues shared by developed countries, such as modifying health systems to
better serve aging and diverse populations while maintaining high-quality care at a low cost.
It then discusses challenges faced by developing nations, such as controlling the spread of
disease, creating and maintaining high-functioning health systems with limited resources,
and dealing with the burdens of morbidity and mortality associated with poverty. Several
emerging issues are also illustrated that could affect global health in the future.

Part IV—comprising chapters 8, 9, and 10—presents an overview of policy analysis,
focusing on examples of commonly used quantitative and qualitative methods. Chapter 8
introduces health policy research (HPR) and highlights the discipline’s defining characteristics,
including applied, policy-relevant, ethical, multidisciplinary, scientific, and population-based
studies. The HPR process is summarized, and the chapter concludes with a discussion of
ways to communicate findings and the challenges in implementing those findings in practice.

Chapter 9 illustrates commonly used methods in HPR. Quantitative methods include
experimental research, survey research, evaluation research, cost–benefit analysis, and cost-
effectiveness analysis. Because evaluation research is closely tied to policy research, the process
involved in this type of research is described in greater detail. Qualitative methods include
participant observations, in-depth interviews (including focus groups), and case studies.
Examples of published studies using these methods are provided.

Chapter 10 provides an example that illustrates the key steps in health policy analy-
sis: assessing the determinants of a health problem, identifying a policy intervention to
address the problem, critically evaluating the policy intervention, and proposing next steps
in addressing the problem.

ne w t O th i s ed i t i O n

This second edition has retained most of the features of the first edition. In addition, sig-
nificant updates have been made in the following key areas.

Ca s e st u d i e s

Each of the chapter-opening case studies from the first edition has been revised or replaced,
and a new, second case study has been added to chapters 1–9.

he a lt h C a r e re f O r m

The latest developments in healthcare reform and legislation have been incorporated into the
book, especially in chapters 2 and 3 and in the many additions to the chapters in part III.

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x v i P r e f a c e

in t e r n at i O n a l he a lt h PO l i C y

The international health policy chapters (chapters 4 and 7) have broadened in scope with
more examples from the array of countries discussed in the book. New WHO initiatives
have also been added.

uP d at e d CO n t e n t th r O u g h O u t

Content, references, and data (including in relevant exhibits) have been updated through-
out. New and revised content includes coverage of the impact of the Affordable Care Act,
new healthcare reform directions, the patient-centered medical home, accountable care
organizations, precision medicine and big data, state and local healthcare reform activities,
private-sector initiatives, and the pharmaceutical industry. More examples of applications
in research have been added.

aC k n O w l e d g m e n t s

My PhD advisee Sarika Rane Parasuraman contributed chapter 10 (an applied example) and
is hereby acknowledged. The editorial staff of Health Administration Press have provided
hands-on assistance in editing the manuscript. Of course, all errors and omissions remain
my responsibility.

Leiyu Shi

in s t r u C t O r re s O u r C e s

This book’s Instructor Resources include a test bank, PowerPoint slides for each
chapter, and answer guides for the book’s discussion questions.

For the most up-to-date information about this book and its Instructor Resources,
go to ache.org/HAP and search for the book’s order code (2374).

This book’s Instructor Resources are available to instructors who adopt this book for
use in their course. For access information, please e-mail [email protected].

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PA R T I

I N T R O D U C T I O N

T
he introduction, which consists of chapter 1, provides an overview of health policy. It defines
key terms related to health policy, reviews the framework of health determinants, and outlines
the concept of health policy formulation. In addition, the chapter introduces topics related to

health policy, including stakeholders, major types of health policies, and the importance of studying
health policy. The introduction provides readers with a foundation for examining how health policy
is established in the United States and elsewhere.

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L e a r n i n g O b j e c t i v e s

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3

L e a r n i n g O b j e c t i v e s

C H A P T E R 1

O V E R V I E W O F H E A LT H P O L I C Y

After completing this chapter, you should be able to

➤ define key terms related to health policy,

➤ appreciate the influence of health determinants,

➤ understand the framework of health policy formulation,

➤ identify the stakeholders in health policy,

➤ describe the major types of health policies, and

➤ discuss the importance of studying health policy.

I have never had a policy. I have simply tried to do what seemed best each day, as

each day came.

—Abraham Lincoln

The health and vitality of our people are at least as well worth conserving as their

forests, waters, lands, and minerals, and in this great work the national government

must bear a most important part.

—Theodore Roosevelt

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I n t r o d u c t i o n t o H e a l t h P o l i c y4

he a lt h C a r e re f O r m: hi l l a ry Cl i n t O n a n d Ba r a C k OB a m a

Two major healthcare reform initiatives have played out on the US political landscape since
the late twentieth century: the Health Security Act, developed by the Clinton administration
in the 1990s and spearheaded by First Lady Hillary Clinton, which failed to pass into law, and
the Affordable Care Act (ACA), drafted by the Obama administration, which became federal law
in March 2010.

The hallmark of the Clinton plan was its universal coverage mandate, which required all
employers to contribute to a pool of funds to cover the costs of insurance premiums for their
workers, with caps on total employer costs and subsidies for small businesses. Competition
among private health plans and a cap on the growth of insurance premiums were to have held
costs in check, and additional financing was to have been provided through savings from cuts
in projected Medicare and Medicaid spending and increased taxes on tobacco (Oberlander
2007; Pesko and Robarts 2017).

The Obama plan focused on reforming the private health insurance market, extending
insurance coverage to the uninsured, providing better coverage for those with preexisting con-
ditions, improving prescription drug coverage in Medicare, and extending the life of Medicare
trust fund accounts. The ACA was expected to be financed through taxes, such as a 40 percent
tax on “Cadillac” insurance policies (policies that offer the richest benefits) and taxes on
pharmaceuticals, medical devices, and indoor tanning services (KFF 2013), and through other
offsets or provisions of the law that reduce the overall cost of enacting legislation, such as
penalties on uninsured individuals.

The political landscape in 2009, as President Barack Obama’s healthcare reform initia-
tive was being debated, was similar to that in the early 1990s: Both the Clinton and Obama
administrations were affiliated with the Democratic Party, both chambers of the US Congress
were controlled by Democrats, and national opinion strongly favored healthcare reform (Sack
and Connelly 2009).

However, whereas the Obama reform initiative became law, the earlier Clinton healthcare
reform package was defeated in Congress. Although Americans supported healthcare reform
in theory, the Clinton plan was derailed by the heavy opposition of the medical and insurance
industries and by antitax rhetoric. The disenchantment of the electorate following that failed
effort helped Republicans gain control of the House of Representatives and Senate in the
1994 election (Trafford 2010), which all but guaranteed that any further Democratic-designed
proposal would fail due to increasing political polarization in Congress.

After Republican president Donald Trump took office in January 2017, the Trump admin-
istration and the Republican-controlled Congress put forth many efforts to “repeal and replace”
the ACA. However, as of mid-2018, none of these attempts had succeeded.

C a s e s t u d y 1

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C h a p t e r 1 : O v e r v i e w o f H e a l t h P o l i c y 5

he a lt h C a r e re f O r m af t e r t h e aCa

Healthcare reform continues to be a deeply partisan issue in US politics, and political gridlock
in Congress has made efforts at reform challenging. Since 2010, Republicans in Congress have
unsuccessfully attempted to repeal the ACA, voting more than 60 times to repeal or alter the
law (Cowen and Cornwall 2017). In January 2016, the Republican-controlled House and Senate
passed a bill that would have repealed the ACA, but President Obama, a Democrat, promptly
vetoed it. The Congressional Budget Office (CBO) review of the proposal concluded that the bill
would have canceled health insurance for 22 million people by 2018 (Cubanski and Neuman
2018). In the 2016 presidential election campaign, every Republican candidate vowed to “repeal
and replace” the ACA (Jost 2015). In January 2017, within hours of taking office, President Trump
issued his first executive order, moving to dismantle parts of the ACA (Davis and Pear 2017).

On March 7, 2017, Republicans introduced the two bills that constitute the original
American Health Care Act (AHCA) of 2017, H.R. 1628, to partially repeal the ACA. The Trump
administration announced its support for AHCA. On March 12, 2017, the CBO released its budget
analysis, projecting that 52 million Americans would be left uninsured under the AHCA and those
with insurance would have to pay higher premiums through 2020. On May 4, 2017, the House
narrowly passed the AHCA, by a vote of 217–213, and sent the bill to the Senate for delibera-
tion. On June 22, 2017, the Senate released a discussion draft for an amendment to the bill,
which would rename it the Better Care Reconciliation Act of 2017. On July 28, 2017, the bill was
returned to the calendar after the Senate rejected several amendments, including the Health
Care Freedom Act, or the “skinny bill,” that would have repealed the ACA’s individual mandate
retroactive to 2016 and the employer mandate through 2025.

Does this legislation point to a new phase of healthcare reform whose success hinges
on support from both major political parties? As Wilensky (2017) suggested, Republicans and
Democrats might need to find a way to work together to enact comprehensive healthcare
reform beyond the ACA.

Or, does it signal a new approach toward dismantling the ACA through the administrative
process, such as policy implementation? In reaction to Congress’s repeated failure to repeal
the ACA, on October 12, 2017, President Trump issued Executive Order 13813, directing federal
agencies to expand the use of association health groups—groups of small businesses that pool
together to buy health insurance (Trump 2017).

The Tax Cuts and Jobs Act of 2017, passed and signed into law in December 2017, effec-
tively repealed the mandate in the ACA that required all Americans to have health insurance.
Although the ACA was still the law of the land during the first year of the Trump administration,
many of its components were being modified in Trump’s second year.

C a s e s t u d y 2

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A
t 16.9 percent of the nation’s total economic activity—also known as the gross
domestic product—healthcare spending in the United States leads all countries
in overall and per capita measures (OECD 2018). Yet the US healthcare system

does not perform well compared with those of other industrialized countries. A 2010 World
Health Organization (WHO) report ranked the US health system thirty-seventh among 191
countries (Tandon et al. 2018). In addition, a Commonwealth Fund study on healthcare
performance ranked the United States behind ten other industrialized countries—Australia,
Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland,
and the United Kingdom—on the basis of quality, efficiency, access, equity, and health
outcome measures (Davis, Schoen, and Stremikis 2014). The US healthcare system also
ranked last in a recent survey of eleven nations (Commonwealth Fund 2017).

Why have health policies tended to fail in the United States while they appear to suc-
ceed in other countries? The answer might be found in the context—the United States—and
the determinants of health and health policy in the country.

The main purpose of this chapter is to present a framework of health policy determi-
nants and discuss their impact in the United States. Understanding this framework will help
the reader appreciate factors that contribute to health policy development in general and in
the United States in particular. The chapter first defines key concepts related to health policy
and later discusses the importance of studying health policy, including an awareness of its
international perspective. The stakeholders of health policy are also presented and analyzed
as key parts of the policy context.

he a lt h de f i n e d

WHO (1946) defines health as “not merely the absence of disease or infirmity but a state
of complete physical, mental and social well-being.” This broad definition recognizes that
health encompasses biological and social elements in addition to individual and community
well-being. Health may be seen as an indicator of personal and collective advancement. It
can signal the level of an individual’s well-being as well as the degree of success achieved
by a society and its government in promoting that well-being (Shi and Stevens 2010). This
definition of health implies that issues such as poverty, lack of education, discrimination,
and other social, cultural, and political conditions found around the world are essentially
public health issues.

However, health is also the result of personal characteristics and choices. This con-
cept is the source of the fundamental tension in public health and has been a major topic
of discussion in the United States in the twenty-first century. Major debates continue over
whether people can be forced to take actions to ensure their own health, such as buying
health insurance (e.g., the “individual mandate” in the ACA), or be prohibited from perform-
ing actions that are unhealthy, such as limiting soft drinks in schools. Health policy in the
United States must attempt to balance the good of the public health with personal liberty,

gross domestic product
The value of all goods
and services produced
within a country for
a given period; a
key indicator of the
country’s economic
activity and financial
well-being.

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often a difficult compromise to make. Indeed, the conflict between the WHO definition of
health and many of the social, cultural, and political issues surrounding the US healthcare
system is one of the most important areas of debate for health policymakers.

Ph y s i C a l he a lt h

The most common measure of physical health is life expectancy—the anticipated number
of remaining years of life at any stage. Exhibit 1.1 shows the ten countries ranking highest
in their population’s life expectancy as of 2015 and includes the US ranking for comparison.

Although good or positive health status is commonly associated with the definition
of health, the most frequently used indicators measure, instead, lack of health or incidence
of poor health—for example, mortality, morbidity, disability, and various indexes that
combine these factors. One such measure is quality-adjusted life years, which combines
mortality and morbidity in a single index. The Learning Point box titled “Measures of
Mortality, Morbidity, and Disability” lists categories by which each indicator is measured.

life expectancy
Anticipated number of
years of life remaining at
a given age.

mortality
Number of deaths in a
given population within
a specified period.

morbidity
Incidence or prevalence
of diseases in a given
population within a
specified period.

disability
A physical or mental
condition that limits
an individual’s ability
to perform functions
considered normal.

quality-adjusted life
years
A combined mortality–
morbidity index that
reflects years of life
free of disability and
symptoms of illness.

KEY LEGISLATION
What Is the Status of Healthcare Reform in the United States?

In the United States, healthcare reform typically denotes a government-sponsored program
that strives to make health insurance available to the uninsured. Heretofore, healthcare reform
has not quite addressed how healthcare should be delivered, such as in resource allocations
across preventive, primary, and tertiary care settings. Although universal health insurance is
a difficult goal to realize, incremental reforms have been successful when political and eco-
nomic environments were favorable. The first such program came in the form of the Old Age
Assistance program, which was enacted as part of the 1935 Social Security Act and provided
direct financial assistance to needy elderly persons.

Full health insurance for the elderly became available under the Medicare program, as did
health insurance for the indigent under the Medicaid program. Both programs were created in
1965 under the Great Society reforms of President Lyndon Johnson in an era when civil rights
and social justice had taken central stage in the United States. Later, authorized under the
Balanced Budget Act of 1997, the State Children’s Health Insurance Program—later renamed
the Children’s Health Insurance Program—was developed, whereby states can use federal
funds to cover children up to age 19 through their existing Medicaid programs.

One of the most significant healthcare reform efforts resulted in the Affordable Care Act
of 2010, designed to bring about major changes to the delivery of US healthcare. The key
objective of the ACA was to provide most, if not all, Americans with health insurance coverage.

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me n ta l he a lt h

In contrast to physical health, measures of mental health are limited. The major catego-
ries of mental health measures are mental conditions (e.g., depression, disorder, distress),
behaviors (e.g., suicide, drug or alcohol abuse), perceptions (e.g., perceived mental health
status), satisfaction (e.g., with life, work, relationships), and services received (e.g., counsel-
ing, drug treatment).

Mental illness ranks second, after ischemic heart disease, as a nationwide burden
on health and productivity (SAMHSA 2016). An estimated 17.9 percent of the US adult
population in 2014 had at least one diagnosable mental disorder, only 41 percent of whom
received any treatment (SAMHSA 2016). Serious mental illness costs the United States
$193.2 billion in lost earnings per year (SAMHSA 2016). Mental illness is a risk factor for
death from suicide, cardiovascular disease, and cancer. Mental health problems are frequently
associated with social problems. For example, with easy access to guns, mental health often
contributes to gun violence in both public and private settings.

sO C i a l we l l-Be i n g

The most commonly used measure of relative social well-being is socioeconomic status (SES).
An SES index typically considers such factors as education level, income, and occupation.
Quality of life is another common measure and may include the ability to perform various
roles (e.g., self-care, family care, social functioning), perceptions (e.g., emotional well-being,

Life expectancy at birth (years)

Rank Country (state/territory) Overall Male Female

1 Japan 83.9 80.8 87.1

2 Switzerland 83.0 80.8 85.1

3 Spain 83.0 80.1 85.8

4 Italy 82.6 80.3 84.9

5 Australia 82.5 80.4 84.5

6 Iceland 82.5 81.2 83.8

7 Norway 82.4 80.5 84.2

8 France 82.4 79.2 85.5

9 Sweden 82.3 80.4 84.1

10 Korea 82.1 79.0 85.2

26 United States 78.8 76.3 81.2

Source: Data from OECD (2018).

exhiBit 1.1
Top Ten Countries

with the Longest
Life Expectancy,
with the United

States as
Comparison

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pain tolerance, energy level), and living environment (e.g., pollution levels, crime preva-
lence). A third set of social well-being measures, often used by sociologists, is composed of
social contacts and social resources. Examples of social contacts include visits with family
members, friends, and relatives and participation in social events, such as membership
activities, professional conferences, and church gatherings. The social contacts factor can be
used as an indicator of social resources by determining whether an individual can rely on
social contacts for needed support and company and whether the people involved in these
contacts meet the individual’s needs for care and love.

Pu B l i C he a lt h de f i n e d

In the early twentieth century, Winslow (1920) defined public health as “the science and
the art of preventing disease, prolonging life, and promoting physical health and efficiency
through organized community efforts for the sanitation of the environment, the control of

social contacts
The frequency of social
activities a person
undertakes within a
specified period.

social resources
Interpersonal
relationships with social
contacts and the extent
to which the individual
can rely on the people
involved in these
contacts for support.

LEARNING POINT
Measures of Morbidity, Mortality, and Disability

Morbidity measures

• Incidence of specific diseases: number of new cases in a defined population within a
specified period

• Prevalence of specific diseases: number of instances in a defined population within a
specified period

Mortality measures

• Crude (unadjusted for any other factors) death rate
• Age-specific death rate
• Condition-specific death rate
• Infant death rate
• Maternal death rate

Disability measures

• Restricted activity days (e.g., bed days, work-loss days)
• Limitations in performing activities of daily living (i.e., bathing, dressing, toileting, get-

ting into or out of a bed or a chair, continence, eating)
• Limitations in performing instrumental activities of daily living (i.e., doing housework

and chores, grocery shopping, preparing food, using the phone, traveling locally,
taking medicine)

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community infections, the education of the individual in principles of personal hygiene, the
organization of medical and nursing service for the early diagnosis and preventive treatment
of disease, and the development of social machinery which will ensure to every individual in
the community a standard of living adequate for the maintenance of health.” It focuses on
prevention and involves the efforts of society as a whole. Public health is intended to protect
lives and improve the health of populations around the globe. Today, the Johns Hopkins
Bloomberg School of Public Health emphasizes the continued importance of public health
in its school motto, “Protecting Health, Saving Lives—Millions at a Time.”

Whereas healthcare is intended to treat, influence, and care for individuals, public
health operates on a larger scale. The field is described by the American Public Health
Association (APHA 2018) as one that “promotes and protects the health of people in the
communities where they live, learn, work and play.”

Public health has broad implications for a population. Successful public health activities
and initiatives can save money by promoting healthy living and prevention, thus reducing
healthcare costs and disease burden. In addition, these activities can improve quality of life, help
children thrive, and reduce the suffering caused by ill health in a population (APHA 2018).
The practice of public health leads to both direct benefits (e.g., healthier children, less chronic
disease, less need for acute care) and indirect benefits (e.g., fewer days missed from school
and work; increased funding available for other initiatives, such as education) for a society.

It is important to remember that public health, healthcare, and health policy are
interconnected areas of study and practice. All three have great influence on health.

wh at ar e t h e de t e r m i n a n t s O f he a lt h?

Numerous theories on the determinants of health have been proposed since the mid-
twentieth century. Blum (1974) offered a framework called Force Field and Well-Being
Paradigms of Health, which suggests four major influences—the force fields—on health:
environment, lifestyle, heredity, and medical care. According to Blum, the most important
force field is the environment, followed by lifestyle and heredity. Medical care has the least
impact on health and well-being.

Twenty-first-century models focus on socioeconomic context and health behaviors.
For example, the Dahlgren and Whitehead (2006) model divides factors that influence health
into two categories. Fixed factors, the first category, are unchangeable, such as age, sex, and
genetic makeup. The second category is composed of modifiable factors, such as individual
lifestyle choices; social networks and community conditions; the environment in which one
lives and works; and access to important goods and services, such as education, sanitation,
food, and healthcare. The factors in the second category form layers of influence around the
population, and modifying them positively can improve population health.

Ansari and colleagues (2003) proposed a public health model of the determinants of
health in which these factors are categorized into four major groups: social determinants,

determinants of health
Factors that influence
health status.
Typically, they include
socioeconomic status,
environment, behaviors,
heredity, and access to
medical care.

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healthcare system attributes, disease-inducing behaviors (see the Learning Point box titled
“Prominent Theories on the Causes of Disease”), and health outcomes.

A conceptual framework developed by the WHO Commission on Social Determinants
of Health (2008) focuses on socioeconomic and political context; structural determinants and
socioeconomic position; intermediary determinants, such as material circumstances, socioenvi-
ronmental circumstances, behavioral and biological factors, social cohesion, and the healthcare
system; and the impact on health equity and well-being measured as health outcomes.

LEARNING POINT
Prominent Theories on the Causes of Disease

Many of the historically dominant theories related to health focus on disease rather than
well-being. The three most prominent theories of disease causality are germ theory, lifestyle
theory, and environmental theory.

Germ theory gained prominence in the nineteenth century with the rise of bacteriology
(Metchnikoff, Pasteur, and Koch 1939). Essentially, the theory holds that every disease has a
specific cause, which should be identifiable. Knowledge of the cause allows for the discovery
of a cure. Microorganisms, the general causal agent identified by germ theory, are thought to
act independently of the environment. Furthermore, the individual who serves as the host
of the microorganism is the source of the disease, which may then be transmitted from one
person to another—a process known as contagion. Strategies to address the disease focus
on identifying people with symptoms and providing follow-up medical treatment. Much
of biomedical research is still based on germ theory. The traditional concept of the agent,
host, and environment as the epidemiological triangle—epidemiology is the study of factors
controlling the presence or absence of a disease—is also based on the single-cause, single-
effect framework of germ theory.

Lifestyle theory tries to isolate specific behaviors (e.g., exercise, diet, smoking, drinking)
as causes of a disease and identifies solutions on the basis of improving or changing these
behaviors. As with germ theory, lifestyle theory defines problems as they relate to individuals
and focuses solutions on individually tailored interventions.

Environmental theory considers the general health and well-being of individuals more
than it does disease. It maintains that health is best understood by examining the larger
context of community. Traditional environmental approaches focused on poor sanitation,
which was connected to certain infectious diseases. With industrialization and its by-products
of overcrowding and filth, contemporary environmental approaches examine the impact of
production and consumption on emerging health problems. Environmental theory consid-
ers disease to be influenced by environmental and social factors. It contends that solutions
should be developed through policy and regulation and focused on systems rather than on
individuals and medical treatment.

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Similarly, the US Department of Health and Human Services (HHS) publication
Healthy People 2020 embraced a holistic approach by considering the range of personal,
social, economic, and environmental factors that determine the health status of individuals
or populations (HHS 2010). Planning is now under way for the HHS Healthy People 2030
initiative and includes establishing a framework for the initiative (including the vision, mis-
sion, foundational principles, plan of action, and overarching goals) and identifying new
objectives (HHS 2018). In the first phase of the process, an expert advisory committee will
develop recommendations for the HHS secretary on the framework and implementation
of Healthy People 2030. Input from members of the public and relevant stakeholders will
guide the development of recommendations. During the second phase, a federal interagency
workgroup will use the advisory committee’s recommendations to establish objectives for
Healthy People 2030 (Haskins 2017). Exhibit 1.2 delineates the evolution of the Healthy
People initiatives and their respective overarching goals.

Exhibit 1.3 provides an overview of health determinants—environment, individual
characteristics, and medical care (discussed in greater detail in the sections that follow)—as

Target year

1990 2000 2010 2020

Overarching
goals

• Decrease
mortality:
infants to
adults

• Increase
independence
among older
adults

• Increase span
of healthy life

• Reduce health
disparities

• Achieve access
to preventive
services for all

• Increase
quality and
years of
healthy life

• Eliminate
health
disparities

• Attain high-quality,
longer lives free of
preventable disease,
disability, injury, and
premature death

• Achieve health equity;
eliminate disparities

• Create social and
physical environments
that promote good
health

• Promote quality of life,
healthy development,
and healthy behaviors
across life stages

No. of topic
areas

15 22 28 42

No. of
objectives/
measures

226 312 1,000 approximately 1,200

Source: Healthy People Initiatives of 1990, 2000, 2010, and 2020 (HHS 2010).

exhiBit 1.2
Evolution of

Healthy People
Initiatives

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they interact to influence health status. For example, although individual characteristics
and medical care affect health on their own, they also interact to become another type of
factor influencing health.

en v i r O n m e n t

The environment in this context is composed of the physical and social dimensions of an
individual’s existence over which the individual has little or no control. These dimensions
exert influence at the family, community, and policy levels of society. Environmental deter-
minants have a greater impact on health than the medical care system does.

Physical Dimension
The use of energy sources (e.g., oil, coal) by a population creates certain health hazards in
the physical environment. Those hazards can present themselves in the form of air, noise, or
water pollution, resulting in hearing loss, infectious disease, gastroenteritis, cancer, emphy-
sema, and bronchitis. To address the impact of climate change, WHO has launched the
Climate and Health Country Profile Project (see the For Your Consideration box titled
“WHO Climate and Health Country Profile Project”).

exhiBit 1.3
Conceptual
Framework
of Health
Determinants

Environment
– Physical
– Social

Individual
characteristics
– Demographic
– Behavioral
– Socioeconomic

Medical care
– Organizing
– Financing
– Delivering

Health status
– Physical
– Mental
– Social

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Social Dimension
The social environment is reflected in a nation’s political, economic, and cultural prefer-
ences, which exert significant influence on the health of the population. Characteristics
of an environment’s social dimension include behavioral health factors and demographic
trends. In the United States, for example, rates of psychological stress, homicide, suicide,
and other behavioral health indicators can be attributed in part to crowding, isolation, and
other social environmental factors. In terms of population trends, the increase in the number
of elderly—those aged 65 years or older—as a proportion of the total population will place
increasing pressure on healthcare systems around the world.

in d i v i d u a l Ch a r a C t e r i s t i C s re l at e d t O he a lt h

Demographic, behavioral, and socioeconomic conditions shape individual characteristics,
which explain much of the variation in health status within populations. As discussed in

FOR YOUR CONSIDERATION
WHO Climate and Health Country Profile Project

According to WHO (2018), the Climate and Health Country Profile Project “aims to raise aware-
ness of the health impacts of climate change, support evidence-based decision making to
strengthen the climate resilience of health systems, and promote actions that improve health
while reducing carbon emissions. The profiles provide country-specific estimates of current
and future climate hazards and the expected burden of climate change on human health,
identify opportunities for health co-benefits from climate mitigation actions, and track cur-
rent policy responses at national level.”

The project has been expected to track national progress on climate action in the health
sector through a WHO climate and health country survey conducted every two years and
designed to provide updated information on such aspects as adaptation and resilience
measures, climate and health finance, disease surveillance, emergency preparedness, lead-
ership and governance, mitigation action in the health sector, and national vulnerability and
adaptation assessments (WHO 2018).

The first set of Climate and Health Country Profiles was released in late 2015 and included
more than 40 countries (WHO 2018). Based on the evidence presented in these profiles, WHO
(2015) contended that “placing a price on polluting fuels that reflected their health impacts
would be expected to cut outdoor air pollution deaths by approximately half, reduce carbon
dioxide emissions by over 20 percent, and raise approximately $3 trillion per year in revenue—
over half the total value of health spending by all of the world’s governments.” Collection
of data for a second set of profiles was expected to be completed in late 2017, the results of
which would be compiled and presented in 2019 (WHO 2018).

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the following paragraphs, these factors interact with and are influenced by the environment,
thereby affecting individuals’ health.

Demographics
Age, gender, and race or ethnicity are strongly associated with health. Advancing age, for
example, contributes to arthritis, diabetes, atherosclerosis, and cancer. Gender health is
influenced in part by the social construct of gender characteristics, such as the association
between masculine identity and risk-taking.

People also experience significant differences in health status depending on their race
or ethnic origin. Explanations for these differences include SES, behaviors, social circum-
stances, level of access to healthcare services (CDC 2005a; Filice and Joynt 2017; Gupta et
al. 2018; James et al. 2017; Shi 1999; Shi, Lee, Chung, et al. 2017; Shi, Lee, Haile, et al.
2017; Shi and Stevens 2010), and factors that are associated with particular racial or ethnic
groups (CDC 2012b).

Behaviors
The leading causes of death in the United States have shifted since the beginning of the
twentieth century. In 1900, infectious diseases such as diphtheria, tuberculosis, measles,
and pneumonia caused 797 per 100,000 deaths in the United States; by the end of the
twentieth century, infectious diseases caused fewer than 100 per 100,000 deaths while
chronic diseases such as heart disease and cancer caused significantly higher mortality
(Armstrong, Conn, and Pinner 1999). This “epidemiologic transition” supports the idea
that behavioral risk factors—including poor dietary habits, cigarette smoking, alcohol
abuse, lack of exercise, and unsafe driving—tend to predict higher risk for certain chronic
diseases and mortality. See exhibit 1.4 for examples of the association between risk factors
and leading causes of death.

The level of behavioral risk factors exhibited by a population is related to SES. For
example, the prevalence of smoking is greater among those with less education; in 2011,
45.3 percent of Americans who had obtained a GED (General Educational Development)
certificate reported being a current cigarette smoker, compared with only 5 percent of those
who held graduate degrees (CDC 2012a). Behavioral risk factors are divided into three
categories: leisure activity risks, consumption risks, and employment participation and
occupational risks (Dever 2006). These categories are determined in part by the collective
decisions made by individuals in a particular group that affect their health. The degree of
control they have in these decisions varies by category: Individuals have the least control
over employment and occupational factors, more control over consumption factors, and
the greatest control over leisure activity–related factors.

Destructive behaviors related to employment and occupational risks are usually dif-
ficult for individuals to control. To offset such risks, the federal government created regulatory

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I n t r o d u c t i o n t o H e a l t h P o l i c y1 6

agencies, such as the Occupational Safety and Health Administration, that require employers
to maintain safe workplaces and practices.

Individuals have more control over consumption than over occupation-related behav-
iors; however, environmental factors, such as availability of affordable, healthy foods, play a
significant role in the extent of their control. Consumption risks include overeating (result-
ing in obesity), high cholesterol intake (heart disease), alcohol consumption (motor vehicle
accidents), alcohol addiction (liver cirrhosis), cigarette smoking (chronic bronchitis and
emphysema, lung cancer, aggravating heart disease), drug dependency (suicide, homicide,
malnutrition, accidents, social withdrawal, acute anxiety), and excessive glucose or sugar
intake (dental caries, obesity, hyperglycemia, diabetes).

Unlike the risks related to employment and occupation, those that accompany leisure
and consumption activities are relatively unregulated, with the exception of efforts to control
the use of illegal drugs and the purchase of tobacco and alcohol products by underage youth.
Leisure-related destructive behaviors include sexual promiscuity and unprotected sex (which can
result in sexually transmitted diseases, including AIDS, syphilis, and gonorrhea) and limited or
no exercise (which may lead to overweight and obesity and aggravate other health conditions).

Socioeconomic Status
The major components of SES are income, education, and occupational status. SES is a strong
and consistent predictor of health status. Individuals with low SES suffer disproportionately

Cause of death

Health behavior 
Heart

disease Cancers Stroke Diabetes Cirrhosis Homicide

Smoking X X        

High blood pressure X   X      

High cholesterol X          

Poor diet X X   X    

Obesity X     X    

Lack of exercise X          

Stress X         X

Alcohol abuse   X     X X

Drug misuse X         X

Unsafe driving X

exhiBit 1.4
The Association
Between Health

Behaviors and
Leading Causes of

Death

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from most diseases and experience higher rates of mortality than those with midlevel or
high-level SES. For example, after controlling for access to medical care, studies show that
countries providing universal health insurance, such as England, report the same SES–health
relationships as those found in the United States, which does not yet offer universal health
insurance (Acheson 1998; Cormman et al. 2015).

SES influences health to the extent to which individuals and populations are exposed
to physical and social threats; have knowledge of health conditions; encounter adverse envi-
ronmental conditions, such as pathogens and carcinogens; and are exposed to undesirable
social conditions, such as crime.

me d i C a l Ca r e

Most items that we buy and sell are commodities—goods and services whose worth can
be calculated as a monetary value, that serve a specific (rather than an intrinsic or esoteric)
purpose, and that can be exchanged with other similar products (Doty 2008). Medical
care differs from traditional commodities in four important ways. First, the demand for
medical care is derived; that is, it stems from the demand for a more fundamental com-
modity—health itself.

The second difference is the presence of the agency relationship. Because patients
generally lack the technical knowledge to make health-related decisions, they delegate this
authority to their physicians with the expectation that physicians will act for patients as
patients would for themselves if they had the appropriate expertise.

If physicians were to act solely in the interests of patients, the agency relationship
would be virtually indistinguishable from normal consumer behavior. However, physicians’
decisions typically reflect the physicians’ self-interests as well as the interests of their patients.
Those self-interests may arise from pressures imposed by professional colleagues and insti-
tutions, adherence to medical ethics, or a desire to make good use of available resources.

One implication of the agency relationship is that medical care may or may not be
provided, depending on the payer of services for the patient. For example, physicians who
treat members of a health maintenance organization (HMO) may have an incentive to
restrict the number of hospital admissions they order because HMO patients’ care is pre-
paid; that is, the physician will not be paid more to provide more services. Acting on this
incentive means that the physician is acting as an imperfect agent.

The third difference between medical care provision and the provision of other products
and services is that healthcare pricing varies according to who pays the fees. Because most patients
are covered by insurance, the amount paid by patients out-of-pocket at the point of care for
most medical services is often significantly lower than the total payment made to the provider.

The fourth difference is that medical care service provision is influenced by its environ-
ment, whereas other commodities are not. In other words, the social, economic, demographic,

agency relationship
In healthcare, delegation
by the patient of some
authority to make
decisions and perform
actions on the patient’s
behalf to an expert such
as a physician or other
healthcare provider.

health maintenance
organization (HMO)
A managed care
organization that
integrates medical
care with payment and
typically requires the
use of a specified panel
of providers.

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technological, political, and cultural contexts dictate how, when, where, and to whom
healthcare services are offered, which is not true of other products and services. For example,
of the forces currently reshaping the healthcare industry, the number of uninsured people
(social context) is a major factor driving health insurance reform debates.

PO l i C y de f i n e d

A policy is a decision made by an authority about an action—either one to be taken or one
to be prohibited—to promote or limit the occurrence of a particular circumstance in a
population. In the United States, the authority charged with making policy is a legislative,
executive, or judicial body operating under the purview of a federal, state, or local public
administration. Public policy—decision making that affects the general population or sig-
nificant segments thereof—is meant to improve the conditions and general welfare of the
population or subpopulations under its jurisdiction. Other countries, however, may have
different mechanisms of developing policies (see the For Your Consideration box titled
“Dominant Political Systems of the World”).

Although public policies are intended to serve the interests of the public at large,
the term public has different interpretations according to the political context in which it is
applied. For example, policymakers tend to be most responsive to the views and wishes of
constituents who are politically active and communicate directly with their representatives.

FOR YOUR CONSIDERATION
Dominant Political Systems of the World

Democracy—political system that allows for each individual to participate either directly or
through elected representatives (United States, Canada)

Republic—political system in which the government remains mostly subject to the people,
and leaders can be recalled (France, Egypt, India)

Monarchy—political system in which the inherited ruler (monarch) is head of state, the con-
stitution limits the monarch’s power, and others make laws (United Kingdom, Denmark,
Kuwait, Spain, Sweden)

Communism/Socialism—political system based on the ideology of communism as taught by
Karl Marx, Vladimir Lenin, or Mao Zedong, often dominated by a single party or an elite group
of people (China, Russia, Cuba)

Dictatorship—political system in which a single person (dictator) is the main individual ruling
the country, not restricted by constitutions or parliaments (Zimbabwe, Uzbekistan, North Korea)

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In the private sector, authority is conferred to the executive or board of directors of
an organization. Private policy—policy that affects the private organization only—is meant
to improve the conditions and general welfare of the employees of that organization. Because
private organizations function in the larger social (public) environment, private policies
must take into account the spirit of public policies.

he a lt h PO l i C y de f i n e d

Miller (1987, 15) defined health policy as “the aggregate of principles, stated or unstated,
that . . . characterize the distribution of resources, services, and political influences that
impact on the health of the population.” This definition and others focus on US federal or
public-level health policy and do not reflect non-US political systems nor account for the
fact that private-sector policy also influences health.

Therefore, in this book we define health policy as policy that pertains to or influences
the attainment of health. In terms of the determinants-of-health framework, health policy refers
to legislation that may influence—directly or indirectly—social and physical environments,
behaviors, SES, and availability of and accessibility to medical care services. Health policies
affect groups or classes of individuals, such as physicians, the poor, the elderly, and children.
They can also affect types of organizations, such as medical schools, HMOs, nursing homes,
medical technology producers, and employers. On the basis of this broad definition, health
consequences may result from virtually all major policies, such as Social Security mandates,
national defense–related guidelines, labor policies, and immigration policies.

Furthermore, in the United States, each branch and level of government can influ-
ence health policy. For example, both the executive and legislative branches at the federal,
state, and local levels can establish health policies, and the judicial branch at each level can
uphold, strike down, or modify existing laws affecting health and healthcare. Examples of
public, or government, health policy include legislative and regulatory efforts to ensure air
and water quality and support for cancer research.

Health policies can also be made through the private sector. Examples of private-sector
health policies are the decisions made by insurance companies regarding their product lines,
pricing, and marketing and by employers regarding health benefits, such as leave policies,
work site health promotion, and insurance coverage.

Health policy must be distinguished from healthcare policy, which refers to that
part of health policy pertaining to the financing, organization, and delivery of care. Health-
care policy may cover the training of health professionals; licensing of health professionals
and facilities; administration of public health insurance programs, such as Medicare and
Medicaid; deployment of electronic health records; efforts to control healthcare costs; and
regulation of private health insurance. Whereas the predominant goal of health policy is to
improve population health, the goals of healthcare policy are typically to provide equitable
and efficient access to high-quality healthcare services.

health policy
Legislation over
individuals,
organizations, or
society whose goal is to
improve health for the
general population or
subpopulations.

healthcare policy
The part of health policy
specifically related to
the financing, delivery,
and governance of
health services for the
general population or
subpopulations within a
jurisdiction.

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ty P e s O f he a lt h PO l i C y

The scope of health policy is determined by the
political and economic system of a country. In
the United States, where pro-individual and pro-
market sentiments tend to dominate (see the For
Your Consideration box titled “The United States
as an Individualist Culture?”), health policies are
likely to be fragmented, incremental, and non-
comprehensive. National policies and programs
are typically crafted to reflect the notion that local
communities are in the best position to identify
strategies to address their unique needs. However,
the types of changes that can be enacted at the

community level are clearly limited. Next, we summarize the two major types of health
policies: regulatory and allocative.

Regulatory Health Policies
Health policies may be used as regulatory tools that call on the government to prescribe and
control the behavior of a particular target group by monitoring the group and imposing
sanctions if it fails to comply. Examples of regulatory policies include prohibition of smok-
ing in public places, licensure requirements for medical professions, and processes related to
the approval of new drugs. State insurance departments across the country regulate health
insurance companies in an effort to protect customers from default on coverage in the case
of a company’s financial failure, excessive premiums, or deceptive practices.

Private health policies can also be regulatory. For example, physicians set standards of
medical practice and hospitals undergo assessments from accreditation service organizations,
such as The Joint Commission, to ensure compliance with all standards.

Allocative Health Policies
Allocative health policies involve the direct provision of income, services, or goods to certain
groups of individuals or institutions. They can be distributive or redistributive. Distributive
policies spread benefits across society. Examples include the funding of medical research
through the National Institutes of Health, provision of public health and health promotion
services, training of medical personnel, and construction of healthcare facilities. Redistribu-
tive policies take money or power from one group and give it to another. This approach
typically creates visible beneficiaries and payers. Examples include means-tested social insur-
ance programs such as Medicaid, which uses tax revenue from the more affluent population
to provide free or low-cost health insurance to the poor, to subsidize the welfare program,

regulatory policies
Regulations or rules that
impose restrictions and
are intended to control
the behavior of a target
group by monitoring
the group and imposing
sanctions if it fails to
comply.

distributive policies
Regulations that provide
benefits or services to
targeted populations
or subpopulations,
typically as entitlements.

redistributive policies
Deliberate efforts to
alter the distribution
of benefits by taking
money or property from
one group and giving it
to another.

FOR YOUR CONSIDERATION
The United States as an Individualist Culture?

The American political culture is characterized by some observ-
ers as being rooted in a distrust of power—particularly govern-
ment power—and a preference for volunteerism and self-rule in
small, homogeneous groups with limited purposes. How would
you describe the political culture of average Americans? Do you
agree or disagree with the characterization posed here? Provide
examples to support your answer.

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and to fund public housing. It should be pointed out that Medicare and Social Security are
not redistributive policies nor “entitlements” because they are supported by funds collected
through deductions from the income of working people before their retirement and then
distributed later to members of that same population after their retirement.

wh at ar e t h e de t e r m i n a n t s O f he a lt h PO l i C y?

As noted earlier, the framework for health determinants includes four major categories:
environment, health status, medical care, and individual characteristics (shown earlier
in exhibit 1.3). The framework for health policy determinants is presented in exhibit 1.5.
Broad determinants include the nature of the health problem, the sociocultural norms that
influence the perception of the problem, and the political system within which the health
policy is formulated. The inner circle of the framework shows the narrower determinants:

◆ Potential solutions to the identified health problem

◆ Views and efforts of the stakeholders

◆ Demonstrated leadership of the policymakers

◆ Available resources needed to implement the health policy

This general framework may be applied to health policies at the national, state, or
local level; to public and private policies; and to health policies in the United States and

exhiBit 1.5
A Conceptual
Framework of
Health Policy
Determinants

Sociocultural norms

Health
problem

Political system

Health
policy

Leadership

Solutions Resources

Stakeholders

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I n t r o d u c t i o n t o H e a l t h P o l i c y2 2

elsewhere. The remainder of this section describes these components in greater detail, and
chapters 2 through 4 illustrate the application of this framework in various settings.

Br O a d de t e r m i n a n t s O f he a lt h PO l i C y

Among the broad determinants of health policy are the nature of the health problem,
sociocultural norms, and the political system of the country, each of which is discussed in
this section.

Health Problem
The nature of the health problem is typically the first consideration of policy, the significance
of which is determined by its magnitude and severity. Magnitude indicates the reach of the
problem. If the health problem affects a large segment of the population (e.g., heart disease,
diabetes), it is considered widespread. Severity denotes the extent to which the problem
is urgent. See the Learning Point box titled “Infectious Disease Epidemics: Severe Acute
Respiratory Syndrome and Influenza” for examples.

LEARNING POINT
Infectious Disease Epidemics: Severe Acute Respiratory Syndrome and
Influenza

Severe acute respiratory syndrome (SARS) is a serious form of viral pneumonia that can result
in acute respiratory distress and, sometimes, death. It first came to the attention of Asian
health officials in February 2003. In just a few months, it had spread throughout North America,
South America, Europe, and Asia, affecting 8,098 individuals in more than 25 countries. Of
those infected, 774 died. The 2003 SARS epidemic demonstrated how quickly an infectious
respiratory disease could spread across the world and registered among the most severe
health problems in the twenty-first century.

Influenza (flu) is a contagious respiratory illness caused by influenza viruses, which can
cause mild to severe illness. Serious outcomes of flu infection can result in hospitalization or
even death. More than 130 million doses of flu vaccine were distributed in the 2017–2018 winter
season. Although the impact of flu varies, it places a substantial burden on the health of people
in the United States each year. The Centers for Disease Control and Prevention (CDC) estimates
that influenza resulted in between 9.2 million and 35.6 million illnesses, between 140,000 and
710,000 hospitalizations, and between 12,000 and 56,000 deaths annually from 2010 to 2017.

Source: CDC (2005b, 2017).

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Sociocultural Norms
Sociocultural norms reflect the accepted values, beliefs, attitudes, and behaviors of a society
or group. These norms play a significant role in the public’s perception of the nature of a
health problem, the role of the government versus individuals in addressing that problem,
and the type of solution or policy implemented to manage it. For example, mental illness
carries a social stigma in many cultures. Although poor mental health has long been a per-
vasive problem in the United States and elsewhere, relatively little public action has been
taken to promote improvements in mental health status, care, and treatment.

Political System
Although a democratically governed country is more likely to develop health policies that reflect
the public’s interests (officials are publicly elected and presumably represent the electorate’s inter-
ests), the process of policy development is typically more difficult in democratic systems than
in single-rule governments, not only because the development of legislation in a democracy is
arduous but also because the public’s interests are rarely coherent. In authoritarian (single-party)
countries, policies can be developed more quickly but may not truly reflect the public’s interests.

na r r O w de t e r m i n a n t s O f he a lt h PO l i C y

The narrow determinants of health policy include solutions, stakeholders, leadership, and
resources, each of which is discussed in this section.

Solutions
Potential solutions to a health problem facilitate policy development. If solutions do not emerge,
policymakers may direct their efforts away from full-fledged policy consideration and toward
finding a solution, likely by initiating a research study. If a health problem has more than one
potential solution, policy research and analysis is conducted to identify the optimal solution
given the political climate, available resources, and expectations of prominent stakeholders.

Stakeholders
Entities or individuals who have a direct or indirect role in the development of policy are
considered stakeholders. The influence of stakeholders is particularly strong in a democracy,
as elected officials often cater to the interests of their constituency—either to fulfill a cam-
paign promise or to gain reelection. Policy is more likely to be enacted when the positions
of the various stakeholders converge. The next major section in this chapter describes the
key stakeholders in US health policy.

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Leadership
No matter how significant the problem or how determined the stakeholders, health policy
addressing a particular problem will not appear on the policy agenda without the approval of
the governing body’s leader. The first case study at the beginning of this chapter demonstrates
the contrasting leadership styles of President Barack Obama and former First Lady Hillary
Clinton. The For Your Consideration box titled “Quotes from Selected US Presidents”
reflects the leadership styles of a number of US presidents throughout the nation’s history
and provides clues as to how they governed.

FOR YOUR CONSIDERATION
Quotes from Selected US Presidents

Associate yourself with men of good quality if you esteem your own reputation; for
’tis better to be alone than in bad company.

—George Washington

To be good, and to do good, is all we have to do.

—John Adams

It is by a thorough knowledge of the whole subject that [people] are enabled to
judge correctly of the past and to give a proper direction to the future.

—James Monroe

If your actions inspire others to dream more, learn more, do more, and become
more, you are a leader.

—John Quincy Adams

Any man worth his salt will stick up for what he believes right, but it takes a slightly
better man to acknowledge instantly and without reservation that he is in error.

—Andrew Jackson

While men inhabiting different parts of this vast continent cannot be expected to
hold the same opinions, they can unite in a common objective and sustain common
principles.

—Franklin Pierce

The test of leadership is not to put greatness into humanity, but to elicit it, for the
greatness is already there.

—James Buchanan

I don’t like that man. I must get to know him better.

—Abraham Lincoln

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Resources
Not even the most effective policy can be implemented without the available financial and
administrative resources. Financial feasibility tests are conducted during the policy develop-
ment process to ensure that adequate funds are available and to verify that the benefits will
outweigh the costs. Administrative feasibility studies examine how policy can be translated
into programs and carried out under an existing or new infrastructure.

sta k e h O l d e r s O f he a lt h PO l i C y

As shown in the framework of health policy determinants (exhibit 1.5), stakeholders fre-
quently exert a powerful influence on health policy development. Indeed, as shown in
later chapters, stakeholders influence not only the formulation of health policy but also its
implementation and modification.

FOR YOUR CONSIDERATION
Quotes from Selected US Presidents (continued)

If you always support the correct principles then you will never get the wrong
results!

—Andrew Johnson

The object of love is to serve, not to win.

—Woodrow Wilson

[People] are not prisoners of fate, but only prisoners of their own minds.

—Franklin D. Roosevelt

It is amazing what you can accomplish if you do not care who gets the credit.

—Harry S. Truman

Efforts and courage are not enough without purpose and direction.

—John F. Kennedy

A leadership is someone who brings people together.

—George W. Bush

Change will not come if we wait for some other person or some other time. We are
the ones we’ve been waiting for. We are the change that we seek.

—Barack Obama

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One type of stakeholder is the interest group. Interest groups are composed of individu-
als or entities that at least nominally present a unified position on their preferences regarding a
particular health problem or its solution. Lobbying by organized interest groups is a common
component of the political process in a democracy. Because stakeholders often differ in their posi-
tions and preferences, and coalition building is usually specific to an issue, interest groups are not
always static, and their formations typically depend on the particular health problem under policy
consideration. The following paragraphs introduce the major stakeholders in US health policy.

Consumers and patients. Consumers and patients are typically the intended benefi-
ciaries of health policy, because they suffer the consequences of a health problem that could
be the target of health policy. However, consumers have diverse health problems, and yet
the prioritization of those problems is not always determined by consumers. Furthermore,
consumers with the same health problem may have diverse interests and different cultural
norms. Consumers’ views may also be influenced by their own economic status, such as
whether they currently have health insurance coverage. For example, those without insurance
are more likely to favor a government program or reform that expands insurance coverage.
Those with insurance coverage are more concerned with lowering the premiums or copay-
ments for their insurance coverage. The more their interests converge and the more organized
they become as a collective, the more likely consumers are to influence policy development.

Healthcare providers. Healthcare providers—individuals who provide direct patient care—
include physicians, nurses, dentists, pharmacists, and other health professionals. Traditionally,
healthcare providers value autonomy and have an interest in preserving the prestige and expertise
associated with their careers. The size and diversity of the US healthcare workforce often result in
a less-than-unified voice in the healthcare provider community—for example, between physicians
and nonphysicians, primary care doctors and specialists, and public health and medical care.

Healthcare organizations. Healthcare organizations are the institutional settings in
which healthcare providers work or provide care
to patients. Traditional settings include hospitals
(inpatient and outpatient) and community-based
offices. Organizational settings now also include
diagnostic imaging centers, occupational health
centers, and psychiatric outpatient centers, among
others. Administrators of these institutions may
share an interest, for example, in serving their cus-
tomers and maintaining the financial well-being of
their institutions at the same time (see the For Your
Consideration box titled “Interests Common to
Healthcare Administrators”). However, like health-
care providers, different healthcare institutions have
different priorities and interests, often tied to con-
sumers, services, and payments.

interest group
A collective of
individuals or entities
that hold a common
set of preferences on
a particular health
issue and often seek to
influence policymaking
or public opinion.

lobbying
Activities seeking to
influence an individual
or organization with
decision-making
authority.

FOR YOUR CONSIDERATION
Interests Common to Healthcare Administrators

Healthcare administrators are responsible for overseeing a health
facility or department. According to the Health Careers Center
(2004), they “plan, coordinate, and supervise” all activities in their
area, including the work of staff members. Healthcare adminis-
trators also take responsibility for developing and implement-
ing standards, operating procedures, and organizational policies
that help the facility operate at peak efficiency, and they can be
involved in developing and expanding programs in new areas, such
as medical research and preventive care.

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Payers and insurers. Payers and insurers can be private (commercial or other private
enterprise) or public (government-operated entity). Private insurance is offered by com-
mercial insurance companies (e.g., Aetna, Prudential); Blue Cross/Blue Shield; self-insured
employers; and managed care organizations (MCOs), such as an HMO or a preferred
provider organization (PPO). Public insurance includes federally funded programs such
as Medicare, which provides insurance for the elderly and certain individuals with disabili-
ties; Medicaid, for the indigent; TRICARE, for US Department of Defense active military
service personnel and their families; and Veterans Affairs programs, for former armed forces
personnel. One interest that private insurance companies and MCOs have in common is
maintaining their share of the health insurance market; in contrast, a main interest of public
payers is ensuring coverage for vulnerable populations at reasonable costs.

Regulators. In addition to providing public insurance for the elderly and indigent, the
government functions as a regulator, seeking to make sure that basic services are provided,
their quality is maintained by the providers, and the overall cost of providing care in the
community or sector is contained.

Medical device and pharmaceutical manufacturers. Manufacturers of medical equipment
and drugs have a vested interest in health policy, especially with regard to payments for the
use of their products. With the rapid advancement of science and technology, numerous
devices and types of equipment have been developed for medical use, such as fetal monitors,
computerized electrocardiograph machines, and magnetic resonance imaging machines.
Such equipment is useful in the diagnosis of diseases but is expensive.

Educational and research institutions. Health policy affects the type and quantity
of healthcare providers to be trained, making educational institutions another significant
stakeholder. Similarly, research facilities are affected by health policy that directs the types
of research to be conducted.

Businesses and corporations. American businesses and corporations have a keen inter-
est in health policy that, among other issues, mandates healthcare coverage levels. These
stakeholders seek to minimize the cost they incur for providing health insurance as a benefit
to their employees.

wh y is it im P O rta n t t O st u d y he a lt h PO l i C y?

Understanding how health policy is developed is the first step toward influencing policy. And
only by knowing the health policy determinants and how they manifest in particular contexts
can one appreciate the key features of policy development (see the For Your Consideration
box titled “Why Is an International Perspective of Health Policy Useful?”).

In addition, the study of health policy allows an individual or a group the ability to
engage in efforts to improve it. For example, policy entrepreneurs—those who work from outside
the government to introduce and implement innovative ideas into public-sector practice—are
instrumental in bringing new ideas and fundamentally changing the usual way of practice.

preferred provider
organization (PPO)
A managed care
organization that offers
unrestricted provider
options to enrollees
and discounted fee
arrangements to
providers.

Medicare
Federal government
insurance plan for
persons aged 65 years
or older, individuals
with disabilities who
are entitled to Social
Security benefits, and
people who have end-
stage renal (kidney)
disease.

Medicaid
Jointly administered
federal and state
insurance plan for the
indigent.

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Furthermore, the importance of health policy itself is another reason to study it. As
shown in the framework of health determinants (exhibit 1.3), policy is an integral compo-
nent of environmental health determinants. Improvements to policy development, such as
ensuring that a policy truly addresses a critical health problem and that it is developed in
an expeditious manner, can significantly improve a population’s overall health. In addition,
policy influences other determinants of health and therefore must be thoroughly understood
to enhance the country’s health system.

➤ Health determinants, such as environment and social structure, interact with biological
factors and medical care to determine an individual’s health status.

➤ Health policy formulation is influenced by broad determinants (health problems,
sociocultural norms, and political system) and narrow determinants (solutions,
stakeholders, leadership, and resources).

➤ The major stakeholders in US health policy include consumers and patients, healthcare
providers, healthcare organizations, payers and insurers, regulators, medical device
and pharmaceutical manufacturers, educational and research institutions, and
businesses and corporations.

k e y P O i n t s

FOR YOUR CONSIDERATION
Why Is an International Perspective of Health Policy Useful?

Countries vary in their demographics, population health needs, and social norms, but they
share commonalities, such as population aging and leading causes of death. Learning from the
best practices of other countries—compared with a country developing its own evidence-based
approaches—can significantly shorten the time in which the country improves healthcare deliv-
ery. Incorporating global trends in health policymaking may also help exert influence on global
health policy (Jones, Clavier, and Potvin 2017). Just as the US experience and lessons can benefit
other countries as they consider healthcare delivery reform, so, too, can the United States learn
from the experiences of other countries in expanding its health policy options. One result of
this convergence of international health policies is the increase in similarity of global trends.

Industrialized countries need not limit their examination to other developed countries;
the experiences of developing countries can also be instructive (Dixon and Alakeson 2010;
Modisenyane, Hendricks, and Fineberg 2017). Such countries tend to focus on basic and
community-oriented public health and primary care, which may prove instructive for devel-
oped countries as they struggle to control costs and improve outcomes.

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➤ US health policy has evolved over time and will continue to change in response to new
health concerns and interests.

Ca s e st u d y 1

After researching the events surrounding the healthcare reform initiatives undertaken by the
Clinton, Obama, and Trump administrations, answer the following questions:

1. What factors might explain why the Obama plan succeeded? What events may have
caused the Clinton plan and Trump’s initial attempts to fail?

2. How do you think the failure of the Clinton healthcare reform effort influenced the
outcome of the congressional election that followed?

3. Why does health reform continue to be controversial despite widespread opinion in
favor of change?

Ca s e st u d y 2

After researching the current developments in healthcare reform, answer the following questions:

1. What are the similarities and differences in the ACA between the Obama administration
and the beginning of the Trump administration?

2. Why do the Republican and Democratic parties have sharp disagreements over how
healthcare reform should take place in the United States? Which segments of the
American public do they represent?

3. Why is healthcare reform so arduous in the history of the United States? In addition to
the presidency and Congress, what are the other determinants for successful
healthcare reform?

1. How is health defined?
2. What are the major determinants of health? How do they interact?
3. What is health policy, and what are its determinants?
4. Who are the stakeholders of health policy? What kinds of concerns does each

stakeholder have about the current US healthcare system?
5. What are the major types of health policies? Cite an example of each type.
6. Why is it important to study health policy?
7. Why is it important to have an international perspective in health policy development?

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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Acheson, D. 1998. Independent Inquiry into Inequalities in Health Report. Accessed May 8, 2018.
www.archive.official-documents.co.uk/document/doh/ih/ih.htm.

American Public Health Association (APHA). 2018. “What Is Public Health?” Accessed March 4. www.
apha.org/what-is-public-health.

Ansari, Z., N. J. Carson, M. J. Ackland, L. Vaughan, and A. Serraglio. 2003. “A Public Health Model of
the Social Determinants of Health.” Sozial und Präventivmedizin [Social and Preventive
Medicine] 48 (4): 242–51.

Armstrong, G. L., L. A. Conn, and R. W. Pinner. 1999. “Trends in Infectious Disease Mortality in the
United States During the 20th Century.” Journal of the American Medical Association 281
(1): 61–66.

Blum, H. 1974. Planning for Health. New York: Human Sciences Press.

Centers for Disease Control and Prevention (CDC). 2017. “Disease Burden of Influenza.” Accessed
February 5, 2018. www.cdc.gov/flu/about/disease/burden.htm.

———. 2012a. “Cigarette Smoking Among Adults and Trends in Smoking Cessation—United States,
2011.” Morbidity and Mortality Weekly Report 61 (44): 889–94.

———. 2012b. “Racial and Ethnic Minority Populations.” Accessed February 5, 2013. www.cdc.gov/
minorityhealth/populations/remp.html (content no longer available).

———. 2005a. “Health Disparities Experienced by Black or African Americans—United States.”
Morbidity and Mortality Weekly 54 (1): 1–3.

———. 2005b. “Severe Acute Respiratory Syndrome (SARS).” Accessed December 10. www.cdc.gov/
sars/about/fs-SARS.html (content no longer available).

Commonwealth Fund. 2017. “Health Care System Performance Rankings.” Published July. www.
commonwealthfund.org/interactives-and-data/chart-cart/report/2017-mirror-mirror/
health-care-system-performance-rankings.

Cormman, J. C., D. A. Glei, N. Goldman, C. D. Ryff, and M. Weinstein. 2015. “Socioeconomic Status and
Biological Markers of Health: An Examination of Adults in the United States and Taiwan.”
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r e f e r e n C e s

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Cowen, R., and C. Cornwall. 2017. “House Votes to Begin Repealing Obamacare.” Reuters.
Published January 13. www.reuters.com/article/us-usa-obamacare/house-votes-to-
begin-repealing-obamacare-idUSKBN14X1SK.

Cubanski, J., and T. Neuman. 2018. “Searching for Savings in Medicare Drug Pricing Negotia-
tions.” Kaiser Family Foundation. Published April 26. www.kff.org/medicare/issue-brief/
searching-for-savings-in-medicare-drug-price-negotiations/.

Dahlgren, G., and M. Whitehead. 2006. European Strategies for Tackling Social Inequities in Health:
Levelling Up Part 2. World Health Organization Europe. Accessed May 8, 2018. www.euro.
who.int/__data/assets/pdf_file/0018/103824/E89384.pdf.

Davis, J. H., and R. Pear. 2017. “Trump Issues Executive Order Scaling Back Parts of Obamacare.”
New York Times. Published January 20. www.nytimes.com/2017/01/20/us/politics/trump-
executive-order-obamacare.html.

Davis, K., C. Schoen, and K. Stremikis. 2014. Mirror, Mirror on the Wall: How the Performance of the
US Health Care System Compares Internationally—2014 Update. Pub. No. 1755. New York:
Commonwealth Fund.

Dever, G. 2006. Managerial Epidemiology: Practice, Methods, and Concepts. Sudbury, MA: Jones &
Bartlett.

Dixon, J., and V. Alakeson. 2010. “Reforming Health Care: Why We Need to Learn from International
Experience.” Nuffield Trust for Research and Policy Studies in Health Services. Published
September. www.nuffieldtrust.org.uk/sites/files/nuffield/publication/Reforming_health_
care_international_experience.pdf.

Doty, T. 2008. “Healthcare as a Commodity: The Consequences of Letting Business Run Health-
care.” Accessed February 5, 2013. www.ucalgary.ca/familymedicine/system/files/
Resident+Research+Review+Report.pdf (content no longer available).

Filice, C. E., and K. E. Joynt. 2017. “Examining Race and Ethnicity Information in Medicare Adminis-
trative Data.” Medical Care 55 (12): e170–e176.

Gupta, V., I. Haque, J. Chakraborty, S. Graff, S. Banerjee, and S. K. Banerjee. 2018. “Racial Disparity in
Breast Cancer: Can It Be Mattered for Prognosis and Therapy.” Journal of Cell Communica-
tion and Signaling 12 (1): 119–32.

Haskins, J. 2017. “Healthy People 2030 to Create Objectives for Health of Nation: Process Underway
for Next 10-Year Plan.” Nation’s Health 47 (6): 1–14.

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Health Careers Center. 2004. “Health Care Administrator.” Accessed May 8, 2018. www.mshealth
careers.com/careers/healthcareadmin.htm.

James, C. V., R. Moonesinghe, S. M. Wilson-Frederick, J. E. Hall, A. Penman-Aguilar, and K. Bouye. 2017.
“Racial/Ethnic Health Disparities Among Rural Adults—United States, 2012–2015.” Morbidity
and Mortality Weekly Report Surveillance Summaries 66 (23): 1–9.

Jones, C. M., C. Clavier, and L. Potvin. 2017. “Adapting Public Policy Theory for Public Health Research:
A Framework to Understand the Development of National Policies on Global Health.” Social
Science & Medicine 177: 69–77.

Jost, T. 2015. “If the ACA Were Repealed, Just What Would Replace It?” Health Affairs Blog. Published
April 14. http://healthaffairs.org/blog/2015/04/14/46989/.

Kaiser Family Foundation (KFF). 2013. “Summary of the Affordable Care Act.” Published April 25.
www.kff.org/health-reform/fact-sheet/summary-of-the-affordable-care-act/.

Metchnikoff, E., L. Pasteur, and R. Koch. 1939. The Founders of Modern Medicine: Pasteur, Koch,
Lister. New York: Walden.

Miller, A. 1987. “Child Health.” In Epidemiology and Health Policy, edited by S. Levine and A. Lil-
lienfeld. New York: Tavistock.

Modisenyane, S. M., S. Hendricks, and H. Fineberg. 2017. “Understanding How Domestic Health
Policy Is Integrated into Foreign Policy in South Africa: A Case for Accelerating Access to
Antiretroviral Medicines.” Global Health Action 10 (1): 1339533.

Oberlander, J. 2007. “Learning from Failure in Health Care Reform.” New England Journal of Medicine
357 (17): 1677–79.

Organisation for Economic Co-operation and Development (OECD). 2018. “Life Expectancy at Birth,
Men/Total/Women/Years, 2015.” Accessed May 9. https://data.oecd.org/healthstat/life-
expectancy-at-birth.htm.

Pesko, M. F., and A. M. T. Robarts. 2017. “Adolescent Tobacco Use in Urban Versus Rural Areas of the
United States: The Influence of Tobacco Control Policy Environments.” Journal of Adolescent
Health 61 (1): 70–76.

Sack, K., and M. Connelly. 2009. “In Poll, Wide Support for Government-Run Health.” New York Times.
Published June 20. www.nytimes.com/2009/06/21/health/policy/21poll.html.

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Shi, L. 1999. “Experience of Primary Care by Racial and Ethnic Groups in the United States.” Medical
Care 37 (10): 1068–77.

Shi, L., D. C. Lee, M. Chung, H. Liang, D. Lock, and A. Sripipatana. 2017. “Patient-Centered Medical
Home Recognition and Clinical Performance in US Community Health Centers.” Health
Services Research 52 (3): 984–1004.

Shi, L., D. C. Lee, G. P. Haile, H. Liang, M. Chung, and A. Sripipatana. 2017. “Access to Care and Sat-
isfaction Among Health Center Patients with Chronic Conditions.” Journal of Ambulatory
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Shi, L., and G. Stevens. 2010. Vulnerable Populations in the United States, 2nd ed. San Francisco:
Jossey-Bass.

Substance Abuse and Mental Health Services Administration (SAMHSA). 2016. Results from the 2015
National Survey on Drug Use and Health: Mental Health Findings. Accessed December 11,
2017. www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2015/NSDUH-FRR1-2015.pdf
(content no longer available).

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formance for 191 Countries.” World Health Organization GPE Discussion Paper Series No.
30, EIP/GPE/EQC. Accessed May 9. www.who.int/healthinfo/paper30.pdf.

Trafford, A. 2010. “Obama’s Struggle with Health-Care Reform Echoes Clintons’ Failure in 1994.”
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article/2010/02/01/AR2010020103200.html.

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Across the United States.” The White House. Published December 12. www.whitehouse.
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HealthyPeople.gov. Updated May 7. www.healthypeople.gov/2020/About-Healthy-People/
Development-Healthy-People-2030.

———. 2010. Healthy People 2020. Washington, DC: US Department of Health and Human Services.

Wilensky, G. 2017. “Republicans Will Own Whatever Happens to the ACA and Health Care Reform.”
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Winslow, C. E. A. 1920. “The Untilled Field of Public Health.” Science 51 (1630): 23–33.

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Accessed May 10. www.who.int/globalchange/resources/countries/en/.

———. 2015. “WHO Launches Country Profiles to Help Action on Health and Climate Change.” Pub-
lished November 16. www.who.int/globalchange/mediacentre/news/country-profiles/en/.

———. 1946. “Preamble to the Constitution of the World Health Organization.” Geneva, Switzerland:
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the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health.
Accessed November 2010. www.who.int/social_determinants/thecommission/finalreport/
en/index.html (content no longer available).

00_Shi (2374) Book.indb 34 11/21/18 10:55 AM

T
his section consists of three chapters that describe how health policy is made in the United States
and elsewhere in the world. Chapter 2 describes policymaking at the US federal level, and chapter
3 illustrates the process at the US state and local levels and in the private sector. Chapter 4 covers

health policymaking by international agencies such as the World Health Organization and provides
examples of the process in selected countries. The spectrum of health policymaking presented in these
chapters is intended to provide students with a broad perspective of health policy development. Such
knowledge is critical in preparing students to examine the specific health issues commonly addressed
by health policy in the United States and in other countries.

PA R T I I

H E A LT H P O L I C Y M A K I N G

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L e a r n i n g O b j e c t i v e s

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3 7

L e a r n i n g O b j e c t i v e s

In any moment of decision the best thing you can do is the right thing, the next best

thing is the wrong thing, and the worst thing you can do is nothing.

—Theodore Roosevelt

If your actions inspire others to dream more, learn more, do more, and become

more, you are a leader.

—Andrew Jackson

After completing this chapter, you should be able to

➤ understand the US policymaking process at the federal level,

➤ discuss the policy formulation stage,

➤ provide examples of the types of health and healthcare policies developed,

➤ understand the policy implementation stage,

➤ describe the policy modification stage,

➤ analyze the characteristics of health policymaking in the United States, and

➤ appreciate the role of interest groups in US health policymaking.

C H A P T E R 2

F E D E R A L H E A LT H
P O L I C Y M A K I N G

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th e de v e l O P m e n t O f me d i C a r e a n d me d i C a i d

In 1965, the US Congress passed amendments to the Social Security Act, creating the Medicare
and Medicaid programs. With this legislation, for the first time in US history, the government
assumed direct responsibility for paying some of the healthcare costs on behalf of two vulner-
able population groups: the elderly (Medicare) and the poor (Medicaid).

Prior to 1965, these populations were forced to rely on their own resources, limited public
programs, or charity from hospitals and individual physicians to obtain healthcare services.
The unemployed, too, received little assistance, as private health insurance—the only widely
available source of payment for healthcare—was available primarily to middle-class working
people and their families.

In the United States, government assistance for the poor and the elderly emerged as a
solution when the market alone did not ensure access to care for these vulnerable populations.
Most poor and elderly individuals could not afford the increasing costs of healthcare without
assistance. Moreover, because the health status of these groups was significantly worse than
that of the general population, the poor and the elderly required a higher level of healthcare
services. The elderly, in particular, experienced higher incidence and prevalence of disease
compared with younger groups.

Through the legislative process, a three-tier program was developed. The first two
tiers constituted Part A and Part B of Medicare, as outlined in Title XVIII of the Social Security
Amendments. Medicare Part A finances hospital insurance and partial nursing home coverage
for the elderly, and Part B covers their physicians’ bills.

The third tier of publicly financed insurance, Medicaid, as set forth in Title XIX of the
Social Security Amendments, extends federal matching funds to the states to cover healthcare
costs for the poor. Recipients of Medicaid are deemed eligible on the basis of means testing—
establishing financial need—administered by each state. Medicaid is available to the indigent
of all age groups.

Although adopted simultaneously, Medicare and Medicaid reflect sharply different tradi-
tions. Medicare has received broad grassroots support and carried no inherent class distinc-
tion; Medicaid, on the other hand, is burdened by the stigma of public welfare. Medicare has
uniform national standards for eligibility and benefits, whereas Medicaid varies from state to
state in eligibility and benefits. Medicaid, in essence, ushered in a two-tier system of medical
care delivery whereby recipients may experience more limited access than the privately insured,
because the reimbursement fees set by the government are low and, as a consequence, some
physicians refuse to accept Medicaid patients.

C a s e s t u d y 1

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th e he a lt h in s u r a n C e PO rta B i l i t y a n d aC C O u n ta B i l i t y aC t
O f 1996

The Health Insurance Portability and Accountability Act (P.L. 104–191, 110 Stat 2023 [1996]), known
as HIPAA, is a law designed to improve the efficiency and effectiveness of the US healthcare
system. HIPAA was passed on August 21, 1996, and consists of two parts. Title I of HIPAA protected
health insurance coverage when people lost or changed their job and addressed issues such
as preexisting conditions. Title II of HIPAA, known as the administrative simplification provi-
sions, specified standards for the new but expanding use of electronic transmission of health
information. At the time, Congress also recognized that developments in electronic technology
could endanger the privacy of health information. Thus, HIPAA mandated the development of
nationwide security standards and safeguards for the use of electronic healthcare information
(Brailer and Blumenthal 2010).

In accordance with the administrative simplification provisions, the US Department of
Health and Human Services (HHS) developed the two-part HIPAA Privacy and Security Rule,
which addressed the use and disclosure of individuals’ identifiable health information by the
covered entities. The effective compliance date of the Privacy Rule was April 14, 2003 (CDC
2003). The Privacy Rule defined protected health information (PHI) as “any information held
by a covered entity which concerns health status, the provision of healthcare, or payment for
healthcare that can be linked to an individual” (CDC 2003).

The Security Rule, which complemented the Privacy Rule, had an effective compliance
date of April 21, 2005 (HHS 2003). Whereas the Privacy Rule pertains to all PHI, the Security
Rule specifically addresses electronically stored PHI (ePHI) and specifies three types of security
safeguards required for compliance: administrative, physical, and technical (HHS 2017). Specifi-
cally, administrative safeguards are policies and procedures designed to clearly show how the
entity will comply with the act; physical safeguards control physical access to areas of data
storage to protect against inappropriate access; and technical safeguards protect communica-
tions containing PHI transmitted electronically over open networks.

In March 2006, HHS established the Enforcement Rule, which specified penalties for the
failure of covered entities to fully comply with the HIPAA Privacy and Security Rules, instituted
procedures for investigations and hearings for violations, and specified fines for avoidable
breaches of ePHI resulting from failure to follow safeguards (HHS 2006).

HIPAA was greatly strengthened in 2009 with the introduction of the Health Informa-
tion Technology for Economic and Clinical Health (HITECH) Act, which widened the scope of
privacy and security protections and increased the penalties for HIPAA violations (Blumenthal
2010). With the primary goal of promoting and expanding the adoption of health information
technology and meaningful use, the HITECH Act also included rules to improve privacy and

C a s e s t u d y 2

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I n t r o d u c t i o n t o H e a l t h P o l i c y4 0

security. The HITECH Act stipulated that entities covered by HIPAA must report data breaches
that affect 500 or more persons to HHS, the news media, and the people affected by the data
breaches. This requirement was subsequently extended in the Final Omnibus Rule of March 2013.

The Final Omnibus Rule of 2013 is the most recent act of legislation in HIPAA history.
The rule filled gaps in the existing Security Rule and breach notification portions of the HITECH
Act, and it made the most extensive changes since HIPAA was first implemented. The most
important changes included specifying the encryption standards of ePHI, establishing more
objective standards for assessing a data breach, and holding HIPAA business associates to the
same standards for protecting PHI as covered entities (Goldstein and Pewen 2013).

The Final Omnibus Rule has achieved its goals of making covered entities more aware
of the HIPAA safeguards and HITECH Act provisions to which they must adhere. Many healthcare
organizations have taken measures to comply, such as using secure messaging solutions for
internal communications, encrypting data on computer networks and portable devices, and
implementing initiatives to archive e-mails securely. As health information technology rapidly
advances and demands for access to more extensive health information grow, continuous policy
efforts are needed to enhance the digitization of health data, on the one hand, and build public
trust in data sharing, on the other.

I
n the United States, health policymaking takes place in the federal, state, and local
governments as well as in the private sector, but it is federal health policy that has the
most profound impact on care delivery. This chapter presents health policymaking at

the federal level. Chapter 3 considers the process at other levels of government and in the
private sector in the United States, and chapter 4 discusses the processes adopted in the
international arena.

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

The political system in the United States operates through three branches of government:
legislative, executive, and judicial (as illustrated in exhibit 2.1).

le g i s l at i v e Br a n C h

The legislative branch of the federal government is referred to as the US Congress and is
composed of two chambers: the House of Representatives and the Senate. Congress is the
most active of the three branches in policymaking by way of the statutes or laws it enacts.
This body of legislators operates by virtue of three powers that drive its influence in health
policymaking:

legislator
An individual
responsible for making
or enacting laws.

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1. The US Constitution grants Congress the power to use any reasonable means not
directly prohibited by the Constitution to carry out the will of the people. With this
mandate, Congress can enact laws influencing a broad array of health policy
issues.

2. Congress possesses the power to tax, which allows it to regulate—albeit
indirectly—the health behavior of individuals, organizations, and states.
Taxes on cigarettes, for example, are intended to reduce individuals’ cigarette
consumption; tax exemptions for employer health benefits are designed to
promote increased insurance coverage for working people.

3. Congress is granted the power to spend. It allocates funding as it deems
appropriate to support the public’s health through federal programs, such as
Medicare. It may also restrict the manner in which states use those funds, such
as establishing minimum requirements for basic services offered by the joint
federally and state-funded Medicaid program.

ex e C u t i v e Br a n C h

The president of the United States and the department heads—referred to as cabinet mem-
bers—within the president’s administration constitute the executive branch of the federal
government. This branch crafts legislation that reflects the administration’s preferred policies
and attempts to convince legislators to enact those policies. Executive branch members also
make policies by establishing rules and regulations used to implement statutes and laws.

legislation
Law made by the
government to achieve a
particular objective.

exhiBit 2.1
The US Political
System—Federal
Level

US federal government

Legislative branch
Senate
House of
Representatives

Executive branch
President and
cabinet

Judicial branch
Supreme Court
US court system

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I n t r o d u c t i o n t o H e a l t h P o l i c y4 2

Ju d i C i a l Br a n C h

The judicial branch, made up of the US court system, influences health policy through
its statutory authority to interpret the law. Whenever a court interprets a statute (a law
enacted by a legislative body), establishes a judicial precedent, or interprets the US Consti-
tution, it makes policy. The courts also have the power to declare that federal or state laws
are unconstitutional. Because federal judges are appointed for life, they are generally not
subject to the types of conflicts of interest that may accompany the reelection efforts of
legislators and the president.

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

The three major stages of policymaking are policy formulation, policy implementation, and
policy modification. Exhibit 2.2 displays a framework of health policymaking at the federal
level (Longest 2016).

The relationships among the three stages of policymaking are not as straightforward as
they may seem. On the one hand, they are consecutive. Policy formulation, which includes
setting the policy agenda and developing the related legislation, begins the policymaking
process. That stage is followed by policy implementation, which includes making the rules
and putting them into operation. Policy modification concludes the process. In this stage,

statutory authority
The capacity to enforce
legislation on behalf
of the government
as granted by the US
Constitution.

exhiBit 2.2
The Process

of Health
Policymaking

E
N
V
I
R
O
N
M
E
N
T

1. Policy formulation stage
Agenda setting
Legislation development

3. Policy modification stage
Feedback
Policy analysis

2. Policy implementation stage
Rule making
Operation

Source: Information from Longest (2016).

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C h a p t e r 2 : F e d e r a l H e a l t h P o l i c y m a k i n g 4 3

policies are adjusted as necessary to accommodate
real-world application.

On the other hand, the three stages are
interactive and reinforcing. For example, the rules
and regulations proposed in the implementation
stage to solidify the policy often become the laws
and policies themselves. Policymaking rarely for-
goes modification; as time passes, new priorities and
needs arise, which in turn affect the formulation
of new policies (see the For Your Consideration
box titled “Public Policy as Health Policy”). The
sections that follow describe the three stages of the
policymaking process in greater detail.

PO l i C y fO r m u l at i O n

The two main components of the policy formulation stage are agenda setting and legisla-
tion development.

Agenda Setting
Agenda setting refers to the selection of a health problem as a policy target. A health prob-
lem can come to the attention of policymakers through multiple pathways. When several
pathways converge on a health problem, its chances of appearing on the policy agenda are
increased (see the Key Legislation box titled “Mental Health Parity and Addiction Equity
Act”). Here we describe the most common pathways to agenda setting.

agenda setting
The ability to influence
the priorities of issues
for policy consideration.

agenda
Issues targeted for
policy consideration.

FOR YOUR CONSIDERATION
Public Policy as Health Policy

Health policies often develop as a by-product of existing public poli-
cies. For example, important changes in the US healthcare system
came about after the end of World War II in 1945. Policies were imple-
mented to exclude fringe benefits from income or Social Security taxes,
and the Supreme Court ruled that employee benefits, including health
insurance, could be legitimately included in the collective bargaining
process. Used to compete for skilled workers, employer-provided
health insurance benefits grew rapidly in the mid-twentieth century.

What other health policy initiatives were developed as the
result of public policy changes?

KEY LEGISLATION
Mental Health Parity and Addiction Equity Act

The Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 requires health insurers
and group health plans to provide the same level of benefits for mental health or substance
abuse treatment and services that they do for medical and surgical care. The Affordable Care
Act (ACA) of 2010 further expanded MHPAEA requirements by ensuring that qualified plans
offered on the ACA health insurance marketplace cover many behavioral health treatments
and services (Center for Consumer Information and Insurance Oversight 2018). Whereas the

( c o n t i n u e d )

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Impact of the health problem. The health problems that lead to legislative action
typically either affect the general population or have a concentrated impact on a small but
visible subpopulation. For example, bioterrorism—the deliberate release of viruses, bacteria,
or other germs (agents) to cause illness or death in people, animals, or plants (CDC 2006;
Shi and Singh 2017)—emerged as a health problem targeted for policymaking following
9/11, the September 11, 2001, terrorist attacks on the World Trade Center in New York
and the Pentagon in Washington, DC. To help prevent, protect against, and respond to any
future acts of terrorism in the United States, President George W. Bush signed into law the
Homeland Security Act of 2002, ushering in a new era in health protection in the United
States (see the For Your Consideration box titled “Homeland Security Act”).

Public opinion. Policy action is most likely when public interest is high and the degree
of conflict or dispute is low. Individuals tend to be concerned with the potential impact of

KEY LEGISLATION
Mental Health Parity and Addiction Equity Act (continued)

regulations of MHPAEA approved in 2008 only applied to the commercial market and not to
Medicaid and the Children’s Health Insurance Program (CHIP), the final regulation published
in 2013 applies these changes to Medicaid and CHIP as well (HHS 2013). This MHPAEA regula-
tion also promotes greater consistency of care for patients across states.

The last regulation of MHPAEA helps ensure equitable treatment at intermediate levels
of care, such as in residential and intensive outpatient settings; transparency as required
by health plans and by law, including disclosure rights; equity among all plan standards,
including geographic limits, facility-related limits, and network quality; and the removal of
ambiguous or unnecessary modifications to the parity rule (HHS 2013).

FOR YOUR CONSIDERATION
Homeland Security Act

The Homeland Security Act (HSA) of 2002, formulated following the 9/11 terrorist attacks, created
the US Department of Homeland Security and the new, cabinet-level position of secretary of
Homeland Security. The primary mission of this department is to prevent terrorist attacks within
the United States, reduce the vulnerability of the United States to terrorism, and minimize the
damage and assist in the recovery from terrorist attacks that occur within the United States.

HSA has a significant impact on US foreign and domestic policies. How do you think it has
affected health policy in the United States and abroad? Can you think of examples?

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new healthcare bills on their personal lives and well-being (see the For Your Consideration
box titled “Public Opinion and Policymaking: Universal Healthcare”). Policymakers must
structure their issues in terms of the concerns of the broad public to achieve high relevance
and support (see the Learning Point box titled “What Research Says About the Impact of
Public Opinion”).

FOR YOUR CONSIDERATION
Public Opinion and Policymaking: Universal Healthcare

The persistent failure of the United States to create a universal healthcare system is an example
of the influence that the public holds over healthcare policy. Although US residents generally
believe that offering healthcare to all is “the right thing to do,” they also express concern that
its implementation could adversely affect their own financial status—for example, by paying
for tax or insurance premiums to cover the previously uninsured.

What do you think? Should the United States expand coverage mandated by the Afford-
able Care Act to all US residents as a universal approach to healthcare? How would you frame
universal coverage legislation to address the concerns of the public at large?

LEARNING POINT
What Research Says About the Impact of Public Opinion

The relationship between public opinion and policymaking has been the subject of numerous
studies in the twenty-first century. A 2003 review found that the impact of public opinion on
policy was substantial and that the prominence of the policy enhanced the impact of public
opinion. In addition, the impact of opinion remained strong even when taking into account
the activities of political organizations and elites (Burstein 2003). Another study found that
the “mood of the public” was often aligned with Supreme Court decisions, with a more liberal
mood suggesting liberal decisions and a more conservative mood suggesting conservative
decisions. When researchers tried to understand why this was so, through quantitative data
and statistical methods, the reasons were still not clear (Epstein and Martin 2010). A third study
concluded that citizens sometimes had influence over a democratic government, and the move-
ment of a policy tended to be in the direction of public opinion; however, three caveats must
be considered. First, politicians and policy entrepreneurs had room to maneuver policy in ways
that were not visible to the public. Second, the causal impact of public opinion was hard to
independently assess, given the ability of politicians to shape views, as well as contradictions
in public views across policy issues. Third, the extent of responsiveness varied widely across

( c o n t i n u e d )

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I n t r o d u c t i o n t o H e a l t h P o l i c y4 6

LEARNING POINT
What Research Says About the Impact of Public Opinion (continued)

issues and at given points in time (Manza and Cook 2002). Additional research on the impact of
public opinion on health policy is needed to further classify and understand these conclusions.

When considering public opinion on government programs in general, one study dem-
onstrated that the delivery mechanism of a government program could dramatically affect
citizens’ likelihood of supporting that program. Americans were found to be more favorably
disposed toward government interventions through taxes than through more direct chan-
nels. Citizens’ responsiveness to particular delivery mechanisms often varied with ideology.
In the same study, conservative support for tax breaks was much higher than for otherwise
identical cash payment programs across the board, while this effect was relatively muted for
liberals (Haselswerdt and Bartels 2015).

The relationship between public opinion and healthcare reform received significant attention
in the second decade of the twenty-first century. One study reported that gubernatorial ACA
announcements and grant activity increased support for the ACA in nearby states, reflecting
spillover effects that influenced opinions in other states. States were more likely to emulate
other states with similar ACA policy preferences when deciding when to announce their ACA
decisions (Pacheco and Maltby 2017). A 2017 infographic highlighted public opinion on healthcare
reform in the United States (Kirzinger et al. 2017). When considering public opinion across party
lines, both Democrats and Republicans noted that lowering out-of-pocket costs for healthcare
was a top priority. Consensus on other topics varied, with more Republicans viewing ACA repeal
as a top priority (63 percent versus 21 percent) and more Democrats viewing lowering the cost of
prescription drugs as a priority (67 percent versus 55 percent). In March 2017, 49 percent of the
public viewed the ACA favorably while 44 percent viewed it unfavorably, and 64 percent of the
public supported guaranteeing a certain level of health coverage for seniors and low-income
people, even if the federal government’s spending and role increased (Kirzinger et al. 2017).

When considering public views of Medicaid, Kaiser Family Foundation (KFF) polls found that
a majority of the public (74 percent) held a favorable view of Medicaid, although this figure
varied slightly across party lines (84 percent of Democrats, 76 percent of independents, and
61 percent of Republicans). A majority of Americans believed that Medicaid worked well for
low-income people and that spending should not be decreased, yet only about 40 percent of
Americans reported being aware that the House of Representatives had passed a plan that
made major reductions to Medicaid funding. Republicans were more likely to support reducing
federal funding for Medicaid expansion but were divided in their opinions concerning how
Medicaid should be funded (KFF 2017).

Several organizations have collected public opinion data related to healthcare and policy,
including the Pew Research Center, American National Election Studies, General Social Survey,
National Annenberg Election Survey, and Gallup Poll (Michigan State University 2018). Research
on the impact of public opinion on public policy continues.

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Presidential involvement. The president may form a policy position on the basis of
input from a variety of sources, including personal interests; recommendations of advisers,
cabinet members, and agency chiefs; campaign information; expert opinions; and public
opinion polls. The president must firmly believe in the merits of an issue to be a strong
advocate for a targeted policy. For example, President Barack Obama, a Democrat, declared
a major goal of his administration to be a drastic reduction in the number of Americans
who have no health insurance coverage. His healthcare agenda was accepted as public policy
through the passage of the ACA in 2010, which was achieved by uniting the Democratic
Party behind this cause. The election of Republican Donald Trump as president in 2016,
combined with the retention of a Republican majority in the House and Senate, raised
uncertainty about the future of the ACA, the structure and funding of the country’s public
health insurance programs (Medicare, Medicaid, and CHIP), and the future direction of
health policy in the United States (Marmor and Gusmano 2018).

Legislator interest. Legislators influence agenda setting by championing a health issue
that either they personally embrace or their constituents demand. The late Senator Edward
“Ted” Kennedy (D-MA), for example, became a national leader and advocate for improving
mental health care following the diagnosis of his son Patrick with bipolar disorder.

Media coverage. In a democracy whose fundamental freedoms include freedom of
the press, the media—newspapers, magazines, radio, television, websites, and even social
media—serve as a layer of checks and balances outside of the government’s purview to guard
against the abuse of power by public officials.

In addition, the media heightens awareness of issues through investigative reporting
and frequent exposure of findings, which may produce strong public reaction that leads
to new regulations and laws. The reporting of Walt Bogdanich (1987) for the Wall Street
Journal is such an example. Bogdanich documented evidence that poorly trained laboratory
technicians were misreading Pap tests, leading to false diagnoses of cervical cancer or missed
diagnoses (Otten 1992). His reporting prompted Congress to pass the Clinical Laboratory
Improvement Amendments in 1988, prescribing minimum standards of training, testing,
and workloads for laboratory technicians. As another example, the media advocacy activities
implemented by the Florida Tobacco Control Program contributed to the passage of tobacco
product placement ordinances in Florida (Niederdeppe, Farelly, and Wenter 2007). Media
interventions can significantly influence policymakers by shaping public opinion, which in
turn exerts pressure on policymakers to respond (Bou-Karroum et al. 2017; Waitzkin and
Hellander 2016).

Legislation Development
Legislation development at the federal level takes place through the federal legislative process
and the work of House and Senate committees.

policy position
The stand taken
regarding a particular
issue. A president’s
policy position often
influences the focus
and orientation of
legislation.

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Federal Legislative Process
Exhibit 2.3 summarizes the progression of US federal legislation, and the steps are described
in greater detail in this section.

A bill introduced in Congress—either the House or the Senate—is assigned to a
congressional committee by the Speaker of the House or the Senate majority leader. The
committee chair forwards the bill to the appropriate subcommittee, which in turn forwards it
to potentially affected agencies, holds hearings and hears testimony, and may amend the bill.
The subcommittee and then the full committee may recommend the bill for consideration
by the entire body of Congress, not recommend it, or defer it by tabling legislation.

Assuming the bill is approved by the committee, the full House or Senate hears it
and may make an amendment; the bill can be approved with or without amendments and
is then sent to the other chamber for consideration. The bill may go back and forth between
the chambers several times for reconciliation before an identical version can be considered
and approved by both chambers.

After the House and Senate have approved an identical bill, it is presented to the
president for a signature. The president has three options in acting on legislation:

1. Sign the legislation, at which point it becomes law.

2. Veto, or reject, the legislation, whereby the bill dies if a two-thirds majority of
Congress cannot override the veto.

3. Neither sign nor otherwise act on the legislation, and it either

– automatically becomes law after 21 days if Congress is in session or

– results in a “pocket veto” if fewer than 21 days remain in the congressional
session.

For an example of healthcare legislation signed into law by the president, see the
Key Legislation box titled “Medicare Prescription Drug, Improvement, and Modernization
Act of 2003.”

Speaker of the House
The presiding officer
of the US House of
Representatives,
typically chosen from
the majority party of the
House.

Senate majority leader
Senate leader elected
by the party that
holds majority in
the US Senate. The
majority leader serves
as the chief Senate
spokesperson for the
party and is responsible
for scheduling the
legislative and executive
business of the Senate.

tabling legislation
An action undertaken by
Congress to postpone
consideration of a bill.

amendment
Change or addition to
a piece of legislation
under consideration
in the US House of
Representatives or
Senate. Amendments
can also be introduced
in Congress to change a
current federal law.

veto
As a verb, to unilaterally
stop an official action;
as a noun, the authority
to do so.

KEY LEGISLATION
Medicare Prescription Drug, Improvement, and Modernization Act of 2003

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (P.L. 108-173),
also called the Medicare Modernization Act (MMA), is a federal law of the United States that
was enacted in 2003 (CMS 2018b). The MMA was signed into law by President George W. Bush
on December 8, 2003, after passing in Congress (US Congress 2003).

The MMA’s most highly touted feature is the introduction of an entitlement benefit for
prescription drugs, through tax breaks and subsidies (US Congress 2003). In the years since

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exhiBit 2.3
The Progression of
Federal Legislation

Bill is introduced in Congress.

Bill is assigned to a congressional committee.

After committee approval, bill is scheduled for congressional consideration.

Bill is passed in Congress.

Bill is presented to the president.

President signs bill into law.

KEY LEGISLATION
Medicare Prescription Drug, Improvement, and Modernization Act of
2003 (continued)

the creation of Medicare in 1965, the role of prescription drugs in patient care has significantly
increased. As new and expensive drugs have come into use, patients—particularly senior citi-
zens at whom Medicare was targeted—have found prescriptions harder to afford. The MMA was
designed to address this problem. The benefit is funded in a complex way, reflecting diverse
priorities of lobbyists and constituencies. The MMA provides a subsidy for large employers
to discourage them from eliminating private prescription coverage to retired workers (a key
AARP goal), prohibits the federal government from negotiating discounts with drug companies,
and prevents the government from establishing a formulary, but it does not prevent private
providers such as health maintenance organizations from doing so.

Rural, independent pharmacies may be negatively affected by MMA implementation as
business shifts from cash to third-party reimbursement. The high degree of variation among
states also has potentially important implications for the implementation of Prescription
Drug Plan regions under the MMA (Fraher et al. 2005).

The projected price tag of a universal Medicare prescription drug benefit makes it more
difficult to spend additional tax dollars on healthcare for other US populations. Regardless
of whether this sea change in philosophy reduces the absolute dollars spent on healthcare
for the elderly, it is certain to reduce the public-sector dollars spent on healthcare for the
elderly (Channick 2006).

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House and Senate Committees
Committees, subcommittees, and legislative panels within both the House and the Senate
directly influence legislation. For those most relevant to healthcare, see the Helpful Resources
box titled “Congressional Committees Involved in Health-Related Legislation.” Some
implications of this fragmentation are discussed later in the chapter.

PO l i C y im P l e m e n tat i O n

After legislation has been signed into law, it is forwarded to the appropriate agency for
implementation. The government’s principal agency for implementing many of the health
laws is HHS, whose mission is to protect the health of all Americans and provide essential
human services, especially for those least able to help themselves (HHS 2018). The following
operating divisions within HHS focus on specific areas of health concern:

◆ Administration for Children and Families

◆ Administration on Aging

◆ Agency for Healthcare Research and Quality

HELPFUL RESOURCES
Congressional Committees Involved in Health-Related Legislation

The House Committee on Ways and Means (http://waysandmeans.house.gov) has sole juris-
diction over Medicare Part A, Social Security, unemployment compensation, public welfare,
and healthcare reform.

The House Energy and Commerce Committee (https://energycommerce.house.gov) oversees
legislation relating to telecommunications, consumer protection, food and drug safety, public
health, air quality and environmental health, energy supply and delivery, and interstate and
foreign commerce in general. This committee has jurisdiction over Medicaid, Medicare Part
B (shared with Ways and Means), and matters of public health.

The House Committee on Appropriations (http://appropriations.house.gov) and its Labor,
Health and Human Services, Education, and Related Agencies subcommittees are responsible
for allocating and distributing federal funds for individual health programs (except those
for Medicare and Social Security, which are funded through the Social Security Trust Fund).

The Senate Committee on Health, Education, Labor and Pensions (http://help.senate.gov)
focuses on health, education, and workplace issues by proposing changes to the healthcare
system, the minimum wage, working conditions and compensation, and welfare and labor laws.

The Senate Committee on Finance (http://finance.senate.gov) and its Subcommittee on
Health, similar to the Ways and Means Committee in the House, have jurisdiction over taxes
and revenues, including matters related to Social Security, Medicare, Medicaid, and Maternal
and Child Health (Title V of the Social Security Act).

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◆ Agency for Toxic Substances and Disease Registry

◆ Centers for Disease Control and Prevention (CDC)

◆ Centers for Medicare & Medicaid Services (CMS)

◆ Food and Drug Administration

◆ Health Resources and Services Administration

◆ Indian Health Service

◆ National Institutes of Health

◆ Office of Inspector General

◆ Substance Abuse and Mental Health Services Administration

The assigned agency develops rules and regulations (the rule-making component),
and the proposed rules and regulations are published in the Federal Register for public
comment and reaction before they are finalized. Then they are put into operation.

Rule Making
Rule making refers to the process by which implementation agencies set detailed rules and
regulations for the application of laws. In this process, experts from multiple disciplines and
backgrounds, such as science, economics, and industry, are brought together to agree on the
rules by which the new law will be enforced. During the preliminary stage of information col-
lection and as part of the comment or negotiation period, the public—both individuals and
groups—may also have the opportunity to provide input on the terms of the proposed rule. After
the rules or regulations are finalized, they become the guidelines for operationalizing the law.

Operation
Legislation is operationalized by the HHS agency assigned to develop the regulations to
implement or enforce it. This portion of the implementation process focuses on carrying out
the rules or regulations in an efficient and effective manner: The program must meet economic
constraints while delivering concrete services to the target population (for an example of a
newer program facing such challenges, see the Key Legislation box titled “Medicare Access
and CHIP Reauthorization Act of 2015”). The ability to attain the policy objective depends
on the presence of a host of requirements, including the following:

◆ The logic of the potential solution is sound.

◆ The structure is in place.

◆ Program activities are designed to reflect the policy intent and logic model (see
Shi, Oliver, and Huang [2000] for a discussion of logic models).

Federal Register
A publicly accessible
source that publishes
presidential and federal
agency documents; a
daily publication of the
US federal government.

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I n t r o d u c t i o n t o H e a l t h P o l i c y5 2

◆ Program activities are carried out effectively and efficiently.

◆ Unintended outcomes will not jeopardize the continuation of the program.

◆ External factors will not jeopardize the impact of the program.

KEY LEGISLATION
Medicare Access and CHIP Reauthorization Act of 2015

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, commonly called the
“Permanent Doc Fix,” is a US statute (US Congress 2015; US GPO 2015) that revises the Balanced
Budget Act of 1997 and changes the payment system for doctors who treat Medicare patients.

As described by Saleh and Shaffer (2016), MACRA led to the formation of two reimburse-
ment paradigms: the merit-based incentive payment system (MIPS) and alternative payment
models (APMs). MACRA effectively repealed the CMS sustainable growth rate (SGR) formula
while combining several CMS quality-reporting programs. As such, MACRA represents an
unparalleled acceleration toward reimbursement models that recognize value rather than
volume. MACRA’s primary provisions include changes to the way Medicare physicians are reim-
bursed, increased funding, and extension of CHIP (Orszag and Emanuel 2010). MACRA-related
regulations also address incentives for use of health information technology by physicians
and other providers. Under MACRA, the HHS secretary is tasked with implementation of MIPS,
which consolidates three incentive programs into one, for eligible physicians (CMS 2018a).

The United States is set to transition from a fee-for-service system, which has allowed
physicians and providers to bill Medicare and Medicaid for services they provided to their
patients, to a pay-for-performance system, using MIPS, APMs, and accountable care organiza-
tions. The new model will now require the provider to provide information on the quality of
service being given, how valuable it is to the patient, and the accountability that the provider
has to the treatment being performed (Hirsch et al. 2016). In replacing the SGR with MIPS,
MACRA paves the way for better benchmarks by providing a strong incentive for physicians
to participate in APMs (US Congress 2015). Where evidence of their effectiveness is strong,
bundled payments can be mandated. The proposal by Medicare to mandate bundled payments
for joint replacements and to transition to a regional benchmark is encouraging, although
many aspects of it are problematic (Miller 2015).

MACRA is the most influential health legislation since the ACA and represents a cohesive
movement toward value-based payment reform. MACRA contains several untested rulings
that will require detailed attention from orthopedic surgeons and healthcare institutions.
Although MACRA has eliminated the historical frustrations associated with SGR, surgeons
must now choose which payment model to pursue. Future decisions will need to incorporate
a more comprehensive look at the advantages and disadvantages of MIPS and APMs in each
unique practice environment to determine which approach will best serve patients in the
short and long terms.

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Other factors may also emerge in the operational stage of policy implementation,
such as unexpected events or influence from additional determinants (see chapter 1) that
may compromise policy success. An example of uncontrolled determinants is the current
prevalence of diabetes and obesity. Since the 1970s, the rate of diabetes and its main contrib-
uting factor, obesity, has steadily increased, triggering major—albeit largely failed—policy
initiatives to combat this health problem. One reason these initiatives failed is that they
focused on changing behaviors (e.g., exercise, diet) but did not address other, larger environ-
mental and social determinants that contribute to unhealthy behaviors. Examples of these
determinants include a sedentary and stressful work or living environment; easy and cheap
access to unhealthy food; limited access to safe, open space; and lack of facilities for exercise.

PO l i C y mO d i f i C at i O n

Policy modification refers to revisions to the rules or regulations pertaining to a piece of original
legislation in order to enhance the legislation’s benefits to the targeted population, reduce
its negative consequences, refine its policy objectives, or address other related issues. Policy
modification typically takes place after the policy has been implemented and incorporates
lessons learned from implementation. It may also occur during agenda setting, where existing
similar policies inform the formulation of the new policy; legislation development, where the
new development, any budgetary changes, or beneficiary demands dictate the adjustment of
policy; rule making, where bureaucracy prompts the operationalizing of policy into regula-
tions and interest groups to use their resources to maximize benefits or minimize negative
consequences; and operation, where administrative structure and budgetary constraints
often determine the scope of the enacted program (Committee for a Responsible Federal
Budget 2016; Forest et al. 2015; Longest 2016).

The need to modify a policy can arise for a number of reasons, including the following.
Change in the logic model. In the course of implementing a policy, new evidence or

theory comes to light that indicates weakness in the logic behind the policy. When the logic
itself is flawed, it must be corrected by modifying the logic model (Brown and Best 2017;
Shi, Oliver, and Huang 2000). This revision often necessitates revision of the policy itself.

Consequences of implementation. Although policymakers try to anticipate potential conse-
quences, not all consequences can be foreseen, particularly if new events take place during policy
implementation or if the consequences are negative for the policy beneficiaries or other stakeholders.

Policy analysis and evaluation. Results of policy evaluation often provide important
insights into the modification of an existing policy. The Congressional Research Service is a
legislative agency within the Library of Congress that provides Congress with information
and analyses on already implemented policy.

Resource constraints. The economic climate may decline following a policy’s imple-
mentation, and a particular issue may no longer be a priority in the face of an economic
downturn and budget cuts.

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Changing goals. The policy goals of one administration may differ from those of the
next. As the administration of the US government changes every four years (in addition to
the more frequent changes in Congress), many policy priorities change accordingly.

Interest group involvement. In the American democracy, interest groups influence
policies at the modification stage as well as at the formulation and implementation stages.
Interest groups that are adversely affected by a policy often expend extra effort to overturn
or modify the enacted policy.

Oversight. The executive, legislative, and judicial branches each have oversight respon-
sibility for enacted legislation. The following are examples for each branch:

◆ Legislative branch: Any congressional committee with jurisdiction over a
particular policy can hold oversight hearings to review its progress and assess
modification needs.

◆ Executive branch: In addition to the agencies assigned to a piece of legislation,
the Office of Management and Budget (OMB) plays a critical role in
supervising, assessing, and ensuring the successful implementation of a policy.

◆ Judicial branch: The courts may become involved in policy modification by
ruling on how laws are interpreted and enforced, especially in disputes over the
interpretation, application, and constitutionality of laws.

Incremental nature of policy development. In the American political landscape, radi-
cal policy is rarely enacted; most policies are incremental and evolve over time. In fact, the
nature of policy development dictates modification of existing policies. Revisions to the
1935 Social Security Act have spanned decades, as a prime example.

at t r i B u t e s O f he a lt h PO l i C y m a k i n g i n t h e un i t e d stat e s

US health policymaking is shaped by a number of important characteristics, as described
in this section: the government’s subordinate role to the private sector in the healthcare
market, the fragmentation of government programs, the incremental approach to reform,
and the importance of congressional support.

gO v e r n m e n t i n su B O r d i n at e rO l e t O t h e Pr i vat e se C t O r

Because the federal government takes a subordinate role to the private sector in providing
healthcare services and private insurance plans, policymaking by government is limited to
addressing market failures or deficiencies. For example, left alone, the healthcare market could

oversight
Activities to review,
monitor, or supervise the
process of formulating,
implementing, and
modifying public policy.

jurisdiction
The authority to
interpret and apply the
law.

Office of Management
and Budget (OMB)
The largest component
of the Executive
Office; implements
and enforces the
commitments and
priorities of the
president and assists
executive departments
and agencies across the
federal government.

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not ensure adequate insurance coverage for the elderly (who tend to be sicker) or the poor
(who typically cannot afford the premiums). Therefore, government intervened and created
health insurance plans for the elderly (Medicare) and the poor (Medicaid). One consequence
of government intervention is that policies tend to be implemented piecemeal, addressing
one market deficiency at a time rather than in a comprehensive and coordinated manner.

fr a g m e n t e d gO v e r n m e n t Pr O g r a m s

The fragmentation of the American political institution is reflected in the development
of health policy legislation. Healthcare programs are similarly fragmented among federal,
state, and local governments, which pursue their own policies with limited coordination.
Exhibit 2.4 provides an example of the variability in healthcare insurance that has emerged.

in C r e m e n ta l aP P r O a C h t O re f O r m

Such fragmentation inevitably leads to incremental change rather than systematic reform.
Compromises struck in the resolution of issues also contribute to the piecemeal nature
of healthcare reform. Consider the broadening of the Medicaid program since its start in
1965. Rather than adopt a single, comprehensive initiative, Medicaid underwent numer-
ous disjointed expansion efforts in the 1980s and 1990s (see the Key Legislation box titled
“Social Security Act”).

The employed Predominantly covered by voluntary private
insurance to which they and their employers
make contributions

The elderly Funded by Social Security tax revenues
(Medicare Part A) and government -subsidized
voluntary insurance for physician, supple-
mentary, and prescription drug coverage
(Medicare Parts B and D)

The poor Covered by Medicaid, which is financed with
federal, state, and local revenues

Special population groups (e.g., veterans;
American Indians; members of the armed
forces, Congress, and the executive branch
of government)

Covered by the federal government directly

exhiBit 2.4
Example of
Fragmented
Healthcare
Programs: Funding
of Health Insurance

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im P O rta n C e O f CO n g r e s s i O n a l su P P O rt

As exhibit 2.5 shows, most of the important US health legislation was passed when both
congressional chambers were controlled by the same party. When the president is of the
same party affiliation, chances of success are even greater.

For example, President Lyndon B. Johnson achieved passage of Medicare and Medicaid
in 1965 not only by virtue of his leadership skills but also because he was operating in an
unusually favorable political environment for advancing legislation. Johnson was a Democrat
serving at a time when Congress was also dominated by the Democrats. Johnson mobilized
the public and Congress behind the bill and efficiently shepherded it through the legislative
process. As a result, the Social Security Amendments of 1965 were signed into law, setting
the stage for the creation of Medicare and Medicaid. The ACA is another example. With
a solid Democratic majority in Congress, President Obama quickly pushed the ACA even
without a single Republican voting in favor of it. President Trump wanted to do something
similar—that is, to “repeal and replace Obamacare,” as he called the ACA—but this time

KEY LEGISLATION
Social Security Act

The 1935 Social Security Act is a landmark policy that established the Social Security program
for the elderly. Since its enactment, a number of health-related modifications have been made.

• Kerr-Mills Act (1960): established a program of medical assistance for the medically
indigent elderly

• Medicare and Medicaid (1965): created as insurance programs for the elderly and the
poor, respectively

• Expansion of public coverage (1967): expanded Medicaid to cover eligible children
up to age 21 and mandated improvement in the quality of care provided in nursing
homes

• Professional standards review organizations (1972): created to monitor the quality and
medical necessity of services provided to Medicare recipients

• Block grant program (1974): consolidated federal–state social services programs, limits
federal matching funds while giving states more flexibility in prioritizing services than
they had prior to the program’s implementation

• Prospective payment system (1983): instituted predetermined payments set by
diagnosis-related groups

• Temporary Assistance for Needy Families (1997): replaced Aid to Families with Depen-
dent Children program placed under Social Security Act

• State Children’s Health Insurance Program for low-income citizens (1997): added to
Social Security Administration

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Date Legislation President Senate Congress

1921 Maternity and Infancy Act Republican Republican Republican

1935 Social Security Act Democrat Democrat Democrat

1937 National Cancer Institute Act Democrat Democrat Democrat

1944 Public Health Service Act Democrat Democrat Democrat

1946 National Mental Health Act Democrat Democrat Democrat

1946 Hospital Survey and Construction Act Democrat Democrat Democrat

1952 Immigration and Nationality Act Democrat Democrat Democrat

1956 Dependents Medical Care Act Republican Democrat Democrat

1963 Health Professions Educational Assistance Act Democrat Democrat Democrat

1963 Clean Air Act Democrat Democrat Democrat

1965 Social Security Amendments Democrat Democrat Democrat

1971 Comprehensive Health Manpower Training Act Republican Democrat Democrat

1972 Consumer Product Safety Act Republican Democrat Democrat

1973 Health Maintenance Organization Act Republican Democrat Democrat

1974 Employee Retirement Income Security Act Republican Democrat Democrat

1983 Social Security Amendments Republican Republican Democrat

1990 Americans with Disabilities Act Republican Democrat Democrat

1990 Ryan White Comprehensive AIDS Resources
Emergency Act

Republican Democrat Democrat

1996 Health Insurance Portability and
Accountability Act

Democrat Republican Republican

1997 State Children’s Health Insurance Program Democrat Republican Republican

2000 Minority Health and Health Disparities
Research and Education Act

Democrat Republican Republican

2002 Health Care Safety Net Amendments Republican Democrat Republican

2005 Patient Safety and Quality Improvement Act Republican Republican Republican

2008 Health Care Safety Net Act Republican Democrat Democrat

2009 American Recovery and Reinvestment Act Democrat Democrat Democrat

2010 Patient Protection and Affordable Care Act Democrat Democrat Democrat

Note: Bold indicates both houses of Congress are controlled by the same party and the president is affiliated with that
party. Italics indicate both houses of Congress are controlled by the same party and the president is affiliated with a
different party.

exhiBit 2.5
Relationship
Between Health
Legislation and
Party Affiliation

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I n t r o d u c t i o n t o H e a l t h P o l i c y5 8

with Republicans in control of Congress. His initial efforts did not succeed, as a result of
a slim Republican majority and disagreements within the ranks of the Senate Republicans,
and he turned his attention toward other issues.

rO l e O f in t e r e s t gr O u P s i n us he a lt h PO l i C y m a k i n g

Interest groups’ efforts to promote their positions affect health policy just as they do any
other policy debate in American politics. Each group aims to protect its best interests, and
although most groups are satisfied with their benefits, the result for any single group may
be less than optimal.

Organizations tend to be effective at demanding health policy. They usually have
the resources to advance their interests, even as those interests tend to be more focused, and
enjoy the diverse interests of individuals. Well-organized interest groups

◆ combine and concentrate their members’ resources;

◆ pursue an active agenda to influence all phases of policymaking, from
formulation to implementation to modification; and

◆ represent a variety of individuals and entities.

In this section we discuss the traditional types of interest groups involved in health
policymaking in the United States—physicians, senior citizens, hospitals, insurance com-
panies, and pharmaceutical research and manufacturing firms. See also the Learning Point
box titled “Interest Groups New to Healthcare Policymaking.”

Ph y s i C i a n s

Physicians as a group have difficulty lobbying for their interests because they represent many
specialties. The American Medical Association (http://ama-assn.org) represented only 18.2
percent of US physicians in 2012, down from its peak of 70 percent in the 1960s. Other
medical groups include the American Academy of Pediatrics (www.aap.org), Physicians for a
National Health Program (www.pnhp.org), the American Society of Anesthesiologists (www.
asahq.org), and the Society of Thoracic Surgeons (www.sts.org). These groups come together
on issues that pose a potential threat to the interests of physicians as a whole, as in 1992,
when the Health Care Financing Administration (now CMS) changed the reimbursement
system from fee-for-service to the Resource-Based Relative Value Scale (physicians did not
prevail in their efforts to overturn the policy). Other issues of interest to some physician
groups are income maintenance, professional autonomy, and malpractice reform.

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se n i O r Ci t i z e n s

AARP (www.aarp.org) assists people aged 50 or older by providing them with information,
advocating for their needs, and offering specific services. It advocates expanding the financing
of public benefits for the elderly to cover housing, food, income, and health. AARP sup-
ported the Medicare Prescription Drug Improvement and Modernization Act of 2003, but
it did not oppose the proposed Medicare cuts in the ACA, perhaps because AARP’s interests
in the funding of Medicare were outweighed by its support of a national healthcare system.

hO s P i ta l s

The American Hospital Association (www.aha.org) represents approximately 5,000 hos-
pitals, health systems, health networks, and other providers of care in issues of national

LEARNING POINT
Interest Groups New to Healthcare Policymaking

Two relatively new types of interest groups have emerged in the health policymaking paradigm:
corporate America and healthcare consumers.

Corporate America
Business has emerged as a singular interest group, albeit one with two prongs: large employers
and small employers. The health policy concerns of American employers are often shaped by
the extent to which they are expected to provide health insurance benefits to their employees,
their employees’ dependents, and their retirees. In general, they are likely to pay attention
to health policies that affect worker health or labor–management relations.

Healthcare Consumers
The health policy spectrum has expanded to include consumer interests. Among the more
vocal voters on this issue were members of the Tea Party movement, which became known for
its demonstrations in Washington, DC, and around the United States prior to and during the
passage of the ACA in 2010. This uniquely American populist political movement represented
both ultraconservative and libertarian interests, calling for reductions in government spend-
ing, the national debt, and the federal budget deficit and opposing taxation and expansion of
insurance coverage to those who were uninsured before the ACA. Tea Party–affiliated candidates
ran as Republicans and won enough seats in the House and Senate in the 2010 elections to
tip the majority from Democratic to Republican, but in 2012, far fewer ran and only a handful
won (Gray 2012), and the movement’s influence waned thereafter.

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I n t r o d u c t i o n t o H e a l t h P o l i c y6 0

health policy development, legislation, regulation, and legal concerns. The implications of
administrative simplification, the reduction of bad debt write-offs, and profitability are
among the current topics of interest to hospitals in general.

he a lt h in s u r a n C e CO m Pa n i e s

America’s Health Insurance Plans (www.ahip.org) represents nearly 1,300 health insurance
companies. This organization supports health insurers in the effort to ensure that affordable
healthcare coverage is expanded to include all Americans. Among the issues holding insurers’
interest are the elimination of cost shifting and the implications of administrative simplification.

Ph a r m a C e u t i C a l re s e a r C h a n d ma n u fa C t u r i n g fi r m s

The Pharmaceutical Research and Manufacturers of America (PhRMA; www.phrma.org)
represents US pharmaceutical research and biotechnology companies by supporting their
efforts to discover new medicines. PhRMA also alerts its members to changes in health policy
and attempts to influence policy formulation related to the approval and monitoring of drugs
and pharmaceutical devices (see the For Your Consideration box titled “‘Big Pharma’ and
Influence on US Health Policy” and the Learning Point box titled “Pharmacist ‘Gag Clauses’”).

administrative
simplification
Provision in the Health
Insurance Portability
and Accountability Act
and the Affordable Care
Act that aims to reduce
administrative costs
through the adoption of
electronic transactions
and standardization of
operating rules.

FOR YOUR CONSIDERATION
“Big Pharma” and Influence on US Health Policy

According to the Commonwealth Fund, US spending on pharmaceuticals exceeded $1,000
per person by 2015, between 30 percent and 190 percent higher than nine other high-income
countries (Sarnak et al. 2017). This difference was attributed to the higher prices of drugs in the
United States, as well as a lack of price-control strategies and centralized price negotiations.
The pharmaceutical industry argues that medicines are a small share of healthcare spending,
with prescription medicines consistently accounting for just 10 percent of healthcare spending
in the country (PhRMA 2016). However, researchers believe that per capita pharmaceutical
spending will increase between 4 percent and 6 percent annually through 2024 (Cox and
Kamal 2015). One study found that spending was expected to increase faster than any other
major medical good or service in the period between 2017 and 2026—at 6.3 percent per year,
on average (Cuckler et al. 2018).

In the most recent healthcare reform, the ACA of 2010, the pharmaceutical industry felt only
a modest impact. The ACA made several changes to the Medicaid drug rebate program, including
increasing the minimum rebate from 15.1 percent to 23.1 percent for pharmaceutical companies.

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FOR YOUR CONSIDERATION
“Big Pharma” and Influence on US Health Policy (continued)

This change meant that the government could recoup costs for medicines in the form of rebates
from manufacturers (Baghdadi 2017). In addition, the branded prescription drug fee is a tax
levied on the prescription drug industry that is split among pharmaceutical companies based on
their prescription drug market share (IRS 2018). This tax is estimated to bring in more than $27
billion over ten years (Joint Committee on Taxation 2010). It is argued that the pharmaceutical
industry conceded on these rebates and taxes in an effort to avoid more significant reforms to
the drug market. Pharmaceutical companies’ primary concerns with the potential revision of
the ACA include reductions in federal Medicaid funding, which could lead to lower revenue if
states cut back on these benefits; the impact of tax and trade reforms on their supply chains;
and consumers seeking more and larger discounts from pharmaceutical companies and turn-
ing to generic prescriptions where possible (PwC Health Research Institute and Strategy 2017).

The pharmaceutical industry argues that lower drug prices may inhibit the ability to conduct
research and develop innovative drugs in the future. However, a 2017 analysis found that the
premiums pharmaceutical companies earned from charging high prices in the United States
were more than the companies spend globally on research and development (Yu, Helms,
and Bach 2017). Another study found that the median cost of developing a single cancer drug
was $648 million, while the median revenue for such a drug was $1,658.4 million (Prasad and
Mailankody 2017). These findings challenge the pharmaceutical industry’s argument that high
drug costs are a reflection of the research and development behind them.

Pharmaceutical companies spend a significant amount of money to influence politicians,
given their interest in keeping their revenues and profit margins high in an age of health policy
uncertainty and reform. In 2016, about 90 percent of the members of the House of Representa-
tives and all but three of the 100 Senate members accepted campaign contributions from drug
companies. During the 2017–2018 election cycle, these numbers stood at about 88 percent of
the members of the House and 94 percent of the Senate (Center for Responsive Politics 2018b).
PhRMA, the leading pharmaceutical lobbying group, raised its lobbying expenditures from $17.2
million in 2014 to $25.8 million in 2017 (Center for Responsive Politics 2018a). A nonprofit group,
Partnership for Safe Medicines, has ties to PhRMA and has recently emerged in lobbying to block
drugs from being imported from Canada. Drugs can be three times more expensive in the United
States than they are in Canada, which pushes the interest in this legislation (Kopp and Bluth 2017).

The ties between the pharmaceutical industry and the federal government are often viewed
as loose, as employees often go through a “revolving door,” switching employment between
the two entities. One report found that nearly 340 former congressional staffers now work for
pharmaceutical companies or their lobbying firms. The same analysis showed that more than
a dozen former drug industry employees now have jobs on Capitol Hill, often on committees
that handle healthcare policy (Lupkin 2018). This finding brings into question the relationships
that exist between pharmaceutical companies and government staff.

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I n t r o d u c t i o n t o H e a l t h P o l i c y6 2

➤ The major stages of policymaking are policy formulation, policy implementation, and
policy modification.

➤ Characteristics of US health policymaking include a fragmented governing system,
strong influence of public opinion, and incremental (rather than radical) changes.

➤ Interest groups have become increasingly influential in the policymaking processes,
representing a wide variety of healthcare stakeholders.

Ca s e st u d y 1

On the basis of your research of the events leading to the enactment of Medicare and Medicaid
legislation and your knowledge of these programs, answer the following questions:

1. Why did the United States forgo attempts to achieve universal health insurance in favor
of focusing on insurance for the elderly and the poor?

2. What are the major similarities and differences between Medicare and Medicaid?

Ca s e st u d y 2

Based on your research of the events leading to the enactment of HIPAA and the ensuing leg-
islation and your knowledge of information and safety, answer the following questions:

1. Why is it necessary to collect patient information, and why it is also important to
safeguard its privacy?

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

LEARNING POINT
Pharmacist “Gag Clauses”

Pharmacists are not allowed to inform patients about less costly ways to obtain their medi-
cines. The National Conference of State Legislatures (2018) recently published a report focus-
ing on consumers being charged higher prices because pharmacists are not allowed to offer
other options to patients with health insurance. The lobbyist for drug benefit companies, the
Pharmaceutical Care Management Association, has filed to block at least one state action in
North Dakota, citing “onerous new restrictions on pharmacy benefit managers” (Pear 2018).

k e y P O i n t s

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C h a p t e r 2 : F e d e r a l H e a l t h P o l i c y m a k i n g 6 3

2. What essential personal information is often collected by healthcare providers, and
how is it used?

3. What are the methods commonly used to safeguard the privacy of PHI, and how
effective are they?

Find examples of policymaking in the health sector at the US federal level, and answer the
following questions:

1. How is the policymaking process demonstrated in your examples?
2. Which components of policymaking are evident in each stage of the process?
3. How do the stages influence each other?
4. Which characteristics of health policymaking do the examples illustrate?
5. What interest groups were involved in your examples of policymaking? What were their

roles in the making of that policy?
6. What policymaking successes and failures can you identify in the examples?

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Bogdanich, W. 1987. “False Negative.” Wall Street Journal, February 2.

Bou-Karroum, L., F. El-Jardali, N. Hemadi, Y. Faraj, U. Ojha, M. Shahrour, and E. A. Akl. 2017. “Using
Media to Impact Health Policy-Making: An Integrative Systematic Review.” Implementation
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Brailer, D., and D. Blumenthal. 2010. “Guiding the Health Information Technology Agenda.” Health
Affairs 29 (4): 586–95.

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US Social Welfare Programs.” Sociological Perspectives 60 (4): 786–809.

Burstein, P. 2003. “The Impact of Public Opinion on Public Policy: A Review and an Agenda.” Political
Research Quarterly 56 (1): 29–40.

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

r e f e r e n C e s

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tion Equity Act (MHPAEA).” Accessed May 16. www.cms.gov/cciio/programs-and-initiatives/
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MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html.

———. 2018b. “Medicare Modernization Act Final Guidelines—Formularies: CMS Strategy for Afford-
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2003: Will It Be Good Medicine for US Health Policy?” Elder Law Journal 14: 237–81.

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Cox, C., and R. Kamal. 2015. “Recent Trends in Prescription Drug Spending, and What to Look Out
For in Coming Years.” Peterson-Kaiser Health System Tracker. Published December 9. www.
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to-look-out-for-in-coming-years/.

Cuckler, G. A., A. M. Sisko, J. A. Poisal, S. P. Keehan, S. D. Smith, A. J. Madison, C. J. Wolfe, and J. C. Hardesty.
2018. “National Health Expenditure Projections 2017–2026: Despite Uncertainty, Fundamen-
tals Primarily Drive Spending Growth.” Health Affairs 37 (3): 482–92.

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Epstein, L., and A. D. Martin. 2010. “Does Public Opinion Influence the Supreme Court? Possibly Yes (But
We’re Not Sure Why).” University of Pennsylvania Journal of Constitutional Law 13 (2): 263–81.

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International Journal of Health Policy Management 4 (5): 265–66.

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Medicare Prescription Drug, Improvement, and Modernization Act of 2003 Affect the Financial
Viability of Rural Pharmacies? An Analysis of Preimplementation Prescription Volume and
Payment Sources in Rural and Urban Areas.” Journal of Rural Health 21 (2): 114–21.

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Policy and Practice.” Public Health Report 128 (6): 554–58.

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from a Survey Experiment.” Political Research Quarterly 68 (3): 607–21.

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and Importers.” Updated February 20. www.irs.gov/affordable-care-act/annual-fee-on-
branded-prescription-drug-manufacturers-and-importers.

Joint Committee on Taxation. 2010. “Estimated Revenue Effects of the Amendment in the Nature
of a Substitute to H.R. 4872, The ‘Reconciliation Act of 2010,’ As Amended, in Combina-
tion with the Revenue Effects of H.R. 3590, the ‘Patient Protection And Affordable Care
Act (“PPACA”),’ as Passed by the Senate, and Scheduled for Consideration by the House
Committee on Rules on March 20, 2010.” Published March 20. www.jct.gov/publications.
html?func=startdown&id=3672.

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caid.” Published June 27. www.kff.org/medicaid/poll-finding/data-note-10-charts-
about-public-opinion-on-medicaid/.

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2017.” Journal of the American Medical Association 317 (15): 1516.

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Kopp, E., and R. Bluth. 2017. “Nonprofit Working to Block Drug Imports Has Ties to Pharma Lobby.”
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Press.

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Opinion in the United States.” American Politics Research 30 (6): 630–67.

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macists from Disclosing Price Options: Recent State Legislation 2016–2018.” Published
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WhatWeDo/default.htm.

US Government Publishing Office. 2010. “Purpose; State Child Health Plans. Title 42—The Public
Health and Welfare, Chapter 7—Social Security, Subchapter XXI—State Children’s Health
Insurance Program, Sec. 1397aa.” www.gpo.gov/fdsys/pkg/USCODE-2010-title42/html/
USCODE-2010-title42-chap7-subchapXXI-sec1397aa.htm.

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7 0

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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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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7 3

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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I n t r o d u c t i o n t o H e a l t h P o l i c y7 4

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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7 5

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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7 7

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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7 9

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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8 1

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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8 3

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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8 7

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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8 9

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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9 1

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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9 3

Abelson, R. 2017. “UnitedHealth Buys Large Doctors Group as Lines Blur in Health Care.” New York
Times. Published December 6. www.nytimes.com/2017/12/06/health/unitedhealth-doctors-
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and-aurora-to-merge-creating-top-10-health-system-poised-to-transform-the-industry.

American Lung Association. 2018a. “Smoking Facts: Health Effects.” Accessed May 18. www.lungusa.
org/stop-smoking/about-smoking/health-effects/smoking.html.

———. 2018b. “Smoking Facts: Tobacco Industry Marketing.” Accessed May 18. www.lungusa.org/
stop-smoking/about-smoking/facts-figures/tobacco-industry-marketing.html.

Ashwood, J. S., M. Gaynor, C. M. Setodji, R. O. Reid, E. Weber, and A. Mehrotra. 2016. “Retail Clinic Visits
for Low-Acuity Conditions Increase Utilization and Spending.” Health Affairs 35 (3): 449–55.

Bartoli, C. 2018. Philadelphia Hospitals Offer Healthier Options with Good Food, Healthy Hospitals.
Centers for Disease Control and Prevention. Accessed May 18. www.cdc.gov/nccdphp/dnpao/
state-local-programs/pdf/philadelphia-hospitals-offer-healthier-options.pdf.

Baxter, S., K. Sanderson, A. J. Venn, C. L. Blizzard, and A. J. Palmer. 2016. “The Relationship Between
Return on Investment and Quality of Study Methodology in Workplace Health Promotion
Programs.” American Journal of Health Promotion 28 (6): 347–63.

Beeuwkes Buntin, M., A. M. Haviland, R. McDevitt, and N. Sood. 2011. “Healthcare Spending and
Preventive Care in High-Deductible and Consumer-Directed Health Plans.” American Journal
of Managed Care 17 (3): 222–30.

Bizjak, T. 2018. “Bike Share Starts in Sacramento: See Where You Can Get One.” Sacramento Bee.
Published May 18. www.sacbee.com/news/local/transportation/article151340982.html.

Bomey, N., and E. Weise. 2018. “Four Ways Amazon-Berkshire-JPMorgan Deal Could Shake Up Health
Care. USA Today. Published January 30. www.usatoday.com/story/money/2018/01/30/
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r e f e r e n C e s

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Boonn, A. 2017. “Raising Cigarette Taxes Reduces Smoking, Especially Among Kids (and the Cigarette
Companies Know It).” Campaign for Tobacco-Free Kids. Published January 18. www.tobacco
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Boulton, G. 2018. “Merger of Aurora Health Care and Advocate Health Care Is Completed.”
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———. 2017. “Aurora Health Care and Advocate Health Care to Merge.” Milwaukee Journal Sentinel.
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Burgermaster, M., J. Koroly, I. Contento, P. Koch, and H. L. Gray. 2017. “A Mixed-Methods Comparison
of Classroom Context During Food, Health and Choices: A Childhood Obesity Prevention
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Burke, M. 2017. “Aurora Health Care, Advocate Health Care to Merge.” Journal Times (Racine, WI).
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———. 2018c. “Smoking and Tobacco Use: Fast Facts and Fact Sheets.” Updated April 3. www.cdc.
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———. 2017a. “Health Effects of Cigarette Smoking.” Updated May 15. www.cdc.gov/tobacco/
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———. 2017c. “Secondhand Smoke (SHS) Facts.” Updated February 21. www.cdc.gov/tobacco/
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———. 2016b. “Michigan State Nutrition, Physical Activity, and Obesity Profile.” Updated November
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———. 2017b. “Legislature.” Accessed July 17, 2018. www2.monroecounty.gov/legislature-index.php.

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———. 2005. “Public Health Law—Article 13-F: Regulation of Tobacco Products and Herbal Ciga-
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Rosenhall, J. 2018. “Bike Share Program Offers California State Employees Another Way to Be
Active.” Accessed May 20. www.cdc.gov/nccdphp/dnpao/state-local-programs/pdf/program-
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ment of Health Risks with Feedback.” American Journal of Preventive Medicine 38 (2 Suppl):
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care.” FierceHealthcare. Published July 2. www.fiercehealthcare.com/payer/humana-
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Insurance.” National Bureau of Economic Research Working Paper No. 21783. www.nber.
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state.ak.us/docs/pdf/legprocess.pdf.

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United States from 2004 to 2017.” Accessed June 11. www.statista.com/statistics/259148/
consumer-spending-us-qsr-sector/.

———. 2018b. “Leading Quick Service Restaurants in the United States in 2016, Based on
Retail Sales.” Accessed June 11. www.statista.com/statistics/240310/leading-quick-
service-restaurants-in-the-us-based-on-retail-sales/.

———. 2018c. “Leading Tobacco Producing Countries Worldwide in 2016.” Accessed June 11. www.
statista.com/statistics/261173/leading-countries-in-tobacco-production/.

Svastisalee, C., T. Pagh Pedersen, J. Schipperijn, S. E. Jorgensen, B. E. Holstein, and R. Krolner. 2016.
“Fast-Food Intake and Perceived and Objective Measures of the Local Fast-Food Environ-
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West Virginia Department of Health and Human Services. 2018. “Drug Free Moms and Babies Proj-
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drug-free-moms-and-babies-project/.

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factsheets/fs339/en/index.html.

———. 2017. “Obesity and Overweight.” Published October 18. www.who.int/mediacentre/fact-
sheets/fs311/en/index.html.

Young, S., M. DeNomie, J. Sabir, E. Gass, and J. Tobin. 2017. “Around the Corner to Better Health: A
Milwaukee Corner Store Initiative.” American Journal of Health Promotion 32 (6): 1353–56.

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L e a r n i n g O b j e c t i v e s

The one who adapts his policy to the times prospers, and likewise the one whose

policy clashes with the demands of the times does not.

—Niccolò Machiavelli

Public health service should be as fully organized and as universally incorporated into our

governmental system as is public education. The returns are a thousandfold in economic

benefits, and infinitely more in reduction of suffering and promotion of human happiness.

—Herbert Hoover

C H A P T E R 4

I N T E R N AT I O N A L H E A LT H
P O L I C Y M A K I N G

After completing this chapter, you should be able to

➤ provide examples of health policymaking at the international level;

➤ describe the functions and policy-related activities of the World Health Organization;
and

➤ understand the basic ideas concerning health-related policymaking in Canada, Sweden,
and China.

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C h a p t e r 4 : I n t e r n a t i o n a l H e a l t h P o l i c y m a k i n g 1 0 3

whO he a lt h y Ci t i e s in i t i at i v e

The World Health Organization (WHO) launched the Healthy Cities (HC) initiative in 1986 with
the aim of establishing “health for all” public policies and health promotion programs in local
areas (WHO Regional Office in Europe 1997, 5). The Ottawa Charter for Health Promotion adopted
that year helped guide the HC initiative in its early stages (WHO 1986). More than 30 years later,
more than 5,000 cities worldwide have implemented HC projects (Hu and Kuo 2016). Among
notable successes, the HC network in Taiwan has achieved a considerable positive impact and
acted as a benchmark model for other participating cities around the world.

As described by Hu and Kuo (2016), the HC program in Taiwan—called Taiwan Alliance for
Healthy Cities (TAHC) —was established in 2008 and has actively engaged local governments in
health development through a process of political commitment, institutional change, capacity
building, partnership-based planning, and innovative projects. The overarching goal of the HC
network in Taiwan is to make health a priority on the social, economic, and political agenda of
city government with combined resources from industrial, public, academic, civil, and research
sectors. Representatives from 23 cities, academic institutions, nongovernment organizations, and
private organizations convened in Taiwan to form TAHC and to generate and sign the Protocol
for HC. TAHC holds annual meetings and workshops, alternating locations among its member
cities. Three commissions within TAHC have specific types of responsibilities: the research and
development group (collection, monitoring, and evaluation of city indicators), the events and
training group (planning for education and training relevant to HC), and the award evaluation
group (planning and selecting awards for HC). Multidimensional indicators are used to assess
the population’s health in each city and to present information on lifestyles and social and
environmental factors that are related to health. Beyond the existing 32 health indicators in
the WHO international HC program, TAHC has added 15 more indicators to its program as a
tool to evaluate the program’s effectiveness in Taiwan. Notably, different cities in Taiwan have
adopted different strategies to achieve their HC project goals because they encounter distinct
opportunities and challenges. Uniquely, Taiwan integrates the HC program with its Age-Friendly
City (AFC) program to simultaneously address its burdens of an aging population and urbaniza-
tion. A key component of the TAHC program is the platform created to exchange and share the
performance of HC and AFC programs with other cities. Specifically, TAHC offers eight perfor-
mance awards for HC and AFC, based on 16 categories for award applications.

The HC network in Taiwan has resulted in a series of positive achievements. Domestically,
the annual HC conference and award ceremonies encourage more cities to participate in the HC
projects. At the international level, the success of TAHC has attracted attention in the Asian region.
The achievements and innovations of the TAHC are documented so that other HC participants
can easily access and learn from them. To help other cities in Asia achieve their HC goals, WHO
has been inviting TAHC members to present at its international biannual conference since 2010.

C a s e s t u d y 1

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By sharing the progress of their HC and AFC programs, TAHC members have helped other Asian
countries resolve many of their current problems. Moreover, TAHC members have been invited
to visit the Japanese chapters of HC and presented Taiwan’s HC and AFC programs to the Shanghai
HC alliance in China. The success of the HC in Taiwan has largely resulted from integration among
the public sector, the private sector, and the community (Hu and Kuo 2016; WHO 2016).

Pr i m a ry Ca r e wO r k f O r C e ar O u n d t h e wO r l d

A robust primary care workforce is critical in a diverse global community that faces the chal-
lenges of aging populations and epidemiologic transitions. There is a worldwide shortage of
primary care physicians and an increased demand for primary care services. In response, the
primary care workforce has been diversifying to include a wider range of health professionals
such as nurse practitioners, registered nurses, and clinical staff members. Although primary
care systems globally face challenges associated with a shrinking workforce and increasing
care needs, there are differences in skill mix and organizational structures within and across
high-income and low-to-middle-income countries.

A skill mix is defined as the combination of posts, grades, or occupations in an organi-
zation, or the combination of activities and skills needed for a particular job within an orga-
nization. Skill mixes differ by countries, sectors, and health systems. Factors such as resource
availability, culture, and demographic makeup may determine the appropriate skill mix (Buchan
and Dal Poz 2002).

In high-income countries such as the United Kingdom, the United States, and Canada,
primary and community care services face the major challenges of increasing workloads, aging
populations, and increasingly complex medical problems (Checkland and Spooner 2015). The
numbers and working hours of primary care physicians are decreasing for reasons including,
but not limited to, an increase in the proportion of female physicians electing to work fewer
hours or part-time and an increase in the number of patients as well as their care demands.
In response, most countries have diversified their primary care teams to include nonphysician
providers such as nurse practitioners and physician assistants. While nurse practitioners and
physician assistants are able to complete at least 60 percent of office-based primary care, owing
to low remuneration and high training requirements, the numbers of nurse practitioners and
physician assistants working in primary care are still low in many countries (Ginsburg, Taylor,
and Barr 2009). It has been suggested that workplace innovations such as shifting tasks from
physicians to nonphysician health professionals are necessary to resolve the current chal-
lenges of primary care. However, such task shifting necessitates a willingness of physicians to
give up tasks and the ability and capacity of nonphysician providers to execute these tasks. In
countries with emerging economies such as Brazil and India, workplace innovations such as
task shifting have been more easily adopted, partly due to fewer established expectations of
professional roles (Freund et al. 2015).

C a s e s t u d y 2

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T
his chapter focuses on health-related policymaking in the international arena. The
World Health Organization (WHO), recognized as the leading international health
authority, is described, and examples from three countries—Canada, Sweden, and

China—illustrate diverse policymaking processes in disparate geographic regions.

th e wO r l d he a lt h Or g a n i z at i O n

WHO is composed of the World Health Assembly, the Executive Board, and the Secre-
tariat (WHO 2018a). Delegations from WHO’s 194 member states make up the World
Health Assembly, the decision-making and policymaking body of WHO (WHO 2018a).
The Executive Board facilitates the work of the World Health Assembly and advises it on
technical issues related to health. The Secretariat is the main implementation body of
WHO’s policymaking work and includes approximately 8,000 health experts and support
staff (WHO 2018d).

whO’s fu n C t i O n s

WHO has six core functions (WHO 2018a):

1. Provide leadership on critical health issues worldwide, and engage in
partnerships where joint action is needed.

2. Shape the research agenda, and stimulate the generation, translation, and
sharing of health-related knowledge.

3. Set norms and standards, and promote and monitor their adoption.

4. Articulate ethical and evidence-based policy options.

5. Provide technical support, encourage innovations, and build sustainable
institutional capacity.

6. Monitor health issues around the world, and assess trends.

In practice, WHO not only sets international health policy but also coordinates
population health programs, such as mass immunization campaigns, emergency response
efforts to natural disasters and disease outbreaks, and statistical monitoring of disease
prevalence (WHO 2018f ). WHO has also made great progress in its reform agenda during
the twenty-first century (see, e.g., WHO 2018f, 2018h). Innovative leadership, managerial
structures, and systems have resulted in increased effectiveness, efficiency, responsiveness,
transparency, and accountability (see also the For Your Consideration box titled “The Impetus
for International Healthcare Reform”).

World Health Assembly
The decision-making
and policymaking
body of the World
Health Organization
(WHO), composed of
delegations from all
WHO member states.

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FOR YOUR CONSIDERATION
The Impetus for International Healthcare Reform

According to WHO (2008), three major trends are pushing forward the need for international
healthcare reform. First, progress has been unequally distributed, with increasing health
gaps between and within countries. While morbidity and mortality rates in the aggregate are
much better today than in 1978, some countries have advanced enormously in health whereas
others have not made similar gains. Second, the nature of health problems has changed due
to significant social, demographic, and epidemiological transitions. Globalization, urbaniza-
tion, and aging of populations have increased the transmission of communicable diseases
and the global burden of chronic and noncommunicable diseases. Third, a lack of governance,
underresourcing, and fragmentation of health services have led to the unregulated commer-
cialization of healthcare, as in fee-for-service health services, which has contributed to the
increased politicization of the right to health and social protection.

WHO has outlined five key elements that are necessary to achieve healthcare reform: (1)
universal coverage reforms, (2) service delivery reforms, (3) public policy reforms, (4) leader-
ship reforms, and (5) increased stakeholder participation (WHO 2008).

Universal coverage reforms: An important WHO target for sustained development in world-
wide health and well-being is to “achieve universal health coverage,” a goal that includes
financial risk protection and access to safe, effective, high-quality, and affordable essential
health services, medicines, and vaccines (WHO 2018h). WHO strongly supports universal
health coverage as a critical method to reduce exclusion and social disparities worldwide.

Service delivery reforms: WHO describes service delivery reforms as a method of “putting
people at the center of healthcare, harmonizing mind and body, people and systems” (WHO
2007a). These reforms should optimize a wide array of healthcare services to organize con-
ventional healthcare delivery into people-centered primary care.

Public policy reforms: WHO describes three types of public policies that complement universal
coverage and service delivery reforms (WHO 2008):

1. Systems policies: Policies that support functional supply and logistics systems
2. Public health policies: Policies that address priority health problems of both acute

and long-term nature (i.e., public hygiene, disease prevention, nutritional campaigns,
epidemic and catastrophe management)

3. Policies in other sectors: Policies that can benefit through intersectoral collaboration

Leadership reforms: WHO describes these reforms as replacing disengaged leadership with
inclusive, participatory, negotiation-based leadership (WHO 2008).

Increased stakeholder participation: WHO advocates for participation from beyond the public
sector, to engage stakeholders that include but are not limited to clinicians, civil society,
communities, and researchers (WHO 2008).

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whO PO l i C y m a k i n g Pr O C e s s

Proposals for new WHO resolutions or motions
can be submitted by any World Health Assembly
member state. Except for sessions convened in
emergencies and other administrative consider-
ations, proposals for new projects and initiatives
can be included on the supplementary agenda of
any assembly session. Following a preliminary
impact analysis by the WHO director-general, a
proposal is referred to the appropriate committee,
which examines the proposal and related report at
plenary meetings. After passing through the com-
mittee, the proposal or resolution is considered for
adoption with a vote by the World Health Assem-
bly. Proposals of particular importance, such as the
appointment of the director-general and proposals
involving other United Nations (UN) agencies (e.g.,
see the For Your Consideration box titled “Sustain-
able Development Goals”), require a two-thirds
majority vote to be adopted. Most policy imple-
mentation is carried out through the WHO Sec-
retariat, which oversees aspects of program design
and the logistics of launching programs.

whO he a lt h Pr O g r a m s

WHO currently operates programs and projects in more than 150 countries. They range
from monitoring chronic diseases such as cancer and heart disease, to conducting eradica-
tion efforts for diseases such as leprosy, to combating infectious diseases such as influenza
and HIV, to operating initiatives to prevent disease by ensuring access to clean water (WHO
2016, 2018g). Perhaps the most well-known WHO program was the campaign to eradicate
smallpox, which came to a successful conclusion in 1979. This effort represents the first and
only time thus far that the eradication of a major infectious disease has been achieved (WHO
2007b). In 1988, WHO partnered with four other public and private organizations—Rotary
International, the Centers for Disease Control and Prevention, the United Nations Children’s
Fund, and the Bill and Melinda Gates Foundation—to form the Global Polio Eradication
Initiative (GPEI), through which it strives for the same success in eradicating polio worldwide
(WHO 2007b; GPEI 2018b). Thirty years after it was established, the GPEI had reduced
global polio cases by 99.9 percent, and the paralyzing disease remained endemic in only
three countries: Afghanistan, Nigeria, and Pakistan (GPEI 2018a).

FOR YOUR CONSIDERATION
Sustainable Development Goals

In September 2015, the United Nations General Assembly adopted
17 Sustainable Development Goals (SDGs) by consensus, many
relating directly to health. Specifically, SDG 3 seeks to “ensure
healthy lives and promote well-being for all at all ages” (UN 2018;
WHO 2018h). In shaping the conversation on healthcare reform,
WHO has used SDG 3 to frame the healthcare reform agenda and
focused on Target 3.8 of SDG 3—achieving universal health cover-
age (UN 2018; WHO 2018h). The two indicators for this target are
(1) coverage of essential health services and (2) the proportion
of a country’s population with catastrophic spending on health,
defined as “large household expenditure on health as a share of
total household consumption or income” (WHO and World Bank
2017, vii). WHO has pinpointed the following key challenges to
achieving healthcare reform and universal health coverage: data
limitations in monitoring health coverage, existing inequalities
within and between countries that exacerbate inequalities in health
interventions, and lack of financial protection against catastrophic
health expenditures (WHO and World Bank 2017).

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One example of an ongoing WHO health program is the WHO Global Task Force
on Cholera Control, which in 2017 introduced a “roadmap” with a three-pronged strategy
to reduce the number of cholera deaths by 90 percent and eliminate cholera in as many as
20 countries by 2030 (WHO 2018b). The roadmap’s three key strategic actions are to (1)
detect cholera outbreaks early and respond quickly to contain them, (2) stop transmission
of cholera in the small areas most heavily affected by the disease, and (3) provide technical
support as well as human and financial resources to assist countries in their local efforts to
control cholera (WHO 2018b).

Two key areas of ongoing focus relating to SDG’s Target 3.3 are hepatitis and HIV,
the virus that in its most advanced form results in AIDS (WHO 2018h). The Global Health
Sector Strategy on viral hepatitis in 2016 called for “elimination of viral hepatitis as a major
health threat” by 2030, measured as reductions of 90 percent in incidence and 65 percent
in deaths (Hutin, Bulterys, and Hirnschall 2018). In 2016, with collaboration among many
departments within WHO and across its regional and country offices, 35 countries established
national hepatitis action plans (WHO 2018h). To combat HIV, WHO has used a strategy
including (1) education to prevent new infections and (2) treatment with antiretroviral
therapy (ART) for those who are infected. As a result, between 2000 and 2016, new HIV
infections decreased by 39 percent, and HIV-related deaths decreased by about 33 percent
(WHO 2018e). Transmission of the virus from an HIV-positive mother to her child during
pregnancy, delivery, or breastfeeding has also been substantially reduced through the use
of ART, and several countries (Armenia, Belarus, Cuba, and Thailand) have achieved the
elimination of mother-to-child HIV transmission as a public health problem (WHO 2018e).

WHO also plays an instrumental role in containing sudden outbreaks of infectious
diseases. For example, it helped coordinate the response to the outbreak of SARS (severe
acute respiratory syndrome) in 2003 and continues to monitor the incidence of avian
influenza—or “bird flu”—around the world.

whO’s in v O lv e m e n t i n he a lt h PO l i C y

WHO is the global leader in formulating health policy. For example, WHO regularly writes
and distributes policy reports on major diseases, such as HIV/AIDS, tuberculosis, and
malaria. It also issues policy statements in response to disease outbreaks and natural disasters.

However, WHO and its policies and actions have often drawn criticism from various
groups (Peabody 1995; Stein 2010). While WHO has increasingly focused its efforts on
disease surveillance, many observers believe that the bureaucratic nature of the organization
and its perceived slow reaction time undermine its ability to respond in urgent situations
(Peabody 1995; Stein 2010). For example, an independent assessment of WHO’s response
to the H1N1 (swine) flu pandemic in 2009, conducted by the Institute of Medicine, con-
cluded that WHO needed improvement in a number of areas (Cohen 2011; Langlois et al.
2016) and included the following points of criticism:

avian influenza
A type-A influenza
viral infection in wild
or domestic birds.
The avian influenza
virus can become a
public health danger
if a change (mutation)
allows it to more easily
infect humans, and it
can potentially start a
worldwide epidemic.

H1N1 (swine) flu
A respiratory disease
caused by influenza
type-A viruses, first
detected in 2009. The
new strain of influenza
A (H1N1) virus is a mix of
swine, human, and avian
influenza viruses that
is contagious and can
cause seasonal flu.

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◆ WHO does not have a standard method to measure the severity of an outbreak.

◆ WHO was not transparent about the members who served on its Emergency
Committee, which led to speculation that they had ties to influenza vaccine–
producing pharmaceutical companies.

◆ WHO had difficulty distributing vaccines in developing countries.

The report recommended that WHO establish an emergency fund for disease out-
breaks, have advance agreements in place with pharmaceutical companies to supply vaccines
on an as-needed basis, and set up a health emergency corps of personnel to mobilize in the
event of an outbreak. Despite those concerns, WHO remains the world’s leading policymaker
and implementer in addressing health problems around the world.

he a lt h PO l i C y m a k i n g i n se l e C t e d CO u n t r i e s

Although WHO conducts high-level research, policy analysis, and emergency response, the
vast majority of health policy in any country is still made at the national level. This section
provides examples from Canada, Sweden, and China to illustrate the diverse political and
healthcare systems, health challenges, and policymaking processes that exist around the
world.

Ca n a d a

Canada is a parliamentary democracy founded on the British system of government. The
king or queen of England is Canada’s head of state and is represented by the governor-general
of Canada, who carries out formal duties on behalf of the British monarch (OCASI 2016).

The Canadian Parliament has two chambers: a lower chamber called the House of
Commons and an upper chamber called the Senate. The House of Commons is the main
legislative body (OCASI 2016; Parliament of Canada 2018a). It is composed of elected
local representatives called members of Parliament (MPs), who typically belong to one of
Canada’s five major political parties:

1. Conservative Party

2. Liberal Party

3. New Democratic Party

4. Bloc Québécois

5. Green Party

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Canada is divided into electoral districts, or ridings, on the basis of population, with
one MP elected per riding. The political party with the greatest number of MPs forms
the government, and the leader of that party becomes the prime minister, Canada’s head
of government (OCASI 2016). Elected officials who are not members of the ruling party
become the official opposition (OCASI 2016). The Senate acts as a review board for leg-
islation introduced by the House of Commons, and its 105 senators are appointed by the
prime minister (OCASI 2016; Parliament of Canada 2018b).

Elected members of the federal and provincial governments can introduce legislation,
which is voted on in Parliament or, for regional legislative issues, in the province’s Legislative
Assembly. The prime minister selects MPs from within the ruling party to form a cabinet.
Cabinet ministers take on special responsibility for one or more federal platform issues (e.g.,
defense, finance, foreign affairs) in addition to representing the members of their electoral riding.

Canada is made up of ten provinces and three territories. Responsibility for such areas
as national defense, foreign policy, and international trade rests with the federal government,
whereas areas such as healthcare and education are provincial or territorial responsibilities.
Large towns and cities also have their own local government, which is responsible for provid-
ing services such as police and fire departments and trash collection. See the International
Policymaking box titled “Health Policymaking in Canada” for a summary of Canada’s health
policymaking process.

INTERNATIONAL POLICYMAKING
Health Policymaking in Canada

The health policymaking process in Canada exhibits the following features (Parliament of
Canada 2018a, 2018b; Senate Canada 2017):

• The Canadian legislative process is based on the British model. Proposals for new
laws or changes to existing laws are referred to as bills.

• Bills are usually introduced in the House of Commons; they may also be introduced in
the Senate. However, it is the House of Commons rather than the Senate that domi-
nates parliamentary government in Canada.

• After a bill is introduced, it must go through three rounds of readings and reviews,
first by the House of Commons and later by the Senate.

• The bill is also sent to a legislative committee to be examined, clause by clause,
before the third and final reading. The committee may bring in experts to testify
on the contents of the bill before the first parliamentary chamber passes, amends,
delays, or defeats the bill.

• If a bill is accepted and passed by both chambers, it is submitted for Royal Assent. In
Canada, this approval is given by the governor general on behalf of the queen of Eng-
land. After receiving Royal Assent, a bill becomes law.

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The Healthcare System
An overview of key statistics related to Canada’s healthcare system is shown in exhibit 4.1.
The Canadian healthcare system is administered by the provincial and territorial governments
and is taxpayer funded, mainly on the provincial level but also through federal taxation by
way of the Canada Health Transfer. The 13 provinces and territories must meet the national
standards outlined in the Canada Health Act to receive the full amount of federal funding
available (Health Canada 2016).

The Canada Health Act stipulates that provinces and territories insure residents for
all medically necessary primary and tertiary care provided by physicians and hospitals. Some
provinces may provide additional benefits, such as coverage for dental or chiropractic care.
Most physicians work in for-profit private practices; however, they bill and are paid through
the public insurance system of their respective province or territory on a fee-for-service basis.
Many large hospitals are not-for-profit and are associated with a religious group or university.

Health Policymaking
The Canada Health Act, the primary piece of health-related legislation at the federal level, was
signed into law in 1984 (Health Canada 2016). The law ensures that all eligible Canadian
citizens and residents have access to prepaid health insurance and services. It also provides
the legal framework for provincial healthcare plans that receive federal funding.

Specifically, the Canada Health Act sets forth the following tenets:

1. Public administration: The healthcare system must be administered publicly and
as a not-for-profit operation.

2. Comprehensive coverage: The system must provide insurance for all necessary
health services.

3. Universality: All residents have the right to the same level of care.

Population 35,544,564 (2014)

GDP per capita (in PPP) US $50,440

% of GDP spent on healthcare 10.4%

Healthcare spending per capita (in PPP) US $4,640

Life expectancy at birth, male/female 80/84 years (2014)

Infant mortality rate 4.6 per 1,000 live births

No. of hospital beds per 1,000 people 3

Note: GDP = gross domestic product; PPP = purchasing power parity. No data for 2014 are available on the number of
hospital beds per 1,000 people.
Sources: Public Health Agency of Canada (2016a); World Bank (2018).

exhiBit 4.1
Canadian
Healthcare System
Key Statistics
(2009–2014 data)

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4. Portability: Insurance must be portable from one province or territory to
another.

5. Accessibility of services: All insured residents should have reasonable access to
healthcare services.

The five listed criteria are considered the pillars of Canada’s healthcare system (OECD
2001). However, there have been gradual erosions of the act in the twenty-first century, espe-
cially with the use of cannabis. Some researchers believe that the Canada Health Act should
be further strengthened and violations punished by imposing fines equitably to protect the
country’s healthcare system (Norton 2017; Sibbald and Stanbrook 2016).

Key Health Policy Stakeholders
Key stakeholders include the federal government; Health Canada, the federal health depart-
ment; the provincial governments, which administer the insurance plans; physicians’ and
nurses’ associations and the Canadian Medical Association; industry and trade groups, such
as the pharmaceutical industry; and the Canadian public (Boyko 2015; CDM 2018).

None of the political parties of Canada seek to dismantle the universal healthcare system;
however, they have differing views on the degree to which it should be privatized. The Conserva-
tives are generally in favor of more privatization, whereas Liberal, New Democrat, Bloc Québécois,
and Green Party members generally favor less. Some politicians advocate for a two-tier health
system, in which consumers can choose between public and private care. The implementation
of this framework has become increasingly likely since June 2005, when the Canadian Supreme
Court struck down a Quebec law prohibiting residents from buying private insurance that covered
services already covered by the public system (Sibbald and Stanbrook 2016).

Many doctors’ and nurses’ associations favor the public healthcare system and do not
support the privatization of clinics and hospitals. Some, however, believe they would be paid
more for their services, if they worked in a private system, than they are currently paid by
the public insurance. The Canadian public is generally in favor of the universal healthcare
system but, similar to the disagreements between the political parties that represent them,
opinions vary on whether the system should remain public and the degree to which the
system should become privatized.

Major Health Issues
When prioritizing current health issues, the Public Health Agency of Canada, Health Canada,
and the Ministry of Health rely on public policy documents and analytical reports, such as
the Report on the Health of Canadians (Parliament of Canada 2002), which are developed
based on national health surveys conducted by Statistics Canada. Other stakeholders in
health policy, such as the Canadian Labor Congress, focus on the broader determinants of
health, including unemployment and homelessness, in the context of their priorities.

privatization
The movement of an
industry in a country
from public to private
control or ownership.

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Those conditions and diseases noted in the report as causing the greatest amount of
mortality or morbidity in the population as a whole, in certain geographic areas, or within
specific demographic groups are considered high priority for intervention. In addition, the
report addresses determinants of health through targeted interventions in the highest-risk
communities. This aspect of the reporting reflects the Canadian government’s overall focus
on preventive health.

Other major areas of focus include the health of the elderly and access to health-
care for those living in rural and remote areas. These priorities directly address two key
demographic challenges in Canada: the aging population and the low population density
outside of major urban areas. In the twenty-first century, the rapidly growing global burden
of noncommunicable diseases affects Canada as well. A 2016 report on the health status
of Canadians indicated that the top three health concerns in Canada were cancer, cardio-
vascular disease, and diabetes (Murray 2017). Specifically, it was estimated that two in five
Canadians (40 percent) would develop cancer in their lifetime (Public Health Agency of
Canada 2016b). Noncommunicable diseases are also closely linked to aging and thus affect
a significant portion of the population (Murray 2017; OECD 2001; Public Health Agency
of Canada 2016b).

sw e d e n

Sweden is a constitutional monarchy and parliamentary democracy. Citizens elect 349 mem-
bers to represent them in the Riksdag, Sweden’s legislative assembly. Elections are held every
four years. Eight political parties were represented in the Riksdag during the 2014–2018
electoral period. The political party whose members win the most seats in the Riksdag forms
the government, which is led by the prime minister. The prime minister, in turn, selects 22
other representatives to become ministers and form the cabinet. The government presents
new proposals for legislation and for amendments to existing laws (Government Offices of
Sweden 2018; Sveriges Riksdag 2018a, 2018b). The Swedish head of state is the reigning
monarch, who has no political powers (Economist 2009; Sveriges Riksdag 2018a).

The Swedish Constitution is made up of four fundamental laws:

1. The Institute of Government outlines the functions of the Swedish government
and elections.

2. The Act of Succession regulates who inherits the throne of the Swedish
monarchy.

3. The Freedom of the Press Act guarantees the people’s right to disseminate
information.

4. The Fundamental Law on Freedom of Expression gives citizens the right to
access government documents.

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These fundamental laws are prioritized over
all other ordinary laws in Sweden (Sveriges Riksdag
2018a). Sweden is also subject to the legislation of
the European Union (EU 2018). Some EU laws are
automatically adopted by Sweden, and some must
pass through a vote in the Riksdag to be formally
incorporated. See the International Policymaking
box titled “Health Policymaking in Sweden” for a
summary of Sweden’s health policymaking process.

Healthcare System
Exhibit 4.2 provides key statistics related to the
Swedish healthcare system. Healthcare in Sweden
is universal and automatic; it is primarily publicly
financed, mainly through a county council income
tax paid by individuals (Glenngård 2018). Patients
are charged a small fee for services, and the county
council pays the remaining costs. The national gov-

ernment sets an annual out-of-pocket ceiling for individuals. Private health insurance, in the
form of supplementary coverage, is uncommon but gradually increasing. Individuals who
purchase private health insurance typically seek to ensure quick access to an ambulatory
care specialist and to avoid waiting lists for elective treatment. In 2016, about 10 percent
of all employed individuals aged 15–74 had private insurance (Glenngård 2018).

The national government is responsible for healthcare regulation but plays no role
in healthcare delivery; this responsibility lies with county councils and municipal govern-
ments. County councils deliver most primary and tertiary care, while municipal govern-
ments arrange for elder care, including basic healthcare delivered in the patient’s home or
a nursing home (Glenngård 2018).

INTERNATIONAL POLICYMAKING
Health Policymaking in Sweden

The health policymaking process in Sweden is distinguished by the
following features (Government Offices of Sweden 2018; Sveriges
Riksdag 2018a):

• The Swedish government is responsible for proposing new
laws. It must appoint a committee of inquiry to assess the
feasibility of a proposed initiative.

• The committee writes a report that is circulated to relevant
agencies and the Council on Legislation for consideration.

• After the committee has gauged the feasibility of the pro-
posed law, the government presents a bill to the parlia-
ment—known as the Riksdag—which then votes on the bill.
If it passes, the bill becomes a new law and is published in
the Swedish Code of Statutes.

Population 9,696,110

GDP per capita (in PPP) US $59,180

% of GDP spent on healthcare 11.9%

Healthcare spending per capita (in PPP) US $5,218

Life expectancy at birth, male/female 80/84 years

Infant mortality rate 2.4 per 1,000 live births

No. of hospital beds per 1,000 people no data

Note: GDP = gross domestic product; PPP = purchasing power parity. Life expectancy figures are for 2014.
Sources: Danielsson and Talback (2012); Glenngård (2018); World Bank (2018).

exhiBit 4.2
Swedish

Healthcare System
Key Statistics

(2009–2014 data)

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Residents with nonurgent conditions first seek healthcare services from general prac-
titioners (GPs) at primary healthcare centers. Primary healthcare centers offer basic medical
and public health services, and the GPs refer patients to a specialized care provider if needed.
County and district hospitals provide specialized care, such as dermatology and ophthalmol-
ogy. Regional hospitals provide highly specialized healthcare services, such as knee replace-
ments, organ transplants, and heart surgery. In addition, highly specialized care often requires
advanced technical equipment and is usually located in university hospitals (Glenngård 2018).

Notably, three basic principles apply to all healthcare in Sweden (Glenngård 2018):

1. Human dignity: All human beings are equally entitled to dignity and have the
same rights regardless of their status in the community.

2. Need and solidarity: Those in greatest need take priority in being treated.

3. Cost-effectiveness: When a choice is made, there should be a reasonable balance
between costs and benefits, with cost measured in relation to improvement in
health and quality of life.

Health Policymaking and Key Health Policy Stakeholders
The national, county, and municipal levels of government in Sweden collectively wield
influence on healthcare and health policy (Glenngård 2018). As such, they are the primary
stakeholders in health policymaking. The various levels of government provide services for
the vast majority of the population’s healthcare needs. Private health insurers are not common
because of the comprehensive public healthcare system. Coverage has been universal since
the 1982 Health and Medical Services Acts were enacted to ensure that the health system
covers all legal residents in Sweden.

The public is also a major stakeholder in Sweden’s healthcare system because it can
indirectly influence health policy on the national level and health priorities on the county
level through the voting process.

Major Health Issues
Healthcare priorities in Sweden are established by the National Board of Health and Welfare’s
Health Reports (see, e.g., National Board of Health and Welfare 2013). These reports are
based on data collected from a variety of sources: government healthcare inquiries, patient data
from public hospitals, literature reviews and existing studies, and national surveys including
interviews with and questionnaires administered to target populations. Examples of data sets
include the Living Conditions Survey, Household Finances Survey, National Public Health
Survey, National Database on Waiting Lists and Wait Times, and Health Care Barometer.

In the 2010 National Public Health Policy Report, 11 objective domains were grouped
into three strategic areas developed from a previous Health Report, which identified the

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most pressing issues facing Sweden in terms of mortality and morbidity in the coming
decade. The 2010 goals addressed the following three strategic areas (Linell, Richardson,
and Wamala 2013):

1. Good living conditions

2. Health-promoting living environments and lifestyle habits

3. Alcohol, illicit drugs, doping, tobacco, and gambling

About 60 percent of the recommendations in these three strategic areas were adopted
within two years after the Public Health Policy Report 2010 was published (Linell, Rich-
ardson, and Wamala 2013). In setting priorities, public health researchers consider not
only the direct causes of mortality and morbidity but also the determinants of health and
the social and economic conditions that may indirectly contribute to an increase in disease
burden in certain populations.

Since the report was issued, Sweden has targeted the promotion of smoke-free dining
environments and healthy eating habits, achieving an improvement over the 2010 goals in
these areas. Many measures and activities have influenced the Swedish people to decrease their
use of tobacco (Linell, Richardson, and Wamala 2013). The Swedish government continually
monitors access to healthcare and healthcare effectiveness to identify additional areas for
improvement. More important, inspiring innovations and reforms are occurring in Sweden.

Ch i n a

Key statistics for China and its healthcare system are shown in exhibit 4.3. The People’s
Republic of China operates under a single-party socialist system of government (Lawrence
and Martin 2013). The Communist Party of China (CPC) manages the national government

Population 1,364,270,000

GDP per capita (in PPP) US $7,683

% of GDP spent on healthcare 5.5%

Healthcare spending per capita (in PPP) US $730

No. of doctors per 1,000 people 1.49

Life expectancy at birth, male/female 75/78 years

Infant mortality rate 9.9 per 1,000 live births

No. of hospital beds per 1,000 people 4

Note: GDP = gross domestic product; PPP = purchasing power parity. Data for the number of doctors per 1,000 people
are for 2011. No data for 2014 are available on the number of hospital beds per 1,000 people.
Sources: Fang (2018); WHO (2018c).

exhiBit 4.3
Chinese Healthcare

System Key
Statistics (2009–

2014 data)

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through the National People’s Congress (NPC),
which is the main legislative body in China, and
through the State Council, which is the executive
body of the Chinese government. The president
is elected by the NPC, leads the government, and
appoints a premier to lead the State Council who,
in turn, nominates individuals for the position of
vice premier and other ministerial posts. Local peo-
ple’s congresses also take place throughout China.

Although elections are held to select repre-
sentatives to the NPC and local people’s congresses,
each candidate for office must be affiliated with the
CPC (Lawrence and Martin 2013).

China is governed by a written constitution.
In part, it stipulates that the CPC is the sole politi-
cal party in power, that China will remain a socialist
society, and that all power belongs to the people
(Lawrence and Martin 2013). See the International
Policymaking box titled “Health Policymaking in
China” for a summary of China’s health policymak-
ing process.

Healthcare System
The laws governing the healthcare system in China
are the Fundamental Health Law and the Hygienic
Common Law. In 2009, China introduced a uni-
versal healthcare system intended to cover 90 percent of the population by 2010 (China
Daily 2011). This target was met: Coverage by publicly financed health insurance is near
universal—exceeding 95 percent of the population—but the level of coverage varies by type
of insurance scheme (Jiang 2015). This reform resulted largely from the expansion of four
government insurance schemes: the basic scheme for urban workers, the urban-resident
scheme for other urban residents such as children and students, the rural cooperative system
for the rural population, and the medical assistance program for the poor. These insurance
schemes work by collecting funds from all insured persons, the local government, and
employers; pooling the funds; and dispensing them according to health need. The Learning
Point box titled “China’s Four Insurance Programs” describes the schemes in greater detail.

Healthcare is primarily delivered by local governments. In some communities, large
employers such as mining companies may also set up health clinics. Primary care is deliv-
ered through local health clinics and small hospitals. Specialized care is provided at regional
borough hospitals or larger teaching and research hospitals in urban areas.

INTERNATIONAL POLICYMAKING
Health Policymaking in China

The health policymaking process in China has the following features
(Lawrence and Martin 2013; China Internet Information Center 2018):

• The NPC and its Standing Committee are the main legisla-
tive bodies in China. Local people’s congresses also draw
up legislation on a regional level.

• The Political Bureau of the Central Committee of the Com-
munist Party of China plans legislation in five-year periods.

• Based on the preparations made in this planning stage,
bills are introduced to the NPC or Standing Committee.
Most bills are introduced by the State Council. Important
bills are published for public feedback before being sub-
mitted to the NPC for review.

• After bills are submitted for consideration, the president
of the NPC and the Council of Chairmen of the Standing
Committee decide whether to add the bill to the agenda or
to discard it. Bills submitted by the president are automati-
cally considered. The remaining bills on the agenda are
debated by the delegates. The Law Committee may make
amendments to a bill before a final vote.

• The bill becomes formal law after it passes a majority vote
and is signed by the president. The president may not veto
a bill once it is passed.

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Health Policymaking
The healthcare reform package of 2009 serves as an example of China’s legislative process.
China’s State Department sets regulations for the healthcare system, and other government
departments, such as the State Food and Drug Administration and the Quarantine Bureau,
can institute department rules concerning public health.

Key Health Policy Stakeholders
China’s national government, including the Ministry of Health (renamed the Commission
of Public Health and Family Planning), plays an enormous role in the healthcare system,
but it is not the only stakeholder (Ministry of Health, Government of China 2009).

LEARNING POINT
China’s Four Insurance Programs

Basic insurance scheme: Designed for urban employees, with relatively generous and com-
prehensive benefit packages. Employees pay premiums and copayments and receive compre-
hensive care at designated hospitals and providers. Participation is mandatory for employees
in urban areas; the population insured under this scheme numbered 283.3 million in 2014
(Mossialos et al. 2016).

Urban-resident scheme: Implemented in 2007 to cover primary and secondary school stu-
dents who are not covered by the basic insurance scheme. Higher premiums are assessed
than for basic insurance. Participation is voluntary at the household level and covered 314.5
million self-employed individuals, children, students, and elderly adults in 2014 (Mossialos
et al. 2016). Both urban employment-based and urban resident basic medical insurance are
administered by the Ministry of Human Resources and local authorities (Mossialos et al. 2016).

Rural cooperative system: Covers rural residents. Government and local subsidies are typically
provided to operate facilities. Benefits are generally low and may only cover catastrophic
illness. Not considered a viable insurance scheme by most policy analysts. Participation is
also voluntary at the household level and covered a rural population of 736 million—about
99 percent of all rural residents—in 2014 (Mossialos et al. 2016). This system is administered
primarily by the National Health and Family Planning Commission and implemented by local
authorities (Mossialos et al. 2016).

Medical assistance program: Aims to cover those designated by the government as poor, but
eligibility varies widely across regions. Less than 10 percent of the population is eligible for
medical assistance coverage (Mossialos et al. 2016).

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Exhibit 4.4 summarizes the responsibilities and roles, resources, and functions of
the following stakeholders:

◆ The central government

◆ Relevant ministries

◆ Local governments

◆ Hospitals and medical institutions

◆ Medical staffs

◆ The pharmaceutical industry

◆ The public

◆ Think tanks

◆ The media

Major Health Issues
China’s size and its geographic and socioeconomic variability can stymie efforts to collect
comprehensive data about all populations and in all regions. The Chinese Ministry of Health
sets priorities by collecting and analyzing data on the conditions that contribute most to
morbidity and mortality in the entire country or in specific regions or populations (WHO
2005; Zheng et al. 1998). Some analysis is carried out in conjunction with WHO and other
United Nations agencies, such as UNAIDS.

China also has a number of health surveillance systems in place to collect data, such
as the Ministry of Health’s National Nutritional Surveillance System, the Chinese Center
for Disease Control and Prevention, and the National Disease Reporting System, the latter
of which was established in 1959 and reports on 37 infectious diseases (Liu et al. 2016;
Zhang et al. 2007).

Other areas on which Chinese health policymakers focus are the prevention of infec-
tious disease outbreaks, diabetes, hypertension, cardiovascular disease, and cancers (Fu et al.
2018). More than half of all men in China smoke, posing another long-term public health
concern. The size of China’s population also fuels government concern over family planning
measures; care for the elderly (e.g., mandatory support for elderly by adult family members;
subsidies for elderly without children; development of “respect the elderly” housing, similar to
the nursing home model in the United States); and the treatment of lifestyle-related chronic
diseases, such as diabetes and cardiovascular diseases (Bi et al. 2015; Wang et al. 2017).

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Stakeholders
Resources
and roles Interests Functions

Government Central
government

The main body in
policymaking; plays a
leadership role

Social and
political
interests

Directly responsible for
decisions at the national
level and overall economic
and social policy formulation

Relevant
ministries

The main body in
policymaking within
jurisdictions

Interests of own
department

Directly responsible for
policymaking within
jurisdictions

Local
governments

Policy interpretation
and implementation

Local interests Directly responsible for the
interpretation of central
policy and local policymak-
ing; express local opinion to
central government

Supply
side of
healthcare

Hospitals
and medical
institutions

Market power;
have influence and
ability to evade
administrative power

Government
funding, hospital
ratings, and
market share

Have influence on policymaking
by relationship with decision
makers and own market
reputation

Medical staff Have the right to
prescribe; hold
information
superiority

Personal devel-
opment, income,
and professional
reputation

Use information superiority
and right of prescription

Pharmaceutical
industry

Market power Profits Provides funding to research
institutions, hires experts
and scholars as consultants,
and forms coalitions of
interest with media and local
government

Demand
side of
healthcare

The public Has the right to
choose medical
services

Healthcare
quality, fairness,
and access to
healthcare

Uses media to form public
opinion; expresses opinion to
decision makers or experts in
the research process

Think tanks Government-
affiliated policy
advisory body

Provide policy
advisory services

Consistent with
the interests of
their respective
ministries

Directly involved in the
policy-making process;
provide policy advice to
decision makers

Independent
research
institutions

Provide policy
advisory services

Social interests Provide policy advisory
support; submit report to
government and releases to
the media

Media Influence public
opinion; support
different stakeholders

Diverse
interests
according
to policy
preferences

Guide public opinion, help
form public agenda, and join
in various policy networks

exhiBit 4.4
Major Stakeholders

in China’s Health
Policymaking

Process

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➤ As the world’s health authority, WHO acts as a leader and partner on health issues
worldwide, sets research priorities and encourages the sharing of health-related
knowledge, establishes standards of practice and supports and monitors their adoption,
advances policy options founded on ethical and evidence-based principles, lends
technical support to health initiatives and contributes to capacity building, and monitors
health issues around the world and identifies patterns and trends.

➤ The Canada Health Act is the primary piece of health legislation in Canada. It ensures
that all eligible Canadian citizens and residents have access to prepaid health
insurance and services. It also provides the legal framework for provincial healthcare
plans receiving federal funding.

➤ The national, county, and municipal levels of government in Sweden collectively wield
influence on healthcare and health policy, and they provide services for the vast
majority of the population’s healthcare needs.

➤ China’s State Council sets regulations for the healthcare system. Other government
departments, such as the Ministry of Health, State Food and Drug Administration, and
Quarantine Bureau, can institute department rules for healthcare delivery and public
health.

Ca s e st u d y 1

After researching the origin and evolution of the WHO Healthy Cities initiative, answer the
following questions:

1. Why was the Healthy Cities initiative developed?
2. What are the initiative’s major objectives? Has it achieved them?
3. What were the ingredients for success for the participants in the Healthy Cities initiative?

Ca s e st u d y 2

After researching the definition and role of the primary care workforce, answer the following
questions:

1. How is primary care defined? What are its major components?
2. What roles does primary care play in healthcare delivery and population health?
3. What strategies can be adopted to expand primary care around the world?

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

k e y P O i n t s

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I n t r o d u c t i o n t o H e a l t h P o l i c y1 2 2

1. What are the functions of WHO?
2. How are health policies made at WHO?
3. Cite examples of WHO-sponsored health programs.
4. Answer the following questions for each country profiled in this chapter:

a. How are health policies made in the country?
b. What is the primary legislation related to healthcare policy in the country, and

what are its main features?
c. What are the top health issues in the country?

5. Using examples from Canada, Sweden, and China, identify stakeholders and describe
their interests in and influence on health policymaking.

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———. 2008. Primary Health Care—Now More Than Ever. Accessed June 11. 2018. www.who.int/
whr/2008/en/.

———. 2007a. People at the Centre of Health Care: Harmonizing Mind and Body, People and Sys-
tems. Geneva, Switzerland: WHO.

———. 2007b. Working for Health: An Introduction to the World Health Organization. Accessed June
11, 2018. www.who.int/about/brochure_en.pdf.

———. 2005. China: Health, Poverty, and Economic Development. Published December. www.who.
int/macrohealth/action/CMH_China.pdf.

———. 1986. “The Ottawa Charter for Health Promotion.” Published November 21. Accessed May
23, 2018. www.who.int/healthpromotion/conferences/previous/ottawa/en/.

World Health Organization (WHO) and World Bank. 2017. Tracking Universal Health Coverage: 2017
Global Monitoring Report. Accessed June 11, 2018. http://apps.who.int/iris/bitstream/
handle/10665/259817/9789241513555-eng.pdf.

World Health Organization (WHO) Regional Office in Europe. 1997. Twenty Steps for Developing a
Healthy Cities Project, 3rd ed. Accessed May 23, 2018. www.euro.who.int/__data/assets/
pdf_file/0011/101009/E56270.pdf.

Zhang, X., Y. Ding, Z. Chen, and C. Schable. 2007. “Development of an Integrated Surveillance System
for Beijing.” Advances in Disease Surveillance 2: 127.

Zheng, G., J. K. Zhang, K. M. Rou, C. Xu, Y. K. Cheng, and G. M. Qi. 1998. “Infectious Disease Reporting
in China.” Journal of Biomedical Environmental Science 11 (1): 31–37.

Hu, S., S. Tang, L. Yuanli, Z. Yuxin, M.-L. Escobar, and D. de Ferranti. 2008. “Reform of How Health
Care Is Paid for in China: Challenges and Opportunities.” Lancet 372 (9652): 1846–53.

WHO Framework Convention on Tobacco Control. 2009. “History of the WHO Framework Convention
on Tobacco Control.” http://whqlibdoc.who.int/publications/2009/9789241563925_eng.pdf.

a d d i t i O n a l r e s O u r C e s

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World Health Organization (WHO). 2018. “Constitution of the World Health Organization.” http://
apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf.

———. 2018. “The Role of WHO in Public Health.” www.who.int/about/role/en/index.html.

———. 1978. Declaration of Alma-Ata. International Conference on Primary Health Care, Alma Alta,
USSR, September 1978. www.who.int/publications/almaata_declaration_en.pdf.

Yamey, G. 2002. “WHO’s Management: Struggling to Transform a ‘Fossilised Bureaucracy.’” British
Medical Journal 325 (7373): 1170–73.

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PA R T I I I

H E A LT H P O L I C Y I S S U E S

P
art III consists of three chapters that provide examples of health policy issues. Chapter 5 focuses
on health policies for US healthcare delivery and financing. Chapter 6 discusses health policy
concerns for people with special needs and other vulnerable populations. Chapter 7 illustrates

health policy concerns in the international community, including both developed and developing
countries.

The broad health policy issues presented in this part of the book should help students under-
stand how health policy is applied in the context of healthcare delivery and other determinants of
health. Knowledge of policy applications prepares readers to examine how health policies are studied
and evaluated—the focus of part IV.

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L e a r n i n g O b j e c t i v e s

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1 3 1

L e a r n i n g O b j e c t i v e s

C H A P T E R 5

H E A LT H P O L I C Y R E L AT E D T O
F I N A N C I N G A N D D E L I V E RY

After completing this chapter, you should be able to

➤ describe how healthcare is financed and delivered in the United States, and

➤ provide examples of financing and delivery and discuss related health policy issues.

Healthcare in our country is too expensive, too complicated. And too many times,

the system is downright unfair.

—George H. W. Bush

Nearly a century after Teddy Roosevelt first called for reform, the cost of our health

care has weighed down our economy and the conscience of our nation long enough.

So let there be no doubt: health care reform cannot wait, it must not wait, and it will

not wait another year.

—Barack Obama

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th e fe d e r a l ly fu n d e d he a lt h Ce n t e r Pr O g r a m: Pr O v i d i n g
aC C e s s, Ov e r C O m i n g di s Pa r i t i e s

The Health Resources and Services Administration (HRSA), a government agency in the US
Department of Health and Human Services (HHS), supports access to care for US residents
through community-based, patient-directed, federally funded health centers, with patients
making up at least 51 percent of board members (HRSA 2011). Health centers have provided
accessible and affordable healthcare services to individuals in the most underresourced com-
munities since the 1960s. To be designated as a health center, healthcare organizations must
meet the following criteria:

• Be located in or provide services to high-need communities—those the government
designates as medically underserved areas or populations

• Provide primary care services and promote access to care exceeding that previously
offered through supportive services, such as translation and transportation

• Provide services at fees based on ability to pay

The scope of health center services includes primary care, dental care, and vision care,
as well as mental health, substance use disorder, and patient support services (HRSA 2017).
Although health centers are not specifically tailored to minorities or the uninsured, a dispro-
portionate number of patients are racial or ethnic minorities; are uninsured; or come from
low-income, underserved communities. In 2016, about 62 percent of health center patients
were racial or ethnic minorities, and about 24 percent were uninsured (HRSA 2018). Health
centers also provide vital services in rural areas, where access to affordable healthcare may
be limited. About one-sixth of rural residents used health center services in 2016 (HRSA 2017).

In 2016, the HRSA granted health center status to 1,367 organizations nationwide, serving
more than 25 million people (HRSA 2018), including more than 330,000 veterans, at more than
11,000 service delivery sites throughout the United States and its territories (HRSA 2017). Health
centers fill a gap in access to critical healthcare for the uninsured by providing high-quality
primary care services; delivering cost-effective care; and offering catalysts for local economic
development, particularly in underserved communities (HRSA 2017).

C a s e s t u d y 1

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Pr e C i s i O n me d i C i n e

Precision medicine is an approach in prevention and treatment that accounts for individual
variability (NIH 2018). The concept has been used before. For example, blood typing has been
used since the early twentieth century to guide blood transfusions. Science has driven and
improved the broad applications of this concept, depending on financial support and emerg-
ing laws and regulations. However, policymaking and regulatory activities related to precision
medicine have taken a while to develop since the Human Genome Project was launched in 1990.

The Human Genome Project had the ambitious goal of determining and mapping “the
nucleotides in a human haploid reference genome” (Sawicki et al. 1993). Progress in this project
has benefited the growing field of precision medicine. Government agencies such as the US
Food and Drug Administration (FDA) have issued guidelines for assessing genetic variations in
the drug development process, and the National Center for Toxicological Research has studied
genetic polymorphisms, individual susceptibility, and drug efficacy, which has helped advance
precision medicine (National Research Council 2011). In the late 1990s, several government advi-
sory committees, including the Secretary’s Advisory Committee on Genetic Testing, established
by HHS, sought to understand the pathway for using genetics more broadly (National Research
Council 2011). Their work helped set the regulatory stage for precision medicine.

In April 2003, the Human Genome Project was declared complete, after taking 15 years to
sequence the first genome and costing $3 billion (Ashley et al. 2010). Considering the mapping
of the human genome and the emerging potential of precision medicine, the FDA issued two
guidelines: the 2005 Pharmacogenomic Data Submissions and the 2007 Pharmacogenomic Data
Submissions Companion Guidance. These guidelines served as the first policy step toward the
real-world application of precision medicine in the drug development and approval process.
The 2005 guideline laid the first regulatory foundation for the FDA’s evaluation of proposed
precision medicine biomarkers, and the 2007 guideline provided specific recommendations
(Ashley et al. 2010; National Research Council 2011).

From 2008 to 2014, the FDA and other government entities created or reorganized offices
and collaboratives to build regulatory infrastructures, issuing several guidelines to address
the expected growth of precision medicine (White House Office of the Press Secretary 2015). In
2013, the FDA launched the Genomic Working Group and published a report, Paving the Way for
Personalized Medicine—FDA’s Role in a New Era of Medical Product Development, to describe the
role and responsibilities of the FDA in personalized medicine and to provide a comprehensive
overview of precision medicine from scientific and regulatory perspectives (FDA 2013).

In January 2015, President Barack Obama announced the launch of the Precision Medi-
cine Initiative (PMI) during his State of the Union Address. The initiative outlined a broad
series of action items, including providing $215 million in funding, and called for the federal

C a s e s t u d y 2

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government to take on a more significant role in promoting scientific research for precision
medicine through the FDA, the National Institutes of Health (NIH), the Department of Veterans
Affairs (VA), and the Department of Defense (White House Office of the Press Secretary 2015).

Specifically, the NIH became responsible for a critical element of the PMI: develop-
ment of a national research cohort program to collect genetic data from more than one mil-
lion volunteer participants in the United States (White House Office of the Press Secretary
2015). The information would form a database for precision medicine projects, especially for
common diseases and conditions, to better understand how diseases occur, predict disease
risk, and improve diagnosis and treatment. The PMI also earmarked funds for the National
Cancer Institute, part of the NIH, to identify genetic elements in certain cancers and develop
better targeted treatments for them (White House Office of the Press Secretary 2015). Intensive
efforts in precision medicine have been applied to cancer, based on innovative clinical trials,
combination therapies, and knowledge of drug resistance.

The VA also developed the Million Veteran Program (MVP), a national volunteer program
that studies how genes influence health. By August 2016, the MVP had voluntarily enrolled
500,000 military veterans and, even though it was only halfway to its goal, had already become
the world’s largest genomic database (VA 2016). The FDA established a “precisionFDA” initiative
to develop open-source methodologies for clinical uses of such databases (White House Office
of the Press Secretary 2015). These initiatives represent an unprecedented level of government
involvement in precision medicine research and help create a new scientific model that encour-
ages participant engagement, responsible data sharing, and privacy protection.

T
he American public health system comprises a network of individuals and organiza-
tions in both the public and private sectors that work together at federal, state, and
local levels (Hyde and Shortell 2012). Public health agencies associated with the

federal government, the governments of the 50 US states plus the District of Columbia,
and 2,794 local governments and 565 tribal agencies constitute the governmental public
health system (Salinsky 2010).

This chapter provides examples of healthcare policies at multiple levels in the United
States that affect healthcare financing and delivery, beginning with a summary of their
current status to help you appreciate the underlying rationales for healthcare policy in the
United States.

fi n a n C i n g us he a lt h C a r e

Healthcare spending is often described in terms of a country’s national health expenditure
(see the Critical Concept box titled “National Health Expenditures”). The United States,

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for example, leads the world in national health
expenditure; in 2016, national health spending
accounted for 17.9 percent of the gross domestic
product (GDP)—more than a threefold increase
from its 1960 level of 5.2 percent (CMS 2018a;
NCHS 2011).

Another way to quantify healthcare spend-
ing is average per capita (per person) spending,
which adjusts the percentage by population size. In
the United States, the amount spent on healthcare
per capita increased from $146 in 1960 to $10,348
in 2016 (CMS 2018a).

In 2016, of the healthcare dollars being
spent in the United States, costs for physician and
other professional services (22.7 percent), hospital
care (32.4 percent), and prescription drugs and medical products (9.8 percent) accounted
for 64.9 percent of total national healthcare expenditures, with the remaining expenditures
including nursing home and home health care (7.7 percent); research, structures, and equip-
ment (4.7 percent); public health (2.5 percent); and administration (1.3 percent), among
others (CMS 2018a, table 2). The distribution of spending was similar to that for 2011
(CMS 2018a, table 2).

Hospitals are the largest source of healthcare spending among institutions. Exhibit
5.1 profiles US hospitals by size and type. The For Your Consideration box titled “Hospital
Value-Based Purchasing” describes a program developed by the Centers for Medicare &
Medicaid Services (CMS) to link hospital payments to quality of care.

CRITICAL CONCEPT
National Health Expenditures

National health expenditures, also referred to as national health
spending or national healthcare costs, are estimates of annual
spending on health services, healthcare supplies, and health-
related research and construction activities. Total healthcare
expenditures are often compared with total economic consump-
tion, represented by the GDP—a measure of the total value of all
goods and services that are produced and consumed during a
given calendar year.

Total number of US hospitals 5,534

Community hospitals 4,840

Federal government hospitals 209

Nonfederal psychiatric hospitals 397

Other hospitals, including nonfederal long-term
care hospitals and hospital units within institutions
(e.g., prison hospitals, college infirmaries)

88

Total number of staffed beds in US hospitals 894,574

Staffed beds in community hospitals 780,272

Source: Data from AHA (2018).

exhiBit 5.1
A Profile of US
Hospitals, 2016

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The many contributing factors in the dramatic rise in US healthcare costs include
the following:

◆ An emphasis on curing disease rather than preventing disease and maintaining
wellness

◆ Advances in technology and its extensive use in delivering healthcare

◆ The inefficiency of a multiple third-party payer system

◆ An increase in the elderly population and accompanying cases of chronic illness

◆ Waste and abuse within the system, due in part to geographic variations in practice

◆ General inflation

◆ Continuing recovery from the Great Recession (December 2007–June 2009)

◆ The practice of defensive medicine

Several forms of health insurance have been developed to help patients pay—and
allow providers to be paid—for healthcare. These mechanisms fall under two general types:
private health insurance and public health insurance.

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

Private insurance is an essential source of healthcare coverage for most Americans. Among
private insurance options, managed care predominates. Managed care plans are available

defensive medicine
The practice of medicine
in which the main goal
is to avoid malpractice
claims, not to ensure
good health for the
patient or maximum
medical efficiency.

managed care
A care model
characterized by a
designated provider
network, standardized
review and quality
improvement measures,
an emphasis on
preventive rather than
acute care, and financial
incentives for doctors
and patients to reduce
use of unnecessary
medical care.

FOR YOUR CONSIDERATION
Hospital Value-Based Purchasing

Under the CMS Hospital Value-Based Purchasing Program, which emphasizes quality of care,
acute care hospitals are paid according to quality of care and encouraged to improve quality
of care by doing the following (Lee and Kaiser 2016):

• Minimizing adverse events (errors in care that harm patients)
• Applying evidence-based standards and protocols for care that yield the best

outcomes for the most patients
• Improving hospital processes and the patient experience
• Increasing transparency of care for consumers
• Recognizing hospitals that provide high-quality care at a lower cost than Medicare

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through managed care organizations (MCOs), such as health maintenance organizations
(HMOs), which tend to be large integrated companies that employ doctors on salary and
have a network of providers and sometimes hospitals, and preferred provider organizations
(PPOs), which contract with doctors and hospitals to offer patients a preferred provider
network for care. (Refer back to chapter 1 for a discussion of HMOs and PPOs.) In exchange
for an insurance premium and deductible from enrollees, MCOs assume financial risk, as
well as responsibility, for delivering care to enrollees through provider networks.

Private health insurance is offered by commercial insurance companies such as Aetna
and Metropolitan Life; nonprofit organizations such as Blue Cross and Blue Shield associa-
tions; self-insured employers; and MCOs, which pay a large portion of healthcare expenses
that subscribers incur. Together, they accounted for about 35 percent of the funding sources
for medical expenditures nationwide in 2016 (CMS 2018a, table 3).

Pu B l i C he a lt h in s u r a n C e

Public insurance programs are health plans that are financed by the government. Together,
these programs account for about 54 percent of funding sources for medical expenditures
(CMS 2018a, table 3).

In this system, the government provides benefits to specific eligible individuals by
reimbursing providers in the private sector for care given to beneficiaries. The Medicare
and Medicaid programs were created under the Social Security Amendments of 1965 and
are administered by CMS under HHS. These and other public insurance programs are
described in more detail next.

Medicare
The Medicare program provides healthcare coverage to (1) individuals aged 65 or older,
(2) people of any age with disabilities who are eligible for Social Security benefits, and (3)
individuals with end-stage renal (kidney) disease. The number of Medicare beneficiaries has
increased substantially, from 19.1 million in 1966 to 44.1 million in 2007, including 36.9
million elderly and 7.2 million nonelderly individuals, and is expected to reach 61 million
by 2020 with the aging of baby boomers (KFF 2018).

Medicare is a four-part program. The parts, labeled using the letters A through D,
are described in the following paragraphs (CMS 2018e).

Medicare Part A covers healthcare services received in hospitals, nursing facilities,
hospice care, and certain home health care programs. Subscribers do not pay a monthly
premium. Part A is financed by mandatory payroll taxes paid by all working individuals.

Medicare beneficiaries who are willing to pay a monthly premium—determined on
the basis of income—may also enroll in Medicare Part B. This supplemental insurance pays
for physician services and for outpatient care that is not covered by Part A. Part A and Part B

managed care
organizations (MCOs)
Organizations that seek
to apply the components
of managed care to a
population to provide
high-quality care at a
lower cost than that
incurred by fee-for-
service care.

premium
The amount an enrollee
must pay to join a
managed care plan. It
serves as a membership
fee and is typically
adjusted annually.

deductible
The amount an insured
patient must pay out of
pocket for medical care
every year before the
insurance plan covers
costs.

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do not cover certain services and devices, such as vision care, eyeglasses, dentures, and hearing
aids. However, Medicare Part B covers Pap tests; mammography; and screening for colorectal
cancer, prostate cancer, and glaucoma, as well as influenza and pneumonia vaccinations.

Medicare Part C, known as Medicare Advantage, is an optional private plan that
contracts with Medicare and provides all Part A and Part B services, plus additional services
as specified by the individual plan. The insurance plan pays participating private health
insurers for services received by beneficiaries in exchange for a monthly insurance premium.

Medicare Part D provides coverage for prescription drugs and offers two types of
private insurance plans that help pay for brand-name as well as generic prescription drugs
purchased at pharmacies listed in the Medicare program.

Medicaid
Medicaid provides healthcare benefits to eligible, low-income, elderly and nonelderly indi-
viduals, with separate programs for low-income women and children and people with
disabilities. In this joint federal–state program, the federal government provides financial
support to states by matching state funding for this program, with federal funding calculated
on the basis of states’ per capita income (CMS 2018c).

Each state sets its own eligibility criteria and covered services—which must meet a mini-
mum threshold of services required by the federal government—as well as amounts of payments
made to providers. Each state also has discretion to establish and define other medically needy
categories for Medicaid coverage, which often include individuals living in institutions (e.g., nursing
homes, psychiatric facilities) and those receiving care in community-based settings (CMS 2018c).

Children’s Health Insurance Program
Children in uninsured families whose income lies within 200 percent of the federal poverty
level (FPL) are eligible to enroll in the Children’s Health Insurance Program (CHIP). This
federal program allows states to expand Medicaid eligibility and establish a special child
health assistance program by providing additional funds to state Medicaid programs. States
can expand the eligibility criteria to cover children younger than 19 years of age in families
with incomes exceeding the FPL established for Medicaid eligibility, pregnant women,
parents of children enrolled in CHIP, and caretaker relatives (CMS 2018c).

im Pa C t O f he a lt h C a r e re f O r m

The Affordable Care Act (ACA) of 2010 introduced new funding mechanisms in both public and
private health insurance. For example, the ACA was expected at the outset to provide financing
to increase the proportion of nonelderly legal residents with insurance from about 83 percent
to about 94 percent, thus lowering the number of the uninsured nonelderly by 32 million by

federal poverty level
(FPL)
A calculation that
reflects federal
government guidelines
for assessing need
from income, based
on cost of living (the
amount of income
needed by families to
be self-supportive).
Many federal assistance
programs use a
percentage of FPL as
part of their eligibility
criteria.

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2019 (CBO 2010). It also allowed for the expansion
of Medicaid coverage (see the Key Point box titled
“Medicaid Expansion”), and states that participated
in the expansion experienced significant gains in cov-
erage and reductions in uninsured rates (Antonisse et
al. 2018). More than 9.2 million people signed up
for care on the national exchange in 2017, down by
about 400,000 from 2016, but the fate of the ACA
remains uncertain under the Trump administration.
With the repeal of the individual mandate to pur-
chase healthcare insurance scheduled to take effect
in 2019, the Congressional Budget Office (CBO)
predicted that about 13 million people would lose
their health insurance by 2027 (CBO 2017).

Under the ACA, individuals as well as small
businesses have access to qualified, affordable health
plans through state health insurance exchanges.
Additional features of the ACA also affect fund-
ing. (See the Learning Point box titled “Covering
the Uninsured” for a more detailed discussion of
healthcare reform law and its funding implications.)

us he a lt h C a r e de l i v e ry

The United States does not have a single, coherent
healthcare system; in its place are multiple subsys-
tems of healthcare delivery. Access to care through
these subsystems—managed care plans, safety net
providers, public health programs, long-term
care services, and military-operated healthcare—
depends on eligibility factors for each subsystem, as explained in the sections that follow.
New models are emerging, however, that may influence the delivery of healthcare, includ-
ing value-based healthcare and integrated healthcare delivery, each of which is discussed in
further detail following the discussion of the existing subsystems.

ma n a g e d Ca r e Pl a n s

Managed care is currently the most prevalent method of healthcare delivery in the United
States. Employers and the government purchase health plans for employees through contracts

KEY POINT
Medicaid Expansion

The ACA expands Medicaid to cover all non-Medicare-eligible indi-
viduals under age 65—including children, pregnant women, parents,
and adults without dependent children—whose incomes fall within
133 percent of the federal poverty level (CMS 2018c).

LEARNING POINT
Covering the Uninsured

The ACA seeks to reduce the number of uninsured Americans by
expanding Medicaid eligibility and offering tax credits for purchas-
ing private insurance. Much of the funding for the ACA comes from
the public sector. For example, the ACA includes funding for the cre-
ation of health insurance exchanges, expansion of the healthcare
workforce (especially primary care), and the addition of community
health centers (CBO 2017). Funding mechanisms include the follow-
ing (CBO 2017): tax credits (e.g., for private insurance and increasing
Medicaid eligibility), grants (e.g., community-based prevention,
health centers, long-term care, market reform), special programs
(e.g., health workforce, maternal and child health, Medicaid and
CHIP expansion, Medicare innovation), and taxes (e.g., penalties
on corporations, certain medical services deemed luxuries).

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with MCOs, which offer HMO, PPO, and point-of-service (POS) plans, and, more recently,
high-deductible health plans (HDHPs).

As reported by the Kaiser Family Foundation (KFF) and the Health Research &
Educational Trust (HRET), managed care expanded rapidly over conventional health insur-
ance from 1981 (covering about 5 percent of health insurance subscribers, primarily through
HMOs) through 1996 (covering 73 percent of subscribers, through a mix of HMOs, PPOs,
and POSs), and by 2017 the transition was nearly complete (covering more than 99 percent
of subscribers, through a mix of HMOs, PPOs, POSs, and HDHPs) (KFF and HRET 2017).

Managed care plans provide specific healthcare services depending on the type of plan,
paying providers through capitation (a fixed fee for each patient), through a discounted
fee-for-service scheme (whereby providers accept discounted fees in exchange for a guar-
anteed pool of patients), or a salary such as that paid in some Kaiser HMO plans. Enrollees
choose providers from within a specified network, and primary care providers function as
gatekeepers to manage routine services and referrals for higher-level or specialty care.

sa f e t y ne t Pr O v i d e r s

Healthcare services for vulnerable populations uniquely seek to provide medical care and
enabling services to the poor, the uninsured, racial and ethnic minorities, and immigrants.
These services are provided by safety net providers, including federally funded health centers
(see the first case study at the beginning of this chapter), physicians’ offices, and hospital
outpatient and emergency departments (see the For Your Consideration box titled “Health
Services Provision for Diverse Populations” and the Learning Point box titled “Pennsylvania
Rural Health Model”). Health policy for diverse populations is discussed in detail in chapter 6.

capitation
A fixed fee for each
patient.

discounted
fee-for-service
A fee agreed on between
an insurance plan and
physicians to provide
medical services at
a lower cost than is
common for the area,
in exchange for access
to the insurance plan’s
pool of patients.

gatekeeper
A qualified health
professional, usually a
primary care physician,
who must approve
specialist visits before
they are covered by an
insurance program.

enabling services
Services that enhance
access to medical care,
such as transportation,
interpretation,
education, and
community outreach.

safety net providers
As defined by the
Institute of Medicine
(IOM 2007), “providers
that by mandate or
mission organize and
deliver a significant level
of healthcare and other
health-related services
to the uninsured,
Medicaid, and other
vulnerable patients.”

FOR YOUR CONSIDERATION
Health Services Provision for Diverse Populations

Despite the public insurance options mentioned so far, members of vulnerable populations
often still lack access to safety net providers. One factor is regional variation in the type and
level of healthcare services available from providers. Another factor is the mounting pres-
sure on safety net providers from increasing numbers of poor and uninsured people seeking
care. In addition, costs for providing uncompensated care—care provided for which no one
pays—cannot be transferred to private insurance (e.g., by charging higher fees for privately
insured patients for anticipated uncompensated care).

What do you think? Are safety net providers available in your region? How might they
provide better care and access to people from diverse populations?

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Pu B l i C he a lt h Pr O g r a m s

State public health agencies operate numerous programs and services, including the follow-
ing five most common ones (Shi and Johnson 2014):

1. Preparedness

2. Vital statistics

3. Tobacco prevention and control

4. Public health research laboratories

5. Women, infants, and children (WIC) programs

Local public health agencies also operate programs, generally at the county level.
State and local public health agencies form the “backbone” of the US public health system
(Salinsky 2010). Agency roles in administrative infrastructure can vary widely, with states
and localities organizing their government public health systems in a number of ways, and
local health boards ranging widely in function, structure, and authority.

Under the US Constitution, states are granted the power to self-govern, including
the role of protecting and promoting population health. Most state health departments are
independent, focused solely on public health or with healthcare functions such as Medicaid
administration. Some state health departments are part of a larger agency (ASTHO 2014),
with functions for services in such areas as public health, behavioral health, and care and

LEARNING POINT
Pennsylvania Rural Health Model

The Pennsylvania Rural Health Model, an alternative payment model created by CMS, aims
to improve rural healthcare access and health outcomes while curbing the rise of spending,
including Medicare fee-for-service, and helping rural hospitals maintain access to healthcare
facilities (CMS 2017).

This model will determine whether modifying care delivery at rural hospitals (including
critical access hospitals and acute care hospitals) leads to improvements in health outcomes
and quality of care for residents in rural areas of the state, keeps hospital expenditures in
check, and helps rural hospitals maintain healthcare access (CMS 2017, 2018b). The model
began testing on January 13, 2017, through the Center for Medicare and Medicaid Innovation
under the authority of HHS (CMS 2017). Implementation of the model was set to continue
through 2023, with performance measured regularly to determine whether specified targets
had been met (CMS 2017, 2018b).

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assistance. State regulation reflects many of the tensions in US health policy among providers,
payers, patients, and institutions caused by structural changes in services and institutions.

lO n g-te r m Ca r e se r v i C e s

Long-term care (LTC) is healthcare that is provided in nursing homes; in skilled nursing,
subacute care, and specialized care facilities; by respite care, restorative care, and hospice
care agencies; and by noninstitutional, community-based programs such as home health
care and adult foster care (Shi and Singh 2018). Most clients of LTC services are elderly
people, who typically suffer from chronic conditions as aging increases the probability of
developing chronic illnesses and experiencing functional limitations. Functional limitations
are measured by activities of daily living (ADLs) and instrumental activities of daily
living (IADLs). For further information on LTC, see the Learning Point box titled “Key
Features of Long-Term Care.”instrumental activities of

daily living (IADLs)
Measure of an
individual’s ability
to perform activities
necessary to live
independently in
noninstitutional settings,
such as driving a car,
shopping, preparing
meals, and performing
light housework.

activities of daily living
(ADLs)
Measure of an
individual’s functioning
that includes six basic
activities: eating,
bathing, getting dressed,
maintaining bowel and
bladder continence,
using a toilet, and
transferring (e.g., getting
out of bed or moving
into a chair).

LEARNING POINT
Key Features of Long-Term Care

Individualized, coordinated services
Specific services are provided according to individualized plans. These plans are determined by
various factors, such as physical, mental, and emotional conditions; medical and social history;
former occupation; and cultural factors (Shi and Singh 2018). As patients’ needs change, such
as when an acute episode (e.g., stroke, bone fracture, pneumonia) occurs, the LTC provider
coordinates care with outpatient settings or hospital inpatient settings, occasionally fol-
lowed by intensive rehabilitation at a hospital-based transitional care unit or the LTC facility.

Maximized functional independence
LTC aims to enable patients to maintain their maximum possible functional independence
and prevent further decline of their abilities by motivating them to perform as many activi-
ties by themselves as possible.

Holistic approach, quality of life
Holistic healthcare emphasizes taking into consideration physical and mental needs, as well as
social and spiritual preferences, when designing the delivery of care and living environment.
The four factors that contribute to quality of life are lifestyle pursuits (personal enrichment
through enjoyable activities), living environment (hygiene, furnishings, aesthetic features),
clinical palliation (relief from unpleasant symptoms), and human factors (caregiver attitudes
and practices, latitude for independency, adequate privacy).

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Most nursing home services are paid for by Medicaid; Medicare Part A covers a
limited number of services. Private insurance is the least popular funding source for LTC
due to its high cost of premiums and limited coverage.

As a result of the recent substantial growth of community-based LTC (e.g., home
healthcare, adult day care and foster care, senior centers, home-delivered meals, homemaker
and handyman services), institution-based facilities (i.e., nursing homes) have experienced
a slight decline in the number of residents (Czaja 2016). However, the growing elderly
population will eventually increase demand for institutional LTC (Sullivan and Willis 2018).

Ca r e de l i v e ry f O r me m B e r s O f t h e mi l i ta ry a n d th e i r fa m i l i e s

The US military medical care system offers ambulatory care and hospital care services, free of
charge, to active-duty military personnel serving in the US Army, Navy, Air Force, Marines,
and Coast Guard, as well as in certain uniformed nonmilitary services, including the Public
Health Service and the National Oceanographic and Atmospheric Association. It operates
through base dispensaries and hospitals, sick bays, first-aid stations, medical stations, and
regional military hospitals.

Families and dependents of active-duty or retired military personnel are covered
through the military-financed TRICARE program. Retired veterans receive healthcare
services through the Veterans Administration healthcare system, which cares for more than
9 million individuals at more than 1,200 sites across the United States, including hospitals,
ambulatory clinics, community clinics, nursing homes, and counseling centers, as well as
residential care facilities and home health care programs (VHA 2018).

va l u e-Ba s e d he a lt h C a r e

Value-based healthcare providers are paid according to patient health outcomes and amount
of services delivered, unlike in a fee-for-service or capitated system (Feeley 2016). Value-
based care is transforming how providers care for patients. New delivery models emphasize
a coordinated care team approach and sharing of patient data to better measure outcomes
(see the Learning Point box titled “Patient-Centered Medical Homes”).

The benefits of value-based healthcare include the following (Feeley 2016):

◆ Better health outcomes at less cost to patients. Value-based care models emphasize
prevention and prompt recovery, and patients spend less on care as their health
improves.

◆ Greater provider efficiency and higher patient satisfaction. Providers spend less
time managing chronic disease.

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◆ Lower payer costs. Payers experience lower financial risk and burden as a result
of improved patient health, fewer insurance claims, and greater efficiency from
bundled payments.

◆ Supplier price adjustments for improved outcomes. Suppliers can align products,
services, and prices with better outcomes and at lower cost.

The shift from a fee-for-service system to a fee-for-value system is gradual, and as
providers increasingly adopt value-based care models, they may experience initial financial
losses before reaping long-term cost savings (Lee and Kaiser 2016). However, this shift is
considered the best way to reduce costs while optimizing quality of care and health outcomes.

in t e g r at e d he a lt h C a r e de l i v e ry

As states in the United States integrate care with health and social services, this collaborative
care involves multiple agents, from patient support systems to providers and practitioners
as well as systems, managers, and purchasers. Managed behavioral healthcare organizations
(MBHOs) are bringing together primary care and behavioral health professionals, and

LEARNING POINT
Patient-Centered Medical Homes

Value-based healthcare integrates primary care, specialty care, and acute care, often through
a healthcare delivery model known as the patient-centered medical home or primary care
medical home (PCMH)—a coordinated care approach led by a primary care physician that
focuses on the patient as a member of the care team (AHRQ 2018; Compton-Phillips, Bloem,
and Singer 2015; NEJM Catalyst 2017). PCMHs share electronic medical records among team
providers, thus lessening redundant care and its costs. The PCMH model provides care that
is comprehensive, patient-centered, coordinated, accessible, and demonstrably committed
to quality and safety (AHRQ 2018).

The PCMH is part of the broader movement toward patient-centered care, which benefits
not only patients and their families (e.g., improved health outcomes and higher satisfaction
scores) but also providers (e.g., improved morale among clinicians and ancillary staff as well
as enhanced reputation of providers among healthcare consumers) and health care systems
(e.g., more efficient allocation of resources, reduction of expenses, and increases in finan-
cial margins) along the continuum of care (NEJM Catalyst 2017). The PCMH strives to improve
the patient experience, health outcomes, and cost with enhanced primary care. Most states
already include PCMH in their Medicaid or CHIP coverage.

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accountable care organizations (ACOs) and com-
munity care organizations are integrating preventive
care, primary care, and tertiary care, including spe-
cialties such as behavioral health (see the Learning
Point box titled “Accountable Care Organizations”).

Under Medicaid, more and more states are
integrating benefits management—for example, the
state of Tennessee contracts with integrated health
plans—although MCOs can subcontract benefits
management for behavioral health in places where
MBHOs also operate.

PO l i C y is s u e s i n he a lt h C a r e
fi n a n C i n g a n d de l i v e ry

Exhibit 5.2 illustrates the intersection of medical
expenditures and health outcomes in the United
States. It reveals a relationship between financing
and health status that is sometimes regarded as
counterintuitive. First, we address the financing
policy issues at play in this relationship, and then
we discuss delivery issues.

fi n a n C e

As shown in exhibit 5.2, delivery costs for preventive health and primary care services (the
intersection at point A) tend to improve health, whereas delivery costs for disease-focused
care, such as secondary and tertiary care (the intersection at point B), do not proportionally
improve health status. At a certain point beyond point B (e.g., delivering high-tech treat-
ment for terminal patients), medical care brings minimal health benefits while potentially
prolonging suffering and incurring additional costs. Because of this disproportionate rela-
tionship, cost containment has become a major health policy priority in the United States.

Regulation-based cost containment is typically achieved through control of supply
(number of providers available), price (fees charged for services), and utilization (extent to
which services are provided). Countries that operate a national healthcare system are well
positioned to contain costs comprehensively by strictly controlling supply and limiting pro-
vider payments using global budgets. In contrast, the multipayer system in the United States
requires cost control to be implemented sector by sector. The following are two examples of
attempts to contain health expenditures through regulation in the United States (IOM 2007):

LEARNING POINT
Accountable Care Organizations

Providers in ACOs, which were established by CMS, work in a coor-
dinated team to deliver the best-quality care to Medicare patients
at the lowest cost. Unlike in fee-for-service healthcare, ACOs do
not incentivize physicians to order more tests or procedures and
take on more patients. As in PCMHs, patients and providers in ACOs
make decisions together and there is an emphasis on coordinating
care and sharing data among the team.

For example, under the Vermont All-Payer ACO model, created
by CMS (2018d), major healthcare payers in the state of Vermont
incentivize the value and quality of care, with an emphasis on
health outcomes. The Vermont All-Payer ACO lets ACOs in the state
join a Medicare ACO initiative and funds coordination of care and
collaboration with community providers; Medicaid is also a partner
in this model (CMS 2018d).

Implementation of the Vermont All-Payer ACO model began on
January 1, 2017, and was scheduled to conclude on December 31,
2022. During this period, CMS is expected to look for improvements
in health outcomes, care delivery, and spending across payers that
offer ACOs risk-based arrangements based on health outcomes
and spending (CMS 2018d).

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◆ Health planning. An example is the implementation of certificate-of-need (CON)
statutes at the state level, whereby state government agency approval is required
for the construction or expansion of healthcare facilities. (CON did not appear to
reduce hospital expenditures on a per patient, per day basis or affect reimbursement
rates, offering no incentive for providers and patients to change utilization behavior.)

◆ Price controls. An example is pay for performance (P4P), a Medicare initiative
that reimburses providers according to the quality of care they provide.
(Although an Institute of Medicine [IOM] study showed that P4P could
decrease access and increase disparities in care, the IOM advised Medicare to
launch a phased implementation with careful monitoring.)

de l i v e ry

Healthcare delivery policy has focused on both the provider and the patient. Provider-related
policies target the healthcare workforce, professional accreditation, and antitrust regulations,
whereas patient-related policies focus on patient access to care and patient rights.

Workforce
Donelan and colleagues (2010) conducted a survey of leader representatives regarding
key stakeholder groups about health workforce policies to examine perceptions on nurse

exhiBit 5.2
Effect of

Increased Medical
Expenditures on

Health Outcomes

A

B

H
ea

lt
h

ou
tc

om
es

Medical expenditures

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workforce issues. Nurses were found to be essential to the quality and safety of care, and given
that nurse shortages were expected to intensify following the passage of healthcare reform,
researchers determined that stakeholders should focus on the lack of advocacy and leadership
to advance issues of the nurse workforce on the US health agenda and in the media (Beck
and Boulton 2016; Donelan et al. 2010). The Critical Concept box titled “Rural Health
Professional Shortage” describes workforce shortages of another kind.

Accreditation
To participate in Medicare or Medicaid, healthcare organizations—including hospitals
and healthcare systems, critical access hospitals, skilled nursing facilities, portable X-ray
service providers, ambulatory surgery centers, and others, as well as suppliers to these

CRITICAL CONCEPT
Rural Health Professional Shortage

MacDowell and colleagues (2010) conducted a national survey of rural hospital CEOs in the
United States to study health professional shortages in rural areas. According to analyses from
335 respondents (a response rate of 34.4 percent), 75.4 percent of rural CEOs reported physi-
cian shortages, with the top three affected specialties identified as family medicine, general
internal medicine, and psychiatric care. Seventy percent of rural CEOs reported shortages
of at least two primary care specialties, such as family medicine, general internal medicine,
or pediatrics. The four most highly sought-after allied health professionals were registered
nurses, physical therapists, pharmacists, and occupational therapists.

In the United States, rural hospital CEOs in states in the region from New England through
Virginia reported the highest workforce shortages in all health professions. These findings
are consistent with the literature in the researchers’ conclusion that (1) physician supply in
most rural areas in the United States is inadequate, and (2) there is a shortage of specialty
physicians, especially psychiatrists and general surgeons (MacDowell et al. 2010). Similarities
in shortages and attributes influencing recruitment across regions indicated the need for
substantial, targeted policy and program interventions to develop a workforce of rural health
professionals that can meet increased demand for care in the wake of healthcare reform.

The study also identified four factors in recruitment and retention that were significantly
correlated with primary care physician shortage: “(1) healthcare is a major part of the local
economy; (2) community is a good place for family; (3) doctors are well respected and sup-
ported; and (4) people in the community are friendly and supportive of each other” (MacDowell
et al. 2010, 1531). The researchers suggest that rural hospital CEOs who seek to improve recruit-
ing should collaborate with community leaders to strengthen public education systems and
build a more robust economy to improve the overall quality of life (MacDowell et al. 2010).

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organizations—must meet eligibility requirements outlined in federal regulations, includ-
ing a certification of compliance with CMS Conditions of Participation.

Healthcare organizations may be accredited by a private accrediting organization,
such as The Joint Commission, that has developed standards that meet or exceed Medicare’s
Conditions of Participation. CMS grants deeming authority to accreditors that it considers
an appropriate proxy ( Joint Commission 2017).

Antitrust
Anticompetitive activities can raise healthcare costs and substantially reduce competition
without expanding access to care. The Federal Trade Commission (FTC) may scrutinize
these activities, which include the following (Feinstein 2010):

◆ Mergers and acquisitions of hospitals, clinics, and pharmaceutical companies
that reduce competition and access to care

◆ Price fixing and boycott agreements among healthcare providers to increase the
fees they charge healthcare plans without improving the quality of care

◆ “Pay for delay” drug patent settlements, whereby a drug company that sells a
brand-name pharmaceutical on the market pays a competitor to sell a generic
version of the drug to delay bringing the lower-cost drug to market

The FTC and the US Department of Justice Antitrust Division provide antitrust
guidelines for various types of healthcare arrangements.

Access to Care
The primary goal of health policy concerning access to care is to serve the neediest and most
underserved populations. Categories of healthcare services to be included in the necessary
level of care, however, are up for debate. Elsewhere in this chapter and throughout the book,
we discuss various aspects of access to care that are related to health policy.

Patients’ Rights
Patients’ rights consist of issues such as informed consent, compliance with Health Insurance
Portability and Accountability Act (HIPAA) of 1996 guidelines, and emergency medical treatment.

Informed Consent
The aims of informed consent are to (1) respect and uphold the autonomy of patients and
research participants and (2) protect patients and research participants from potential harm

Conditions of
Participation
Health and safety
standards defined by
the Centers for Medicare
& Medicaid Services
(CMS) as the minimum
requirements that
hospitals and medical
centers must meet to
serve publicly insured
patients.

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(Jefford and Moore 2008). Fulfilling these aims depends on three primary components:
prerequisites, including competence (being able to understand and make decisions) and vol-
untariness; clear and truthful information; and free and voluntary enrollment, including the
opportunity to withdraw consent without affecting the quality of care the patient receives
(Bromwich and Rid 2014; Petrini 2010).

HIPAA
HIPAA helps protect patients in the following ways (HHS 2018):

◆ It protects patients against discrimination from insurers that restrict enrollment
or demand unaffordable premiums based on individual health factors, including
preexisting medical conditions, previous medical claims, and personal genetic
information.

◆ It lets certain individuals enroll in group health plans or individual health plans
after losing employment-based coverage.

◆ It requires that personal health records be maintained to increase patient access
to and ownership over healthcare information by adhering to data security laws
and other privacy protection regulations.

EMTALA
The Emergency Medical Treatment and Labor Act (EMTALA) was passed in 1986 to eliminate
discriminatory practices by providers and thus increase access to healthcare for the indigent
and uninsured. All Medicare-participating hospitals with emergency departments must provide
a medical screening examination, stabilization, and further care or a transfer as needed to all
patients, regardless of patients’ ability to pay. EMTALA also requires hospitals to keep a list of
on-call physicians and prohibits hospitals with specialized capabilities or facilities from refusing
an appropriate transfer if the hospital can treat the individual (CMS 2010).

➤ Many factors have contributed to the dramatic rise in US healthcare costs, including
an emphasis on curing disease instead of maintaining wellness, the inefficiency of
a multiple third-party payer system, and an increase in the elderly population and
accompanying chronic illness.

➤ The United States does not have a single, coherent healthcare system but instead
consists of multiple subsystems of healthcare delivery. These subsystems include
managed care plans, safety net providers, public health programs, long-term care
services, and military-operated healthcare.

k e y P O i n t s

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➤ As a result of high healthcare costs, cost containment is a major priority for US
policymakers through both regulatory (e.g., price controls) and delivery (e.g., promoting
accountable, integrated care) approaches.

Ca s e st u d y 1

Based on your research of the federally funded health center program and its achievements,
answer the following questions:

1. What are some examples of recent studies that demonstrate the value of the health
center program?

2. Do health centers adequately address the lack of access to care for diverse and
vulnerable populations?

3. How can health centers prepare for future challenges?

Ca s e st u d y 2

Based on your research of the evolution and status of precision medicine, answer the follow-
ing questions:

1. What is the purpose of precision medicine?
2. What is required to implement precision medicine for both public and private

healthcare sectors?
3. How does precision medicine align with the goals of access, quality, and cost?

1. Describe healthcare financing in the United States, and list reasons for the country’s
high healthcare expenditures.

2. What are the major types of private health insurance in the United States? Who are the
beneficiaries of these programs?

3. What are the major types of public health insurance in the United States? Who are the
beneficiaries of these programs?

4. What are the major subsystems of healthcare delivery in the United States? Why were
they developed?

5. What are the critical policy issues in healthcare financing in the United States?
6. Cite examples of price control in healthcare.
7. What are the critical policy issues for healthcare delivery in the United States?
8. What kinds of current healthcare issues involve patients’ rights?

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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Agency for Healthcare Research and Quality (AHRQ). 2018. “Defining the PCMH.” Accessed June 11.
https://pcmh.ahrq.gov/page/defining-pcmh.

American Hospital Association (AHA). 2018. “Fast Facts on US Hospitals.” Updated February. www.
aha.org/research/rc/stat-studies/fast-facts.shtml.

Antonisse, L., R. Garfield, R. Rudowitz, and S. Artiga. 2018. “The Effects of Medicaid Expansion Under
the ACA: Updated Findings from a Literature Review.” Kaiser Family Foundation. Published
March 28. www.kff.org/medicaid/issue-brief/the-effects-of-medicaid-expansion-under-
the-aca-updated-findings-from-a-literature-review-march-2018/.

Ashley, E. A., A. J. Butte, M. T. Wheeler, R. Chen, T. E. Klein, F. E. Dewey, J. T. Dudley, et al. 2010. “Clinical
Assessment Incorporating a Personal Genome.” Lancet 375 (9725): 1525–35.

Association of State and Territorial Health Officials (ASTHO). 2014. “State Health Agency Struc-
ture and Governance.” Issue brief. www.astho.org/Profile/Volume-Three/Issue-Briefs/
Structure-and-Governance/.

Beck, A. J., and M. L. Boulton. 2016. “The Public Health Nurse Workforce in US State and Local Health
Departments, 2012.” Public Health Reports 131 (1): 145–52.

Bromwich, D., and A. Rid. 2014. “Can Informed Consent to Research Be Adapted to Risk?” Journal
of Medical Ethics 41 (7): 521–28.

Centers for Medicare & Medicaid Services (CMS). 2018a. “NHE Fact Sheet.” Updated April 17. www.
cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/national
healthexpenddata/nhe-fact-sheet.html.

———. 2018b. “Pennsylvania Rural Health Model.” Updated March 30. https://innovation.cms.gov/
initiatives/pa-rural-health-model/.

———. 2018c. “Program History.” Accessed June 5. www.medicaid.gov/about-us/program-history/
index.html.

———. 2018d. “Vermont All-Payer ACO Model.” Updated March 30. https://innovation.cms.gov/
initiatives/vermont-all-payer-aco-model/index.html.

r e f e r e n C e s

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———. 2018e. “What Medicare Covers.” Accessed June 4. www.medicare.gov/what-medicare-covers/
index.html.

———. 2017. “Medicare Program; Funding in Support of the Pennsylvania Rural Health Model-
Cooperative Agreement.” Federal Register 82: 17998. Published April 14. www.federalregister.
gov/documents/2017/04/14/2017-07555/medicare-program-funding-in-support-of-the-
pennsylvania-rural-health-model-cooperative-agreement.

———. 2010. “Emergency Medical Treatment and Labor Act (EMTALA): Applicability to Hospital and
Critical Access Hospital Inpatients and Hospitals with Specialized Capabilities.” Federal
Register 75 (246): 80762. Published December 23. http://edocket.access.gpo.gov/2010/
pdf/2010-32267.pdf.

Compton-Phillips, A., B. R. Bloem, and S. J. Singer. 2015. “NEJM Catalyst.” Published September
30. https://catalyst.nejm.org/videos/primary-care-providers-whole-care-coordinators/.

Congressional Budget Office (CBO). 2017. “Repealing the Individual Health Insurance Mandate: An
Updated Estimate.” Published November 8. www.cbo.gov/publication/53300.

———. 2010. Letter to the Honorable Nancy Pelosi providing an analysis of the amended recon-
ciliation proposal, March 20. www.cbo.gov/ftpdocs/113xx/doc11379/AmendReconProp.pdf.

Czaja, S. J. 2016. “Long-Term Care Services and Support Systems for Older Adults: The Role of Tech-
nology.” American Psychologist 71 (4): 294–301.

Donelan, K., P. I. Buerhaus, C. DesRoches, and S. P. Burke. 2010. “Health Policy Thought Leaders’
Views of the Health Workforce in an Era of Health Reform.” Nursing Outlook 58 (4): 175–80.

Feeley, T. 2016. “Why Value in Health Care Is the Target.” NEJM Catalyst. Updated October 24. https://
catalyst.nejm.org/why-value-in-health-care-is-the-target/.

Feinstein, R. A. 2010. “Prepared Statement of the Federal Trade Commission on Antitrust Enforce-
ment in the Health Care Industry.” Federal Trade Commission. Published December 1. www.
ftc.gov/os/testimony/101201antitrusthealthcare.pdf.

Health Resources and Services Administration (HRSA). 2018. “2016 National Health Center Data.”
Accessed June 4. https://bphc.hrsa.gov/uds/datacenter.aspx.

———. 2017. “Health Center Program.” Published August. https://bphc.hrsa.gov/about/health
centerfactsheet.pdf.

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———. 2011. “Operating a Health Center: Legislation and Regulations; Authorizing Legislation.”
Accessed June 7. http://bphc.hrsa.gov/policiesregulations/legislation/index.html (content
no longer available).

Hyde, J. K., and S. M. Shortell. 2012. “The Structure and Organization of Local and State Public
Health Agencies in the US: A Systematic Review.” American Journal of Preventive Medicine
42 (5): S29–S41.

Institute of Medicine (IOM). 2007. Rewarding Provider Performance: Aligning Incentives in Medicare.
Washington, DC: National Academies Press.

Jefford, M., and R. Moore. 2008. “Improvement of Informed Consent and the Quality of Consent
Documents.” Lancet Oncology 9 (5): 485–93.

Joint Commission. 2017. “Facts about Federal Deemed Status and State Recognition.” Published October
18. www.jointcommission.org/facts_about_federal_deemed_status_and_state_recognition/.

Kaiser Family Foundation (KFF). 2018. “Total Number of Medicare Beneficiaries, 2015.” Accessed
June 4. www.kff.org/medicare/state-indicator/total-medicare-beneficiaries/.

Kaiser Family Foundation (KFF) and Health Research & Educational Trust (HRET). 2017. “2017 Employer
Health Benefits Survey: Summary of Findings.” Published September 19. www.kff.org/
report-section/ehbs-2017-summary-of-findings/.

Lee, T. H., and L. S. Kaiser. 2016. “Turning Value-Based Healthcare into a Real Business Model.”
NEJM Catalyst. Updated October 24. https://catalyst.nejm.org/turning-value-based-
health-care-into-a-real-business-model/.

MacDowell, M., M. Glasser, M. Fitts, K. Nielsen, and M. Hunsaker. 2010. “A National View of Rural
Health Workforce Issues in the USA.” Rural and Remote Health 10 (3): 1531.

National Center for Health Statistics (NCHS). 2011. Health, United States, 2010. Hyattsville, MD: US
Department of Health and Human Services.

National Institutes of Health (NIH). 2018. “All of Us Research Program: Program FAQ.” Accessed June
17. https://allofus.nih.gov/about/program-faq.

National Research Council. 2011. Toward Precision Medicine: Building a Knowledge Network for
Biomedical Research and a New Taxonomy of Disease. Washington, DC: National Academies
Press.

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NEJM Catalyst. 2017. “What Is Patient-Centered Care?” Published January 1. https://catalyst.nejm.
org/what-is-patient-centered-care/.

Petrini, C. 2010. “Informed Consent in Experimentation Involving Mentally Impaired Persons: Ethical
Issues.” Annali dell’Istituto Superiore di Sanita 46 (4): 411–21.

Salinsky, E. 2010. “Governmental Public Health: An Overview of State and Local Public Health
Agencies.” National Health Policy Forum Background Paper No. 77. Published August 18.
www.nhpf.org/library/background-papers/BP77_GovPublicHealth_08-18-2010.pdf.

Sawicki, M. P., G. Samara, M. Hurwitz, and E. Passaro. 1993. “Human Genome Project.” American
Journal of Surgery 165 (2): 258–64.

Shi, L., and J. Johnson (eds.) 2014. Public Health Administration: Principles for Population-Based
Management, 3rd ed. Burlington, MA: Jones and Bartlett.

Shi, L., and D. A. Singh. 2018. Essentials in Health Care Delivery, 5th ed. Sudbury, MA: Jones and
Bartlett.

Sullivan, L., and D. G. Willis. 2018. “Towards Changing the Long Term Care (LTC) Paradigm: Explicat-
ing the Concept of Thriving in Older Adults Living in LTC.” Issues in Mental Health Nursing
39 (5): 1–10.

US Department of Health and Human Services (HHS). 2018. “Summary of the HIPAA Privacy Rule.”
Accessed June 12. www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html.

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base in World.” News release, August 1. www.va.gov/opa/pressrel/pressrelease.cfm?id=2806.

US Food and Drug Administration (FDA). 2013. Paving the Way for Personalized Medicine—FDA’s Role
in a New Era of Medical Product Development. Published October. https://errorstatistics.
files.wordpress.com/2014/07/508-paving-way-for-personalized-medicine-2013_reduced.pdf.

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aboutvha.asp.

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Medicine Initiative.” News release, January 30. https://obamawhitehouse.archives.gov/
the-press-office/2015/01/30/fact-sheet-president-obama-s-precision-medicine-initiative.

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1 5 5

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

The moral test of government is how it treats those who are in the dawn of life . . .

the children; those who are in the twilight of life . . . the elderly; and those who are

in the shadow of life . . . the sick . . . the needy . . . and the disabled.

—Hubert Humphrey

Millions of our citizens do not now have a full measure of opportunity to achieve

and enjoy good health. Millions do not now have protection or security against the

economic effects of sickness. The time has arrived for action to help them attain that

opportunity and that protection.

—Harry S. Truman

After completing this chapter, you should be able to

➤ define vulnerable populations;

➤ identify policy issues for racial and ethnic minorities;

➤ describe policy issues for those with low income;

➤ highlight policy issues for the uninsured; and

➤ discuss policy issues for vulnerable subpopulations such as the elderly, people
with chronic illness, people with mental illness, women and children, people with
disabilities, the homeless, and people with HIV/AIDS.

C H A P T E R 6

H E A LT H P O L I C Y F O R D I V E R S E
P O P U L AT I O N S

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th e he a lt h Ce n t e r Pr O g r a m

Since the 1960s, health centers—nonprofit, community-directed healthcare providers, also known
as federally qualified health centers—have provided primary and preventive care services to
predominantly low-income, racial or ethnic minority patients in medically underserved areas
(HRSA 2017, 2018). In addition to clinical care, health centers provide enabling services such as
transportation, translation, and education to facilitate access to care for diverse populations.
Health centers coordinate with other community services and are governed by boards made
up mainly of health center patients.

Health centers face significant challenges, including the following:

• Persistent economic slowdown
• Shifting demographic trends
• Shifting disease burden
• Increasing complexity of the healthcare delivery system
• Health and healthcare disparities
• Healthcare workforce shortage
• Rapid rate of technological innovation

Yet health centers are making a difference in underserved communities across the
United States. As of 2017, nearly 1,400 health centers provided care at more than 11,000 sites
throughout all 50 states and several US territories (HRSA 2017). The National Association of
Community Health Centers (2018) has chronicled stories of how health centers have provided
access to affordable primary healthcare and are saving lives and taxpayer dollars. Following
are several examples:

• Center for Family Health (Jackson, Michigan) became a one-stop center for women’s
health, pediatrics, and related medical services.

• Crescent Community Health Center (Dubuque, Iowa) invested in the implementation of
electronic medical records and in patient education.

• Family Health Services (Twin Falls, Idaho) undertook three expansion projects through-
out Magic Valley that include medical, behavioral, dental, and pharmacy services.

• Family Practice and Counseling Network (Philadelphia) recruited additional dentists to
provide many children with regular dental cleaning before they start school.

• La Clinica Health Care (Medford, Oregon) installed a new ultrasound machine to
provide better medical imaging for uninsured and underinsured pregnant women.

• United Neighborhood Health Services (Nashville, Tennessee) became able to serve as a
medical home to mothers and children.

C a s e s t u d y 1

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• West Cecil Health Center (Cecil County, Maryland) expanded services to include more
evening hours.

• Westside Healthcare (northern Delaware) built a new site to expand access to more
than 5,000 people.

• Will County Community Health Center (suburban Chicago) acquired a mobile dental van
that provides families in the county with dental care.

my he a lt h gPs Pr O g r a m f O r Pat i e n t s w i t h mu lt i P l e
Ch r O n i C CO n d i t i O n s

One method of addressing the needs of patients with multiple chronic conditions involves enlist-
ing community health workers, typically members of underserved or indigenous communities
who serve as frontline healthcare professionals (Love, Gardner, and Legion 1997). The duties of
community health workers range from facilitating access to care and performing outreach to
improving healthcare quality and reducing costs (Witmer et al. 1995). The My Health GPS program
is one of two state programs requiring community health workers to be part of the care team.

Under the Affordable Care Act of 2010 (Section 2703), states may submit state plan
amendments to coordinate care for people enrolled in Medicaid who have chronic conditions
using a “whole-person” philosophy and integrating care across the full range of services needed
(CMS 2018). In 2017, the District of Columbia Department of Health Care Finance (DHCF) launched
My Health GPS, a coordinated care benefit program for Medicaid beneficiaries with multiple
chronic conditions enrolled in either fee-for-service or managed care plans (DHCF 2018). The
program seeks to improve outcomes and reduce unnecessary hospitalizations and emergency
department (ED) visits by integrating an interdisciplinary team led by primary care.

My Health GPS targeted about 25,000 beneficiaries with 3 or more chronic conditions
assigned to a provider via an opt-out process (District of Columbia State Innovation Model 2017).
Providers under My Health GPS must demonstrate delivery and document all home services,
directly provide or subcontract for provision of services, and follow communication protocols
with external health partners. Providers are also required to provide patient-centered medical
home recognition, certified electronic health records, hospital and ED alerts for enrollees, 24/7
access to clinical advice, and a staffing model of qualified persons or comparable alternatives
(District of Columbia State Innovation Model 2017). The preapproved staffing model for My
Health GPS includes a health home manager, a nurse care manager, a care coordinator or social
worker, a licensed clinical pharmacist, and a peer navigator or community health worker, with
an assigned staffing ratio for each role.

Beneficiaries are classified based on the severity of their conditions. Individuals with
lower acuity have three or more chronic conditions (Group 1) and are expected to have two
25-minute contacts per month with a care team consisting of a nurse manager, a health home
manager, and a community health worker (District of Columbia State Innovation Model 2017).

C a s e s t u d y 2

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Those with higher acuity (Group 2) have three or more conditions as well as a qualifying risk
score and are expected to have six 40-minute contacts per month with a care team consisting
of a nurse manager, a health home manager, a care coordinator, a clinical pharmacist, and a
community health worker (District of Columbia State Innovation Model 2017).

Providers are paid on a per-member, per-month (PMPM) basis. To receive the initial pay-
ment, providers must (1) inform the beneficiary of this health home benefit, (2) receive consent
from the beneficiary, and (3) develop a care plan for the beneficiary. Providers must deliver at
least one home health service within a given calendar month to receive a PMPM payment that
month. Payments are made directly from the DHCF. Providers were paid $46 PMPM for patients
with Group 1 acuity and $137 PMPM for patients in Group 2. During the first quarter of the pro-
gram (July–September 2017), providers were given a onetime payment incentive of $475.91 per
beneficiary for starting a care plan (District of Columbia State Innovation Model 2017).

As of mid-2018, the program had not yet been evaluated, having been implemented for
less than a year; however, starting in 2019, providers were to be evaluated for readmissions,
preventable inpatient admissions, and avoidable utilization.

T
his chapter discusses healthcare policies for diverse populations and vulnerable sub-
populations of people with special needs. The populations covered in the chapter
include racial or ethnic minorities, the uninsured, and individuals with low income.

Vulnerable subpopulations include the elderly, people with chronic illness, people with
mental illness, women and children, people with disabilities, the homeless, and people
with HIV/AIDS.

de f i n i n g vu l n e r a B i l i t y

No consensus has been reached on how to define vulnerability and vulnerable populations.
For purposes of our discussion, this chapter defines vulnerability as the convergence of health
risks. Health risks can manifest in the following categories:

◆ Physical (e.g., having a fever or other physical symptoms)

◆ Mental (e.g., feeling depressed)

◆ Social (e.g., resulting in poor school or job performance)

Because poor health in one dimension can be compounded by poor health in other
dimensions, health needs tend to be considerably greater for people with multiple health

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problems than for those with a single health prob-
lem (Hu et al. 2016; Shi and Stevens 2010; Shi
et al. 2017). Health risks consist of predisposing,
enabling, and need characteristics at the individual
and ecological levels (see the Learning Point box
titled “Definitions of Health Risk Characteristics”).

Vulnerable populations, such as those pre-
sented in this chapter, experience a convergence of
these health risk factors and, as a result, typically
exhibit poorer health status than those without
multiple risk factors. The For Your Consideration
box titled “Why Should We Care About Vulner-
able Populations?” lists and describes compelling
reasons to focus national attention on the need to
reduce the health and healthcare disparities they
experience.

he a lt h PO l i C y is s u e s f O r di v e r s e
PO P u l at i O n s

The following sections explore health policy issues
for the following types of populations: racial or
ethnic minorities, the uninsured, and people with
low socioeconomic status (SES).

LEARNING POINT
Definitions of Health Risk Characteristics

The following are definitions of the three characteristics of health
risks (Andersen 1995):

Predisposing characteristics, which indicate the propensity of
individuals to use care services:

• Demographic characteristics (e.g., age, sex, family size)
• Social structure variables (e.g., race or ethnicity, education,

occupation)
• Health beliefs (e.g., beliefs about health and the value of

healthcare)

Enabling characteristics:

• Resources available to individuals and families for the use
of services (e.g., income, insurance coverage)

• Attributes of the surrounding community or region that
affect the availability of and access to healthcare services

Need characteristics:

• Specific illnesses or health needs that drive the receipt of
healthcare services

FOR YOUR CONSIDERATION
Why Should We Care About Vulnerable Populations?

Possible answers to this question include the following:

• Vulnerable populations have significantly greater health needs.
• The prevalence of vulnerability in the United States is increasing.
• Vulnerability is influenced by social forces and therefore should be remedied by them.
• Vulnerability is fundamentally linked with national resources.
• Vulnerability and equity cannot coexist.

What do you think? Are these points valid? Explain your answer.

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ra C i a l O r et h n i C mi n O r i t i e s

The US Census Bureau (2018) estimates that more than 34 percent of the country’s popula-
tion is made up of racial or ethnic minorities:

Blacks or African Americans 13.3 percent

Hispanics or Latinos 17.8 percent

Asians 5.7 percent

Native Hawaiians and other Pacific Islanders 0.2 percent

American Indians and Alaska Natives 1.3 percent

Identified as two or more races 2.6 percent

Racial and ethnic minorities experience significant problems in accessing high-quality health-
care, leading to disparities in health status as compared with the white, non-Hispanic population.

Healthcare Access
The regular source of care (RSC) measure is commonly used to evaluate patient access
to care. Research indicates that having an RSC increases the chances of receiving better
coordinated care, better treatment for chronic and acute health conditions, fewer delays in
care, and access to preventive care. Studies show, however, that members of racial and ethnic
minorities are less likely than whites to have an RSC, even when accounting for SES, insur-
ance status, and health conditions (Ailawadhi et al. 2017; Grzywacz, Hussain, and Ragina
2017; Lo et al. 2017; Shi and Stevens 2005). Hispanic adults were the least likely to have
an RSC, followed by American Indians and Alaska Natives, African Americans, and Asians.
Whites were shown to be the most likely to have an RSC. Similar trends were seen among
children from racial and ethnic minority populations compared with children from the
white, non-Hispanic population (HHS 2018a, 2018b; Irvin et al. 2018; Tai et al. 2017).

Factors contributing to the lack of an RSC include the following (HHS 2018a):

◆ Lack of health insurance coverage

◆ Low family income

◆ Language other than English spoken in the home

The inability to afford care was reported as the most common reason for Hispanic
adults lacking an RSC (Shi and Stevens 2005). Additional factors that limit access to care,
especially for Latinos and Asians, include English language barrier, poor geographic prox-
imity to a source of care, and lack of providers offering culturally appropriate services.

regular source of care
(RSC)
A usual place where, or
a usual provider from
whom, an individual
receives healthcare
services.

culturally appropriate
services
Efforts by healthcare
organizations and
providers to increase
understanding and
produce effective
interventions for
patients by taking
into account patients’
cultural and linguistic
characteristics.

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Healthcare Quality
Racial and ethnic minority patients are more likely to report dissatisfaction with quality of
care and patient–provider interactions than white patients are. One reason is that patients
from these groups commonly perceive discrimination in quality of treatment. Lack of English
language proficiency not only affects access to care for racial or ethnic minorities but also
contributes to disparities that racial or ethnic groups experience in receiving high-quality
preventive care (Njeru et al. 2018).

Health Status
Racial and ethnic minorities experience disparities in perceived health status, causes of death,
and health risk behaviors as compared with non-Hispanic whites. For example, the 2007
National Children’s Health Survey showed that Hispanic and African-American children
were the least likely to be perceived by their parents as having “excellent” or “good” health,
even after adjusting for SES and family demographics (CDC 2017d). Regarding cause of
death, among all racial and ethnic groups, African Americans exhibit the highest mortality
rates for homicide, stroke and coronary heart disease, and colorectal cancer, as well as the
highest morbidity rates for diabetes and HIV/AIDS (CDC 2013, 2017b, 2018c). These
causes of death have important implications for healthcare policy because they are preventable
through law enforcement, regular screening and early detection, health education, and access
to effective medications. As for health risk behaviors, American Indians and Alaska Natives
have the highest smoking prevalence (CDC 2013, 2017a; Garrett et al. 2011). Additionally,
Asians and Latinos are more likely than whites to live in an area with substandard air qual-
ity as compared with the US Environmental Protection Agency standard (Yip et al. 2011).

Programs to Eliminate Racial and Ethnic Disparities
Programs to eliminate racial and ethnic disparities in the United States operate at the federal,
state, and local levels of government as well as through private organizations.

Federal Initiatives
The Office of Minority Health (OMH) and the Indian Health Service (IHS), both part of
the US Department of Health and Human Services (HHS), are among the federal agen-
cies that address issues related to racial or ethnic minority health. The OMH, according to
its mission statement, “is dedicated to improving the health of racial and ethnic minority
populations through the development of health policies and programs that will help elimi-
nate health disparities” (OMH 2018). The IHS provides comprehensive health services to
federally recognized American Indians and Alaska Natives residing in 12 Indian Health
Service Areas across the United States.

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State and Local Initiatives
State and local programs work independently to meet the specific needs of minority popula-
tions in state, county, and municipal communities. At the same time, state programs often
serve as models for federal initiatives. Two examples are Minnesota’s Eliminating Health
Disparities Initiative and the California Department of Public Health Strategic Plan, both
initiated in 2008. They serve large numbers of individuals, and their goals are closely aligned
with the determinants of health in Healthy People 2020 (HHS 2010).

Private Initiatives
One example of private endeavors to eliminate disparities is the Association of Schools of
Public Health, which, with the support of the W. K. Kellogg Foundation, promotes health
professional involvement in racial and ethnic health disparities research (Horowitz et al.
2000). Another example is the Building Healthy Communities Initiative launched in 2010
by the California Endowment (2018), which seeks to promote long-term improvements
in health status in 14 communities with high rates of health disparities through broad
investment in social, environmental, and medical interventions, with a primary focus on
children and youth.

th e un i n s u r e d

In 2015, more than 9 percent of the US population lacked health insurance (Shi and Singh
2018). Studies show that people without health insurance face barriers to healthcare access,
quality of care, and positive health outcomes (Akinlotan et al. 2017; Garfield and Damico
2012; Kenney et al. 2012; Moonesinghe, Zhu, and Truman 2011; Weissman et al. 2008).
Advocates have long urged lawmakers to expand public insurance programs—such as Medi-
care, Medicaid, and the Children’s Health Insurance Program (CHIP)—and have called for
the improvement of the quality of care received through these programs.

One primary goal of the Affordable Care Act (ACA) of 2010 was to reduce the
number of uninsured Americans. Several provisions in the ACA sought to extend coverage
to previously uninsured groups. Examples include the development of health insurance
exchanges, which established insurance markets for individuals and small business owners,
and the expansion of Medicaid to provide insurance coverage to all individuals and families
with an income at or below 133 percent of the federal poverty level (Shi and Singh 2018).
In 2013, the year before the major provisions of the ACA took effect, more than 44 million
nonelderly people were uninsured, but by 2016, only 27.6 million were uninsured (Foutz
et al. 2017). However, after the tax revisions led by President Donald Trump in 2017
eliminated the ACA requirement that all individuals have health insurance, the number
of uninsured Americans began to rise again (Beaton 2018; Collins et al. 2018). By March

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2018, 4 million fewer working people aged 19–64 had health insurance (Collins et al. 2018).
Among lower-income adults in particular, the uninsured rate increased from 20.9 percent in
2016 to 25.7 percent in March 2018 (Collins et al. 2018). If the ACA were to be repealed
entirely, as the Trump administration seeks to do—either without replacement or replaced
by a plan favored by President Trump—the projected number of uninsured people would
rise to about 48 to 49 percent of the population (Statista 2018).

Healthcare Access
Lack of health insurance increases the likelihood of delayed care by increasing the chance
that the uninsured individual does not have an RSC. Uninsured children in particular suffer
negative consequences. A study on young children aged 0–3 showed that uninsured children
had a lower chance of obtaining needed medical care, prescription medications, dental care,
and an RSC (Newacheck et al. 2002). Studies have further shown that the type of insurance
that patients are covered by affects their rates of ED use and preventable hospitalization.
According to several studies, individuals with public insurance are more likely than those
with private insurance to use an ED instead of a physician’s office as their primary source
of care (Gindi, Cohen, and Kirzinger 2012; Meisel et al. 2011; Pukurdpol et al. 2014).

Healthcare Quality
The association between quality of healthcare and type of health insurance has been well
documented, as has the impact of insurance status on how many of recommended services
an individual receives. One study found that uninsured individuals experienced more deficits
in receiving preventive care and less likelihood of receiving care as the uninsured period
increased (Garfield and Damico 2012; Foutz et al. 2017; Moonesinghe, Zhu, and Truman
2011; Weissman et al. 2008). This pattern was consistent across most preventive services.
Furthermore, poorer access to primary care services among uninsured individuals may result
in a greater number of preventable hospitalizations, which are avoidable with timely, quality
primary care (Davis et al. 2018; Foutz et al. 2017).

Programs to Eliminate Disparities in Health Insurance
Government and community organizations are at the forefront of the national drive toward uni-
versal and more comprehensive health coverage, creating several programs to raise the number
of individuals covered by health insurance. Federal programs, such as Medicare, Medicaid, and
CHIP, cover nearly 40 percent of the US population. The impact of these programs has been
especially noticeable in reducing the number of the uninsured among vulnerable populations.

Many states are expanding Medicaid or CHIP eligibility, and these expansion pro-
grams have been credited for improved access to care and health status (Dubay and Kenney

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2009; Holahan and Headen 2010; Howell and Kenney 2012; Sommers, Baicker, and Epstein
2012). To assist the remaining uninsured individuals, some states and private organizations
have created their own programs for those who cannot afford health insurance but whose
income level makes them ineligible for Medicaid or CHIP.

For example, Kentucky is one of a few southern states that have expanded Medicaid
under the ACA, extending Medicaid eligibility to many people who are too poor to pur-
chase individual market coverage yet too “rich” to qualify for traditional Medicaid eligibility.
Benitez, Creel, and Jennings (2016) found that Medicaid expansion raised accessibility of
coverage and affordability of healthcare for populations experiencing financial constraints
in using medical care.

In an attempt to improve access to healthcare for all of its people, Minnesota created
the Health Care Homes program as part of the state’s health reform initiative. The program
links primary care with prevention and wellness, self-management, and community services
(Minnesota Department of Health 2018). Minnesota has also attempted to provide crucial
mental health services through its Medicaid program (see the For Your Consideration box
titled “Minnesota’s Measuring Adolescent Depression Screening and Treatment in Medicaid”).

Because states have broad flexibility in defining their public health role, state-level
public health policy throughout the United States varies widely. State governments might
pursue any of several strategies in relation to the uninsured (Bowman and Kearney 1988;
Brace 1993; Coughlin and Zuckerman 2005; Dye 1966; Erikson, Wright, and McIver
1993; IHPP 1995). First, they may choose to do little regarding uninsurance, enacting few
or no reforms and relying on the national government to remedy the problem. Although
such inaction is inexpensive in the short run, it provides no assurance that something will
be done to mitigate the inadequacy of insurance coverage, as even national policies can be
expected to provide, at best, variable solutions to uninsurance across states. Second, states
might choose a mix of state-based and market-based reforms to create a balanced policy
portfolio. A balanced set of policies might provide some benefits: Relying on state-based
policies would ensure that coverage is provided to certain blocs of the population and
provide a fallback in the event of rising unemployment, which would lead to a reduction
in employment-based coverage. By contrast, market-based policies would limit the state’s
financial obligations during times of economic prosperity. Third, states may follow purely
state-based or purely market-based policy strategies. With a state-based policy portfolio,
states assume large financial risk but receive great assurance that citizens will receive coverage
through active state intervention. With a market-based policy focus, legislatures may claim
credit for both addressing uninsurance and improving the business climate, and the state
assumes little financial risk (Glied and Gould 2005; Hall 2000). However, the suitability of
this approach is related to the incentives offered to business and the insured. It is one thing
for employers to offer insurance benefits, but it is another to make those benefits truly acces-
sible to employees. Passing such policies might address a political imperative to take action
while not adequately addressing the uninsurance problem. Alternatively, selling state-based

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FOR YOUR CONSIDERATION
Minnesota’s Measuring Adolescent Depression Screening and Treatment
in Medicaid

Depression among adolescents has demonstrated an increasing trend over time. Major depres-
sive disorder among adolescents increased by 37 percent—from 8.7 percent in 2005 to 11.5
percent in 2014 (Mojtabai, Olfson, and Han 2016). Tasked by 2008 state health reform law, the
Minnesota Department of Health established a statewide system of clinical quality measures
to apply across coverage types and demographic characteristics (Honsberger and King 2017). In
partnership with MN Community Measurement, a nonprofit organization focused on improving
quality of healthcare in Minnesota through measurement and public reporting, the Minnesota
Statewide Quality Reporting and Measurement System was established. The system requires
quality reporting from all physician practices and health centers in the state. The development
of these statewide measures was supervised by a committee of providers, health plans, and
consumer representatives, who made recommendations and approved measures and report-
ing policies, and examined issues regarding data collection (Honsberger and King 2017). To
address the issue of measuring adolescent depression within the state, the Statewide Quality
Reporting and Measurement System developed a specific measure to determine the rate of
screening for depression among adolescents in a clinical setting.

To develop a meaningful quality measure, the Statewide Quality Reporting and Measure-
ment System established the denominator of eligible adolescents—people aged 12–17 who
received a well visit—and identified a reliable measure of individuals screened. The numerator
of eligible adolescents chosen consisted of those who were screened using validated mental
health tools in their medical record. To increase the accuracy of the measure, adolescents
previously diagnosed with other mental health conditions were excluded (Honsberger and
King 2017). Implementation was facilitated by provider support from MN Community Measure-
ment to meet reporting standards via informational webinars, data submission guides, and
technical assistance (Honsberger and King 2017). The Minnesota Department of Health Early
and Periodic Screening, Diagnostic Treatment provided additional training in mental health
screening and services for clinics and providers (Honsberger and King 2017).

After a pilot study in 2013 to test the data-collection process and validate the data, the
Statewide Quality Reporting and Measurement Systems launched the statewide measure and
collected data for the 2014 measurement year from providers in January 2015 (Honsberger
and King 2017). Preliminary results showed that fewer than half of adolescents in the state
were screened for depression or other mental health conditions, and approximately 10 per-
cent of those screened were identified as possibly having a mental health condition (Smith
and Ghere 2015). Rates of screening for adolescent depression increased in follow-up years
(Honsberger and King 2017).

The study showed that Statewide Quality Reporting and Measurement Systems may have
a positive influence on preventive care quality measures of importance in public health, such
as screening for depression among adolescents.

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strategies in the modern era may be politically untenable, even if the ultimate effects were
beneficial for providing more broad-based insurance coverage (Holahan and Ghosh 2005).

Pe O P l e w i t h lO w sO C i O e C O n O m i C stat u s

SES is defined by several factors, the most common ones being income level, educational
level attained, and occupational status. Those with lower SES typically face greater barriers
in accessing healthcare than those higher on the SES scale. For people of lower SES who are
able to receive care, their overall health status and quality of care are still typically inferior
to those for people of higher SES.

Healthcare Access
SES has shown greater impact than race or ethnicity on access to healthcare. According to
an analysis of the California Health Interview Survey (Brown et al. 2007), poor adults are
more than twice as likely to lack an RSC as their counterparts who are not poor. Those
with higher levels of education were more likely to maintain an RSC and to seek care at a
doctor’s office instead of at community clinics and EDs.

Healthcare Quality
Several studies examined the link between SES and healthcare utilization. Women with lower
educational levels were less likely to report receiving Pap tests and mammograms (Monnant
2014), and women with low household income had lower utilization rates for influenza
vaccinations, cervical and colon examinations, and bone densitometry (Earle et al. 2003).
Regarding SES and healthcare quality, low levels of income and education showed a negative
effect on physicians’ perceptions of patients, which in turn adversely influenced physicians’
selection of treatments and recommendations (Van Ryn and Burke 2000).

Health Status
Low income, low educational level, and low occupational status have long been associated
with high health risks, poor health status, and high mortality rates (see, e.g., Cutilli et al.
2018; Singh et al. 2017; Syme and Berkman 1976). Individuals living in poverty were four
times more likely to report fair or poor health status than those who were not impoverished
(i.e., those with incomes greater than 200 percent of the federal poverty level). Furthermore,
the percentage of adults aged 55–64 with functional limitations also increases as income
level decreases, with a nearly sixfold difference between the highest and lowest income levels
(Minkler, Fuller-Thomson, and Guralnik 2006).

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In a study of the relationship between SES and mental health, the Centers for Disease
Control and Prevention (CDC) found that high-income individuals were two to three times
more likely to report frequent mental distress than were low-income individuals (APA 2005).
Low-income adults also showed a high prevalence of health risk behaviors (e.g., physical
inactivity, smoking, smoking during pregnancy, short breast-feeding period).

The effect of SES on disparities in mortality rates has also been documented. For
example, the 2017 Health, United States report showed that infant mortality rates, com-
municable disease mortality rates, and HIV mortality rates among men are closely associ-
ated with educational level (NCHS 2017). A 2011 study found that states with the highest
proportions of residents whose incomes were less than 200 percent of the federal poverty
level had an amenable mortality rate (defined as death “before age 75 from complications of
conditions that might be avoided by timely effective care and prevention”) twice as high as
states with lower poverty rates (Schoenbaum et al. 2011).

Programs to Eliminate Socioeconomic Disparities
Programs to eliminate disparities based on SES in the United States are operated at the
federal, state, and local levels of government as well as by private organizations.

Federal Initiatives
Often referred to as the “healthcare safety net,” federal programs to address SES disparities
have focused on increasing access to care for low-income populations. Federal programs
for specific low-income subpopulations include the Public Housing Primary Care program,
the Health Care for the Homeless program, and Head Start, which helps disadvantaged
preschool-aged children acquire basic math and reading skills. Unlike federal programs that
focus on reducing economic and geographic barriers to healthcare, Head Start is the only
federal program that invests directly in increasing educational level—an often overlooked
contributor to SES disparities in healthcare.

State and Local Initiatives
A notable state program is South Carolina’s Welvista program, a public–private nonprofit
partnership founded in 1991 that offers free or low-cost primary care, free prescription
services, and free pediatric dental care to uninsured low-income people (Welvista 2018).
Services are provided by volunteer health professionals, pharmaceutical companies, hospi-
tals, and laboratories, and a number of corporate and community providers are involved
(Welvista 2018).

A local initiative for the uninsured is TeleKidcare in Kansas City, Kansas, established
through a partnership between the Kansas University Medical Center and a local school

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district consisting of elementary schools as well as middle and high schools (KansasHealth-
Matters 2018). Videoconferencing technology allows providers to conduct physical exams and
provide acute care and mental health services to schoolchildren in need of medical assistance.

Private Initiatives
One example of a privately funded program addressing SES disparities is Interact for Health,
which awards grants to improve health in Cincinnati, Ohio, and surrounding counties
(Interact for Health 2013, 2018).

Another example of addressing SES disparities has to do with employment oppor-
tunities provided by the private sector (Thornton et al. 2015). Employment can positively
affect health through its provision of resources. In addition, because employers typically
provide health insurance, the employed experience better access to health care than the
unemployed do. Research indicates that employment and income gains led to increases in
life expectancy between the mid-1960s and mid-1970s, and these increases were larger for
blacks than for whites and greater for black women than for black men (Kaplan, Ranjit,
and Burgard 2008). Research examining employment interventions for women of low SES
and for people with severe mental illness suggests that employment interventions can be
effective in reducing health disparities in these particularly vulnerable populations (Kneipp,
Kairalla, and Sheely 2013; Luciano, Bond, and Drake 2014).

he a lt h PO l i C y is s u e s f O r vu l n e r a B l e su B P O P u l at i O n s

This final section of this chapter takes a closer look at health policy issues for each of the fol-
lowing vulnerable subpopulations: the elderly, people with chronic illness, people with mental
illness, women and children, people with disabilities, the homeless, and people with HIV/AIDS.

th e el d e r ly

For the elderly, primary care and health policy concerns broadly revolve around the following:

◆ Containing costs of care

◆ Reforming the health delivery system to better serve the growing elderly population

◆ Improving quality of life as far as possible into old age

Cost Containment
Healthcare costs can be daunting for any American. For the elderly in particular, costs are
often prohibitive to seeking care. According to the AARP Public Policy Institute, more than

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25 percent of US adults aged 50–64 (who are not yet eligible for Medicare), as well as nearly
40 percent of older adults covered by a public insurance plan (e.g., Medicare, Medicaid),
spent a significant amount of their disposable income (at least 10 percent) on healthcare
(Smolka, Purvis, and Figueiredo 2009). Costs increased for patients with at least one chronic
disease, and especially for many elderly patients, who have a much higher disease burden
(with two or more diseases). A Medicare patient with a single chronic health condition sees,
on average, four physicians per year (Bodenheimer, Chen, and Bennett 2009). Patients with
five or more chronic conditions see, on average, 14 different physicians per year, and a higher
number of chronic conditions seems to be related to a higher number of providers seen.
After the ACA was implemented, overall US healthcare spending increased further, reaching
$3.3 trillion in 2016, with out-of-pocket healthcare costs incurred directly by consumers
rising by 3.9 percent—the fastest growth rate since 2007 (Johnson 2017).

Any out-of-pocket healthcare costs for typical elderly individuals is significant,
whether covered through public insurance, insured through a private health plan, or paid
out of pocket due to lack of insurance. And healthcare costs for the elderly are on the rise,
mainly due to higher numbers of chronic diseases per patient in an overall aging population
(Bodenheimer, Chen, and Bennett 2009). The number of people aged 85 or older, who
have the most multiple chronic conditions, has been projected to grow from 5 million to
21 million from 2005 to 2050, substantially increasing the number of high-cost patients
(Bodenheimer, Chen, and Bennett 2009). Most efforts to rein in these expenditures will
require major health system reforms.

Quality of Life
According to Bodenheimer, Chen, and Bennett (2009), the most proactive methods to raise
the quality of life for the elderly are to provide effective, low-cost preventive treatments
designed to lower risk for adverse health outcomes throughout the patient’s life. If policies
were implemented earlier in life to reduce behavioral risk factors, such as smoking, the rise
in chronic diseases might slow, and the resulting lower disease prevalence would improve
quality of life (Barile et al. 2015; Bodenheimer, Chen, and Bennett 2009).

The relationship between quality of life and absence of disease may not be absolute.
Even with the increase in chronic diseases, many people younger than age 85 experience
delays in the onset of limitations and disabilities, in part due to early diagnosis, better treat-
ment, and more effective amelioration of prevalent diseases (Christensen et al. 2009). This
finding suggests that a highly functioning health services system is crucial to improving the
quality of life for everyone by its potential to help postpone disability.

Service Availability
The availability of assistive technology, specialized facilities, and customized services may
be adding further distance between disease and disability, as are indirect changes such as

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housing, transportation, structural improvements for people with disabilities, women’s
empowerment, and other social issues (Christensen et al. 2009). Improved funding and
coordination of government and private programs to address these issues would simplify
the process of obtaining necessary care and improving health outcomes for many elderly
patients (Reinhard, Kassner, and Houser 2011).

The ACA and the Elderly
Many experts believe that the current system of healthcare administration in the United
States is less than optimal. Issues such as high costs, insufficient focus on prevention, recur-
ring medical mistakes, and a sense of discord among stakeholders are pervasive, especially for
the elderly. The ACA attempts to address several of these challenges. One study found that
changes in how healthcare providers are paid through Medicare and Medicaid create more
incentives to focus on preventive care and coordinate care across providers and facilities while
also reducing growth in healthcare spending and providing better value for public payers
(Thorpe and Ogden 2010). Reducing hospital readmissions, improving the monitoring of
controllable chronic diseases (such as diabetes and hypertension), and helping community
health teams coordinate care among physicians and organizations will improve the healthcare
delivery system. These modifications are expected to simplify the system, making it more
patient centered and better able to serve the changing needs of US patients, particularly the
elderly (Bodenheimer, Chen, and Bennett 2009; Thorpe and Ogden 2010).

As the US population ages, it faces unique
issues, especially in healthcare cost, treatment coor-
dination, and quality of life, concerns which may
move to the forefront of the health policy agenda.
Injury prevention is a key area of healthcare gaining
increased attention (see the For Your Consideration
box titled “Injury Prevention and Control”).

Pe O P l e w i t h Ch r O n i C il l n e s s

Chronic diseases are the leading cause of death,
disability, and healthcare costs in the United States.
According to the CDC, half of all adults have a
chronic disease, 70 percent of deaths are associ-
ated with chronic diseases, and the majority of
healthcare costs are due to treating chronic diseases
(Dietz, Douglas, and Brownson 2016).

FOR YOUR CONSIDERATION
Injury Prevention and Control

Among the various events that can cause injuries are incidents such
as car crashes, fires, falls, drownings, poisonings, and assaults. The
growing recognition of the costs of injuries to a person and to soci-
ety and of their predictability and preventability helped promote
the development of programs for injury prevention and control
in local and international health organizations. For example, The
Joint Commission (2015) issued a Sentinel Event Alert on preventing
falls and fall-related injuries in healthcare facilities—injuries that
can be particularly dangerous for the elderly—and offered an array
of suggestions and tools to address this issue across healthcare
settings (Joint Commission 2015).

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Chronic conditions are on the rise worldwide. In the United States, the primary
care system needs to be overhauled to accommodate the dramatic rise of chronic disease
patients, requiring innovation to provide high-quality care and meet their needs (Kimura,
DaSilva, and Marshall 2008). Patients with chronic illness in the United States experience
less organized care at a higher cost (Schoen et al. 2009; Thorpe and Philyaw 2012). Every
year, 86 percent of healthcare costs go toward care for chronic illness and mental health
disorders (Schoen et al. 2009; Thorpe and Philyaw 2012).

Uninsured patients who have chronic conditions face a double burden. According to
a 2008 study of the National Health and Nutrition Examination Survey, conducted by the
CDC National Center for Health Statistics (Wilper et al. 2008), 11.4 million Americans aged
18–65 were living with at least one chronic health condition. According to the study (Wilper et
al. 2008), the uninsured faced barriers to care and were more likely not to have visited a health
professional (22.6 percent of uninsured vs. 6.2 percent of insured) and not to have a standard
care site (26.1 percent vs. 6.2 percent), but if they did
have a standard care site, it was more likely to be an
ED (7.1 percent vs. 1.1 percent). Failing to receive
appropriate, timely primary care can lead to worse
health outcomes, which can be especially serious in
patients already suffering from a chronic condition.

Addressing the Burden of Chronic
Disease
The burden of chronic illness is borne both by patients,
who experience frustration, high costs, and poor health
outcomes, and by the healthcare system, which often
cannot provide appropriate, effective, and efficient
care. Policy changes with a focus on chronic illness can
significantly ease that burden. Programs that test vari-
ous approaches to chronic care have been introduced
in the United States, but none has been accepted on
the scale required for major change (Shortell et al.
2009). National policies addressing chronic diseases
should take these attempts into account to control cost
and improve care for the chronically ill (see the For
Your Consideration box titled “CDC and Chronic
Disease Programs” and the Learning Point box titled
“Combating Chronic Diseases”).

FOR YOUR CONSIDERATION
CDC and Chronic Disease Programs

In response to the health and financial burden of chronic diseases,
the CDC leads national efforts to prevent and control chronic dis-
eases and their risk factors (e.g., tobacco use, poor nutrition, lack of
physical activity, excessive alcohol use) through its National Center
for Chronic Disease Prevention and Health Promotion (NCCDPHP).
Specifically, NCCDPHP focuses on the following (CDC 2018a):

• Tracking chronic diseases and their risk factors through
surveys and research

• Improving environmental strategies to make healthy
options easier for people to choose

• Strengthening healthcare systems to deliver prevention
services that keep people well and diagnose diseases early

• Connecting clinical services to community programs that
help people prevent and manage their chronic diseases

NCCDPHP supports various programs at the national, state, and
community levels in the areas of cancer, diabetes, heart disease
and stroke, smoking and tobacco use, and chronic diseases, as
well as community health, nutrition and physical activity, oral
health, population health, and reproductive health (CDC 2018a).

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LEARNING POINT
Combating Chronic Diseases

Cancer
National Breast and Cervical Cancer Early Detection Program (NBCCEDP): Breast cancer is
the most common cancer among women, and cervical cancer is the leading cause of cancer
mortality among women in the United States. Breast cancer screening with a mammogram
and cervical cancer screening with a Pap test reduce mortality rates from these cancers (CDC
2014). NBCCEDP has provided timely breast and cervical cancer screening and diagnostic
services to low-income, uninsured, and underserved women in more than 11,000 primary
care clinics since the early 1990s (DeGroff et al. 2016).

Evidence suggests that NBCCEDP screening for breast cancer has lowered breast cancer
mortality among uninsured and underinsured low-income women. However, another study
reveals that the US-affiliated Pacific islands face significant barriers to implementing NBCCEDP
screening for cervical cancer (Hoerger et al. 2011; Senkomago et al. 2017).

Colorectal Cancer Control Program (CRCCP): In 2015, the CDC provided $23 million in funding
to the American Cancer Society, universities, state primary care associations, local health
departments, and selected nonprofit organizations to implement the CRCCP over a five-year
period. CRCCP grantees partner with health systems and clinics to implement four main
evidence-based interventions—patient reminders, provider reminders, provider assessment
and feedback, and reducing structural barriers—and other supporting activities (including
media, community health workers, patient navigation, and provider education) to increase
rates of screening for colorectal cancer (CDC 2018b).

Tangka and colleagues (2017) analyzed the extent to which the CRCCP program model
resulted in funding going toward implementation of the interventions recommended by
the Guide to Community Preventive Services. Their findings revealed that all 29 CRCCP grant-
ees carried out media activities, and more than 90 percent used client reminders, provider
assessment feedback, or patient navigation. However, grantees spent one-third of their total
budget on broad-based recommendations instead of targeted education on evidence-based
strategies by the Community Guide (Tangka et al. 2017).

Diabetes
National Diabetes Prevention Program (DPP): Established by the CDC, the DDP is a partnership
that brings public and private sectors together to offer evidence-based, affordable interven-
tions in communities to prevent type 2 diabetes. Some of the primary partners include federal
agencies, state and local health departments, community organizations, public and private
insurers, healthcare professionals, employers, and businesses that focus on wellness. The
overarching goal of the DPP is to enable partner organizations to build a workforce that can
effectively deliver and implement CDC-recommended programs for lifestyle change through

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LEARNING POINT
Combating Chronic Diseases (continued)

organizations nationwide, as well as to increase referrals to and participation in the program
(CDC 2018e).

Heart Disease and Stroke
Paul Coverdell National Acute Stroke Program: This program was established by the CDC in
2001 to build a high-quality system of care to improve care for patients who have experienced
a stroke and to save lives. The stroke system of care aims to improve care and support for
patients throughout their journey of care—from the first symptoms of stroke, emergency
medical services (EMS), hospital care, and rehabilitation to follow-up with outpatient provid-
ers to prevent stroke complications and recurrences. Together, EMS agencies, hospitals, and
healthcare organizations collect and analyze data about stroke patients and care, and they
share best practices to improve patient care. Through the Coverdell Program, the CDC funds
nine state health departments that partner with many hospitals, EMS agencies, healthcare
facilities, and community services (CDC 2018f ).

Hospitals have been recruited by states since 2007 to join the Paul Coverdell National
Acute Stroke Registry Program. By 2012, more than 213,500 patients had been treated and
benefited from improved quality of care in more than 300 participating hospitals across the
United States (CDC 2015a).

Sodium Reduction in Communities Program (SRCP): Strong scientific evidence has proved the
health benefits of reducing dietary sodium intake. SRCP is a national program administered
by the CDC’s Division for Heart Disease and Stroke Prevention. Grantees in SRCP across the
United States partner with local organizations that serve or sell food, such as schools and
work sites, to implement strategies for reducing sodium intake as recommended by the Dietary
Guidelines for Americans. The CDC funds eight communities to collaborate with food industry
partners to make lower-sodium foods more available and accessible, and the CDC monitors
and measures their effectiveness (CDC 2018g).

In addition, SRCP has developed several evidence-based toolkits such as Partnering with
Food Service to Reduce Sodium: A Toolkit for Public Health Practitioners to reduce sodium
intake and maximize program impact. Also, award recipients of SRCP, such as the Los Angeles
County Department of Public Health and the Philadelphia Department of Health, work at the
community level toward meeting SRCP’s short-term goal of facilitating environmental changes
that make lower-sodium foods more available and accessible as well as its long-term goal
of bringing sodium intake levels down to recommended limits (Mugavero et al. 2012; Welsh
et al. 2014). Although the CDC has published the official Sodium Reduction in Communities
Program Outcome Evaluation Toolkit, researchers need to conduct more evaluation studies
to assess the outcome and impact of SRCP programs (CDC 2018g).

( c o n t i n u e d )

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LEARNING POINT
Combating Chronic Diseases (continued)

Community Health Programs
National Implementation and Dissemination for Chronic Disease Prevention: This national
program supports three community capacity-building awardees (American Heart Association,
American Planning Association, and National WIC Association), and two dissemination and
training awardees (Association of State and Territorial Directors of Health Promotion and
Public Health Education, and Society for Public Health Education). Both types of awardees
develop strategies and technical assistance to maximize their collective impact, raise local
and national awareness of community health workers, and ensure that the communities they
serve can increase their capacity and achieve sustainable improvements even after funding
for the program ends (CDC 2017c).

Racial and Ethnic Approaches to Community Health (REACH): To reduce racial and ethnic
health disparities in the United States, the CDC initiated REACH as a national program that
funds state and local health departments, universities, community-based organizations, and
American Indian tribes. The awardees use these funds to plan and implement local, cultur-
ally appropriate programs to resolve health issues among such federally classified racial and
ethnic groups as African Americans, American Indians, Hispanics/Latinos, Asian Americans,
Alaska Natives, and Pacific Islanders. Beyond providing funding, the CDC also offers technical
support from experts to the REACH awardees (CDC 2017e).

The REACH program has successfully established community ownership. As a result, various
REACH grantees across the United States have initiated local community health programs to
address the needs and expectations of their local communities. For example, the Community
Asthma Initiative is a program that addresses asthma disparity at Boston Children’s Hospital,
which reduced hospitalization rates for children by 80 percent, and yielded $1.73 of return on
investment per dollar spent a year after the program began. The Medical University of South
Carolina launched a Community Diabetes Education Program, which reduced the frequency of
amputation and yielded cost savings. The University of Alabama at Birmingham has trained 170
community health advisers to advocate for mammography screening and reached more than
3,000 women, which ultimately reduced the mammography screening disparity significantly,
from 18 percent to 3 percent (CDC 2015b).

Tips from Former Smokers: In 2012, the CDC launched the first paid national campaign for
tobacco education—Tips from Former Smokers, known more commonly by the shorthand
Tips. The Tips campaign profiles real people living with serious health effects from smoking
and secondhand smoke exposure. It features compelling stories of former smokers living
with smoking-related diseases and disabilities as well as nonsmokers who suffered from
exposure to secondhand smoke. With a focus on health issues caused by or associated with
smoking and exposure to secondhand smoke, the primary goal of the Tips campaign has

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Some chronic diseases cause chronic pain, which in some cases may be treated with
medications containing opioids. However, overdependence on such narcotics can create
further problems for patients who become addicted to them (see the Critical Concept box
titled “The Opioid Crisis”).

Pe O P l e w i t h me n ta l il l n e s s

Mental health has become an increasingly important public health issue in the United States.
Based on the Diagnostic and Statistical Manual of Mental Health Disorders, Fourth Edition
(DSM-IV) classification system, half of Americans are estimated to be affected by a mental
disorder in their lifetime, and a quarter of Americans are affected in any given year (Kessler
and Wang 2008). In 2005, 27 percent of those younger than age 65 with Medicare cover-
age were considered mentally disabled (Goldman, Glied, and Alegria 2008). Mental health
disability is rising, and in 2018, about one in five US adults was living with some degree
of mental illness (MHA 2018).

These statistics reveal serious health concerns. Poor mental health is associated with
increased risk for early mortality, and many mental disorders exhibit an early-age onset
that leads to a lifetime of healthcare needs (Goldman, Glied, and Alegria 2008; Kessler et
al. 2008). However, in the early twenty-first century, only 41.1 percent of Americans with
a DSM-IV-recognized mental disorder were treated for that disorder (Wang, Lane, and
Olfson 2005).

In fact, mental health care in the United States has traditionally suffered from mar-
ginalization. Only recently has the focus on mental health shifted from specialized, inpatient

marginalization
A process in which a
person or an idea is
pushed aside in favor of
another. A marginalized
subject typically receives
few resources and little
attention.

LEARNING POINT
Combating Chronic Diseases (continued)

been to raise public awareness of the health damage caused by smoking and exposure to
secondhand smoke (CDC 2018h).

Tips has demonstrated significant impact. As of 2017, an estimated 1.83 million smokers
had tried to quit smoking, and 104,000 smokers had actually quit smoking. Nonsmokers
reported having conversations with family or friends about the harm of smoking and showed
an increased knowledge of smoking-related diseases. Smokers who had watched Tips ads
showed a greater intention to quit smoking within the next 30 days or next six months, and there
was a close relationship between exposure to the ads and intention to quit. More important,
since the launch of the Tips campaign, the call volume of national “quitlines” dramatically
increased, registering 92.7 percent higher than the two-week baseline period (CDC 2018h).

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treatment options to treatment integrated into the broader healthcare system; a 2012 study
found that most mental health patients are identified in the primary care system, and because
primary care physicians often report difficulties in obtaining mental health care referrals for
their patients, mental health care provided in a primary care setting could improve health
outcomes (Kessler 2012). Consistent with this finding, a recent study on veterans’ health
found that the US Department of Veterans Affairs (VA) Primary Care–Mental Health
Integration services increased accessibility to mental health care for primary care VA clinic
patients as used in place of non-primary-care-based mental health specialty visits—without
increasing acute care use or costs (Leung et al. 2018).

In the course of this shift toward integration into primary care, general practitioners
have become far more involved in mental health care than in the past. By the early twenty-
first century, 22.8 percent of mental health patients were being treated solely by a general
health medical professional, higher than the percentage seen by any type of specialist (Wang,
Lane, and Olfson 2005).

This trend, while indicative of better integration of mental health services with general
medicine, may also reflect a shortage of specialized mental health professionals. A survey of general

CRITICAL CONCEPT
The Opioid Crisis

Among the greatest drug-related concerns for Americans today is the opioid crisis. Every day,
more than 115 Americans die from an overdose of some form of opioid, including prescription
pain relievers, heroin, and synthetic opioids (CDC 2018i). According to the CDC, prescription
opioid misuse causes the United States an economic loss of $78.5 billion per year, including
the actual costs of healthcare, addiction treatment, enforcement of criminal justice, and the
opportunity cost of lost productivity (Florence et al. 2016).

In response, several cities, counties, and states have filed lawsuits against pharmaceutical
companies over the opioid crisis (Noguchi 2017). Many observers argue that the pharmaceuti-
cal industry started and perpetuated the opioid crisis by encouraging the overprescription of
pain pills by doctors, leading to higher rates of overuse, abuse, and addiction. An investigation
by the Washington Post and 60 Minutes found that the Ensuring Patient Access and Effective
Drug Enforcement Act of 2016 removed the authority of the US Drug Enforcement Administra-
tion (DEA) to block suspicious narcotic shipments from drug distribution companies, thereby
worsening the problem of easy access to drugs (Higham and Bernstein 2017). The investigation
also reported that political action committees contributed at least $1.5 million on behalf of
the pharmaceutical industry to the 23 lawmakers who sponsored or cosponsored the four
versions of the bill (Higham and Bernstein 2017). The DEA and government officials argue,
however, that the DEA has effective methods to curb inappropriate narcotic transactions.

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practitioners found that 66.8 percent had difficulty obtaining a referral for their patients to any
mental health specialist (Cunningham 2009), and another analysis detected unmet patient need
for mental health professionals in 96 percent of all counties in the United States (Thomas et al.
2009). Evidence also indicates that the mental health services rendered by general practitioners
are of lower quality than those provided by mental health professionals, with only 12.7 percent
of general practitioner visits resulting in “treatments that exceeded a minimum threshold of
adequacy,” compared with 48.3 percent of visits to specialists (Wang, Lane, and Olfson 2005).

This need for increased numbers of mental health professionals may be exacerbated
by a major legislative development in mental health care: the passage of federal and state
mental health parity laws. On a national level, the Paul Wellstone and Pete Domenici
Mental Health Parity and Addiction Equity Act of 2008 requires equal coverage in group
health insurance plans for mental health and physical health benefits (Cunningham 2009).
Several states followed with their own similar policies. Despite these policies, disparities in
care between mental and physical health continue, as do disparities between Americans with
mental health disorders and those without.

The ACA was expected to expand coverage and thus diminish barriers to adequate
mental health care. However, the issues mentioned, if left unexamined and unaddressed,
will continue to prevent progress in mental health care delivery in the United States (Bartels,
Gill, and Naslund 2015).

wO m e n a n d Ch i l d r e n

According to the US Census Bureau (2018), in 2017, 50.8 percent of the US population
was female, and nearly 23 percent of the population was aged 17 or younger. Both women
and children face unique health issues that deserve policy attention, and maternity and
childbirth present yet another set of concerns.

Women
Women’s health is an emerging field centered on health issues and concerns that dispropor-
tionately affect women. For instance, women tend to live longer, yet also report more physi-
cally and mentally unhealthy days each month, and have higher rates of chronic conditions
in old age than men (MCHB, HRSA, and HHS 2013; Strobino, Grason, and Minkovitz
2002). Women—especially those who are poor—are less likely to meet minimum physical
activity recommendations than men are. Women are also more likely than men to be obese
and report more activity limitations (MCHB, HRSA, and HHS 2013; Strobino, Grason,
and Minkovitz 2002).

In 2009, 36.6 percent of female-headed households were classified as food-insecure,
and 15 percent of all women experienced food insecurity—placing them at increased risk

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for health problems caused by poor nutrition (MCHB, HRSA, and HHS 2013; Strobino,
Grason, and Minkovitz 2002). Of those adults who receive aid through the Supplemental
Nutrition Assistance Program (SNAP), 64.4 percent were women (MCHB, HRSA, and
HHS 2013; Strobino, Grason, and Minkovitz 2002).

These factors, combined with disparities perpetuated by the limitations of women’s
traditional roles as caregivers and by economic inequality, call for increased attention to
women’s health issues.

Children
The health issues faced by children are continuing to rise. For example, chronic conditions
in children have increased dramatically in the twenty-first century; in 2007, more than 7
percent of children had a chronic condition that limited their function to perform basic
daily activities, as compared with 1.8 percent in 1960 (Perrin, Bloom, and Gortmaker
2007). High-prevalence chronic conditions among children now include obesity (affect-
ing 18 percent of children and adolescents aged 18–25, as compared with 5 percent in the
early 1970s), asthma (9 percent of children and adolescents, double the percentage for the
1980s), and attention deficit hyperactivity disorder (ADHD, affecting 6 percent of school-
age children), and poverty is associated with an increased risk for many chronic conditions
(Perrin, Bloom, and Gortmaker 2007; Wijlaars, Gilbert, and Hardelid 2016). Particularly,
conditions such as asthma and ADHD have increased at a disproportionately higher rate
among children living in poverty (American Academy of Pediatrics 2016).

As children become greater consumers of medical care, the quality of care they receive
increases in importance. A medical record analysis conducted by Mangione-Smith, DeCris-
tofaro, and Setodji (2007) shows that, on average, children seeking medical care received
only 46.5 percent of the services recommended or prescribed by a healthcare provider—a
reminder that merely expanding access to health services, a primary policy focus for many
years, does “not deliver necessary services [and] will not result in optimal outcomes.”

Maternity and Childbirth
Pregnancy and childbirth can lead to both temporary and permanent health conditions,
including maternal mortality (Misra and Grason 2006). Receiving proper prenatal care is
essential for good neonatal health in the United States, but preventive care must be obtained
early and continued throughout pregnancy. For example, folate, a substance that helps
prevent adverse fetal outcomes such as spina bifida, must be present in adequate levels early
on in pregnancy. Thus, women must be able to obtain adequate levels of this nutrient even
before conception (Misra and Grason 2006). Considering that 42 percent of the births in
the United States in 2008 were reported as unintended, ensuring this level of preventive
care is difficult (MCHB, HRSA, and HHS 2010).

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Women from racial or ethnic minorities receive prenatal care at lower rates than
non-Hispanic white women do (MCHB, HRSA, and HHS 2010). In 2015, 6 percent of
pregnant women in the United States received late or no prenatal care (Kids Count Data
Center 2018). Pregnant women who received inadequate prenatal care, and lacked educa-
tion related to the purpose of such care, experienced an increased risk of providing poor
nutrition to their unborn baby. In turn, this practice may increase the risk of the child being
diagnosed with obesity, asthma, or ADHD. Maternal cigarette smoking during pregnancy
is among the most-documented risks for asthma, obesity, and ADHD in children. Alcohol
use during pregnancy introduces serious risks as well (Perrin, Bloom, and Gortmaker 2007).

Although considerable progress has been made in improving prenatal care, and thus
the health of women and children, these gains have not been evenly distributed. Health
disparities between women and children of different ethnic, racial, and socioeconomic groups
still exist, and primary care for these groups has great potential for additional improvement.

Pe O P l e w i t h di s a B i l i t i e s

As the US population ages, more people will experience disabilities and need specialized
care. The groundbreaking 1991 Institute of Medicine (IOM) report Disability in America
and the follow-up 1997 IOM report Enabling America highlighted disability as a topic of
public health action and scientific inquiry (IOM 1991, 1997). IOM predicted substantial
growth in the disabled elderly population between 1997 and 2027 (IOM 1997). At the
same time, the number of children and young adults facing disability is rising as survival
odds increase for once-fatal birth and childhood conditions and as chronic conditions in
the young become more common (Iezzoni 2011; Wijlaars, Gilbert, and Hardelid 2016).

Combined, these trends have led to significant, increasing levels of disability in the
United States. The World Health Organization estimated that the United States lost 41.372
million disability-adjusted life years (DALYs) in 2004 (McKenna et al. 2005). The DALY
measure has been used since the mid-1990s to capture the true health burden caused by
disability, combining measures of both the years of life lost to disabling conditions and the
quality of life lost over the years spent living with a disability (McKenna et al. 2005). DALYs
measure the number of life years lost to disability only for people living with disability, yet the
effects of disability are also felt by those who care for the disabled and by society as a whole.

In addition to the underlying issues of poor socioeconomic, educational, income,
and employment outcomes, people with disabilities in the United States encounter a health
system characterized by discrimination and barriers to accessing care. Although many years
have passed since the Americans with Disabilities Act went into effect in 1990, “inaccessible
facilities, equipment, and communication systems still compromise healthcare experiences
for individuals with disabilities in the United States. . . . The barriers that disabled patients
confront represent quality problems and also heighten patients’ sense of stigmatization,
disenfranchisement, and demoralization” (Kirschner, Breslin, and Iezzoni 2007).

disability-adjusted life
years (DALYs)
A measure of the loss
of healthy life. The
DALY measurement is
intended to capture
the economic, social,
and functional realities
that a person with a
disability faces and the
corresponding loss in
health status and quality
of life.

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Although more large-scale research needs to be conducted in this area, studies that
have been done so far suggest that far lower rates of preventive care are provided to people
with disabilities. According to Iezzoni (2011), only half of women with a severe disability
had received a recommended mammogram or Pap test, compared with almost three-quarters
of women without any disability who had received a mammogram and more than 80 per-
cent of women without any disability who had received a Pap test. Approximately half of
Americans with disabilities are eligible for governmental assistance, such as Medicaid or
Medicare, and many more have private coverage. State and federal government spending
on individuals with disabilities totaled more than $400 billion in 2008, and patients with
disabilities accounted, on average, for almost three times more healthcare expenditures each
year than for patients without disabilities (Kirschner, Breslin, and Iezzoni 2007; Livermore,
Stapleton, and O’Toole 2011). These expenditures were predicted to only rise, especially after
the ACA expanded Medicaid to cover a greater number of Americans with disabilities and
prohibited refusal of insurance due to preexisting health conditions in the private market.

th e hO m e l e s s

Homeless people in the United States are among the most marginalized groups in society;
however, their health needs are not marginal. A study published in the first decade of the
twenty-first century revealed that up to 3.5 million people each year experience homeless-
ness in the United States, and 700,000 people are classified as homeless on any given night;
furthermore, 7 percent of US residents will experience homelessness at least once in their lives
(Reid, Vittinghoff, and Kushel 2008). Additionally, many more Americans will face housing
instability, a precarious position that, while less drastic than homelessness, predisposes them to
several risk factors that can lead to worse health outcomes (Reid, Vittinghoff, and Kushel 2008).

Homeless and housing-unstable people are subject to much higher resource com-
petition than most of the general population, and health issues that others would consider
absolutely critical may be sidelined by the homeless in favor of more basic needs such as food
and shelter (Kidder et al. 2007). As a result of reduced healthcare, the homeless experience
significantly higher rates of morbidity and mortality, greatly reduced access to healthcare
(especially preventive services), and, therefore, much higher rates of hospitalization and
self-reported poor health than the broader population does (Baggett et al. 2010; Kidder et
al. 2007; White et al. 2018).

Several studies have attempted to identify factors that increase ambulatory and pre-
ventive care utilization among the homeless. First and foremost, housing situations with
greater stability have been shown to increase the amount of healthcare received, especially
ambulatory care (Kushel, Vittinghoff, and Haas 2001). The Housing First program was
developed in response to these findings, and it realized positive results in reducing ED
visits and hospitalizations among the chronically homeless population in several cities,
by providing necessary, no-strings-attached housing (Kertesz and Weiner 2009). A recent

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study revealed that becoming housed is a key facilitator of reduced ED utilization and that
efforts to provide housing for homeless adults may also greatly decrease ED use (Moore
and Rosenheck 2017).

Another factor, the lack of insurance among the homeless population, was analyzed by
Reid, Vittinghoff, and Kushel (2008), who suggested that health outcomes would improve
with better insurance options or with options to receive regular care. An earlier study found
that health services utilization by the homeless did not increase greatly with either housing
stability or insurance coverage alone and, instead, was associated with better community
ties and social support. Increased community support was, in turn, correlated with housing
stability (Stein et al. 2000).

Overall, homelessness in the United States is a complex and poorly understood
issue. Yet ignoring the health problems faced by homeless or housing-insecure people will
only exacerbate an already difficult societal situation. Many innovative and comprehensive
approaches to improving the health outcomes of the homeless are being developed. The
Boston Health Care for the Homeless program, a leading outreach program, works to
integrate care across the medical spectrum and to create housing situations that provide
continuous services and preventive care (O’Connell et al. 2009). The Homeless Outreach and
Proactive Engagement initiative launched in the San Fernando Valley around Los Angeles in
2016 (Walton 2016). The program connects Los Angeles Police Department officers with
the city’s Sanitation Department, mayor’s office, city attorney’s office, and the Los Angeles
Homeless Services Authority to identify encampments for homeless people and help them
transition into permanent housing.

Pe O P l e w i t h hiv/aids

In the relatively short time since the disease was recognized, AIDS has dramatically changed
the lives of millions of people, their communities, and the US healthcare system (see the
Learning Point box titled “HIV/AIDS in the United States”). Although there have been
marked improvements in the prevention and care of HIV and AIDS, more than 35,000 people
contract the virus each year (CDC 2018c). At the end of 2015, about 1.1 million people in
the United States were living with a diagnosed HIV infection (CDC 2018c). A major factor
in the continued high number of transmissions is that 14 to 15 percent of the people infected
with HIV do not know that they are HIV-positive (CDC 2018c; KFF 2018b).

Impact on HIV/AIDS Subpopulations
Current health disparities in the United States are also reflected in the trends in AIDS infec-
tion. Men who have sex with other men (a category referred to as MSM) constitute only 2
percent of the US population yet accounted for 68 percent of new HIV infections in 2015
(KFF 2018b). Although the proportion of women who are HIV-positive or have AIDS is

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I n t r o d u c t i o n t o H e a l t h P o l i c y1 8 2

significantly lower than that of men, the disease has
become more prevalent in the female population
over time, and research shows that more barriers
to care exist for women than for men (KFF 2014).
Minorities also carry a disproportionate share of
that health burden; African Americans accounted
for 43 percent of HIV diagnoses although they
comprise only 12 percent of the US population
(KFF 2018a). The HIV diagnosis rate for African
Americans in 2016 was double the rate for Lati-
nos and eight times higher than for whites (KFF
2018a).

As with other health conditions and dis-
eases, socioeconomic factors also influence the rate
of HIV acquisition. Lower SES is associated with
higher AIDS mortality, and infection prevalence is
higher among Americans with less education, lower
incomes, and higher unemployment rates (KFF
2018a; Rubin, Colen, and Link 2010). Even as the

demographic profiles of HIV-infected residents have evolved, those living with AIDS still
face discrimination, reduced access to care, and other disparities that greatly affect health
outcomes.

Implications of Advances in Treatment
People infected with HIV/AIDS fare better today than they did at the beginning of the
twenty-first century, thanks to the discovery and widespread use of new treatment options,
particularly antiretroviral drugs used in combinations of multiple drug classes. These thera-
pies are only effective, however, if administered early and continuously over the course of
the infection. For those patients who have access to expert medical care and powerful drug
“cocktails,” these advances “have transformed HIV/AIDS from a terminal illness to a chronic
disease,” whereas those with limited means may still face a bleak outcome (Lubinski et al.
2009). The barriers that inhibit HIV-positive people from accessing lifesaving medications
are significant; the most important among them is the lifetime health costs associated with
the diagnosis. In 2006, the total costs of treating HIV and AIDS per person were estimated
to be more than $385,000, of which 73 percent was spent on antiretroviral medications
(Schackman et al. 2006). The estimate of lifetime HIV treatment costs was $379,668
(Schackman et al. 2006).

Assuming that an individual has access to these treatments, by 2006, the average
patient’s life expectancy increased to 24.2 years following diagnosis with HIV or AIDS

LEARNING POINT
HIV/AIDS in the United States

HIV is the abbreviation for human immunodeficiency virus; the
term AIDS is derived from acquired immune deficiency syndrome.
HIV is a retrovirus that infects the human body and, over time,
destroys the immune system, leading to AIDS. A person who has
AIDS is typically in the final stages of HIV, after the immune system
becomes unable to defend itself. HIV is transmitted by having sex
without a condom; by sharing syringes, needles, or drug works; and
through pregnancy, childbearing, or breast-feeding.

The CDC identified the first AIDS cases in the United States in
1981. Since then, 1.7 million US residents have become infected
with HIV, and more than 700,000 have died from AIDS, leaving
more than 1.1 million people in the United States living with HIV/
AIDS today (CDC 2018c, 2018d; KFF 2018b).

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(as compared with the average expected 6.8 years in 1998), but this greatly expanded life
expectancy accounts for much of the rise in treatment costs (Schackman et al. 2006). As
discussed next, the federal government pays a substantial portion of these expenses.

Funding
In fiscal year 2017, the US government spent $19.6 billion on HIV-related care and treat-
ment (KFF 2017b). In 2014, Medicare covered about 120,000 people infected with HIV,
nearly triple the 42,520 covered in 1997 (KFF 2016b). Medicaid covered 242,000 patients
in 2011, a 14 percent increase compared with 212,900 in 2007 (KFF 2016a). The federal
government spent nearly $5.8 billion in 2017 for Medicaid HIV activities (KFF 2017b),
an amount which is supplemented by state funding. Medicare is the largest federal funder
of HIV care and treatment in the United States, followed by Medicaid (KFF 2017b).

Additional funding is provided by the Ryan White HIV/AIDS Program, a federal
initiative named after a 13-year-old hemophiliac boy who was diagnosed with AIDS after
a blood transfusion in 1984. White gained national fame when he fought for the right to
return to school, having been barred from attending because of AIDS (HRSA 2016). The
program aims to assist HIV patients who lack sufficient means to obtain treatment by
disbursing discretionary funds provided by the US Congress to states, cities, not-for-profit
organizations, and healthcare providers. By 2016, this program had become the third-largest
source of federal funding for HIV care in the United States, providing about $2.3 billion
that year (KFF 2017a, 2017b).

President Trump’s budget request for fiscal year 2018 called for decreased funding
of HIV/AIDS programs (KFF 2017b).

Policy Initiatives
Two major initiatives in US healthcare policy prior to 2017 showed the potential to lead to
improved health outcomes for people with HIV/AIDS. First, President Barack Obama’s 2010
National AIDS Strategy for the United States, hailed as “the most comprehensive federal
response to the domestic HIV epidemic to date,” set three targeted goals for the country to
achieve over the next ten years: (1) reduce new HIV infections, (2) increase access to care and
improve outcomes, and (3) reduce health disparities for HIV/AIDS (Yehia and Frank 2011).

In 2015, an updated National HIV/AIDS Strategy was released, still with a view
toward 2020, which added a fourth goal—to achieve a more coordinated national response
to the HIV epidemic (HIV.gov 2017; White House 2015).

Second, accompanying this greater focus on HIV health issues were mandates set
forth in the ACA. The ACA raised the income level for Medicaid eligibility and outlawed
the denial of coverage due to preexisting health conditions, both of which helped HIV/
AIDS patients continue to receive lifesaving healthcare (Dawson and Cates 2017).

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Under President Trump, the federal government’s willingness to address health dis-
parities for people with HIV/AIDS has appeared uncertain. In addition to his request for
reduced funding of HIV/AIDS programs (KFF 2017b), there were indications that Trump’s
desired changes in federal healthcare programs overall could result in a reduction of coverage
through Medicaid and elimination of ACA protections for individuals with preexisting
health conditions (Dawson and Cates 2017; Kessler and Kelly 2018; Luhby 2018), both of
which would have negative repercussions for people with HIV/AIDS.

➤ Vulnerable subpopulations, such as racial and ethnic minorities, the uninsured, and
those with low SES, typically experience a convergence of multiple health risk factors and,
consequently, exhibit poorer health status than do other subpopulations.

➤ For the elderly, concerns about primary care and health policy broadly revolve around
containing costs of care, reforming the health system to better serve a growing elderly
population, and increasing their quality of life.

➤ The US primary care system will need to be fundamentally overhauled to accommodate
the increase in the number of patients with chronic diseases, requiring new ideas on
how best to provide high-quality care and meet the needs of this growing population.

➤ Although half of all Americans are affected by at least one mental disorder in their
lifetime, mental health care in the United States has traditionally been marginalized.

Ca s e st u d y 1

Based on your own research on health centers, answer the following questions:

1. How would you describe the efficacy of health centers? What are their roles in improving
access to care, quality of care, and health outcomes for vulnerable populations?

2. How can health centers cope with the challenges they face?

Ca s e st u d y 2

Based on your own research on chronic illness, answer the following questions:

1. What are some innovative models of care delivery that target people living with chronic
illnesses? How do these models differ from the status quo?

k e y P O i n t s

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

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2. The care team approach is often used to provide community-based primary care,
particularly to people with chronic illnesses. What is the composition of the team? Why
are these individuals essential members of the team?

3. How can low-cost technology be used in community-based primary care for people
with chronic illnesses? Provide illustrative examples.

1. Why should health policy focus on vulnerable populations?
2. What health policy issues do racial and ethnic minorities face? Cite examples of

programs to eliminate racial and ethnic disparities in healthcare.
3. What health policy issues do uninsured US residents face? Cite examples of programs

to eliminate insurance disparities.
4. What is socioeconomic status (SES)?
5. What health policy issues do people with low SES face? Cite examples of programs to

eliminate SES disparities.
6. List the health policy issues for each of the following subpopulations:

a. The elderly
b. People with chronic illness
c. People with mental illness
d. Women and children
e. People with disabilities
f. The homeless
g. People with HIV/AIDS

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

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———. 2017c. “National Implementation and Dissemination for Chronic Disease Prevention: Award-
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———. 2017d. “National Survey of Children’s Health.” Updated September 6. www.cdc.gov/nchs/
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2 0 2

L e a r n i n g O b j e c t i v e s

Letting a hundred flowers blossom and a hundred schools of thought contend is

the policy for promoting the progress of the arts and the sciences and a flourishing

culture in our land.

—Mao Zedong

Protecting Health, Saving Lives—Millions at a Time.

—Johns Hopkins Bloomberg School of Public Health

C H A P T E R 7

I N T E R N AT I O N A L H E A LT H
P O L I C Y I S S U E S

After completing this chapter, you should be able to

➤ describe the critical health policy issues in developed countries,

➤ discuss the critical health policy issues in developing countries,

➤ understand how various countries address their health challenges,

➤ appreciate the common and unique health challenges in an international context, and

➤ explore emerging and intensifying global health issues.

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Cl i m at e Ch a n g e a n d Pu B l i C he a lt h

The natural environment has a profound impact on human health, as reflected in the United
Nations (UN) Framework Convention on Climate Change (Singh et al. 2011). Climate scientists
predict that the world will warm 4°C by 2100, yet the relationship between rising global tem-
peratures and human health is not fully understood. Severe weather events, such as heat waves,
earthquakes, floods, hurricanes, and cyclones, pose direct threats to human life and health.
Some argue that changing weather patterns have already indirectly affected food yields, water
flows, patterns of infectious disease (e.g., the increasing reach of tropical diseases beyond the
typical geographic areas of occurrence, changes in the seasonality of certain diseases), and
population displacement (Chowdhury, Dey, and Smith 2018; Hundessa et al. 2018; McMichael
et al. 2003).

Public health experts are calling for climate change policy interventions that have an
immediate, positive impact on population health. For example, policies to encourage reduced
meat consumption mitigate the excess intake of saturated fats and remove some methane (a
greenhouse gas) from cattle-producing regions (McMichael and Lindgren 2011). Examples such
as these and findings from other emerging research show that a public health discussion must
be incorporated into the larger climate change discourse.

A public health perspective can unite all actors from disparate sectors behind the
common cause of public health and wellness in families, communities, and nations. Reduc-
ing inequities not only within but also between countries is crucial to greater climate change
resilience and better global health. Neither can be achieved without sustainable development
to address fundamental determinants of health such as access to safe water and clean air, food
security, strong health systems with good access, and reduced social and economic inequity.
Any focus on global health must therefore prioritize sustainable development and climate
change (Watts et al. 2015).

By itself, a top-down approach—creating an international agreement, followed by estab-
lishing national legislation for individuals and businesses to follow—to addressing climate
change is no longer adequate. Organizations and individuals are already taking their own steps
to reduce emissions. At the same time, climate change is only one of many factors considered
by decision makers, and rarely the one given the highest priority. Adaptation to climate change
is clearly also an inadequate response, and current trends in energy production and consump-
tion are driving the world toward a future of great climatic risk.

The most powerful strategy to protect human health from the risks of climate change
would be a government mandate of carbon pricing, in ways that strengthen over time until the
problem is under control (Boyle 2015). Like tobacco taxation, the policy of carbon pricing would
send clear signals to all actors in the system—from producers to users—that the world’s econo-
mies must shift away from the use of fossil fuels, such as coal—the worst offender in terms of

C a s e s t u d y 1

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carbon intensity and damage. In addition to direct incentives, the revenues generated from
carbon pricing could go toward wide-ranging measures including adaptation; the development
of renewable, low-carbon energy sources; and the global diffusion of improved technologies
and practices. Carbon pricing thus holds great potential, particularly when carried out as part
of a comprehensive policy package. This potential solution, however, still faces political obstacles.
The current drivers of economic growth force communities into patterns of energy use that no
reframing can change without coordinated realignment of these drivers. And the idea that

“others” are to blame and should be the ones to address climate change remains a potent
excuse for inadequate action (Vignola, McDaniels, and Scholz 2013). The ideal international
agreement would support stronger efforts at all levels in every country. To be effective, any
agreement will need not only to set goals but also to identify needs at international and national
levels to achieve the goals. Such an agreement may also require a motivation mechanism, such
as a “feedback loop,” that strengthens national ambitions over time (Marteau, Hollands, and
Fletcher 2012).

Pr i m a ry Ca r e ar O u n d t h e wO r l d

In 1978, the International Conference on Primary Health Care created the Declaration of Alma-
Ata, which underscored not only the necessity of a robust primary healthcare system to sustain
a comprehensive national health system but also the importance of establishing healthcare as
an essential human right (WHO 1978). Globalization has continued to put pressure on health
systems that are under strain to provide services that are high quality, universally accessible,
and affordable. There is clear evidence that primary healthcare leads to better health for all
and better-functioning healthcare systems.

While global health has improved on aggregate, a number of political, demographic,
and epidemiological transitions have increased inequalities in progress within and between
countries. These transitions have put a strain on existing healthcare systems, and a focus on
primary care as an essential part of healthcare reform is necessary. The World Health Organi-
zation (WHO) considers universal healthcare a critical aspect of a move toward reform based
on primary care. Since the adoption of the Sustainable Development Goals (SDGs), WHO has
framed its advocacy for universal healthcare around Target 3.8 of SDG 3, which focuses on
service coverage and financial protection (WHO 2018d, 2018e).

With rising healthcare costs and disorganized systems for financial protection, personal
health expenditures now force more than 100 million people into poverty each year. Vast dif-
ferences in health occur between and within countries and even within individual cities. In
reemphasizing primary healthcare, WHO argues that its core principles and approaches are
more relevant than ever, a conclusion which several findings support (Van Lerberghe 2008).

Using existing preventive measures more efficiently may reduce the global burden of
disease by as much as 70 percent (Van Lerberghe 2008). Tasks performed by specialists may

C a s e s t u d y 2

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be better managed by general practitioners, family doctors, or nurses. Specialist-oriented
care contributes to inefficiency, restricted access to care, and deficiencies in comprehensive
care. When healthcare is skewed toward specialist care, a range of protective and preventive
care interventions may be lost (WHO 2006). Unequal access to care and disparities in health
outcomes are usually worst when health is regarded as a commodity and care is profit driven.
Workforce shortages in primary care also pose a significant challenge (as described in Case
Study 2, “Primary Care Workforce Around the World,” in chapter 4).

An effective primary healthcare approach protects against many of these problems,
emphasizing a holistic view of health in which prevention is as important as cure in a care
continuum that extends over the human life span. The primary healthcare approach targets key
health determinants in multiple nonhealth sectors, in effect launching an “upstream attack” on
threats to health (Van Lerberghe 2008). The main strategy for addressing disparities in healthcare
is to shift toward universal health coverage with an emphasis on the values of equity, social
justice, and solidarity and the overarching goals of fairness and efficiency in service delivery.

T
his chapter provides examples of important health policy issues from the interna-
tional community, using selected countries—both developed and developing—to
demonstrate their impact. Students’ exposure to these issues not only helps them

understand international health policy applications but also introduces them to global
health (as defined by Koplan et al. 2009) as a field and globalization (as defined by Shi
and Singh 2017) as a reality.

The advent of globalization, technological advances, and shifting global demographics
brings challenges in achieving equitable global health. Although globalization brings con-
formity in some areas of people’s lives, differences in economic policies, political and legal
structures, social and cultural norms, and religious beliefs remain from country to country
and region to region, creating additional barriers to the equitable delivery of healthcare (see
the For Your Consideration box titled “Worldwide Access to Care”).

global health
A field of study, research,
and practice that
focuses on improving
health and wellness and
attaining health equity
for all people worldwide.

globalization
Worldwide changes
in many aspects of
people’s lives driven
by the exchange
of information
across borders and
characterized by
increased production
of goods and services
by developing countries
and the expanded
interdependence of
developed and emerging
economies.

FOR YOUR CONSIDERATION
Worldwide Access to Care

According to a 2017 global monitoring report, more than 50 percent of the world’s population
does not have access to essential healthcare services, more than 800 million people spend
in excess of 10 percent of their household budget on healthcare, and nearly 100 million
people experience extreme poverty due to healthcare costs (WHO and World Bank 2017). In
today’s world, countries face a fast-growing need for equitable, inclusive, and fair primary
healthcare systems.

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The greater ease of travel and communica-
tions has not only diminished barriers between
countries but has also ushered in new concerns
of disease transmission and other global health
threats. Recently considered a problem predomi-
nantly afflicting the developing world, infectious
diseases have become a concern for all countries as
global trade, tourism, international relations, and
migration facilitate the spread of disease. Another
issue of global concern is injury prevention, particu-
larly when injuries are the result of violence in the
country (see the For Your Consideration box titled

“Injury Prevention”). The United Nations (UN)
works with several constituent organizations on
global health initiatives; in addition, WHO coor-
dinates some health activities between countries
and surveillance of global health concerns. These
organizations, and policymakers around the world,
face varied problems and tough decisions regarding
global health.

This chapter begins by discussing issues shared by many industrialized countries.
Japan, Denmark, Canada, and South Korea are profiled in terms of their major health issues
and the solutions they have proposed to address these issues. Next, the chapter discusses
both common and unique challenges faced by developing nations. The variety of unique
issues confronted by emerging economies is demonstrated in discussions of China, Ukraine,
Nigeria, and Colombia. The chapter also includes several Global Health Impact boxes to

FOR YOUR CONSIDERATION
Injury Prevention

Several governments around the world have developed national
injury-prevention policies, strategies, or plans of action (WHO
2018f ). Although these instruments vary in nature and scope, they
help guide a country’s efforts to prevent injury-related death and
disability. WHO suggests that responsibility be assigned for all
stages of implementation and that these injury-prevention poli-
cies or action plans be developed in a collaborative way, involving
both government and nongovernment participants. Some policies
are developed by and for a single sector (such as health, trans-
port, justice, or education), but ideally they should be developed
across multiple sectors. WHO also recommends that policymakers
and planners take into account at an early stage the human and
financial requirements that will be necessary for their policies’
implementation.

GLOBAL HEALTH IMPACT
Migration

The UN Department of Economic and Social Affairs estimates that 3.1 percent of the world’s
people live outside of their country of origin (International Organization for Migration 2017).
In addition, many people are internally displaced, meaning that they have been forced from
their homes but remain within the country’s boundaries.

People migrate for a variety of reasons, including to take advantage of economic opportu-
nities, in reaction to political instability, and to avoid conflict. Two aspects of migrant health
must be addressed. The first is the public health threat inherent in the migratory movement

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illustrate issues that could affect global health in the future, challenging policymakers to
rethink their approaches to public health (see, for example, the one titled “Migration”).

he a lt h PO l i C y is s u e s i n de v e l O P e d CO u n t r i e s

Some health policy issues are unique to advanced economies. Most developed nations have con-
trolled the spread of communicable diseases through well-established public health infrastructures
and effective sanitation services (although the threat of importation of communicable disease
from uncontrolled regions is a concern caused by globalization and increased travel and trade).
However, their health systems are strained by an aging population and widespread chronic diseases.

CO m m O n PO l i C y is s u e s

All industrialized nations with established healthcare systems struggle to adapt these systems
to meet changing needs. They must maintain an adequate, well-trained workforce and
integrate new technologies while keeping costs at a manageable level.

Researchers first found that healthcare spending was rising among the Organisation
for Economic Co-operation and Development (OECD) countries in the 1970s; a 2009
study confirmed the continuation of this trend by showing that OECD countries spent an
average of 9.5 percent of their gross domestic product (GDP) on health, compared with
an average of 5.3 percent in the 1970s (OECD 2011).

GLOBAL HEALTH IMPACT
Migration (continued)

of people. Infectious disease concerns exist in all phases of such a journey, and the ease with
which people and products can move around the world directly corresponds to the rapidity
with which a disease threat may spread.

The second issue concerns the health needs of individual migrants after they reach their
destination. In many countries, the health system restricts migrants’ access to healthcare or
does not provide culturally appropriate care, leading to poor health outcomes (International
Organization for Migration 2017).

Australia, in which one-fourth of the population was born elsewhere, has a well-developed
system of healthcare delivery for migrants (Bulletin of the World Health Organization 2008).
In contrast, Spain has only just begun to consider the health concerns and integration issues
of migrants (International Organization for Migration 2017). Migrant health issues will grow as
people continue to move around the world to find work or to escape undesirable conditions.

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Policymakers in industrialized countries constantly seek ways to achieve sustainable
growth and allocate adequate funding to ensure fiscal and population health. To meet the
challenge of cost control, many countries have experimented with alternative methods of
paying for and delivering health services. For example:

◆ The Australian healthcare system provides universal access to a comprehensive
range of services, largely publicly funded through general taxation. Australia has
a federal system of government, with a national (Commonwealth) government
and six states and two territories. At the time of federation, health remained
the responsibility of the states. However, the Commonwealth government
holds the greatest power to raise revenue, so states rely on financial transfers
from the Commonwealth to support their health systems. This setup makes
the Australian healthcare system a complex division of responsibilities and roles
across levels of government (Duckett and Willcox 2015).

◆ The Canadian provinces and territories have primary responsibility for
organizing and delivering health services and educating, accrediting, and
licensing healthcare providers. Generally, these regional health authorities are
responsible for the funding and delivery of hospital, community, and long-
term care, and mental and public health services. Some jurisdictions have
consolidated a number of these authorities. Healthcare providers are almost
entirely private (Hutchison et al. 2011).

◆ The Danish government consolidated health services administration, decision
making, and services provision (Andersen and Jensen 2010).

◆ Israel placed its health system budget under the jurisdiction of the Ministry of
Finance rather than the health ministry as in most other countries (Ministry
of Finance, State of Israel 2017). The relationship is intended to help control
spending: The Ministry of Finance sets the level at which it will fund the
national health insurance after estimating the amount that will be collected
from cost-sharing provisions (Ministry of Finance, State of Israel 2016).

◆ Italy decentralized the authority of the Servizio Sanitaris Nazionale as a way to
control federal health spending (Tediosi, Gabriele, and Longo 2009).

◆ The Japanese government regulates almost all aspects of the universal public
health insurance system. The national government sets the fee schedule by
developing consensus among stakeholders; gives subsidies to local governments,
insurers, and providers to implement its policies; and establishes and enforces
detailed regulations for insurers and providers (Ikeda 2004).

◆ New Zealand replaced its former healthcare model with one called the Primary
Health Care Strategy, which increased public funding of preventive and public

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health activities, encouraged general practitioners to form nongovernmental
primary health organizations, and changed payments from fee-for-service to
capitated fees paid to primary health organizations (Cumming and Mays 2011).

◆ In the United Kingdom, the National Health Service (NHS) provides
healthcare, including hospital and physician services and prescription drugs,
to all of its residents. Under the terms of the NHS Health and Social Care
Act 2012, the day-to-day responsibility for running the NHS rests with NHS
England, formerly known as the NHS Commissioning Board (Bevan and Hood
2006; Department of Health and Social Care 2012).

Each of these countries faced similar problems and shared the goals of providing low-cost
healthcare while achieving positive health outcomes. Yet, they developed different solutions,
each of which took into account the particular country’s level of political will and societal
values.

In addition to experimenting with health system structure, some countries have
developed mechanisms for determining suitable treatment methods in the hope of reducing
pharmaceutical expenditures without negatively affecting health outcomes (Clement et al.
2009). Australia, the United Kingdom, Canada, and other countries have governmental
agencies that evaluate the cost-effectiveness of certain pharmaceutical products by analyzing
cost and comparative effectiveness evidence to make national coverage decisions. Australia
has taken this measure a step further by often delaying the recommendation of drugs for
use until the price is negotiated to a level low enough to be deemed cost-effective (Clement
et al. 2009).

Some cost-reduction policies aim to directly improve health outcomes. For example,
the United Kingdom has set up a physician payment model called pay for performance,
under which physicians treat patients following disease-based clinical practice guidelines.
The guidelines are drawn from evidence-based medicine and are designed to reflect the
best path to achieving high-quality healthcare and strong patient outcomes. Not all experts
agree that evidence-based care is the best mode of service delivery. Researchers assert that
because patients experience diseases differently, treatment should be patient centered rather
than disease centered (Prey et al. 2014; Starfield and Mangin 2010). Still, this example
illustrates that most governments struggle to ensure that the money allocated for health
systems is used to deliver the best possible health outcomes and high-quality care. In fact,
France codified quality assurance—a medical practice supported by the government—in its
creation of the National Agency for the Development of Medical Evaluation in 1990 and
the Hospital Act in 1991, which made quality-of-care assessment mandatory. In 2004, a
newer agency called the Agency for Accreditation and Evaluation of Health Care was given
responsibility for these activities (Legido-Quigley et al. 2008).

Other countries have imposed varying levels of cost sharing, the amount of which
depends on income, on their residents in an attempt to reduce government expenditures while
ensuring adequate care for society’s poorest inhabitants. Ireland introduced a three-tiered

pay for performance
Payment-related
incentives often used
by insurance companies
or government payers
to reward healthcare
providers, such
as physicians and
hospitals, for meeting
preestablished
performance measures
for quality and efficiency.

clinical practice
guidelines
Systematically developed
protocols (statements)
used to assist
healthcare providers
in making appropriate
healthcare and clinical
decisions regarding
specific conditions or
circumstances.

evidence-based
medicine
Using the best available
evidence acquired
through the scientific
method to guide clinical
decision making.

cost sharing
The obligation of patients
to pay for a portion of
the healthcare services
they receive. Cost sharing
is typically used as
an incentive to avoid
excessive or unnecessary
utilization. However,
it may also deter
appropriate utilization.

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payment system to address health equity issues. Those in the bottom tier (corresponding to
the lowest-income residents) receive free health services, the middle-tier population shares
some costs, and those in the highest tier overwhelmingly opt out of public insurance and buy
private health insurance. Rather than providing equitable access to health services, however,
this system created increased inequality in access (Smith and Normand 2011).

These examples illustrate that an individual’s income and sociodemographic status
are among the most important predictors of unmet healthcare needs; that is, disparity is
a multifaceted issue that extends far beyond the health system (Bryant, Leaver, and Dunn
2009; Chen et al. 2018). To determine the best solutions to meet these challenges, each
country’s government must clarify its values and priorities with regard to health equity
and cost sharing. As the burden of chronic disease increases in industrialized countries,
disease prevention is promoted as a way to improve public health and reduce healthcare
costs. Obesity is a preventable risk factor associated with many chronic diseases, such as
cardiovascular disease, diabetes, cancer, and premature death. The treatment, management,
and health complications associated with these chronic diseases generate high healthcare
expenditures (Guy et al. 2017; Sassi 2010). Therefore, some countries are taking a public
health approach to addressing obesity by encouraging lifestyle changes. Nordic countries
have placed taxes on unhealthy foods in the hope of steering consumers to healthier choices.
However, the obesity epidemic is not merely a result of an individual’s food choices; it also
reflects broad changes that have occurred in the everyday lives of people in the modern
world compared with preindustrial times. As such, some governments are considering new
transportation and urban planning policies, among other programs, to improve health and
decrease obesity rates.

un d e r ly i n g fa C t O r s

Several factors affect healthcare costs in developed countries, including the impact of aging
populations and technological progress, as previously discussed. Country GDP, the participa-
tion of women in the labor force, and public budgetary values are also important variables
that influence cost trends (Lavigne, Brown, and Matzke 2017; Pammolli, Riccaboni, and
Magazzini 2012). For instance:

◆ As a country’s total income rises, so do healthcare expenditures.

◆ As an increasing number of women enter the workforce, caregiver
responsibilities shift from the private sphere to the public sphere.

◆ Countries tend to spend more money on those social goods most valued by
society, which may be related to healthcare or its associated products and
services.

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un i Q u e PO l i C y is s u e s, B y se l e C t e d CO u n t ry

Maintaining a healthy population should be a high priority for any nation, just as cost control
should be. Taking these two priorities into consideration, countries have approached the
creation and implementation of health system administration, quality, and access policies in
different ways. We discuss Japan, Denmark, Canada, and South Korea to illustrate unique
health policy issues addressed by developed nations.

Japan
Japan adopted universal health insurance coverage in 1961. Since that time, its model has
served as a blueprint for other counties to build a successful low-cost, high-quality, and highly
equitable health system. However, the Japanese system is reaching a critical crossroads. The
population has been rapidly aging since the late twentieth century (currently, more than 20
percent of the population is aged 65 or older), which has enormous implications for the cost
of healthcare. At the same time, the government cannot rely on increasing tax revenues to
pay for the health system because population growth and, consequently, economic growth
are stagnant (Shibuya et al. 2011). In response to these challenges, the Japanese government
has introduced innovative ways to slow spending.

In 2000, the government instituted its Long-Term Care Insurance (LTCI) program
to care for the country’s aging population. The goal of LTCI is to provide long-term care
services to adults aged 66 or older at the institutional and community levels and to ease
financial and emotional burdens for both the patient and the patient’s caregivers (Tsutsui
and Maramatsu 2007). To pay for LTCI, Japan set aside a portion of general tax revenues
and levied a new tax on adults aged 41 or older.

Compared with other industrialized countries, Japan has made few formal efforts to
ensure healthcare quality. While healthcare payment is under tight control, healthcare delivery
is not; providers within the system are free to deliver care as they see fit. They are reimbursed
on the basis of diagnosis–procedure combination categorization, thus diluting healthcare
quality data that would be available under a fee-for-service payment system; monitoring fee-
for-service data is the primary way providers can be held accountable. Although its health
outcomes are comparable to those of other countries, Japan has no accountability mechanism
in place, such as the pay-for-performance model in the United Kingdom and the quality
assurance law in France. As Japan’s health system continues to undergo reform, structural
measures of quality assurance might eventually be considered (Hashimoto et al. 2011).

Out of total health expenditures, 80.5 percent were financed through the public
sector through the universal Statutory Health Insurance System in 2009 (Matsuda 2018;
OECD 2011). Insurance premiums accounted for about half of the total health expendi-
ture and are determined on a per capita, per-household, income-related, and asset-related
basis. Employer-based insurers levy premiums on employee wages, and employers pay half

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of these employee premiums. The rates of such plans vary from 3 percent to 10 percent of
wages, while rates are about 10 percent of income for employees of small- and medium-sized
employers, who are insured by the Japan Health Insurance Association (Matsuda 2018;
OECD 2011). Rates also vary among municipalities, albeit to a lesser degree. Government
employees are covered by their own system of insurers (known as Mutual Aid Societies), as
are some groups of professionals (e.g., physicians in private practice). Government subsidies,
funded from the general budget, are provided mainly to Citizens Health Insurance insur-
ers, Health Insurance for the Old-Old (a federal program) insurers, and, to a lesser extent,
small-business employer-based insurers. There are also cross-subsidies from Citizens Health
Insurance and employer-based insurance to Health Insurance for the Old-Old, and between
Citizens Health Insurance and employer-based insurance (Ikegami and Anderson 2012).

In 2012, the federal government revised its health promotion objectives, known
as Health Japan 21, and made reduction of health disparities a general goal. Its objectives
include a target for reducing disparities in healthy life expectancies and cancer treatment
delivery between prefectures; the government gives subsidies to prefectures to develop cancer
care centers (Ueno 2013).

One emerging trend has been to promote evidence-based policymaking. For example,
the current process through which the Central Social Insurance Medical Council revises
the national fee schedule has been criticized for a lack of transparency and for vulnerability
to potential abuses and conflicts of interest. Introduction of economic evaluation methods
into health technology assessments, although highly controversial, has been increasingly
discussed. Policymakers have also stressed the importance of prevention and wellness in
reducing healthcare costs. Current priorities in prevention include reducing smoking and
reducing the incidence of cardiovascular disease, diabetes mellitus, and hyperlipidemia. Since
2008, statutory health insurers have been responsible for delivering annual health checks to
beneficiaries aged 40–74 (Matsuda 2018). Policy tools for improving quality and efficiency,
such as comparable quality indicators, are being developed. As an early victim of bioterrorism,
Japan also has had to consider security threats posed by the deliberate release of infectious
diseases and address this issue in its policies and laws (Sugishima 2003; see also the Global
Health Impact box titled “Bioterrorism, Global Health Security, and Surveillance”).

Despite a lack of quality standards, Japan’s long-standing health system has achieved suc-
cesses that other developed countries are still striving toward. All of the measures described here
were adopted to maintain good health outcomes and quality of life at low cost to both consumers
and the government, making it a model worthy of consideration by other developed nations.

Denmark
The Danish parliament passed major legislation in 2007 to reorganize and consolidate the
country’s governmental structure; 215 local municipalities were condensed to 98, and 13
counties were reduced to 5 regions. The health system underwent a similar recentralization.

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Key areas in need of improvement had been identified in hospital future planning and
current efficiency, primary care coordination, and public health prevention (Andersen and
Jensen 2010). Denmark has one of the lowest life expectancies and highest cancer mortal-
ity rates in the European Union (Economist Intelligence Unit 2011; OECD 2016). The
population is also getting older, and as a result, the chronic disease burden is increasingly
cumbersome (OECD 2016).

Denmark’s 2007 health reform legislation, called the Health Act, included several
measures to address the country’s pressing health policy concerns. To improve coordination
of care, Danish officials put into effect a series of regulations (Andersen and Jensen 2010):

GLOBAL HEALTH IMPACT
Bioterrorism, Global Health Security, and Surveillance

A notorious example of bioterrorism is the 1995 attack in a Tokyo subway, where a domestic
terrorist group released a chemical weapon called sarin. Sarin is a nerve agent that can paralyze
muscles needed for breathing; in the Tokyo subway attack, 13 people were killed and 50 were
severely injured. Also in the twentieth century, Iraq and the former Soviet Union were found
to have military bioweapons programs (Khan et al. 2000). Scientists in the United States and
the Netherlands exposed the possibility of disease-related bioterrorism when they created
a highly contagious strain of avian flu in late 2011 (Novossiolova, Minehata, and Dando 2012).

The 2014 Ebola virus outbreak in West Africa was of unprecedented scale and impact and
brought attention to global health security—its definition and role in programs and policy.
For example, the government sought to strengthen its core public health capacities to meet
the International Health Regulations, and experts sought to define global health security
concerns. The lessons learned from the Ebola outbreak can serve to inform better global
health governance. Once viewed merely as a protection from the pandemic spread of infec-
tious diseases, health security demands greater collective action to ensure “access to safe and
effective health services, products, and technologies” for the health security of all individuals
(Heymann et al. 2015). This more inclusive definition recognizes that collective health security
derives from individual health security, and it compels an adequate global response to pro-
vide all people worldwide with access to essential healthcare services (Heymann et al. 2015).

Health policy to counter bioterrorism should focus on preparedness efforts, as with natural
disasters and pandemics, and plans that are put in place must be carefully and thoroughly
executed. Local jurisdictions can also take measures to reduce their vulnerability to bioterror-
ism by assessing their infrastructures and environment, health system capacity, and emergency
response teams and procedures. International cooperation is required on a far larger scale
to establish better disease surveillance systems, laws and policies that strengthen health
systems, and preventive measures against violent conflicts to make the world a healthier
and safer place for all people.

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◆ Regional health authorities were charged with creating patient rehabilitation
plans for hospital discharge.

◆ General practitioners were asked to participate in coordination-of-care strategies
by reporting patient data in a shared database.

◆ The newly formed regions were required to plan hospital systems whereby all
hospitals are expected to provide an array of basic, frequently needed services,
accounting for about 90 percent of hospital services; one hospital per region is
to provide specialized services; and a few hospitals in the country will perform a
limited number of highly specialized services.

These initiatives are meant to work together to provide coordinated and high-quality care
for all Danish patients, whether they have an acute condition or a chronic disease.

The 2007 reform aimed to centralize hospital care administration to enhance the
coordination of delivery and improve quality and efficiency. The five regions established
under the reform are reorganizing their hospital systems, closing or merging small hospitals,
and building new hospital infrastructure, at a total cost of 40 billion Danish kroner, or about
US$7.2 billion (Rigsrevisionen 2013). Reorganization of acute care with stronger prehospital
services and larger specialized emergency departments is an important aspect of this new
structure. The Danish Health and Medicines Authority has also issued new guidelines for
the localization of specialized treatments and departments; generally, these guidelines support
centralization. The structural reform also introduced municipal cost sharing (about 20 per-
cent of the cost of treatment) for hospital services to encourage municipalities to emphasize
disease prevention and health promotion. Mandatory agreements between municipalities
and regions are also intended to promote collaboration. These agreements are formalized at
least once during each four-year election term for municipal and regional councils, and they
must be approved by the Danish Health and Medicines Authority (Rigsrevisionen 2013).

Apart from the government, semi-independent organizations also play a governance
role. The Danish Healthcare Quality Program (known by its Danish abbreviation, DDKM)
consists primarily of medical professionals and works to develop extensive accreditation
standards to improve quality across all healthcare sectors. The DKKM is developed, planned,
and managed by the Danish Institute for Quality and Accreditation in Healthcare (known
by its Danish abbreviation, IKAS), a board that comprises representatives from the Danish
Health and Medicines Authority, the Danish regions, and the Ministry of Health. The
International Society for Quality in Healthcare, in turn, oversees both the DDKM and the
IKAS. The DDKM has now been implemented in all hospitals and is being introduced in
primary care and pharmacies. It aims to include all healthcare delivery organizations, and
it applies both organizational and clinical standards. The core of the program is a system of
accreditation based on annual self-assessment and external evaluation (every third year) by
a professional accreditation body. The self-assessment involves reporting of performance

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against national input, process, and outcome standards, which allows comparison over time
and between organizations. The external evaluation considers the self-assessment when
determining the status of providers’ overall quality improvement activities and opportuni-
ties. Quality data for a number of treatment areas are captured in clinical databases and
published online. The data are used for a variety of purposes, including patients’ choice of
hospitals and the management of hospital quality (EU 2011).

The implementation of Danish health reform is well under way, but it is progressing
at a sluggish pace. Successful implementation seems to depend on the goals of the dominant
political party in each region. Yet to be seen is how political and ideological tensions—such
as those present in most countries—will affect the end result of the Danish health reform
(Andersen and Jensen 2010).

Canada
Canada’s health policy issues are different from those of Japan and Denmark. Its population is
not aging as rapidly as Japan’s, and, unlike Denmark, its provincial decentralization of the health-
care system has been stable since the late twentieth century. However, Canada faces problems
related to paying for healthcare and an increasing public health burden from preventable diseases.

Based on OECD (2011) data, Canada spends a greater percentage of its GDP, and
more per capita, on healthcare than many industrialized countries do (but less than Germany,
Denmark, and the United States spend). In the twenty-first century, the country has taken
steps to control healthcare spending at all levels of government. For example, the Common
Drug Review process was introduced in 2003 to assess the safety, clinical effectiveness, and
cost-effectiveness of new drugs presented by pharmaceutical companies and to provide
recommendations regarding eligibility for public reimbursement to all participating drug
plans (CADTH 2018). In this way, Canada seeks to promote the use of the most effective
and least expensive pharmaceuticals.

Canada’s drug plans, which are administered separately from general health services
plans, attempt to use cost-sharing mechanisms to control public expenditures. For example,
the province of British Columbia implemented the policy Fair PharmaCare in May 2003. It
is an income-based benefits program with three main goals: (1) to keep government spending
low while (2) providing access to all necessary medication (3) in a way that is equitable for
people of all income levels. Analyses show that decreases in public pharmaceutical funding
would work against stated policy goals and that federal money infused into the states is key
to access and equity (Morgan et al. 2006).

Canada’s struggle to achieve equity in medication access and affordability reflects
its larger struggle with health disparities. The life expectancy at birth of an aboriginal man
living on a reserve (67 years) is nine years less than that of a man in the general population
(76 years); aboriginal status and socioeconomic status are the biggest contributors to health
inequities in Canada, with disadvantaged populations having increased infant mortality

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rates, risky health behaviors (e.g., smoking), infectious disease, and chronic disease (Health
Council of Canada 2011). These disparities are primarily attributable to differences in
access to resources and opportunities (Farmer, Peressini, and Lawrence 2017; Frohlich, Ross,
and Richmond 2006; Rocheleau et al. 2017). As with the public health agencies of other
countries grappling with similar issues, research findings about Canadian health issues are
slowly being translated into programs and policies designed to reduce health disparities.

According to the Canadian Institute for Health Information (CIHI 2012a), pri-
vate health insurance covers about two-thirds of the 23 million people who make up the
Canadian population. In 2010, it accounted for approximately 12 percent of total health
spending (CIHI 2012a). Private health insurance covers services such as vision and dental
care, prescription drugs, rehabilitation services, home care, and private rooms in hospitals
(which are not covered by public programs). Out-of-pocket payments made by private
households accounted for about 15 percent of total health expenditures in 2010 (OECD
2011). According to CIHI (2012a), the main services sought with out-of-pocket spending
in 2010 were dental care (20 percent), nonhospital institutions (mainly long-term care
homes) (20 percent), prescription drugs (17 percent), vision care (12 percent), and over-
the-counter medications (10 percent). In 2011, approximately 85 percent of premiums for
private health plans were paid through group contracts with employers, unions, or other
organizations (CLHIA 2018). Supplementary private insurance to provide faster access to
publicly funded physician and hospital services was not available. Providers set their own fees
for services covered by private insurance, and each insurer sets its own reimbursement level
(e.g., based on the lowest fee among representative providers in a particular geographic area).

In 2010, of the 69,699 total doctors in Canada, about half were family doctors and
half were specialists (CIHI 2011). Primary care physicians largely act as gatekeepers for fur-
ther care. Most physicians are in private practices and are remunerated on a fee-for-service
basis, although an increasing number of family doctors receive alternative forms of public
payment such as capitation, salary, and blended funding. For 2010–2011, fee-for-service
payments made up 50 percent of payments to family physicians in Ontario, compared with
70 percent in Quebec and 86 percent in British Columbia (CIHI 2012b).

South Korea
South Korea adopted universal health insurance coverage in 1989. Since then, it has worked
to improve the health system, but with minimal success. Although the country has achieved
admirable gains in health outcomes (e.g., increased life expectancies), the health system is
plagued with several problems, including the following:

◆ The healthcare benefits that citizens enjoy are still limited compared with those
of other developed countries.

◆ The public sector has little involvement in healthcare delivery.

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◆ Costs are rapidly rising.

◆ Some insurance plans are in financial distress.

These problems are caused by a diverse set of factors and will likely take significant effort
over many years to resolve (Moon and Shin 2007).

From 1989 to 2000, South Koreans were covered under a multi-insurance fund that
included about 370 insurers. The National Health Insurance Act, enacted in 2000, integrated
these multiple insurers into a single insurer and established the Health Insurance Review
and Assessment Service (HIRA) to review medical fees and assess the quality of healthcare
services provided to those who are insured (HIRA 2018a, 2018b). The government insti-
tuted the National Health Insurance Corporation (NHIC) in 2000 under the Ministry
of Health, Welfare, and Family Affairs (MIHWAF). South Korea is currently working to
increase health insurance benefits, which is particularly difficult because of the variety of
sources that fund the NHIC, including the public sector, out-of-pocket payments, private
financing, and voluntary and charitable contributions (Ahn et al. 2015; Chun et al. 2009).

In South Korea, under the Medical Law, only authorized healthcare profession-
als—doctors, dentists, nurses, oriental medicine doctors, and midwives who are licensed by
MIHWAF—can provide health services. Nurse’s aides, acupuncturists, and massage therapists
are considered “quasi-medical professionals.” Based on OECD health data, there were 91,400
physicians, 23,114 dentists, 16,663 traditional oriental medicine doctors, 57,176 pharmacists,
8,587 midwives, and 235,687 nurses in South Korea in 2007 (Moon and Shin 2007). To
address the high utilization of physician and medical technology services, South Korea piloted
a diagnosis-related group financing mechanism with promising results (Moon and Shin 2007).

A major problem concerning healthcare resources in South Korea is regional dispari-
ties in medical services. Due to medical profit maximization strategies, most private medical
facilities are located in urban areas, as are 92.1 percent of physicians, 90.8 percent of hospital
beds, and 79.7 percent of the population (National Health Insurance Corporation 2018).

South Korea is becoming an aging society faster than any other country in the world.
Along with the increase in the elderly population, there has been a rise in medical expendi-
tures for chronic degenerative diseases, which has become a great social burden. The South
Korean government is trying to reduce the financial burden, especially for younger people,
with comprehensive healthcare reform. The MIHWAF is also taking various measures to
care for the elderly, such as expanding healthcare facilities and introducing Long-Term Care
Insurance Program (National Health Insurance Corporation 2018).

he a lt h PO l i C y is s u e s i n de v e l O P i n g CO u n t r i e s

The health policy issues of developing countries are, in many ways, fundamentally distinct from those
of developed countries. Developing countries face a range of health problems, from communicable,

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highly contagious diseases to incipient, invisible problems that manifest from exposure to polluted
environments. These nations must address the drivers of preventable morbidity and mortality to
improve health outcomes and, relatedly, increase economic growth and development.

In this section, we discuss the policy issues shared by developing countries, including
the communicable and noncommunicable diseases that cause the highest burden of disease.
Because developing nations rely heavily on international governing bodies to provide assis-
tance regarding health concerns, we also outline the types of policy actions these international
agencies take to address these concerns. Finally, as with the selected developed countries, we
delve into the particular problems faced by selected developing countries—China, Ukraine,
Nigeria, and Colombia.

CO m m O n PO l i C y is s u e s

Distinct policy issues and risk factors related to both communicable diseases and noncom-
municable diseases are common problems in developing countries. Communicable diseases
include acute diarrheal disease, sexually transmitted diseases, HIV/AIDS, tuberculosis (TB),
malaria and other tropical diseases, and other infectious diseases, particularly when they
spread quickly and become a worldwide threat (see the Global Health Impact box titled

“Pandemics: SARS, H1N1, Avian Flu, and Zika”). Noncommunicable diseases—illnesses
not traditionally seen in abundance in developing nations, such as cancer, cardiovascular
disease, diabetes, chronic pulmonary disease, and mental illness—are becoming increasingly

communicable diseases
Illnesses caused by
organisms such as
bacteria, viruses,
fungi, and parasites.
Communicable diseases,
also called infectious
diseases, may be
transmitted by one
infected person to
another, from an animal
to a human, or from an
inanimate object to an
individual, depending on
the disease.

noncommunicable
diseases
Noninfectious medical
conditions or illnesses,
typically of long duration
and slow progression.

GLOBAL HEALTH IMPACT
Pandemics: SARS, H1N1, Avian Flu, and Zika

A single businessman traveling from the Guangdong province of China through Hong Kong and
on to Hanoi, Vietnam, brought severe acute respiratory syndrome (SARS) to global attention. He,
and the doctor who diagnosed him, died of the disease while it was spreading rapidly throughout
Asia, and later to 24 other countries worldwide (A.D.A.M. Medical Encyclopedia 2018). The story
of SARS illustrates the negative impact of globalization and migration and the ease with which
a highly contagious disease can spread worldwide and cause a pandemic (Shi and Singh 2017).

Threats of widespread illness from H1N1 (swine) influenza and West Nile virus evolved
in similar fashion, and avian flu is the next major infectious disease to watch, according to
observers (CDC 2017b; Pompe et al. 2005). Typically, only people who had worked in close
contact with infected birds are known to have been infected with avian flu. However, it is a
highly deadly influenza virus, and if it were to mutate and become easily transmitted from
human to human, serious consequences would follow.

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common in developing countries and come with a different set of health policy consider-
ations (George et al. 2017; Walker et al. 2018).

A common theme among these diseases is the economic depression that accompanies
the high incidence of disease and the paradoxical need for large economic inputs (capital, labor,
and innovation) to prevent the transmission and onset of disease, which places low-income,
developing countries at a particular disadvantage in solving these public health problems.

The way to address health policy issues in developing countries is increasingly envi-
sioned as a stewardship of trust and legitimacy between a government and its people for
improving the welfare of a population. Health policy today involves multiple actors and
increasingly involved global and international agencies. Increased investment in the context
of the Millennium Development Goals (a UN effort to improve health and healthcare around
the world) is also placing greater attention on good national and international governance
(WHO 2008). This approach has demonstrated benefits for the specific diseases being
addressed, yet it threatens other programs and the capacity of local authorities to meet broad
health needs. National governments in developing countries should set clear priorities on
the basis of health needs and infrastructure capacity as well as on sound ethical guidance
that will help achieve maximum improvement in health for minimum expenditure.

GLOBAL HEALTH IMPACT
Pandemics: SARS, H1N1, Avian Flu, and Zika (continued)

The Zika virus is a growing public health concern. As documented by Flahault and colleagues
(2016), the Zika virus is found in parts of Africa, was reported in Southeast Asia, and is rising in
the Americas and Caribbean. Since it was first detected in Brazil in 2015, it has become a major
public health challenge in the Americas. Although the virus can cause mild illness (characterized
by conjunctivitis, fever, rash, and joint pain), many affected countries also reported neurological
and autoimmune complications potentially related to the Zika virus, including more cases of
Guillain-Barré syndrome and birth defects such as microcephaly. Aware of the growing body of
evidence suggesting an association between infection by the Zika virus and the development of
neurological disorders, including adverse pregnancy outcomes, WHO established a framework to
systematically assess for a causal relationship based on three types of clinical outcomes: (1) auto-
immune disorders, including Guillain-Barré syndrome; (2) acute central nervous system disorders,
including myelitis; and (3) congenital anomalies, including microcephaly (Flahault et al. 2016).

In efforts to thwart pandemics, worldwide reporting and surveillance systems have been
developed and are improving, but many countries lack critical laboratory infrastructure and
access to vaccines and antiviral medications. Any country that has not already done so should
establish emergency preparedness plans that account for social distancing, travel, health
system processes, and mass vaccination procedures.

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Comprehensive national health accounting is an important policy tool to track health
spending from all sources. Performance assessment can support policymaking in monitoring
and evaluating progress toward critical outcomes and the efficiency of the health system in a
way that allows comparison over time and across systems. Particular attention is being given
to financing healthcare for the more than 1.3 billion people in rural poverty and workers
in the informal sector in developing countries who have no financial protection against
catastrophic costs of healthcare (González-Block et al. 2009).

Success with these and other efforts will depend on solving the multiple challenges
facing the health workforce. Relying on a public–private mix of services to address health
infrastructure raises the question of the capacity of government to develop contracts, set
prices, and monitor and supervise private providers. It is not always easy to reconcile effi-
ciency with equity in health policy. Equity should be a primary concern for sustainable
policymaking, and tools are available to measure how greatly national investments benefit
the poor and needy. In many respects, health policy in developing countries is all about the
encouragement of innovation and the scaling up of lifesaving technologies and systems (see
the Global Health Impact box titled “Technology and Innovation”). Access to knowledge
and technology has accounted for a high proportion of the decline in mortality rates. New

GLOBAL HEALTH IMPACT
Technology and Innovation

The advancement of information technology, and of clinical technology in particular, has
greatly altered how healthcare is delivered. Examples of these technological innovations in
healthcare include health informatics, mHealth, electronic medical records, telemedicine,
and virtual physician visits. Medical innovations have also brought safer surgical and imag-
ing procedures; genetic testing and gene therapy; and therapeutic uses for vaccines to treat
diseases such as cancer and HIV/AIDS.

As with any area of technological innovation, the positive aspects of clinical technology
are accompanied by a number of challenges. The development of useful medical technolo-
gies often comes at a very high cost, which may make it difficult for poorer countries to
bring technological innovations to their populations. In addition, technological advances
in processes can threaten the privacy of individuals and patient confidentiality because of
increased access to medical records.

The US Department of Health and Human Services, in its Global Health Initiatives state-
ments, has described the need for the government to strengthen regulatory systems and
to monitor the safety of the medical products, food, and feed that enter the United States
through global manufacturing and supply chains (HHS 2013). Another approach to addressing
the challenges brought by technology is for the health department of a country to assess
community needs and ensure that appropriate medical devices and technologies reach people
in need in a cost-effective manner.

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strategies for organizing health research systems can contribute to making evidence-based
policy a reality in developing countries (González-Block et al. 2009).

The term universal health coverage is gaining popularity among countries that have not
yet attained it. A majority of the world’s developing countries plan to implement universal
health coverage to protect vulnerable citizens who cannot afford healthcare services and
thus may incur catastrophic expenses as individuals and families. If a nation can provide
universal health coverage, it can bring all of its citizens under the provision of equal and
high-quality care. However, implementation of universal health coverage is not an easy task.
Good governance and a sustainable health financing system are fundamental to establishing
universal health coverage in developing countries (Zaman and Hossain 2017).

Communicable Diseases
Acute diarrheal disease and other diseases attributable to poor water sanitation (e.g., acute
respiratory disease, some tropical diseases) account for about 10 percent of the global burden
of disease. Nearly 1.7 million deaths each year are attributable to acute diarrheal disease;
about 95 percent of these deaths occur in children aged four or younger in developing
countries (Van Minh and Hung 2011). Worldwide, at least 2 billion people lack access to
a clean water supply—one of the most important preventive measures that can be taken to
lower mortality rates (WHO 2018b).

The UN has recognized this type of disease as a global public health problem. In its
Millennium Development Goal (MDG) 7.C, the UN stated that it aims to “halve, by 2015,
the proportion of the population without sustainable access to safe drinking water and basic
sanitation” toward ensuring environmental sustainability (UN 2010). Cost–benefit analyses
suggest that achieving this MDG could result in a total worldwide economic benefit of $38
billion annually (Van Minh and Hung 2011). Some countries have accepted the challenge,
but, as the UN has noted, “disparities in urban and rural sanitation remain daunting” (UN
2010). These challenges were illustrated by the cholera epidemic in Haiti following the
devastating earthquake there in 2010, which showed that poor sanitation and resulting dis-
eases can shut down entire industries (Haiti Libre 2010). By 2018, at least 2 billion people
worldwide still were using a drinking water source contaminated with feces (WHO 2018b).

The MDG also addresses HIV/AIDS, TB (which often accompanies AIDS), malaria,
and other major diseases in MDG 6 (UN 2010), as the burden of these diseases is felt more
strongly in developing countries. At the same time, some global health experts argue that the
attention given to HIV/AIDS prevention and treatment diverts resources from more basic
public health and health system needs (Wu, Roychowdhury, and Khan 2017; Yu et al. 2008).

Noncommunicable Diseases
Much has been written about the devastating effects of communicable diseases, as well as
their prevention and treatment modalities (on HIV/AIDS, see, e.g., Bongaarts and Over

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2010; Potts et al. 2008; Sambo and Kirigia 2011; Stanecki et al. 2010; UN 2010; Weiss et
al. 2008; and on TB and other infectious diseases, see Avert 2018b; Kirwan 2009; WHO
2018a). However, noncommunicable diseases are beginning to have an equally disruptive
impact on developing countries (Islam et al. 2014; see also the Global Health Impact box
titled “Noncommunicable Diseases”). In these nations, 80 percent of deaths related to
noncommunicable diseases occur before the age of 60—the age at which people tend to
reach their peak economic productivity, therefore reducing economic growth and progress
in the country.

GLOBAL HEALTH IMPACT
Noncommunicable Diseases

The global rise in noncommunicable and chronic diseases is one of the greatest current
challenges faced by all countries, whether they are developed, emerging, or developing.
In September 2011, WHO Director-General Dr. Margaret Chan discussed noncommunicable
disease in her address to the General Assembly (UN 2010):

The worldwide increase of non-communicable diseases is a slow-motion disaster, as
most of these diseases develop over time, but unhealthy lifestyles that feed these
diseases are spreading with a stunning speed and sweep. I can understand why some
developing countries are being taken by surprise by the onslaught of these diseases.
Their initial burden was greatest in affluent societies.

Noncommunicable diseases were once considered to be confined to wealthy people and
wealthy nations. That paradigm is shifting as the burden of noncommunicable and chronic
diseases, and associated risk factors, is now being felt worldwide. A fundamental shift is also
being seen in the United States and other developed countries as community wellness and
preventive care are increasingly viewed as a vital part of controlling and reducing chronic
disease prevalence in their populations (Bauer et al. 2014; Navarro et al. 2007). In general,
noncommunicable diseases are quickly becoming the leading cause of death worldwide and
have been associated with nearly 70 percent of all global mortalities (Bauer et al. 2014; Navarro
et al. 2007). Although not currently the largest cause of mortality in sub-Saharan Africa, deaths
from noncommunicable diseases in the region are projected to surpass deaths from mater-
nal, perinatal, and nutrition-related diseases by 2030 (Bauer et al. 2014; Navarro et al. 2007).

The risk factors associated with many noncommunicable diseases are well documented in
the scientific literature. Risky behaviors such as tobacco use, alcohol abuse, unhealthy diet
habits, and physical inactivity have been linked to cancers, cardiovascular diseases, chronic
respiratory diseases, and diabetes. Lifestyles in developing nations are changing to include
these behaviors, sometimes as a consequence of development, such as the emergence in
low- and middle-income countries of supermarkets—the largest providers of processed foods

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Mental illnesses are a group of noncommunicable diseases responsible for about
13 percent of the global burden of disease. Mental illnesses in particular do not generally
attract international health policy attention. Neuropsychiatric disorders that affect people
in developing countries include unipolar depressive disorder, bipolar disorder, schizophrenia,
epilepsy, substance abuse disorders, dementia, anxiety disorders, mental retardation, and
some neurological disorders (Patel 2007). Those who experience mental illness often endure
many years of living with a disability. In addition, the societal costs of mental disorders, such
as the impact on families, social services, and the criminal justice system, are significant and
essentially immeasurable.

Globally, most people in need of mental health care lack access to high-quality
mental health services. Stigma, insufficient human resources, fragmented service delivery

GLOBAL HEALTH IMPACT
Noncommunicable Diseases (continued)

that are high in fat, sugar, and sodium and low in nutritional value (Vancampfort, Stubbs, and
Koyanagi 2017; Wagner and Brath 2012). The health-related costs of development are stunning:
In 2005, the estimated national economic losses from heart disease, stroke, and diabetes
were (in US dollars) $18 billion in China, $11 billion in the Russian Federation, $9 billion in
India, and $3 billion in Brazil (WHO 2006).

Researchers working in developing countries have produced a robust literature on the
epidemiology of noncommunicable diseases in most regions of the world (except for sub-
Saharan Africa, but see Dalal et al. [2011]). Evidence suggests that public health policymak-
ers have several policy tools by which to address noncommunicable diseases and their risk
factors. Yet such policies are not well defined at the national or global levels, even though
science and medicine have enhanced our understanding of the determinants of chronic dis-
ease. Observers note that the most effective policies are long-term, collaborative approaches
that engage both the public and private sectors. For example, WHO has deemed “best buy”
interventions to be cost-effective in reducing disability-adjusted life years associated with
noncommunicable diseases. Examples of such interventions include raising tobacco taxes,
restricting access to alcohol, providing primary care diet counseling, promoting healthy living
and physical activity in mass media, and offering vaccination programs (Dalal et al. 2011).

The consequences of failing to stem noncommunicable diseases are enormous. In devel-
oped countries, where clinical chronic care is currently available, the increasing burden of
disease will place increasingly greater strains on the health financing system. In developing
countries, where clinical chronic care is less available and more people go undiagnosed,
primary prevention is essential to saving lives and improving life expectancies (Alaofè et al.
2017). Policymakers at all levels, as well as other stakeholders, have the power to reshape
this intensifying public health issue.

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models, and lack of research capacity for implementation and policy change contribute
to the mental health treatment gap. The global mental health landscape has transformed
since 1990 with the raised visibility of the disease burden of mental health and substance-
use disorders. Mental health disorders comprise 7.4 percent of disability-adjusted life years
and 22.7 percent of years lived with disability worldwide (Baingana et al. 2015). The main
contributors are depression and dysthymia, which account for 9.6 percent of all mental
health disorders; anxiety, which accounts for 3.5 percent; and schizophrenia, substance-use
disorders, and bipolar disorder, which together account for about 2.0 percent (Baingana
et al. 2015). According to Baingana and colleagues (2015), alcohol and substance-use dis-
orders are the second-leading cause of mental health disorders in most of the developing
world, especially for southern Africa (drug use) and Eastern Europe (alcohol). The global
prevalence of mental health and substance-use disorders is predicted to rise in coming years,
with the most dramatic increase expected in low- and middle-income countries as a result
of longer life expectancy, population growth, and underresourced healthcare. For example,
the associated health burden of alcohol and substance misuse is predicted to increase by 130
percent in sub-Saharan Africa by 2050 as a result of population growth and aging (Baingana
et al. 2015). Untreated mental health disorders are associated with a high burden on the
economy. Yet commonly used health metrics do not reflect the additional social burdens of
living with mental illness. Pervasive stigma and human rights violations increase the suffer-
ing associated with these disorders and exacerbate the social vulnerabilities of people with
mental illnesses (Baingana et al. 2015).

People who are poor, less educated, or experiencing acute financial strain are at a greater
risk for mental illness than are those who are financially secure and educated. In turn, those
who suffer from mental illness are likely to remain impoverished due to lost wages or the cost of
medical care. Mental health disorders can be effectively treated, but policymakers in developing
nations face enormous challenges in legislating and financing effective interventions; the aver-
age government mental health spending (in US currency) in 2016 was a mere two cents per
person per year in low-income countries and $1.05 per person per year in lower-middle-income
countries, as compared with $2.62 per person per year in upper-middle-income countries
and a whopping $80.24 per person per year in high-income countries (WHO 2018c). People
in developing countries experience similarly huge disparities in their access to mental health
professionals (including psychiatrists, other medical doctors, psychologists, social workers,
nurses, and other paid workers working in mental health). In 2016, low-income countries
had an average workforce of 1.6 mental health professionals for every 100,000 people, and
lower-middle-income countries had an average workforce of 6.2, as compared with 20.6 in
upper-middle-income countries and 71.7 in high-income countries (WHO 2018c).

To help countries identify gaps in their existing mental health system and address
any deficiencies with system-level policy changes, WHO developed the WHO Assessment
Instrument for Mental Health Systems (WHO-AIMS), which evaluates countries across
several domains (e.g., policy/legislative framework, existing mental health services) to present

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a broad picture of their mental health provision capabilities (WHO 2009). Nearly 40 low-
income and lower-middle-income countries have used WHO-AIMS, and the resulting data
reports are available through WHO (2009, 2018g). As additional countries implement
WHO-AIMS, policymakers can comprehend the state of their country’s mental health
services and policy as a whole, which will enable them to make better policy decisions that
can lead to improvement.

Weak Health Infrastructure
The lack of a sound health system infrastructure affects care for all diseases and impedes
access to essential health services. At the beginning of the twenty-first century, governments
in developing countries generally spent about 5 percent of their total budget on health
(Nambiar et al. 2007); in contrast, the average developed country spent more than 10 per-
cent of its GDP on health, according to OECD data. Low government spending leads to
extremely low quality of care and creates long waiting times, constant shortages of essential
drugs and supplies, and inadequacy of staff training. In addition, out-of-pocket expenses
can prohibit residents of developing countries from seeking care.

Modern Environmental Hazards
In the developing world, substances such as mercury, lead, pesticides, asbestos, air toxins,
and hazardous waste are commonly released into the environment by unregulated mining
operations (e.g., mining for gold ore), soap product and paint manufacturers, gasoline pro-
ducers, agricultural operations, emissions from automobiles, and industrial waste disposal.
Such toxins are associated with a host of complicated health problems, including nerve or
nerve tissue damage, birth defects, and hormone dysfunction—problems that the health
systems of many developing countries are ill equipped to handle.

These and other modern environmental health hazards are emerging in a health
environment that is already overwhelmed by poverty, malnutrition, and communicable
and chronic diseases. With the understanding that governments in developing nations
must take swift preventive measures, the United Nations Environment Program has made
headway with its Partnership for Clean Fuels and Vehicles initiative for removing lead from
gasoline and sulfur from diesel fuel. Other initiatives aim to reduce or control stockpiles of
harmful pesticides, introduce cleaner methods of gold mining (which is strongly associated
with mercury poisoning), and initiate substance monitoring programs for manufacturing
and other operations.

Most of this work has been performed by nongovernmental organizations, with less
substantive action taken by national governments. Going forward, policymakers must take a
population-level approach toward addressing modern environmental health hazards to reduce
the burden of preventable ill health and premature mortalities (Nweke and Sanders 2009).

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un d e r ly i n g fa C t O r s

These health-related challenges raise the question of how to use health policy to strengthen
health systems and public health infrastructure in developing countries. Industrialized coun-
tries are seeking ways to provide aid to developing nations that will help their overwhelmed
ministries of health. The sectorwide approach, which focuses on centralizing public health
leadership, improving health sector management, and increasing coordination, is one such
method that has had some success.

In recognition of the fact that good governance is essential for an effective health
system and overall development, WHO devised a method for assessing health system gover-
nance. This framework allows researchers to assess public health problems with health system
leadership and governance at the policy and operational levels and to suggest improvements.
Using the WHO method allows motivated governments to effectively promote and protect
population health (Siddiqi et al. 2009).

Addressing noncommunicable diseases requires that health policies be designed to
work together at various levels of government. For example, one policy might impose taxes
to deter people from smoking cigarettes, and other policies might ensure that people who
need it can access care for chronic obstructive pulmonary disease.

un i Q u e PO l i C y is s u e s i n se l e C t e d CO u n t r i e s

Many blanket statements have been made about health issues in developing countries, but it
is essential to recognize the great diversity between and within countries when considering
health issues and health policies. China, for example, has a huge land mass and a diverse
population of urban and rural dwellers. This situation poses health policy challenges that are
unique to that country. Each country is dealing with a particular set of factors that largely
determine what health issues are pertinent and what policy solutions are feasible in that
particular country. In the following sections, we examine the unique situations of four devel-
oping countries: China, Ukraine, Nigeria, and Colombia. The small nation of Singapore is
also highlighted; see the For Your Consideration box titled “Singapore’s Healthcare Delivery.”

China
With more than 1.4 billion people, China has one of the largest populations in the world
(Worldometers 2018). The country has experienced overwhelming transformations since
the late twentieth century, which have dramatically affected population health.

Prior to 1978, the Chinese government headed up extensive public health improve-
ments, leading to lower infant and maternal mortality rates, greater life expectancies, and
improved quality of water and sanitation. The associated policy decisions emphasized disease
prevention and community involvement, reflecting an approach to health rooted in basic
public health principles (Gong, Walker, and Shi 2007).

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A major change in China occurred in 1978, when it moved from a communism-based
to a capitalism-based market economy. This shift brought many positive developments as
well as a number of challenges to China’s health system:

◆ Overall spending on healthcare has rapidly increased, while government
funding for public health institutions has steadily fallen (Gong, Walker, and Shi
2007; Nofri 2015).

◆ Rates of noncommunicable diseases and health disparities are on the rise (Hu,
Liu, and Willett 2011; Zhu et al. 2017).

◆ The cost of healthcare has become prohibitively expensive for many people,
particularly those living in rural areas (Hu, Liu, and Willett 2011).

In response to these emerging issues and to create a solid health policy framework
for the coming years, in 2008 the Chinese government passed the Healthy China 2020

FOR YOUR CONSIDERATION
Singapore’s Healthcare Delivery

Singapore has one of the most successful healthcare systems in the world, based on its effi-
ciency in financing and the positive results it has achieved in community health outcomes.
The Singaporean government combines the ideas of individual responsibility and government
control in a financing system of federal subsidies for primary care, hospital services, phar-
maceuticals, and individual savings accounts (Bai et al. 2018; Brookings Institution 2018). In
1983, the government established a National Health Plan, which detailed plans for the infra-
structure for the next 20 years, together with the idea of individual savings accounts, called
Medisave. The restructuring of public-sector hospitals in 1985 started merging the business
and financial sectors into healthcare services to provide higher-quality services and more
efficient financing. In 2002, the government promulgated the ElderShield plan to help the
elderly and people with severe disabilities in particular.

Singapore provides all citizens with universal healthcare coverage, funded by a combination
of federal subsidies, financing schemes, and individual savings, all administered nationally.
Capital expenditures for healthcare are calculated at the national level in the federal budget.
In the first tier of financial protection, the government subsidizes up to 80 percent of the total
bill in public hospitals and primary care polyclinics. Subsidies of up to 80 percent are also
provided for bills in government-funded intermediate and long-term care institutions. This
coverage is funded by a network of savings and insurance programs known as the “3Ms” (Medi-
save, MediShield, and Medifund) to help individuals and families pay for their care. Together,
these programs play a critical role in maintaining the health and welfare of all Singaporeans.

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act to address healthcare equity and accessibility through five mandates that correspond to
major health problems identified by the Chinese Ministry of Health (Chen 2009; Hu et
al. 2011; Ling et al. 2011):

1. Health insurance must be expanded to cover 90 percent of the population.

2. A national drug system must be established to meet basic pharmaceutical needs.

3. Grassroots-level improvement of medical care and public health must occur.

4. Basic public health services, including preventive health, must expand.

5. Hospital reform must be instituted to abate the health system’s increasing
tendency to commercialize.

The development of a “Healthy China” is central to the Chinese government’s agenda
for health and development. President Xi Jinping has placed health at the center of the
country’s entire policymaking operations, and China’s leaders have made health a national
political priority with the approval of the Healthy China 2030 Planning Outline by the
Central Party Committee and the State Council (Tan, Zhang, and Shao 2018).

Through advanced technologies and an improved health insurance system, China
hopes to achieve health equity for its people by 2030. Significant steps have already been
taken toward that end. In 2009, China embarked on a major national health system reform
(Nofri 2015), aiming to extend care to those residing beyond its prosperous urban centers.
At the beginning of the twenty-first century, less than one-third of the population had access
to health insurance. Now nearly 100 percent do (Tan, Zhang, and Shao 2018). China has
provided its huge population a healthcare safety net that protects its people from becoming
impoverished by the costs of healthcare (Tan, Zhang, and Shao 2018).

Still, China faces many health challenges. They include increasing rates of cancer;
higher incidence of cardiovascular disease linked to such lifestyle factors as smoking; and
demographic trends such as an aging population (Nofri 2015; Tan, Zhang, and Shao 2018).
These challenges cannot be met sustainably in a health system that relies solely on hospitals.
Therefore, a key component of Healthy China is the promotion of healthy lifestyle behaviors
and physical fitness, including through the development of the Healthy Cities program, to
emphasize prevention over treatment. One of the most important steps toward a Healthy
China is a national smoke-free law, which would have a significant impact on the preven-
tion of many associated noncommunicable diseases.

According to Tan, Zhang, and Shao (2018), to better protect people’s basic right to
health, a series of plans have been implemented, including the Healthy China 2030 Plan-
ning Outline, the National Fitness Program (2016–2020), the Thirteenth Five-Year Plan
for Medical and Health Service Development, and the Plan for Deepening Reform of the
Medical and Healthcare System During the Thirteenth Five-Year Plan Period (2016–2020).

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The Chinese government has set a “three-step” goal: (1) establishment of a sound basic
medical and healthcare system with distinctly Chinese characteristics covering both urban
and rural residents, such that its main health indicators would place China in the forefront
of the rankings of high- and middle-income countries by 2020; (2) improvement of the
health-promotion system such that its main health indicators would be in the ranks of those
of high-income countries by 2030; and (3) existence of a healthy China that conforms to
the requirements of a modern socialist country by 2050 (Tan, Zhang, and Shao 2018).

Ukraine
Over the five years following the fall of the former Soviet Union in 1991, Ukraine faced—and
continues to battle—several debilitating public health issues. The population is plagued by
epidemics of HIV and TB, which are interrelated: In 2015, 22 percent of tested TB patients
were HIV-positive (CDC 2017a). In addition, cardiovascular disease, the leading cause of
mortality in the country, is highly prevalent among the population, partly because of high
rates of smoking and alcohol consumption.

Inconsistencies in public health legislation and implementation, resulting from an
unstable parliament, create a difficult political environment in which to address these chal-
lenges and improve health (Lekhan, Rudiy, and Shevchenko 2015). For example, the Global
Fund for AIDS, Tuberculosis, and Malaria initially granted $98 million to the Ukrainian
government to respond to the combined AIDS/TB epidemic; however, the Global Fund
switched its grantee to community organizations instead because the government was not
transparent with the use of funds (Hurley 2010). As a result, local community organizations
now provide most HIV/AIDS prevention and treatment services in Ukraine, with funding
from the Global Fund (Hurley 2010).

Poor development and implementation of policies distinguish Ukraine’s TB control
from that of the rest of Europe. For example, TB infections are often transmitted through
the prison system, but postincarceration treatment plans are not coordinated before prisoners’
release. Furthermore, many ex-prisoners do not adhere to medication plans and transmit
the disease to the public, as evidenced by higher-than-average TB infection rates in areas
surrounding prisons. In addition, Ukraine lacks a centralized TB monitoring system, and
most regional TB recording and reporting systems do not meet WHO recommended stan-
dards (Atun and Olynik 2008).

Policies aimed at reducing the burden of noncommunicable disease in Ukraine have
been more successful—the tobacco excise tax is one example. Estimates from 2005 suggest
that 66 percent of men and 20 percent of women smoked cigarettes (Ross, Stoklosa, and
Krasovsky 2011). Following the lead of other countries that adopted tax policy reform in
response to high rates of disease, premature death, and lost productivity, Ukraine imple-
mented excise taxes on tobacco in 2009 and 2010. These taxes significantly reduced tobacco
consumption, illustrating that tobacco use is price sensitive (Ross, Stoklosa, and Krasovsky

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2011). By 2015, cigarette smoking rates had fallen to about 49 percent among men and 14
percent for women (Tobacco Atlas 2018).

From 2006 to 2012, the average life expectancy in Ukraine increased, even with
little progress in policy implementation. During the 2010s, armed conflict created a new,
large-scale humanitarian crisis in Ukraine, and the health system proved ill equipped to
cope with it. Even before the turmoil that led to this crisis, the Ukrainian health system
was weak and far from equitable. Pilot reforms initiated in 2010, which aimed to reorient
the system toward a primary care focus, were still in early stages, and scale-up was delayed
indefinitely (Lekhan, Rudiy, and Shevchenko 2015). In many respects, as Lekhan, Rudiy,
and Shevchenko (2015) observed, the pilot reforms showed that change is possible in the
system, although a lack of meaningful reform since independence from the Soviet Union
meant that many inefficiencies were deeply entrenched. In October 2017, the Ukrainian
Parliament approved a bill that made major changes to the country’s healthcare system effec-
tive January 1, 2018, including the establishment of a National Health Care Agency and
a financing model similar to that of the United Kingdom (Raczkiewycz 2017). However,
the country’s political instability made successful implementation of the approved changes
uncertain.

As Lekhan, Rudiy, and Shevchenko (2015) contend, successful implementation of
the health system reforms requires both political will and popular consensus, including com-
munity and health worker engagement in the reform and belief in its benefits. Perhaps most
important, changes to a health system need policy windows. For example, although economic
crises can spur focused efforts to make health systems more efficient, a policy environment
of political, social, and economic turmoil can push health systems concerns far down the
policy agenda. The successful implementation of health systems reform requires a certain
degree of stability, but stabilizing such conditions is beyond the control of the health sector.

Nigeria
Nigeria’s health issues are all-encompassing, ranging from communicable diseases, such as
HIV/AIDS, TB, rare tropical diseases, and even poliomyelitis (polio), to noncommunicable
diseases, such as cardiovascular disease and the effects of modern environmental health
hazards. Each of these health problems has been inefficiently managed by the Nigerian
government and exacerbated by a weak health system, little health financing, and loss of
health professionals through emigration (FMTalk360 2016; GPEI 2018).

Two key health issues set Nigeria apart from other sub-Saharan nations with otherwise
similar health problems. First, Nigeria is the only African country (and one of only three
countries in the world, the other two being Afghanistan and Pakistan) to have failed to ever
eliminate polio (GPEI 2018). Efforts implemented by the Global Polio Eradication Initiative
(GPEI) beginning in 2009 greatly reduced the total number of cases, to the point that the
country went for two years with no new cases of polio detected. However, in July 2016, one

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type of wild poliomyelitis reemerged, triggering a GPEI response in which nearly 58 million
children were vaccinated to help prevent further outbreaks (GPEI 2018; WHO 2016).

Second, Nigeria has encountered particular difficulty implementing key components of
standard disease control protocol in combating HIV/AIDS. In 2016, only about 30 percent
of the 3.2 million people living with HIV in Nigeria were receiving antiretroviral therapy,
and the death rate from AIDS was about 148,000 people per year (Avert 2018a). The rate of
mother-to-child transmission remains high—at 22 percent in 2016—and Nigeria accounts
for nearly 27 percent of all the mother-to-child transmission cases in the world (Avert 2018a).

Several types of barriers impede Nigeria’s ability to effectively address the HIV/AIDS
epidemic, including the following (Avert 2018a):

◆ Cultural practices that increase HIV vulnerability among the general
population (e.g., female genital mutilation, marriage of young girls to much
older men, encouragement of men to have multiple female sexual partners,
low levels of condom use) as well as the social stigma of being known as HIV-
positive, which inhibits testing

◆ Strict laws against homosexuality (punishable by up to 14 years in prison) that
discourage men who have sex with men from seeking treatment; laws against sex
work (punishable by two years in prison) that make sex workers reluctant to dis-
close their occupation to healthcare workers during provision of healthcare services

◆ Lack of sites for HIV testing and treatment for those willing to seek it

◆ Low levels of funding by the Nigerian government to address the epidemic,
exacerbated by gender inequality, with less than 1 percent of government
spending on HIV allocated for women despite the fact that 58 percent of the
people living with HIV are women

Closely related to the challenges in addressing the HIV/AIDS epidemic is the dramatic
rise in Nigeria of TB, which is a common coinfection that can develop in people living with
HIV and has likewise reached an epidemic level (Avert 2018a, 2018b). Multidrug-resistant
strains of TB in Nigeria increased by 30 percent between 2015 and 2016, making the disease
even harder to treat effectively (Avert 2018a).

Unavailability of modern equipment and obsoleteness of existing equipment is a
major issue with the Nigerian healthcare system. Lack of proper or properly functioning
equipment has been identified as a root cause of incorrect diagnoses and is reportedly a key
reason foreign medical trips remain the only option for affluent Nigerians or patients in dire
need of a correct diagnosis (see the Global Health Impact box titled “Medical Tourism”).
Stories of medical errors and how they have accounted for avoidable deaths in some Nigerian
medical facilities have also been reported, further contributing to Nigerians’ discomfort with
seeking medical care in their own country (FMTalk360 2016).

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GLOBAL HEALTH IMPACT
Medical Tourism

Medical tourism is an international phenomenon by which people travel to another country
for medical services. Travel often occurs on a regional level, and most procedures are elec-
tive (e.g., weight loss surgery, cosmetic surgery, dental care, fertility treatment). For example,
Americans travel to Mexican border towns for dental procedures that are very expensive in
the United States (IMTJ 2012) and seek affordable healthcare procedures, such as knee and
hip replacements and cardiac surgery, outside of the country. Some countries are known to
specialize in the provision of medical tourism procedures, including gender reassignment
surgery in Thailand and cell transplants in China (Aizura 2010; Alleman et al. 2011; Song 2010).

Major US medical schools have partnered with other countries to set up tertiary and referral
hospitals that provide higher-level care and procedures. These ventures can control costs for
private insurers and improve the standards of care for those seeking care abroad. Joint Com-
mission International has accredited more than 600 hospitals and certified hundreds of other
specialty facilities and programs worldwide (JCI 2018). People also travel to the United States to
receive healthcare at leading institutions, such as the University of Texas MD Andersen Cancer
Center in Houston; Mayo Clinic in Rochester, Minnesota; and Jackson Memorial Hospital in Miami.

Since 2003, the government of Thailand has attempted to make its country a global center
for medical tourism through the Center of Excellent Health Care of Asia initiative. It has held
international road shows and allowed tax exemptions for investment in new health facilities
to target medical tourists and recruit patients. In 2011, revenues from medical tourists gener-
ated the equivalent of an estimated 0.4 percent of Thailand’s GDP (Noree, Hanefeld, and Smith
2016). Despite such financial benefits, there is concern about the impact of medical tourism on
equity in care, especially in areas with weak health systems and limited resources that may be
diverted toward caring for patients from abroad (Noree, Hanefeld, and Smith 2016).

Facilitators of medical tourism have established an industry focused on connecting people
with medical services abroad. However, several challenges have arisen with this emerging
field. Reports have surfaced of complications after surgeries that could have been avoided
if proper quality standards had been followed, underscoring the need for uniform standards
of care across various settings, such as those used by Joint Commission International. Public
health concerns also can be an issue for medical tourists, as they may become vectors (able
to spread infectious agents) or victims of multidrug-resistant bacteria—a threat whenever
physicians are unprincipled in their use of antimicrobial medications (Cusumano et al. 2017;
Rogers, Aminzadeh, and Paterson 2011). Critics cite ethical issues regarding the use of the
healthcare workforce and resources for medical tourism that takes away resources from the
basic local medical needs of the country’s citizens. Another concern is the current lack of
regulation and oversight of the providers of medical tourism; ethical issues have been raised
concerning patients traveling after being given very limited information and foreign patients
purchasing organs or surrogacy services from local populations in low- and middle-income
countries (Noree, Hanefeld, and Smith 2016). As the medical tourism market continues to
develop and become established, these and numerous other issues will need to be addressed.

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Despite these difficulties, the prospects for improving global health policies are prom-
ising. The 2011 presidential election in Nigeria was deemed by some experts as the most
legitimate and transparent election the country ever held. The National Assembly passed
the National Health Bill in May 2011, placing health at the top of the national agenda with
an emphasis on ensuring basic access to health services for all citizens, retaining trained
health professionals, and holding the government accountable for complete implementation
of the bill’s mandates (Lancet 2011). With widespread support from health professionals
and the general public as well as a demonstrated commitment to health by the Nigerian
president, the bill was signed into law on October 31, 2014, and became known as the
National Health Act (Enabulele and Enabulele 2016). A study in December 2015, however,
found that although most health professionals were aware of the National Health Act and
viewed it favorably, nearly 74 percent of them showed poor knowledge of it (Enabulele
and Enabulele 2016), signaling a need for further education on the provisions of the act.

In 2016, the Nigerian Sovereign Investment Authority (NSIA), along with the country’s
Ministry of Health, agreed to modernize and expand healthcare services with the involvement
of the private sector. They aimed to build the capacity of specialist hospitals and diagnostic
centers to ensure that they can provide advanced medical care. Ten memorandums of coopera-
tion had already been signed between the NSIA, Ministry of Health, and various healthcare
facilities in the country’s six geopolitical zones, with six of them in advanced stages. Although
Nigeria’s National Health Insurance Scheme (NHIS), introduced in 1999, aims for universal
coverage, penetration remains low. In 2016, less than 5 percent of the population was enrolled
in the NHIS, and an estimated 120 million people lacked health insurance (Oxford Business
Group 2018). Stakeholders in the insurance sector—such as the NHIS and health mainte-
nance organizations—also called for legislators to make it mandatory for employers with more
than ten employees to provide them with health insurance (Oxford Business Group 2018).

Colombia
Colombia faces challenging public health issues that are deeply rooted in an ongoing conflict
and urban–rural disparities.

Insurance Scheme
Colombia’s health disparities are evident in examinations of its universal health insurance
system. Law 100 was approved in 1993, granting all citizens the right to health insurance
with an essential benefits package, regardless of ability to pay. By 2009, about 80 percent of
Colombians were covered under one of two health insurance schemes—the Contributory
Regime (CR) or the Subsidized Regime (SR). The CR covers those who work and earn
more than a set minimum level of pay, and the SR covers those who are considered poor, as
determined by a means test. The SR offers a meager benefits package compared with that for
the CR; for example, the SR offers only basic primary care services and coverage for cata-
strophic costs, whereas the CR offers comprehensive coverage. Critics say that the managed

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care model used by insurers covering both CR and SR limits access to care, restricts utiliza-
tion, and has changed public providers’ behaviors to suit a competitive market scheme—all
resulting in increased health disparities (Vargas et al. 2010). Meanwhile, proponents argue
that this universal health insurance approach improved on the previous model covering SR
subscribers by increasing access and reducing catastrophic health spending (Giedion and
Uribe 2009). Although the government plans to implement policies to reach 100 percent
insurance coverage of the population, no concurrent strategy is in place to address the great
disparities inherent in this insurance scheme.

Vector-Borne Diseases
Colombia is also working to prevent and treat vector-borne communicable diseases,
which are still prevalent and dangerous across about 20 percent of the country’s land area
(Castillo-Riquelme et al. 2008). Vector-borne diseases include malaria, Chagas disease, and
dengue fever, which are preventable with the proper insecticide treatment measures. However,
prevention measures are not executed in a systematic, efficient way in Colombia (Castillo-
Riquelme et al. 2008), and the bulk of the money allocated to vector-borne diseases is spent
on treatment several years after contraction.

For example, sufferers of Chagas disease, which is typically transmitted by an insect,
usually do not present with symptoms for at least a decade after exposure, and when
symptoms do manifest, they often resemble other general cardiac illnesses (Cucunubá et
al. 2017). Significant amounts of money, at levels that far surpass prevention efforts, are
needlessly spent on diagnostic testing for and treatment of cardiomyopathy (deterioration
of the heart muscle) and congestive heart failure (Castillo-Riquelme et al. 2008; Cucunubá
et al. 2017). The government pays the majority of costs under Law 100, which grants
universal health insurance coverage, but those with Chagas do not experience a positive
health outcome (Castillo-Riquelme et al. 2008; Cucunubá et al. 2017). A comprehensive
study by Cucunubá and colleagues (2017) concluded that a “a firm commitment from all
levels of government and a coordinated, collaborative global response from international
organizations and other stakeholders” are needed to successfully address the issues associated
with Chagas disease in Colombia.

Colombia has had some success in its efforts to prevent vector-borne diseases, how-
ever. In 2013, it became the first country in the world to eliminate onchocirciassis (river
blindness), an infection caused by a parasite, as verified by WHO (Cucunubá et al. 2017;
Nicholls et al. 2018).

Violence
Colombia is among the leading Latin American countries in homicides, fueled by gang
activity, civil strife, and general civil disobedience exacerbated by alcohol consumption. The

vector-borne
communicable diseases
Diseases spread to
humans by another
species, often an
arthropod (e.g., insect).

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murder rate in 2012 was 30.8 homicides per 100,000 people, compared with the US rate
of 4.7 per 100,000 (UNODC 2013).

Law enforcement policies are in place to tackle gangs and paramilitary forces, and
municipalities address the “culture of violence” through social outreach and restrictive poli-
cies that mitigate the effects of alcohol use (Ceaser 2007). For example, between 2004 and
2008, the government of Cali enacted three policies dictating the availability of alcohol.
Studies showed that when alcohol sales were stopped earlier in the night, homicide rates
dropped significantly (Sánchez et al. 2011). To further reduce the homicide rate, Colombia
must address underlying social factors leading to multiple types of violence.

Overall, Colombia’s health policy issues reflect larger societal problems. Tropical
diseases, health inequities, and violence must be curbed in conjunction with broader social
and economic policies. The Colombian government under Alvaro Uribe, president from
2002 to 2010, began to address these issues (especially those related to violence), and his
successor, Juan Manuel Santos, has followed suit.

Healthcare Reform
In 2015, Colombia underwent an economic recovery and transitioned toward an improved
healthcare system, enacting important health-sector legislation, such as the Statutory Health
Act (Act 1751) in basic welfare law and the National Development Plan (Act 1753), which
builds on the General System of Social Security in Health and emphasizes key healthcare topics
such as health system equity, access, quality, timeliness, trust, legitimacy, and sustainability. The
revised health system includes features such as an integrated healthcare policy; an integrated
healthcare model that comprises primary healthcare, a family and community healthcare focus,
risk management, and a differential approach; further development of the Ten-Year Public
Health Plan (2012–2021) in the country’s regions; creation of a unit to administer system
resources; and strengthening of the pharmaceutical policy that was implemented in 2012. The
Colombian government made peace with the armed rebel group Revolutionary Armed Forces of
Colombia (known by its Spanish initials, FARC) in 2017 and in early 2018 was pursuing talks
with another rebel group, the National Liberation Army (known by its Spanish initials, ELN),
in a continuing effort to bring an end to Colombia’s ongoing civil strife (Charles 2018). As a
result of the FARC talks, Colombia established a public health and postconflict policy jointly
coordinated by the Ministry of Health and the Ministry for Post-Conflict. It also created a
program for psychosocial and integrated care for victims of armed conflict, which guarantees
the right to health and restoration of physical, mental, and psychosocial conditions according
to relief and rehabilitation measures in the Victims Act (Charles 2018).

All Colombians have access to the same services as well as financial protection from
excessive healthcare spending. Patient out-of-pocket expenses make up 14 percent of all
health spending—one of the lowest proportions in Latin America and lower than the OECD
average of 19 percent (OECD 2011).

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In Colombia, the informality of the labor market presents a significant challenge to
raising health system revenues. About half of the total health system funding comes from
contributory sources (employer and employee payroll contributions). It has proven difficult
to substantially increase this component of funding due to the size of the informal labor
market: about 60 percent of the workforce. Informality narrows the contributory and tax
bases and creates financial hurdles in all public sectors. These financial issues are exacerbated
in the health sector, however, because of the Constitutional Court’s requirement to expand
the range of services in the SR and make them equal to the CR.

Healthcare providers in Colombia tend to be largely concentrated in densely popu-
lated areas, with a notable increase in the number of private providers in those areas since
the beginning of the twenty-first century. In contrast, people living in remote and rural
provinces have very little choice of provider, even for simple outpatient care. Providers in
these areas tend to be public providers and often struggle with issues such as high opera-
tional costs and difficulties in attracting and maintaining an adequate number of health
professionals, which is likely to affect the quality of care provided.

Although unmet healthcare needs and visit waiting times have been significantly
reduced, health insurers in Colombia have not yet transformed into effective, efficient
purchasers of healthcare services. Payments to providers should reward quality of care and
good health outcomes, rather than volume of services provided (Charles 2018).

➤ Although most developed nations have controlled the spread of communicable
diseases, their health systems are strained by an aging population and widespread
chronic disease. They must maintain an adequate, well-trained workforce of health
professionals and integrate innovative technologies while keeping healthcare costs at
a manageable level.

➤ Several factors affect rising healthcare costs in developed countries, including aging
populations, rapid technological progress, the participation of women in the labor
force, and public funding for healthcare.

➤ Developing countries experience a range of public health problems, from
communicable, contagious diseases to incipient, invisible health effects from exposure
to pollution. These nations must address the drivers of preventable morbidity and
mortality if they are to increase economic growth.

➤ The lack of a sound health system infrastructure in most developing countries affects
the spread of all diseases and impedes access to essential health services. Further,
low government spending leads to low quality of care and creates long waiting times,
constant shortages of essential drugs and supplies, and lack of trained staff.

informal labor market
A workforce made up
of people who engage
in productive activities
that are not taxed
or registered by the
government.

k e y P O i n t s

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Ca s e st u d y 1

Based on your own research on climate change and its impact on public health, answer the
following questions:

1. Why is addressing climate change important for public health?
2. What health policies and public health strategies could mitigate the effects of climate

change?

Ca s e st u d y 2

Based on your own research of the global primary care workforce, answer the following questions:

1. Why is there a shortage of primary care providers worldwide?
2. What strategies might nation states adopt to expand their countries’ primary care

workforce?

1. What are the primary health policy issues in developed countries? In developing
countries?

2. What are the specific health challenges in Japan?
3. What has Denmark’s health reform accomplished?
4. What is Canada’s health policy agenda?
5. What are the public health challenges facing South Korea?
6. What goals is China’s Healthy China 2020 attempting to accomplish?
7. What are the public health challenges faced by Ukraine?
8. What are the public health issues of Nigeria?
9. What factors do Colombia’s health policies target?

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“Treatment Gap in the National Health-Screening Program in Korea: Claim-Based Follow-Up

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

r e f e r e n C e s

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

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PA R T I V

H E A LT H P O L I C Y R E S E A R C H

P
art IV of this book consists of three chapters that describe how policy issues can be studied
and analyzed. Chapter 8, “Overview of Health Policy Research,” provides an introduction to
the field of health policy research, including definitions and general characteristics. Chapter

9, “Health Policy Research Methods,” illustrates some commonly used methods—both quantitative
and qualitative—for conducting health policy research. Chapter 10, “An Example of Health Policy
Research,” concludes the book with an example of an application of health policy research. The
introductory and illustrative materials presented in this part may stimulate students to delve further
into health policy research at an advanced level. We include health policy research in an introductory
health policy book because, ultimately, solid health policy hinges on solid evidence, and well-conducted
research is a means to sort out the relevant evidence.

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L e a r n i n g O b j e c t i v e s

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2 5 5

L e a r n i n g O b j e c t i v e s

Honesty is the best policy.

—Benjamin Franklin

The advancement and diffusion of knowledge is the only guardian of true liberty.

—James Madison

After completing this chapter, you should be able to

➤ define and understand the characteristics of health policy research,

➤ describe the process as applied to health policy research,

➤ discuss how to communicate findings from health policy research, and

➤ appreciate the challenges in implementing findings from research to health policy
application.

C H A P T E R 8

O V E R V I E W O F H E A LT H P O L I C Y
R E S E A R C H

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th e rand he a lt h in s u r a n C e ex P e r i m e n t

The RAND Health Insurance Experiment was one of the largest and most comprehensive health
policy studies carried out in the United States. The Health Insurance Experiment was a random-
ized experiment conducted between 1971 and 1986; a total of 2,750 families, including more than
7,700 individuals aged 64 or younger, were chosen from six sites across the country to participate
(RAND Health 2018). The study answered two questions regarding the financing of healthcare:

1. If medical care were free, how much more would patients use?
2. Are patient health outcomes affected by the cost of medical care?

The study subjects were randomly assigned to one of five types of health insurance plans:

• Free care
• 25 percent coinsurance
• 50 percent coinsurance
• 95 percent coinsurance
• A health maintenance organization (HMO) that provided care free of charge

The key findings of the study, as noted by Brook and colleagues (2006), were the following:

• Patients who had to contribute toward the cost of medical care used fewer services
than did those who received services free of charge.

• Coinsurance equally reduced patient utilization of highly effective and less effective
medical care.

• The quality of medical care was not significantly affected by coinsurance.
• Overall, coinsurance was not shown to negatively affect patients’ health; however,

medical care provided free of charge brought about improvements in hypertension,
dental and vision health, and other serious conditions. This difference was found to be
the greatest among patients with poor health and low income.

The study’s findings provided input for policymaking related to restructuring private
insurance and strengthening managed care.

C a s e s t u d y 1

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id a h O’s Pr e v e n t i v e he a lt h as s i s ta n C e Pr O g r a m

Providing incentives for positive health behaviors is one approach that can lead patients to use
preventive services, including vaccinations, screening, and other single-visit health outcomes
(Kane, Johnson, and Town 2004; Sutherland and Christianson 2008). Idaho was one of the first
states to implement changes to its Medicaid program under the 2005 Deficit Reduction Act
(PL 109-171) in 2006 (Kenney and Pelletier 2010). Through its Children’s Health Insurance Plan
(CHIP), or the Idaho Health Plan for Children, the state added a preventive health benefit in
2007. The Preventive Health Assistance (PHA) program offers incentives to encourage wellness
activities (such as use of preventive children’s care) and healthy behaviors (such as weight
management through diet and exercise). The children’s wellness benefit promotes the timely
and appropriate wellness visits and immunizations for children in accordance with guidelines
issued by the American Academy of Pediatrics.

Beginning in January 2007, Idaho’s PHA program began to reward parents of children
who received up-to-date well-child care by paying for delinquent premiums (Kenney and Pel-
letier 2010). Although in the initial nine months of implementation additional points could be
issued as vouchers for car seats, bicycle helmets, or sports equipment, eventually points were
used exclusively to offset premiums—current and delinquent. A key to the success of the PHA
program was the early support of the Idaho Legislature.

Idaho’s PHA program has been highlighted as an example of the successful use of incen-
tives to promote health behaviors among patients (Barth and Greene 2007; Blumenthal et al.
2013). Data from Idaho Medicaid officials indicate that loss of coverage due to failure to pay
premiums decreased from a range between 15 and 20 percent before the PHA benefits began
to less than 1 percent in 2009 (Kenney and Pelletier 2010). As reported by Blumenthal and col-
leagues (2013), a quasi-experimental study of the program compared the outcomes of children
with CHIP (who paid a monthly insurance premium) to children with Medicaid (who did not pay a
monthly insurance premium). The following two Healthcare Effectiveness Data and Information
Set measures were considered in the assessment of completion of recommended guidelines:

1. Well-child visits in the third, fourth, fifth, and sixth years of life
2. Adolescent well care visits for patients aged 12 or older

Follow-up years were compared with the baseline period, before any cost sharing or
incentive policies started. As reported by Barth and Greene (2007), in the first year, well-child
visits increased among CHIP children who paid a $10 premium by 36 percent and among CHIP
children with a $15 premium by 49 percent; in the second year, well-child visits increased for
CHIP children with $10 premiums (118 percent increase) and $15 premiums (75 percent increase)
as well as children with Medicaid (13 percent increase). On the other hand, the success of the

C a s e s t u d y 2

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weight management plan was less conclusive. Despite providing Medicaid beneficiaries nearly
$160,000 in incentive payments, less than 1 percent of Idaho Medicaid enrollees were partici-
pating in the weight management program (Blumenthal et al. 2013).

N
ow that we have a basic understanding of the policymaking process and major health
issues in the United States and elsewhere, we continue with an overview of the field of
health policy research (HPR), which contributes significantly to policy development

and improvement. In this chapter, HPR is defined and its unique characteristics highlighted.
The process of HPR is then summarized, followed by a discussion on how to communicate find-
ings from HPR. The chapter concludes by underscoring the challenges in implementing HPR.

de f i n i n g he a lt h PO l i C y re s e a r C h

Health policy research is the process of scientific investigation that applies various health-
related and social science methodologies to formulate and evaluate health policies (WHO
2005). The goal of HPR is to improve the health of populations through needs assessment,
policy and program development, implementation, and evaluation.

Harrison (2001) identifies the following aspects of the policy process that researchers
actively investigate:

◆ How issues come to be seen and defined as problems

◆ How some issues reach policy agendas and others do not

◆ How policies and decisions are made, and why proposed options are rejected

◆ The normative and explanatory theories espoused by researchers

◆ The impact that implementation attempts have on the policy itself

◆ Why certain policies survive whereas others are abandoned

◆ The factors that contribute to successful interventions

Although this book does not make the distinction (i.e., the two terms are used
interchangeably), health policy research is technically different from health policy analysis:
Although both disciplines address a particular health problem, policy research tends to be
conducted in a rigorous and systematic fashion, whereas policy analysis is time sensitive
and relies on existing and current information.

In the second edition of the classic text A Practical Guide to Policy Analysis, Bardach
(2005, 13) elaborates on the multiple roles and tasks of policy analysts:

policy research
A rigorous, systematic
process of scientific
investigation that is
used to formulate and
evaluate policies.

policy analysis
A systematic approach
by which to assess
problems and guide
decision making, based
on existing information,
often with limited
information and time
constraints.

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Policy analysts help in planning, budgeting, program evaluation, program design, program
management, public relations, and other functions. They work alone, in teams, and in
loose networks that cut across organizations. They work in the public, nonprofit, and for-
profit spheres. Although their work is ideally distinguished by transparency of method
and interpretation, the analysts themselves may explicitly bring to their jobs the values
and passions of advocacy groups as well as “neutral” civil servants. The professional
networks in which they work may contain—in most cases, do contain—professionals drawn
from law, engineering, accounting, and so on and in those settings the policy-analytic
point of view has to struggle for the right to counter—or better yet, synthesize—the
viewpoints of the other professionals. Although policy-analytic work products typically
involve written reports, they may also include briefings, slide presentations, magazine
articles, and television interviews. The recipients of these products may be broad and
diffuse audiences as well as narrowly construed paying clients or employers.

As Bardach describes, the work of policy analysts informs the decision making of, and
guides program implementation for, policymakers and professionals in other fields. Policy
analysts often follow a five-step framework to assess problems, as described in the classic
work by Stokey and Zeckhauser (1978): (1) establishing the context and goals for a particular
issue, (2) identifying alternative approaches to addressing the issue, (3) evaluating alterna-
tives and predicting the consequences, (4) valuing the outcomes, and (5) making a choice.

Health policy analysis is performed by a wide array of researchers and research orga-
nizations, including academics, government officials, think tanks, and consulting firms, each
yielding different types of policy analysis products. For example, academic researchers tend
to produce scholarly articles or policy analysis books for publication; government officials
write policy memos or briefs to inform policymakers; and think tanks and consulting firms
issue reports tailored to the needs of particular clients. For example, the not-for-profit think
tank RAND Corporation (the same company that sponsored the research described in Case
Study 1) released a report on the diffusion of health information technology (HIT) in 2005
(Taylor et al. 2005). In this study, RAND performed classic policy analysis by summarizing
the current state of HIT adoption by the US healthcare system, identifying factors predict-
ing its adoption, determining policy alternatives to improve HIT diffusion, discussing the
alternatives, and making policy recommendations regarding HIT (Taylor et al. 2005).

Ch a r a C t e r i s t i C s O f he a lt h PO l i C y re s e a r C h

HPR can be characterized by five main attributes: its nature as an applied field, its ethics
framework, the multidisciplinary input it enjoys, its basis in science, and its focus on
population.

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Applied Field
HPR is an applied field in which objectives are largely determined by priorities within health
systems and concerns of society. To illustrate this point, the pioneering researcher Anderson
(1985, 237) wrote, “Research in the field of health services has generally stemmed not from
curiosity, but from a need to have facts on which to base organization, administration, and
legislation and this search for facts has been frankly for public policy purposes, to provide
a factual basis for a given policy.”

HPR aims to address problems related to specific populations (e.g., pregnant women,
the elderly, migrants) and to enhance health interventions at local, national, and international
levels. Findings from HPR are used by clinicians, healthcare administrators, and formulators
of healthcare policy, and researchers must often frame findings in a way that will be useful
for various stakeholders.

The objectives of researchers and policymakers are not always complementary. This
view is echoed in the early twentieth-century work of Lavis and colleagues (2002), who used
organizing frameworks from three disciplines—organizational behavior and management
research, knowledge utilization, and political science research—to study the role of HPR in
public policy formulation in Canada. They found that interactions between researchers and
policymakers can affect the amount of influence research has on policymaking.

For example, small-scale, content-driven pol-
icies (e.g., HIV prenatal testing, needs-based fund-
ing formulas) appeared to be particularly amenable
to recommendations from research findings, but
larger-scale policy decisions (e.g., broad healthcare
financing schemes) seemed less affected because of
various conflicting and influential political factors.

The practical application and problem-
solving orientation of HPR must remain balanced
with theory-driven standards. Theory and systematic
methodologies provide the framework within which
healthcare problems are modeled. Health policy
researchers should ensure that their techniques and
the findings they uncover are generalizable beyond
specific populations or settings to properly assess the
quality of research and corresponding findings. For
an example of a program that uses multiple research
strategies, see the For Your Consideration box titled
“The Michigan Maternal Infant Health Program.”

Exhibit 8.1 shows the policymaking pro-
cess as developed by Longest (2016). Health policy
research and analysis may occur at several points

FOR YOUR CONSIDERATION
The Michigan Maternal Infant Health Program

The Michigan Department of Health and Human Services evaluates
the Maternal Infant Health Program (MIHP) using multiple strate-
gies, including administrative data analyses, certification reviews
to ensure consistent fidelity to the program model, and an inde-
pendent, evidence-based evaluation conducted by Michigan State
University (MSU) research partners (MDHHS 2018). Because MIHP is
a population-based program, a randomized trial is not feasible (i.e.,
all Medicaid-insured pregnant women are eligible for the program).
Instead, MSU researchers use a quasi-experimental design. They
created matched comparison groups with baseline equivalence on
a variety of characteristics. Subjects enrolled in MIHP were matched
to nonparticipants based on similar characteristics.

MIHP has been shown to reduce the risk of adverse birth out-
comes in Medicaid-insured women, with benefits especially noted
for African-American women who are at higher risk for adverse
outcomes.

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00_Shi (2374) Book.indb 261 11/21/18 10:55 AM

I n t r o d u c t i o n t o H e a l t h P o l i c y2 6 2

throughout the policy process. For example, HPR often comes into play as the life of a policy
begins—at the policy formulation stage, during which problems and possible solutions are
evaluated against the current political and social climate. Researchers may investigate successful
(or failed) policies to inform policymakers or offer suggestions for the direction of future efforts.
As mentioned in earlier chapters, for a policy to be fully developed, there must be a window of
opportunity, which is determined by the current landscape of social, economic, political, ethi-
cal, and legal factors. Regardless of the amount and quality of evidence gathered by researchers,
this window of opportunity must be present for successful acceptance and implementation.

After a policy is implemented and appropriate regulatory rules are in place for it to
function, policy researchers may conduct evaluations to assess whether the policy and associ-
ated programs are meeting objectives and the needs of target populations. Policy researchers
may also compare the current policy’s performance against existing or past efforts.

On the basis of findings from policy researchers or of feedback from individuals,
organizations, or interest groups, a policy may enter the policy modification stage, during
which it is further evaluated and assessed for impact. Thus, the policy process is a feedback
cycle that is constantly informed by policy research.

Framework of Ethics
Ethical standards dictate the proper conduct of research, including accommodation of the
interests of its human research subjects. Health policy analysts must consider all relevant
ethical issues when developing research plans to ensure the safety and rights of study par-
ticipants. The organization that sponsors the research typically has an institutional review
board (IRB), whose responsibility is to review the study design before the research begins
to ensure that researchers have thoroughly considered all ethical implications of their work
and to consider potential legal implications if ethical negligence were to occur.

For example, study designs should not place participants at risk for potential physi-
cal or psychological harm. Researchers must seek voluntary participation and disclose any
associated risks. Ethical standards for research are particularly important to follow when
dealing with “captive audiences,” such as students or prisoners.

Throughout the duration of the study, the privacy of subjects should be protected
through anonymity (i.e., participants remain anonymous throughout the study, even to the
researchers) or confidentiality (i.e., identifying information is not made available to anyone
who is not directly involved in the study).

An important ethical consideration for health policy researchers is to avoid succumbing
to the prior beliefs of either the sponsors or the users, especially when the users may influence
the career pathways of the researchers. Providing selected evidence to justify their previously held
beliefs could gain researchers a short-term advantage but would eventually tarnish the researchers’
reputations and, more seriously, undermine the policy that the research is supposed to enlighten.

institutional review
board (IRB)
A committee that
examines the ethical
implications of research
to protect study subjects
from physical or
psychological harm.

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Multidisciplinary Approach
HPR incorporates a wide variety of biological and social sciences in its approach to find-
ing the best solutions to complex health-related problems—particularly disciplines used in
problem solving and public decision making, as described in a seminal paper by Bice (1980).
In fact, many health policy researchers are trained in social science disciplines, including
sociology, economics, law, psychology, and political science, and they often incorporate the
theories and methods from these areas when addressing health policy concerns.

Knowledge from the biological sciences is often applied in the beginning stages
of policy analysis, during which an existing health issue or program must be analyzed.
As described in a seminal work by the Institute of Medicine (IOM 1979), the biological
sciences include the study of biological determinants, risk factors, and consequences of
health processes—as well as methods and techniques to characterize such phenomena—to
contribute to the understanding of human populations. Examples of research that involves
the biological sciences include the study of the prevalence or incidence of a given condition
and the genetic makeup of a certain population (Mozaffarian 2016; Norton et al. 2016).

In the social sciences, health policy researchers benefit from knowledge of demography,
or population studies. Facts about population size, composition, and growth rates are needed
for the early stages of program planning. Mapping technologies can be particularly helpful
for health policy researchers (Chambers, Chenoweth, and Neumann 2016). For example,
using data on hospital patients and estimates of population size, local health researchers can
compute hospital discharge rates for their local geographic or service areas. Such informa-
tion might be used to guide funding decisions and allocation of resources to areas of need.

Economics is another area of expertise from the social sciences that is critical to health
policy research, particularly with regard to cost–benefit and cost-effectiveness analyses of
healthcare interventions (Neumann et al. 2016). Findings from health economics–related
research enable decision makers to best allocate limited resources.

Finally, the behavioral sciences are crucial to HPR, drawing from epidemiological stud-
ies that identify behavioral determinants of illness or risk factors, such as diet and smoking
habits, and examining the social and psychological components of these determinants (Koon,
Hawkins, and Mayhew 2016).

Although many biomedical and social science disciplines are incorporated into HPR,
true multidisciplinary research is uncommon. Researchers from diverse fields do not often
collaborate when conducting health-related research that could affect policy. For example,
economic theory and methodologies have been used in research on prospective payment
systems to assess the systems’ impact on hospital cost containment, but knowledge that is
often closely related—such as research from the behavioral sciences about patient charac-
teristics or research from population studies on the community—is not usually considered.
Such fragmentation of knowledge and disciplines restricts the impact that research toward
problem solving and decision making can have on policy solutions.

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Scientific Basis
Theories from the social sciences and methodologies used in empirical research can provide
guidance for HPR and include problem conceptualization, data collection, analysis, and
interpretation. Incorporating scientific methodologies can also help health policy researchers
maintain objectivity about their work.

Although such methods could be useful to health policy researchers, the application
of scientific principles is often constrained due in part to the complex nature of health-
related problems. HPR often examines specific settings and populations; thus, findings from
a particular study are not always generalizable. For example, the policy decisions that apply
to healthcare delivery in rural areas are usually drastically different from those that emerge
in urban areas in terms of access issues and financing (Humphreys et al. 2009).

The types of data available often impose limitations on HPR, which must rely on
information from existing population surveys, records, and documents as well as direct
observation. Seeking information beyond these sources is usually outside the scope of the
study design because it can be an expensive and time-consuming activity. For example,
health policy researchers studying the effect of technological advances on healthcare spending
among cancer patients may be limited to the data contained in the annual series of national
healthcare expenditure estimates produced by the Centers for Medicare & Medicaid Services
(i.e., annual healthcare expenditures by type of service and source of funding)(CMS 2018);
reports from the National Health Care Survey (i.e., national estimates of the prevalence of
illness and the use of various health services)(NCHS 2011); or the Medical Expenditure
Panel Survey (Stagnitti and Carper 2014), which could be outdated or not fully applicable
to the researchers’ populations of interest.

The gold standard for scientific research is the randomized controlled trial, in which
research subjects are randomly assigned to an experimental group or a control group. How-
ever, this experimental design is often incompatible with HPR because researchers must
consider determinants of health and environmental factors beyond those captured under
strict experimental conditions. Ethical standards of HPR do not allow experimental research
on humans. Furthermore, the effects of bias introduced into study results because of the
inability to control outside influences can skew findings. To address these concerns, health
policy researchers typically use quasi-experimental designs, cohort studies, longitudinal
analyses, survey analyses, and multidisciplinary approaches (discussed later in this book).

Population Focus
HPR differs from other health-related research in that it focuses on healthcare solutions
for the population rather than for the individual. In contrast, clinical research primarily
focuses on the efficacy of the preventive, diagnostic, and therapeutic services applied to
individual patients (IOM 1979). In addition, biomedical research is largely concerned with

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the conditions, processes, and mechanisms of health and illness at the biological level within
the human body (Frenk 1993).

Epidemiological research investigates questions at the population level, focusing on
frequency distribution and determinants of health and disease among populations. In other
words, epidemiological research begins with a specific condition and studies its various
determinants. Bioepidemiology, clinical epidemiology, decision analysis, and technology
assessment are some examples of disciplines that are similar to HPR in that they also deal
with connections and interfaces among the major types of health-related research.

th e Pr O C e s s O f he a lt h PO l i C y re s e a r C h

HPR or analysis can be undertaken in a number of ways. The most widely used approach
is a rationalist model (see exhibit 8.2), similar to the five-step framework outlined earlier
in this chapter, in which problem definition leads to the identification and evaluation of
alternatives followed by policy implementation. (Chapter 9 provides a more detailed discus-
sion of this approach.)

A more formal approach to conducting HPR is presented in exhibit 8.3, which dis-
plays the steps involved in systematically conducting health policy research. This approach
is similar to that followed when conducting health science–related research. Exhibit 8.4
breaks down these steps into their critical elements. Although the sequencing is not fixed,
the stages are interdependent, and some stages must be conducted before others are initiated.

exhiBit 8.2
The Process of
Health Policy
Analysis Under the
Rationalist Model

Implement the
preferred policy

Determine
evaluation criteria

Identify
alternative policies

Select the
preferred policy

Evaluate alternative
policies

Define the problem

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For example, an adequate hypothesis cannot be formulated without a proper under-
standing of the underlying subject matter. Similarly, the early steps of the research process
must be executed properly to achieve a successful study. Writing an untestable hypothesis
and securing an inadequate sample are two examples of execution errors that prevent suc-
cessful completion of a study.

CO n C e P t u a l i z at i O n

The conceptualization stage of the research process requires the researcher to understand
the general purpose of the research, determine the specific research topic, identify theories
and literature relevant to the topic, specify the meaning of the concepts and variables to
be studied, and formulate general hypotheses or research questions. Research hypotheses
differ from research questions in that hypotheses suggest relationships between the variables.

Theoretical research generally involves the testing of hypotheses developed from
theories that are intellectually interesting to the researcher, whereas research questions
typically arise from current social problems. Applied policy research focused on current
social problems generally specifies its purpose through research questions. Hypotheses may
be formulated if current knowledge (from theories and evidence) indicates an anticipated
direction of the relationships among the variables of interest.

exhiBit 8.3
Steps in

Conducting Health
Policy Research

1. Conceptualization

2. Groundwork

4. Design

5. Sampling 6. Measurement

7. Data collection

8. Data processing

9. Data analysis

10. Application

3. Method

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exhiBit 8.4
Key Elements
of the Research
Process Steps

Sampling
– Random/probability (simple, systematic,
stratified, cluster)
– Nonrandom/nonprobability (convenience,
quota, purposive, snowball)
– Sample size

Data collection
– Available versus empirical
– Published versus unpublished
– Instrument versus observation
– Impact on research projects
– Impact on respondents
– Impact on interviewers
– Impact on instrument
– Choices among methods
– Improving response rate

(continued)

Measurement
– Levels (nominal, ordinal, interval)
– Validity (construct, content, concurrent,
predictive)
– Reliability (test-retest, split-half,
interrater)
– New measures and validation

Conceptualization
– Research aims and objective
– Problem statement and significance
– Literature and theory
– Conceptual framework
– Research hypotheses and/or questions

Design
– Choices of methods
– Validity threats
– Designs and pitfalls

Groundwork
– Data
– Funding
– Proposal
– Infrastructure

Methods
– Research review
– Secondary analysis
– Qualitative research
– Experiment/quasi-experiment
– Survey
– Evaluation
– Longitudinal study

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The conceptualization phase completes the development of a conceptual framework,
which is a preliminary model of the problem under study that depicts relationships among
critical variables of interest and between variables and concepts of interest. This phase, which
is founded in literature and existing theory, helps researchers synthesize and guide the course
of research and its subsequent analysis.

Conducting literature review is a critical step within the conceptualization com-
ponent. Literature review informs researchers about the current state of the study on the
topic as well as the existing limitations in the body of research. Findings from literature
review can be used to direct research efforts to areas that need to be explored or to those
with conflicting results.

In addition to helping researchers narrow and refine a topic, literature review facilitates
the identification of theories and provides guidance in the formulation of hypotheses to be
tested. As a result, researchers do not need to confine themselves to the generally accepted
practices of their discipline when searching for relevant theories. They can either extend
existing theories in the literature or use alternative approaches and theories to stimulate their
research and generate more thorough findings than they might otherwise.

Another benefit of literature review is that it helps researchers identify relevant study
and control variables to be included in the analysis. Exhibit 8.5 illustrates this process. The
initial topic of interest is represented by the variable Y, and researchers are interested in

conceptual framework
A preliminary model
of the problem under
study that depicts
relationships among
critical variables of
interest and between
variables and concepts
of interest.

exhiBit 8.4
Key Elements

of the Research
Process Steps

(continued)

Data processing
– Questionnaire coding
– Code book
– Data entry and merging
– Data cleaning
– Data exploration

Data analysis
– Univariate statistics
– Bivariate statistics
– Multivariate statistics
– Hypothesis testing

Application
– Communicating
– Publishing
– Implementing

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finding out the causes of Y. The variable X is identified as a potential cause on the basis
of the researchers’ experience or the observed evidence; however, researchers have limited
experience with Y and thus are unable to consider all potential causes of Y. Literature review
helps identify not only the potential causes (i.e., variable Xs) but also other potential fac-
tors (variable Zs). Furthermore, literature review may suggest different dimensions of the
topic (variable Ys). In short, literature review enables researchers to operationalize abstract
concepts—a prerequisite for empirical research.

Literature review also suggests pertinent research design, procedures, and analyses by
indicating how other researchers have addressed a given topic. Researchers may use a previ-
ous investigator’s method, revise the research design, or even replicate an earlier study. (See
the Learning Point box titled “Conducting a Systematic Literature Review” for a summary
description of the systematic research literature review process.)

Researcher’s initial area of interest:

? Y

Researcher’s initial focus of study:

X Y

Researcher’s refined focus after performing systematic literature review:

Xs, Zs Ys

exhiBit 8.5
Looking for
Variables Through
Literature Review

LEARNING POINT
Conducting a Systematic Literature Review

1. Identify the Topic
The choice of a topic for review is influenced by the interests of the policy community. A
topic is probably not suitable for independent review unless sufficient research activity
already surrounds it.

2. Prepare a Coding Sheet
After the topic is identified and refined, a coding sheet should be constructed to collect
relevant information from articles to be reviewed. A coding sheet enables the researcher
to collect all needed information during the first reading. The preparation of a coding
sheet is even useful for reviewing a small number of studies because the information
collected will assist the investigator in analyzing and reporting those studies.

( c o n t i n u e d )

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LEARNING POINT
Conducting a Systematic Literature Review (continued)

The information to be collected in the coding sheet should be determined on the
basis of the preliminary review and the strategy to be adopted in analyzing and synthe-
sizing studies. Generally, any information that may be analyzed and used in the review
should be collected at the time of the review, because it is better to collect too much
information than to have to reread the published studies.

The general categories of information related to empirical research in which an
investigator is likely to be interested include a study’s background, design, measure-
ment, and outcome characteristics.

In the background category, the source indicates the media or information channel
from which a study is retrieved.

In the design category, the general categorization as presented may not be sufficient
to generate information. Researchers may then include additional design characteristics
(e.g., whether restrictions were placed on the types of individuals sampled in the original
study, when and where the study was conducted, whether time series or longitudinal
designs were used).

In the measurement category, investigators may document the use of particular
scales, available instruments, and specific features of the analytic models (e.g., number
of variables used, types of measures implemented for the same construct, tests of
interaction terms and nonlinearity).

In the outcome category, if more quantitative analysis is envisioned, precise statistical
information related to study results may be recorded. Examples include means, standard
deviations, sample sizes for each comparison group (to be used for effect size calcula-
tion), association between variables (e.g., correlation coefficient), values of inferential
test statistics (e.g., c 2, t ratio, F ratio), and the strength of an F ratio (e.g., regression, R2).

It bears reemphasizing that the construction of a coding sheet is the result of, rather
than a prelude to, preliminary review. The development of a coding sheet forces research-
ers to think ahead about the review and analysis strategy and to be precise in their
approach to gathering the information.

3. Search Research Publications
Five major sources of literature are available for reviewers to retrieve: (1) books; (2) jour-
nals, including professional journals, published newsletters, magazines, and newspapers;
(3) theses, including doctoral, master’s, and bachelor’s degree theses; (4) unpublished
work, including monographs, technical reports, grant proposals, conference papers,
personal manuscripts, and other unpublished materials; and (5) the internet, including
institutional and individual websites.

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Policy-oriented reviews summarize current knowledge of a topic to draw out the
policy implications of study findings. Such reviews require knowledge of the major policy
issues and debates and common research expertise. (See the For Your Consideration box
titled “Steps in Synthesizing Policy Research Studies” for a way to make the findings relevant
to your work.)

LEARNING POINT
Conducting a Systematic Literature Review (continued)

4. Synthesize Research Publications
The relationship between synthesizing and coding studies is a close one. Before studies
can be synthesized, they need to be properly coded. The proper coding of studies relies
on knowledge about how the studies will eventually be analyzed and synthesized. Thus,
although analysis and synthesis are performed much later in the literature review process,
the strategy needs to be delineated before the coding sheet is designed.

Synthesizing research entails categorizing a series of related studies, analyzing and
interpreting their findings, and summarizing those findings into unified statements about
the topic being reviewed.

FOR YOUR CONSIDERATION
Steps in Synthesizing Policy Research Studies

1. Compile an inventory of public policies that might address the health problem under
study.

2. Determine the policy that will be the focus of your synthesis.
3. Detail the sequence of effects that you expect will link the policy to the problem.
4. Synthesize data on the impact of this policy in areas of previous implementation (e.g.,

effectiveness, unintended effects, effects related to equity) and on related issues (e.g.,
cost, feasibility, acceptability).

5. Consider the data drawn from the literature review in terms of the present context
under study.

Source: Adapted from NCCHPP (2010).

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gr O u n d w O r k

In the groundwork stage, the researcher identifies relevant data sources, explores potential
funding, develops a research plan or proposal by which to obtain funding, and makes orga-
nizational and administrative preparations to carry out the research.

Choosing a data source for policy research can be a difficult endeavor; policy-related
evidence is not as clearly available as evidence from experimental research in the life sciences.
For example, a researcher planning to investigate the effects of tobacco control policies might
need to examine economic data on tobacco taxes as well as health outcome information
from local healthcare systems. Those engaged in policy research often use a range of data
types, including quantitative, qualitative, experimental, and descriptive data. Although it
is difficult to fully assess the quality of data sources that might be used for policy research,
investigators should weigh the positive and negative factors associated with using each
relevant data source.

me t h O d s

After completing the groundwork stage, the researcher must choose the appropriate research
methods with which to conduct the study. Many methods are available for researchers under-
taking policy analyses, such as research review (e.g., meta-analysis), secondary analysis (e.g.,
research analysis of administrative records), qualitative research (e.g., focus group, in-depth
interview, case study), survey methods (e.g., longitudinal study), experimental methods,
and evaluation research. Each method has its own strengths and weaknesses, and the best
strategy often is a combination of methods.

There are three categories of research methods: exploratory, descriptive, and explana-
tory. The appropriate application of the research method varies according to these categories.
Researchers should carefully consider the field of supporting evidence, research questions,
population of interest, and funding and administrative resources prior to choosing one or
more methods.

Exploratory research methods are used to learn more about a little-known topic or
to test new research methods. Examples of exploratory research include qualitative efforts,
such as case studies or focus groups, observations, and interviews. Although it is among the
least expensive research methods (due, in part, to the frequent use of small sample sizes),
exploratory research is also considered the least rigorous, and findings may not be generaliz-
able to other contexts or research questions. However, exploratory research has been increas-
ingly used in the scientific field as a methodology through which to provide context-rich
information that can inform further, more rigorous research study design.

Descriptive research methods are used to investigate study characteristics among sub-
jects; one example is the administration and analysis of survey data. Although descriptive

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research methods are considered more rigorous than exploratory methods, they can be
expensive to conduct because they often require large sample sizes.

The final type of research method, explanatory research, includes experimental stud-
ies—considered the gold standard among research study methods—as well as case control
studies and longitudinal research. These methods are among the most rigorous in design, and
thus their findings have the greatest level of generalizability compared with other research
methods. Explanatory research can be expensive, however, requiring large sample sizes and
complex statistical analysis.

de s i g n

After the research problem has been identified, the researcher develops an overall framework
for investigation. Research design addresses the planning of scientific inquiry by anticipating
subsequent stages of the research project, including choosing the research method; identify-
ing the unit of analysis and the variables to be measured; establishing procedures for data
collection; and devising an analysis strategy. Potential implementation strategies must also
be considered because much of the value of HPR lies in using research to bring effective and
targeted programs and resources to populations in need (Atkins and Kupersmith 2011; Xiu-xia
et al. 2015). Problems that arise in the future would necessitate changes to the research plan.

sa m P l i n g

In the sampling stage, the researcher must clearly define the population of interest in the
study. It is not feasible to study every individual in the population; thus, a sample must be
taken to draw conclusions about that population.

Four types of sampling methods—often referred to as probability sample designs
because each subject in a sampling frame has a known probability of being selected for the
sample—incorporate varying degrees of random selection:

1. Simple random sampling is the most basic method, in which every subject in the
sampling frame has an equal probability of being selected.

2. Systematic sampling is a bit more complicated. Every kth subject from the
sampling frame is selected, with the interval between selected subjects (k)
having been determined by the researcher (e.g., every fifth subject is selected
from the sampling frame).

3. Cluster sampling involves the distribution of subjects in the sampling frame into
heterogeneous groupings called clusters, which are then randomly selected to

sampling frame
The population from
which a sample is
selected.

random selection
Methods by which
subjects from a sampling
frame are chosen to
create a representative
sample, such that
each subject has a
known probability of
being selected and the
selection process is
not biased against any
particular individual in
the sample.

heterogeneous
Consisting of different
types; a term used
to describe a sample
or a population
composed of subjects
that have dissimilar
characteristics.

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comprise a sample of clusters. Cluster sampling can be a cost-effective way to
conduct research over a broad geographic area.

4. Stratified sampling is similar to cluster sampling in that subjects from the
sampling frame are divided into groups; however, these groups (known as strata)
are homogeneous. Simple random sampling is used within each of the chosen
strata to select a final sample. Stratified sampling is used to ensure that the
sample is representative of the population about which a researcher hopes to
draw inferences in terms of characteristics of interest.

See exhibit 8.6 for an evaluation of probability sampling designs.
A number of nonprobability sampling methods are also available, such as convenience

sampling, quota sampling, purposive sampling, and snowball sampling. The probability
of subject selection in a sample is unknown when these methods are used. Although non-
probability sampling methods can be less expensive to employ than probability sampling
methods, nonprobability methods cannot be used to make inferences about a population
and are subject to research bias.

me a s u r e m e n t

The measurement, or operationalization, stage involves devising measures that link concepts
of interest to empirically observable events or variables. The measurement validity and
measurement reliability should also be ascertained. Because survey research is frequently

homogeneous
Consisting of the same
type; a term used to
describe a sample or a
population composed
of subjects that have
similar characteristics.

measurement validity
The extent to which
the measurement tool
accurately measures the
intended concepts.

measurement reliability
The extent to which
results are similar if the
measurement tool is
reapplied in a consistent
way.

Simple
random

sampling
Systematic
sampling

Cluster
sampling

Stratified
sampling

Precise Highest Moderate Lowest Highest

Able to capture groups of interest No No Yes Yes

Cost-efficient No No Yes Yes

Requires knowledge of population
in advance

No No Yes Yes

Allows for disproportionate
sampling

No No Yes Yes

Involves complex data analysis No No Yes Yes

exhiBit 8.6
Trade-Offs of

Commonly Used
Random Sampling

Methods

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used, health policy researchers should be knowledgeable of the general guidelines and specific
techniques for writing survey questionnaire instruments.

data CO l l e C t i O n

Data for HPR can come from a variety of sources, typically categorized as primary sources and
existing sources (see exhibit 8.7). The research method chosen often influences the method
used for data collection. Two commonly used primary data-collection tools are interviews
and administration of questionnaires. Primary data are collected by researchers for the pur-
pose of their specific study, so primary data tend to be more relevant and hence more valid
than existing data. Researchers can design the questions they use to gather primary data
specifically according to the study objectives, whereas existing data from another study may
not contain all of the information desired for analysis. However, existing, or secondary, data
are widely used in HPR because they tend to be more generalizable and are more efficient
in terms of saving time and cost than primary data.

data Pr O C e s s i n g

Generally, data in their raw format are difficult to analyze and interpret. Before data can
be interpreted, the researcher must transform or process the data into a format that can be

exhiBit 8.7
Health Policy
Research Data
Sources

Health policy
research data

Primary
sources

Existing
sources

Unpublished (research
institutions, researchers)

Observation

Questionnaire
instrument

Published (library)

Self-
administered

Administered
by others

Nonparticipant

Participant

Mail

Group

More
structured

Less
structured

Face-to-face

Telephone

Focus group
study

In-depth
interview

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analyzed. For example, the data may need to be converted into numerical values or “cleaned”
to identify data-entry errors. In addition, the researcher may need to identify missing data
and account for them.

data an a ly s i s

After the raw data have been processed, they are ready for analysis. The researcher employs
statistical procedures to manipulate the processed data and draw conclusions about the
study population.

aP P l i C at i O n

The final stage of research deals with the interpretation and use of research. Applying
research findings to scientific theory and policy formulation can be the most satisfying step
in the research process (see detailed discussion in the next sections). Researchers should also
provide recommendations for further research on the subject and outline limitations that
may be avoidable in future studies.

CO m m u n i C at i n g he a lt h PO l i C y re s e a r C h

The way in which evidence is disseminated depends on the intended audience. Potential
audiences may be divided into three groups: the research community, stakeholders (e.g.,
funders, policymakers), and the public. The research community includes scientists or others
who share similar research interests. Stakeholders are those who provide funding or have a
key role in implementing research findings. The public is the population at large affected
by the findings of the research who are neither researchers nor stakeholders. Investigators
should adapt and tailor their communications to specific audiences to maximize compre-
hension and acceptance.

re s e a r C h CO m m u n i t y

When the intended audience is part of the research community, certain assumptions can be
made about prior knowledge. Research findings may be summarized, rather than explained
in great detail, and technical terms may be used. Researchers must also be as transparent as
possible, clearly explaining methods and the reasons behind them. Transparency is even more
important regarding studies that employ modeling because the findings that a researcher
chooses to include or omit in a study can have an enormous impact on the results (Padula,
McQueen, and Pronovost 2017; Søgaard and Lindholt 2011).

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The most common way of communicating results to the scientific community is by
publishing an article on the research in a peer-reviewed scientific journal. Prior to submitting
a paper for publication, researchers should be aware of the manuscript preparation guidelines
of the journal in question. Because it often takes months from the time of submission for an
article to be published, researchers often seek out other ways to publicize research findings.

Professional conferences are another common way to present findings. Professional
associations generally hold annual conferences that offer members the opportunity to pres-
ent their research. Conferences are an excellent outlet because it is often much easier to get
a paper selected for a conference than to have an article accepted by a journal for publica-
tion and because results can be presented sooner than in a journal. Conferences also enable
the researcher to receive comments, suggestions, and criticisms that may be useful for later
submission of a research article to a journal. However, certain journals prohibit content
from being released prior to publication, and researchers may need to show what they have
presented when submitting articles for review.

Working papers and monographs are a third way in which results can be presented
to the research community. The implication of calling a document a “working paper” is that
a journal article is in progress. A working paper is typically circulated among those with the
same research interests, with an implicit request for comments and suggestions. Because
professional reputations are not at stake when distributing a working paper, tentative analyses
and interpretations can be included. Similar to working papers, which are preludes to journal
articles, monographs are drafted in preparation for writing books. Monographs are usually
written for large, complex projects and may also be circulated among peers for suggestions.

sta k e h O l d e r s

When stakeholders are the intended audience, investigators cannot assume any prior knowl-
edge of the research subject and terminology. Stakeholders include funders or sponsors, people
affected by the research results, and primary users of the research results. It is important
to consider how to best translate research findings for these distinct kinds of stakeholders
(Fontaine et al. 2018; Milstein, Wetterhall, and CDC Evaluation Working Group 1999;
Montague et al. 2016).

A research proposal is often the first point of contact a researcher has with the spon-
sor or funders. A research proposal is written by the investigator to convince a potential
sponsor of the investigator’s qualifications for performing research and to answer questions
that are important to a sponsor or funder.

Perhaps the most common means of communicating with stakeholders is through
technical reports required by funders and sponsors. Reports often serve the additional
purpose of informing policymakers, administrators, and other groups interested in study
results. The report should directly address the questions posed by sponsors or funders and

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be consistent with the intended use and audience of the research. If applicable, it also may
summarize the ways in which the research has advanced scientific knowledge.

Stakeholders such as sponsors and policymakers may also be invited to symposia
where the research and its implications for decision makers are discussed. Symposia provide
a forum where the research and its importance to the stakeholders can be fleshed out.

Pu B l i C

When the intended audience is the general public, investigators can rely on the mass media
to publicize significant research findings. In this instance, presentations to the press should
avoid technical language and clearly explain any key terms or concepts. No assumptions
should be made about the audience’s existing knowledge of the research topic.

Fact sheets and issue briefs are other ways to synthesize and communicate research
findings to the public. Many government and private research agencies regularly disseminate
summaries of major studies or analyses this way. For example, the Henry J. Kaiser Family
Foundation has produced periodic issue briefs and fact sheets on such topics as healthcare
disparities, global health policy, Medicaid, Medicare, the uninsured, private insurance, and
women’s health policy (KFF 2018).

Researchers must expend more effort to educate the public on HPR. With improved
dissemination of research results, members of the public may take more notice of healthcare
findings and implement policy research into their healthcare decision making.

In some cases, the use of community-based participatory research—a partnership
approach that equitably involves community members, local organizations, and researchers
in all aspects of the research, and in which all partners contribute expertise and share decision
making and ownership—can lead to the dissemination of research to the public, as noted in
the classic work by Israel and colleagues (1998). For example, a study of the cardiovascular
risks among Mexican Americans living along the Mexico–United States border not only
collected data on the cardiovascular risks of the population but also informed these subjects
of the study results through the community-based researchers (Balcazar et al. 2009). Another
study showed that public libraries could be an important avenue in community-based par-
ticipatory research to reduce the burden of cancer in medically underserved communities
(Rapkin et al. 2017).

For researchers conducting studies in the field of health services, the ultimate chal-
lenge is to see their findings through to implementation in policy decisions. Because of the
applied nature of HPR, a major goal is to apply disciplinary knowledge to solve current and
emerging health-related problems. The synthesis and dissemination of HPR have played, and
continue to play, an important role in health policy formulation (Ginzberg 1991; Price et al.
2016). Historically, HPR influenced early health policy formulation, implementation, and

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clinical practice with respect to HIV/AIDS-related illness and primary care (AHRQ 1990;
National Center for Health Services Research and Health Care Technology Assessment 1985).

im P l e m e n t i n g he a lt h PO l i C y re s e a r C h

The impact of HPR on health policy has increased over time. For example, research identifying
large gaps in access to healthcare has compelled the formulation of policies aimed at healthcare
reform to reduce these gaps. The Robert Wood Johnson Foundation’s Covering Kids and Fami-
lies (CKF) initiative represents an elegant integration of HPR and practice (Morgan, Ellis, and
Gifford 2005). The CKF initiative aimed to improve states’ reenrollment processes for children
and families covered by Medicaid and CHIP. An evaluation of the initiative found that it had a
positive impact on reenrollment in 45 states and allowed states that have succeeded in improv-
ing their reenrollment processes to advise struggling states (Morgan, Ellis, and Gifford 2005).
Workplace health promotions based on research evidence have also been proven successful
(see the For Your Consideration box titled “Evidence-Based Workplace Health Promotions”).

FOR YOUR CONSIDERATION
Evidence-Based Workplace Health Promotions

Based on a benchmark study in workplace health promotion supported by the Robert Wood
Johnson Foundation, the Promoting Healthy Workplaces project (Institute for Health and
Productivity Studies 2016; Kent et al. 2016), the following characteristics of best and promising
practices in workplace health promotion programs are summarized:

• They create and sustain a culture of health (a physically and socially supportive envi-
ronment and active employee involvement).

• They apply strategic communications (effective strategic communications are
designed to educate and motivate employees and build trust).

• They set goals with reasonable expectations.
• They have leadership commitment.
• Their program design is employee driven (i.e., tailored to employees’ needs and

wants, includes employee ownership).
• They feature “smart” incentives, especially intrinsic motivation—the key for health

behavior changes.
• They include screening and triage programs.
• They measure program impact by leveraging available administrative data.

( c o n t i n u e d )

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FOR YOUR CONSIDERATION
Evidence-Based Workplace Health Promotions (continued)

Following are two examples of successful workplace health promotion programs based
on research evidence.

Johnson & Johnson
Johnson & Johnson is a large multinational corporation active in more than 60 countries and
is regarded as a pioneer in developing health promotion programs. Johnson & Johnson intro-
duced its first workplace health promotion program in 1979, and the program has continued
to evolve up to today because of its demonstrated positive effects. For example, Johnson &
Johnson experienced average annual growth in total healthcare spending that was 3.7 percent
lower than that of comparable large companies. Average annual per employee savings were
$565 in 2009 dollars, producing a return on investment of $1.88 to $3.92 saved for every dollar
spent on the program (Carls et al. 2011; Henke et al. 2011; Ozminkowski et al. 2002).

The key success factor was that the organization provided various health promotion programs
(e.g., biometric screening; healthy coaching; on-site pharmacy, health clinic, and fitness center)
to meet employees’ diverse needs and interests. Making these programs convenient helped
employees make healthy choices more easily. Leadership communicated consistent messages
to support full integration of health into the way the organization operated. The program had a
strong system to measure and evaluate its effects, through internal self-assessment annually as
well as external evaluation every three years (Institute for Health and Productivity Studies 2016).

Next Jump
As reported by the Institute for Health and Productivity Studies (2016), Next Jump is a small
e-commerce company in New York City with about 200 employees. It developed a workplace
wellness program internally with direct feedback from employees (i.e., without hiring outside
vendors), thus giving them a sense of engagement and ownership throughout the process.
Leadership support was another key factor in the success of the program; the company’s CEO
was directly involved and committed to creating a healthy company culture. At the time the
program began, Next Jump had no on-site fitness center, so the CEO brought in trainers to
conduct fitness classes in the company’s conference room. After the company’s own fitness
center was built, the CEO routinely attended fitness classes there with the employees. Next
Jump also restructured the physical environment to encourage consumption of healthy food.
Although the small company lacked a cafeteria, it created a healthful food environment by
replacing candy jars with fresh fruit and nuts, and management stocked the on-site refrigera-
tor with free healthy snacks, such as yogurt. The company also set up specific but attainable
health promotion goals for employees. Specifically, employees at Next Jump were encouraged
to work out twice a week for 20 minutes each time. More than 90 percent of the employees
met this goal (Institute for Health and Productivity Studies 2016).

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Research is often dismissed or improperly reflected in policy efforts, leaving inves-
tigators frustrated. The remainder of this section identifies barriers to the implementation
of research in policy and some ways to overcome these barriers.

re l e va n C e

Sometimes, a scientifically significant study may not have immediate or obvious policy sig-
nificance. Further investigation may be necessary to make such a study more relevant from
both a clinical and a health policy perspective. Studies that translate scientific discoveries
into practical (i.e., clinical) applications are termed translational research (see the Learning
Point box titled “Phases of Translational Research”).

ty P e O f st u d y

Adoption of research findings by policymakers and practitioners is also influenced by the
type of study conducted. Research with a clinical focus is typically adopted more quickly
than that focused on organization because of the importance that evidence plays in clinical
practice. Research related to organization is often slowly adopted because organizational

LEARNING POINT
Phases of Translational Research

The phases of translational research are summarized as follows (Gannon 2014):

T0 Research: Basic biomedical research, including preclinical and animal studies, not includ-
ing interventions with human subjects

T1 Research: From basic biomedical to humans, including Phase 1 clinical trials, and focused
on new methods of diagnosis, treatment, and prevention in highly controlled settings

T2 Research: From basic biomedical to patients, including Phase 2 and 3 clinical trials, and
controlled studies leading to clinical application and evidence-based guidelines

T3 Research: From controlled clinical trials to clinical practice, including comparative effec-
tiveness research, postmarketing studies, clinical outcomes research, health services, and
dissemination and implementation research

T4 Research: From clinical practice to communities, including population-level outcomes
research; monitoring of morbidity, mortality, benefits, and risks; and impacts of policy and
change

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practices require more time to change. An emphasis on quality improvement within an
organization will often speed up an organization’s propensity to change.

Research focusing on a national health problem or need takes much longer to influ-
ence policy. Often, national policies are formulated through political processes in which
stakeholders strongly advocate for their own interests. In this context, research is merely one
form of advocacy that competes with other influencers for the attention of policymakers.

Pr i O r i t i e s

A potential conflict exists between policy priorities and research priorities. Decision makers,
who choose a course of action in response to a given health problem, are generally concerned
with the most pressing and current issues. Researchers, who are generally at liberty to choose
their research focus, often study problems that do not align with the concerns of decision
makers, which can limit the reach of useful HPR.

Increasing the frequency of meetings between investigators and decision makers would
facilitate the communication process and, in turn, enhance the applicability of research. One
way to achieve this increase is by ensuring the presence of decision makers in the governing
or consultative bodies of research institutions. Their access to the institutions may more
easily bring their needs to the attention of researchers as possible projects.

Community-based participatory research, in which academics partner with commu-
nity leaders who have direct knowledge of community health issues, is becoming increasingly
important (Greenhalgh et al. 2016; O’Brien and Whitaker 2011). The practicality of this
type of research is enhanced by including not only decision makers but also stakeholders
and community leaders as contributors to the study (Israel et al. 1998; Rapkin et al. 2017).

ti m e ta B l e

Another potential area of conflict between decision makers and investigators is their respective
expectations regarding the research timetable. Decision makers facing a pressing problem
expect research results immediately. Researchers, on the other hand, are concerned with the
validity of the study design and findings and often require more time than decision makers
are willing to give them to collect and analyze the evidence and complete the research.

This discrepancy can be reduced by involving decision makers in the research planning
phase so that more-realistic expectations are set. This gap can also be bridged by producing
a series of progress reports outlining intermediate results from the study. During data col-
lection, the participation of respondents and their characteristics can be summarized and
reported. Also, immediately after data collection, descriptive summaries can be shared with
decision makers before in-depth analyses are conducted.

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CO m m u n i C at i O n

To enhance the comprehension by decision makers about study findings, research results
must be expressed accurately without using technical terms. Investigators are trained to
communicate results with specific scientific terms, in part to adhere to scientific journal
guidelines, but decision makers often have trouble understanding study design descriptions
or statistics used in data analysis. Researchers should help decision makers reach a clear
understanding of results by providing them with nontechnical reports that avoid scientific
language. The technical details such as methodology and definitions of terms can be included
in an attached appendix.

sC O P e

Differences between policy scope and research scope constitute another barrier to the imple-
mentation of research findings. Because of the inherent complexity of social problems,
decision makers require research to provide broad, integrated results that account for all
dimensions of the problem. To deliver such results, investigators must overcome their ten-
dency to focus on a well-defined subject and provide broad results instead.

Researchers must be knowledgeable about the context of the problems under inves-
tigation so that an integrated project that takes into account all important policy issues can
be designed. Effective research will include an analysis that reflects the multiple interests in
both the political system and the healthcare system.

va l u e s

Researchers and decision makers often place different values on research. Investigators may
desire publication in a prestigious scientific journal, whereas decision makers are focused on
the applicability of the research to problem solving. Decision makers should, at a minimum,
value the contribution that scientific inquiry has made toward improved decision making
and understand the criteria for judging quality research. In turn, the scientific community
must accept that excellence in research is defined not only as scientific knowledge but also
as application for health policies and problem solving.

Because of the role that funding agencies play in the research process, they can often
serve as intermediaries between policymakers and researchers. Funding agencies take into
account the importance of political needs while balancing a desire to gain advances in sci-
ence. In short, funding agencies often shape the direction of policy and science by accom-
modating the values of both the policymakers and the researchers (Braun 1998; Tsey et al.
2016).

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le a d e r s h i P

Although investigators may provide valid and practical research, leadership is required to
transfer HPR into politically acceptable policy. The development and implementation of
policy depend on the initiatives taken by decision makers across all levels of society. For
example, leaders must promote local ownership of the clinical effectiveness agenda among
clinicians and managers, make better use of the skills and expertise available in higher educa-
tion organizations, increase understanding of the mechanisms that encourage the adoption
of new interventions, and facilitate organizational receptivity of new research (Harvey et
al. 2011).

ra P P O rt

Researchers and decision makers operate interdependently. Decision makers rely on inves-
tigators to assist them in making sound and legitimate decisions on the basis of scientific
evidence. Researchers need decision makers to help identify research problems, obtain
funding, gain access to research sites and subjects, and implement findings. By cooperating,
decision makers and researchers increase the potential impact of HPR on policymaking.

sk i l l s

Although researchers may possess some background in related disciplines, such as medicine,
public health, and political science, they must be competent in six specific skill areas. These
six skill areas are relevant to each stage of HPR and include knowledge of subject matter,
methodology, statistics, statistical application software, writing, and public relations—each
of which is described briefly in the sections that follow. If investigators lack any of these
skills, proper steps must be taken to ensure that a member of the research team is able to
compensate for the lack of expertise. Many of these skills can be acquired in the classroom,
but proficiency in research can be achieved only through experience in the field of HPR.

Subject Matter
The most important research skill is subject knowledge. In-depth knowledge of the subject
matter, research data, instruments, funding sources, and survey design is critical to the con-
ceptualization, groundwork, and measurement steps in HPR. For example, conceptualization
requires an investigator to clearly understand the topic and purpose of the research, relevant
theories and literature, and the process of formulating hypotheses and research questions.

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Methodology
The second critical research skill is a command of general research methods. Without a clear
understanding of the general approaches to research, the investigator will be unable to select
the appropriate research method, study design, sampling model, and type of data collection.

Statistics
The third important research skill is statistical knowledge. This skill is particularly critical
in the data analysis, design, sampling, and measurement phases of research. Knowledge of
the choice and appropriate application of statistical procedures enable the investigator to
conduct research independently.

Statistical Application Software
The fourth research skill—knowledge of statistical application software—is especially criti-
cal for analyses of large data sets. This skill is particularly useful in the data processing and
analysis stages of HPR.

Writing
The ability to write well is a fifth critical research skill. Whether drafting proposals for fund-
ing or reports for scientific publication, investigators must properly convey their research
goals and specific findings. In many cases, they can follow established formats (e.g., research
proposals, journal articles). However, the ability to write concise and clear text is extremely
valuable in producing reports.

Public Relations
The sixth and final skill is public relations, which is particularly useful in the groundwork, data-
collection, and application stages of research, as well as for project management. Excellent
“people skills” are essential in acquiring potential funds for a study, obtaining access to research
sites and subjects, and collaborating successfully with decision makers for policy formulation.

➤ HPR can be characterized by five main attributes: its nature as an applied field, its
ethics framework, the multidisciplinary input it enjoys, its basis in science, and its
focus on population.

k e y P O i n t s

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I n t r o d u c t i o n t o H e a l t h P o l i c y2 8 6

➤ Formal approaches to HPR typically include ten steps: conceptualization, groundwork,
methods, design, sampling, measurement, data collection, data processing, data
analysis, and application.

➤ HPR findings should be communicated to the research community, stakeholders, and
the public.

➤ Numerous barriers constrain the implementation of research in policy. However,
researchers and decision makers should operate interdependently.

Ca s e st u d y 1

On the basis of your research of the RAND Health Insurance Experiment, answer the following
questions:

1. How does the RAND study illustrate the characteristics of HPR?
2. What specific contributions did the RAND study make to health policies regarding

health insurance?

Ca s e st u d y 2

In conducting an evaluation study such as this case study, answer the following questions:

1. What kinds of variables must be collected both before and after the intervention?
2. How can one design evaluation studies to address real-life constraints while adhering

to scientific rigor at the same time?

1. Define HPR. What is the difference between HPR and health policy analysis?
2. What are some differences and trade-offs between the sampling methods commonly

used in HPR?
3. What distinguishes reliability of measurements from validity of measurements?
4. What six skills are needed to become a health policy researcher? Why are these

particular skills so important?

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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2 9 2

L e a r n i n g O b j e c t i v e s

C H A P T E R 9

H E A LT H P O L I C Y R E S E A R C H
M E T H O D S

After completing this chapter, you should be able to

➤ appreciate commonly used methods for health policy research,

➤ discuss experimental research,

➤ understand survey research,

➤ describe the process of conducting evaluation research,

➤ differentiate between cost–benefit analyses and cost-effectiveness analyses, and

➤ appreciate qualitative research methods.

Facts, and facts alone, are the foundation of science. . . . When one devotes oneself

to experimental research it is in order to augment the sum of known facts, or to dis-

cover their mutual relations.

—François Magendie

It is by a thorough knowledge of the whole subject that [people] are enabled to

judge correctly of the past and to give a proper direction to the future.

—James Monroe

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he a lt h Ce n t e r s a n d t h e fi g h t ag a i n s t he a lt h di s Pa r i t i e s i n
t h e un i t e d stat e s

The United States has experienced a long history of inequality among its citizens. From civil
rights violations and suffrage restrictions, which only began to be resolved in the mid-twentieth
century, to the widening income gap between the poor and rich into the early twenty-first
century, inequality continues to pervade many aspects of modern life, including education,
employment, housing, healthcare, and other means for fulfilling life necessities. Those most
deeply affected are groups delineated by race or ethnicity, socioeconomic status, immigration
status, culture and language, gender, and sexual orientation (Shi, Lee, Haile, et al. 2017; Shi and
Stevens 2010). Perhaps the most persistent manifestation of inequality has been the ongoing
and, in some cases, growing disparity in health and well-being across these social divisions.
Today, it is not unusual to see major health differences between whites and racial or ethnic
minorities such as African Americans and Latinos, between the wealthy and the poor, and
between the insured and the uninsured. Although the United States spends by far the highest
per capita amount on healthcare in the world (OECD 2017, 132–33), it ranks in the middle of the
pack in international comparisons of quality of care and health status (Macinko, Starfield, and
Shi 2003; OECD 2017, 28, 22; Reinhardt, Hussey, and Anderson 2002).

Recognizing the inefficiencies and injustices created by health disparities, the US Depart-
ment of Health and Human Services (HHS), through its decennial Healthy People publication,
has sought to eliminate these disparities (HHS 2010). Similarly, the Institute of Medicine (IOM)
published landmark reports in the early twenty-first century, including Crossing the Quality
Chasm (IOM 2001) and Unequal Treatment (IOM 2003), to increase awareness of these issues.
Research on the various domains of primary care (accessibility, continuity, comprehensiveness,
and coordination) showed that high-quality primary care can reduce the adverse impact of
income and racial or ethnic inequality on health (Gaston et al. 2001; Hu et al. 2016; Shi, Stevens,
and Politzer 2007; Starfield and Shi 2007). In response to these findings, the federal government
launched the health center model as a primary care approach to improving health equity.

The health center model features community, migrant, homeless, and public housing
health centers, collectively known as federally qualified health centers. They are not-for-profit,
community-directed healthcare providers that offer primary and preventive care to predomi-
nantly low-income, underserved urban and rural communities, including homeless people,
agricultural workers, residents of public housing, and veterans. Health centers are governed by
boards composed of at least 51 percent (a majority) health center patients, and these centers
have served as a crucial component of the nation’s safety net system since the 1980s (HRSA
2017; Hu et al. 2018; Lefkowitz 2007; Nath et al. 2016; Sardell 1988; Shi, Lee, Chung, et al. 2017;
Thompson et al. 2018). Today, there are nearly 1,400 health centers operating more than 10,000
service delivery sites in the United States and its territories (HRSA 2017).

C a s e s t u d y 1

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In addition to clinical care, health centers provide enabling services, such as trans-
portation, case management, and health education, to facilitate access to care for vulnerable
populations (HRSA 2017). As of 2016, nearly 26 million people nationwide (about 15 million
more than in 2001) relied on a federally qualified health center for primary healthcare services,
including more than 330,000 veterans as well as about 33 percent of people living in poverty,
10 percent of children aged 17 or younger, and nearly 17 percent of rural residents in the United
States (HRSA 2017).

Numerous studies have demonstrated that health centers improved access and delivered
high-quality, cost-effective care (Frick and Regan 2001; Hadley and Cunningham 2004; Hadley,
Cunningham, and Hargraves 2006; Landon et al. 2007; O’Malley et al. 2005; Politzer et al. 2003;
Proser 2005; Shi and Stevens 2010; Shi, Stevens, and Politzer 2007; Shin, Markus, and Rosenbaum
2006; Vanderpool et al. 2016). In addition, a number of studies found that patient outcomes
and quality of care in health centers were comparable to or better than those in the private
sector (Falik et al. 2006; Hicks et al. 2006; Shin et al. 2008; Ulmer et al. 2000). Studies have also
been conducted to examine whether health centers were able to overcome health dispari-
ties—that is, to narrow the differences in healthcare access, quality, and outcomes across racial,
ethnic, and socioeconomic population groups—and have revealed mixed findings so far (Gold-
man et al. 2015; HRSA 2017).

vermOnt’s aCCOuntaBle COmmunities fOr health learning laB

The Centers for Medicare & Medicaid Services (CMS) presented the Accountable Health Com-
munities Model as a strategy that “addresses a critical gap between clinical care and community
services in the current healthcare delivery system by testing whether systematically identifying
and addressing the health-related social needs of Medicare and Medicaid beneficiaries through
screening, referral, and community navigation services will impact healthcare costs and reduce
healthcare utilization” (CMS 2018).

The Vermont Accountable Communities Model sought to align programs and strategies
related to integrated care and services for individuals with prevention efforts throughout the
community to improve health outcomes. This effort was carried out in two phases. First, the
Accountable Communities for Health (ACH) were defined and core elements were identified
through research. Second, the Vermont ACH convened multidisciplinary teams from across
the state to explore implementation and community capacity building through the ACH Peer
Learning Lab (State of Vermont Health Care Innovation Project 2018a). Using in-person and
distance learning methods, the Peer Learning Lab aided participants in increasing their capacity
and readiness across nine core elements: (1) mission, (2) multisectoral partnership, (3) inte-
grator organization, (4) governance, (5) data and indicators, (6) strategy and implementation,

C a s e s t u d y 2

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(7) community member engagement, (8) communications, and (9) sustainable financing. Findings
and lessons learned from the Peer Learning Lab will help inform future state decision making,
including infrastructural and resource concerns on multiple levels (State of Vermont Health
Care Innovation Project 2017b, 2018b).

The Public Health Institute’s (PHI) Survey Research Group and Population Health Inno-
vation Lab collaborated to conduct a formative evaluation of the Vermont ACH Peer Learning
Lab project. Ten ACH sites throughout Vermont participated in the Peer Learning Labs (State
of Vermont Health Care Innovation Project 2017a). Evaluation measures were collected before
and after project completion via web-based, self-administered surveys to assess changes in
participants’ understanding, ability, and readiness after participating in the Peer Learning Labs
(State of Vermont Health Care Innovation Project 2017a).

In postassessment surveys, most respondents agreed that the Peer Learning Labs helped
improve their understanding and readiness to implement eight of the nine core elements—all
except sustainable financing, for which the findings were mixed (State of Vermont Health Care
Innovation Project 2017a). Evaluators also reported that sentiments of confidence and trust in
other members and confidence in the ability to achieve goals increased among respondents
(State of Vermont Health Care Innovation Project 2017a). Thus, the Peer Learning Lab approach
seemed to be an effective strategy for implementing an accountable community for health
among Vermont’s ACH sites.

F
ollowing an overview of health policy research (HPR) in chapter 8, this chapter
illustrates methods commonly used in HPR. Examples of both quantitative and
qualitative methods are provided.

Qu a n t i tat i v e me t h O d s

Quantitative methods in HPR include experimental or quasi-experimental research, survey
research, evaluation research, cost–benefit analysis, and cost-effectiveness analysis.

ex P e r i m e n ta l re s e a r C h

Since the mid-twentieth century, the purpose of experimental research has been to study
causal relationships between independent and dependent variables—by testing hypotheses
under predefined intervention settings to either establish a direct link between two factors or
measure the magnitude of their association (Broota 1989; Cochran 1957; Kirk 2013). The
Learning Point box titled “Causal Relationship” provides the definition and characteristics
of causal relationships.

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Essential Elements of Experimental Research
The ultimate goal of experimental research is to enable inferences to be drawn between the
independent and dependent variables in particular intervention conditions. Key components
of experimental research include (1) experimental and control groups, (2) randomization,
(3) pretesting and posttesting, and (4) application of the intervention.

Experimental and Control Groups
The experimental group includes those individuals who receive the intervention, while the
control group includes those who do not receive the intervention (or who receive an alterna-
tive form of intervention, such as the status quo).

The main purposes of a control group are to assess the true impact of the service or
intervention being studied and to account for possible effects on the outcome from par-
ticipation in the experimental intervention. In social science experiments, control groups
are also used to account for factors or events occurring outside the experimental setting. In
this case, both experimental and control groups are subject to the effects of outside events,
but the control group helps account for potential biases and determine the true effects of
the experiment. Although, ideally, subjects within the control group should be as similar
as possible to those in the experimental group in all key characteristics except receipt of
the experimental intervention, in reality the degree of similarity varies between groups. As
defined by pioneering researchers Fitz-Gibbon and Morris (1987), control groups are either
true control groups (made equivalent by random assignment, generally ensuring a nonbiased

LEARNING POINT
Causal Relationship

An association between variables must have the three following characteristics to be con-
sidered a causal relationship:

1. Statistical association. Two variables must have a statistically significant relationship,
or correlation, for causality to be present.

2. Sequence of influence. A clear temporal sequence must exist between the two vari-
ables to determine a cause–effect relationship. The causal factor must occur first,
before the effect.

3. Nonspuriousness. A change in one variable results in a change in another regardless
of the actions of other variables. Nonspuriousness can occur when an association or a
correlation between variables cannot be explained by any variable other than the two
variables of interest.

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distribution of the various characteristics) or comparison groups (nonequivalent in terms of
assignment—i.e., assigned in a nonrandom way).

Randomization
Randomization refers to the allocation of a set of subjects to either an experimental or a
control group by means of some procedure that is not biased against any individuals in
the set. Under the ideal randomization method, each subject has an equal chance of being
assigned to either group.

In a pure experimental design, random sampling (as described in chapter 8) is used
to select a representative number of study subjects from a target population to ensure that
study results are generalizable to the population. Randomization procedures are then used
to allocate each member of the sample to the experimental group or the control group,
thereby ensuring internal validity of the study. Randomization also eliminates potential
bias from self-selection, taking into account that people who volunteer for a study likely
differ from those not choosing to volunteer. Randomization is the most effective way to
eliminate alternative explanations of an intervention effect, because it helps account for a
variety of characteristics (including those not explicitly captured in the study itself ) that
may otherwise influence study results.

Pre- and Posttesting
Experimental and control groups are typically tested or observed before (pretest) and after
(posttest) the intervention at identical points in time, as explained in the classic work by
Fitz-Gibbon and Morris (1987). Pretest and posttest results are then compared to assess the
impact of the intervention. In the simplest experimental design, a single pretest measurement
is taken prior to the subjects’ exposure to an intervention and a single posttest measurement
is taken following the intervention.

Researchers may make additional observations while the intervention is taking place
to measure the impact of the intervention over time. Similarly, a series of measurements or
tests may be conducted after a program concludes to measure the long-term impact—called
a time series test if measurements are taken at equal time intervals before and after the pro-
gram. Often, a time series test can eliminate the need for a control group because results
from pretests may project the outcome without the intervention.

Application of the Intervention
The main independent variable in an experiment typically takes the form of the experi-
mental stimulus, or intervention, that is either present or absent. It is essential that both the
independent variable and dependent variable be operationally defined for the purpose of

independent variable
The variable
representing the
treatment, characteristic,
exposure, or other
intervention that is
being examined to
determine its effect on
the dependent variable.

dependent variable
The variable that is
examined to determine
whether its observed
value changes when
the independent
variable is present or
when exposed to the
independent variable.

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the experiment. Examples of common interventions include taking a new therapeutic drug,
undergoing a new treatment procedure, becoming eligible for a new service, or responding
to a questionnaire that might influence behavior.

Types of Experiments
In the sections that follow, we discuss four types of experiments in which interventions may
be applied: (1) laboratory (or controlled) experiments, (2) field experiments, (3) natural
experiments, and (4) simulations.

Laboratory Experiments
Laboratory experiments are conducted in artificial settings in which researchers have full
control over the random assignment of subjects to treatment and control groups and the
application of the intervention. This is the ideal type of scientific experiment; however, labo-
ratory experiments are rarely used in HPR because the ability to randomly assign subjects is
limited and the manipulation of interventions by social, economic, or health-related factors
causes practical and ethical concerns.

Field Experiments
Health policy studies often employ field experiments, which are conducted outside of labo-
ratories in natural, real-life settings. For example, researchers may study the triage system
in emergency departments of urban hospitals, unobtrusively making experimental obser-
vations of the normal activities of subjects. Field experiments have high external validity,
usually yield generalizable results, and are particularly suitable for applied research focusing
on problem solving, because they enable the researcher to gain insight into how complex
problems unfold in the real word.

A major weakness of field experiments is the limited control the researcher has over
experimental conditions (as compared with complete control in laboratory experiments).
Furthermore, because random assignment to study groups may not be possible due to ethi-
cal considerations or subject preferences, systematic differences may result between control
and experimental groups in participant characteristics and levels of exposure to independent
variables and other environmental factors. For an example of a field experiment, see the
Research from the Field box titled “Experimental Research: Field Experiment.”

Randomization of participants to an experimental or a control group, application
of an intervention, and observation of outcomes in a real-world setting are key features of
field experiments. Because they examine the real-world impact of an intervention, field
experiments are critical to HPR.

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Natural Experiments
Natural experiments are characterized by a complete lack of control over experimental
conditions, as compared with field experiments, which retain some level of artificiality (i.e.,
experiments occur purely for research purposes) and in which researchers have control over
the random allocation of subjects to treatment or control groups. In studies such as those
assessing the effects of lack of access to care on health status, researchers must often rely on
truly naturally occurring events in which different levels of exposure exist.

Simulations
Stokey and Zeckhauser (1978) first defined simulation, or modeling, as a special type of experi-
ment that does not require subjects or a true intervention. Simulations are dynamic models
that operate over a specified period to demonstrate the structure of the system of interest and
the effects on system components when one or more of those components are altered. It is a
powerful method that enables researchers to artificially observe what a world exhibiting the
study factors of interest might look like as it moves into the future, giving users the opportu-
nity to intervene and attempt to make improvements to system performance (Dooley 2002).

RESEARCH FROM THE FIELD
Experimental Research: Field Experiment

HealthPlus, a not-for-profit organization that provides HMO coverage for Michigan residents
and employers, initiated a program in 2008 that gave members online access to performance
and quality reports on their plan physicians. To examine how effectively the reports helped
members select high-quality physicians, researchers from RAND Corporation conducted a
randomized controlled field experiment of new enrollees (Martino et al. 2012).

In 2009 and 2010, the researchers randomly assigned new HealthPlus enrollees to either
the experimental group or the control group. Each week, the researchers randomized batches
of participants who had yet to select a primary care physician, using an adapted coin-flip tech-
nique. Participants in the control group were not encouraged to view the online reports, while
participants in the experimental group were encouraged to do so. The encouragement—the
intervention in this experiment—included a letter from the plan’s chief medical officer outlining
the importance of the reports and a follow-up phone call. The encouragement intervention was
associated with members’ selection of higher-rated physicians, indicating that encouragement is
a feasible intervention for increasing access to physician data and possibly also quality of physi-
cian chosen, although missing data in the reports limited their effectiveness (Martino et al. 2012).

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The major advantages of simulations are their high economic feasibility (compared
with other types of experiments), ability to magnify the visibility of a phenomenon, ability
to control and manipulate conditions, and availability as a safe alternative to experimentation
that may be dangerous or unethical (Fone et al. 2003). The major downside to simulations
is their artificiality. The possibility always exists that a simulation is inaccurate or incomplete
and that conclusions garnered from a working model are not applicable to the phenomena of
interest. Simulation is thus more useful when a significant amount of empirical knowledge
is already available because a model is only as good as its assumptions.

As this discussion demonstrates, trade-offs are inherent in each experimental tech-
nique, and in certain situations, a combination of modeling and real-life experiments is
necessary. For example, simulation can illuminate the effects of a program’s intervention by
allowing greater control over certain factors, but field experiments can reveal the degree to
which the actual environment may alter the intervention. Policymakers can benefit from
using both modeling and studies conducted in the field when examining certain topics of
interest (Chen et al. 2009).

Perhaps the best-known health policy experiment is the RAND Health Insurance
Experiment. See the discussion of RAND in chapter 3, in the “Private Health Foundations”
section, and the first case study presented in chapter 8 on the Health Insurance Experiment
for more detailed information about the organization and this experiment. For another
recent health policy experiment, see the For Your Consideration box titled “An Example of
Experimental Research.”

FOR YOUR CONSIDERATION
An Example of Experimental Research

Mobile applications have been increasingly used as crucial tools to deliver health interven-
tions. The purpose of a study by Mummah and colleagues (2017) was to investigate the efficacy
of a mobile app, termed the Vegethon Mobile App (which primarily includes goal setting and
self-monitoring of vegetable consumption), in increasing daily vegetable consumption among
a large sample of overweight adults attempting to maintain weight loss.

The study group consisted of 135 overweight adults living in Stanford, California, who were
aged 18–50 and had a body mass index in the range of 28–40 kg/m2 but were nondiabetic and
nonhypertensive and had no cancer or heart, kidney, or liver disease. These subjects were
recruited from a 12-month weight loss trial and randomly assigned to either the Vegethon
Mobile App group of 68 or a wait-listed control group (told to expect an eight-week delay for
the app) of 67. The random assignment procedure ensured that the two groups were similar to
each other prior to the Vegethon intervention. Specifically, a researcher who had no contact
with participants assigned them to each group using a random, computer-generated allocation

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Qu a s i-ex P e r i m e n ta l re s e a r C h

Although randomization is crucial for valid experimental results, in many situations (as in
HPR), it is not always feasible for practical and ethical reasons. For example, people may
object to being randomly assigned to interventions that will significantly affect their lives. In
addition, withholding certain interventions from a control group may be deemed unethical.
To avoid these issues, researchers may employ quasi-experimental research methods. Quasi-
experimental research is similar to controlled laboratory experiments in that researchers
are concerned with the effect of a treatment or intervention but do not randomly assign
participants to treatment groups. (See the For Your Consideration box titled “An Example
of Quasi-Experimental Research” for further insight into this research method.)

FOR YOUR CONSIDERATION
An Example of Experimental Research (continued)

sequence, and communication with the participants was performed by a research assistant who
was not informed of their group assignment nor involved in data collection and analysis. The
study participants were also not told whether they were in the intervention or control group.

The primary measure was intended to gauge the effect of the app intervention on par-
ticipants’ overall vegetable consumption, using an adapted Harvard Food Frequency Ques-
tionnaire. The secondary measure was intended to capture subjects’ recall of the number of
daily vegetable servings they consumed during the previous 24 hours, through questioning
by interviewers who were unaware of which group the subjects had been assigned to, using
the Nutrition Data System for Research. The Vegethon app usability and satisfaction were
examined using a 21-item questionnaire that was built into the system software. Statistical
analyses were conducted using linear regression models to assess the main effect of the app
and to investigate the influences of possible effect moderators.

The study findings indicated that daily vegetable consumption was significantly greater in
the intervention group than in the control group for both primary and secondary measures.
Specifically, the participants who had received the Vegethon app consumed an average of
two more servings of vegetables per day than members of the control group did when mea-
sured by the Food Frequency Questionnaire. The app users reported consuming an average
of one more serving on a daily basis than the control group members did when measured by
the 24-hour dietary recall interviews. The study also suggested that baseline vegetable con-
sumption significantly moderated the impact of the intervention in that effects increased as
baseline vegetable consumption increased. The Mummah group’s study findings implied that
theory-based mobile interventions might be an affordable, scalable, and effective approach
to support dietary behavior changes among overweight adults.

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Because quasi-experimental studies lack the element of random assignment essential
to true experimentation (Rossi, Lipsey, and Freeman 2004), researchers must use other
methods to ensure some level of comparability between study groups, such as propensity
score matching (Austin 2011). Matching is a strategy commonly used for the nonrandom
assignment of subjects to study groups. Under this approach, researchers attempt to create
a control group that is as similar as possible to the experimental group by controlling for
one or more major characteristics of the two groups. For example, if demographics are
important, researchers select control group subjects on the basis of how their demographic
characteristics compare to the experimental group. As a result, the average demographic
characteristics of the experimental group (e.g., age, gender, racial composition) are comparable
to those of the control group. Characteristics should only be matched if they are expected
to affect the outcome of the intervention (if not taken into account in the study design).

matching
The process of ensuring
equal representation
among experimental
and control groups by
matching participants
or proportions of
participants on the
basis of selected
characteristics.

FOR YOUR CONSIDERATION
An Example of Quasi-Experimental Research

The Massachusetts 2006 healthcare reform was hailed as a model for the Affordable Care Act
for attaining near-universal insurance coverage while increasing access to care. Its effect on
population health was less clear. The quasi-experimental research conducted by Sommers,
Long, and Baicker (2014) aimed to determine whether the Massachusetts reform was associ-
ated with changes in all-cause mortality and deaths from causes amenable to healthcare.

The researchers compared mortality rates before and after the reform in Massachusetts,
looking at changes in mortality rates for adults aged 20–64 in Massachusetts from 2001 to
2005 (prereform) and 2007 to 2010 (postreform) versus changes in a propensity score–defined
control group of adults in other states. The researchers used all-cause mortality data in
age-, sex-, and race-specific cells (n = 146,825) from the Centers for Disease Control and
Prevention’s Compressed Mortality File (Sommers, Long, and Baicker 2014). Mortalities from
causes amenable to healthcare, insurance, access to care, and self-reported health served
as secondary outcomes.

The researchers found that the Massachusetts healthcare reform was associated with a
significant decrease in all-cause mortality (2.9 percent; p = 0.003, or an absolute decrease of
8.2 deaths per 100,000 adults) and in deaths from causes amenable to healthcare (4.5 percent;
p < 0.001). The decreases were more significant in counties with lower household incomes and
higher uninsured rates before the reform. There were also significant increases in insurance
coverage, access to care, and self-reported health. The number needed to treat was 830 adults
obtaining health insurance to prevent one more death per year. In summary, the healthcare
reform in Massachusetts was associated with significant decreases in all-cause mortalities
and deaths from causes amenable to healthcare (Sommers, Long, and Baicker 2014).

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Matching ensures some level of similarity between characteristics of the experimental and
control groups, other than the intervention, and helps yield more valid findings than would
be obtainable from unmatched groups.

Stratified random sampling is a similar strategy that combines elements of match-
ing and randomization and may be employed in studies where the sample size is small and
the population is heterogeneous. From a target population, researchers first create strata of
study subjects who are similar in the characteristics to be matched. Next, subjects are chosen
from each of the strata and randomly assigned to the study groups.

su r v e y re s e a r C h

The administration of surveys is the most common method of data collection (Houser and
Bokovoy 2006; Miller and Brewer 2003) and is used extensively both inside and outside the
scientific community for various purposes (Bailer and Lanphier 1978; Dillman and Smyth
2014; Fowler 2014; Miller and Salkind 2002; Singleton and Straits 2017). Its application is
also widespread among health policy researchers. Those conducting qualitative research (e.g.,
case studies, which are discussed later in this chapter) may integrate a survey component
into the data-collection process. Researchers conducting experimental research commonly
use surveys to collect additional information on the impact of an intervention. Similarly,
survey findings are often used in evaluation research to fully assess a program’s impact.

Survey research is defined as (1) the use of a systematic method to collect data directly
from respondents that are of interest to researchers and (2) the subsequent analysis of the
data using quantitative methods. It aims to measure the distribution of certain character-
istics or results among a study sample to provide a detailed description of the population.

Survey administration is popular with researchers because it enables a wide range of
topics to be covered. It may be used to discover factual information, such as use of healthcare
services and their spending, or to ascertain beliefs, opinions, or values, such as satisfaction
with care experience and treatment outcome. When properly constructed, surveys can help
researchers explore factors associated with a phenomenon of interest and later test a specific
hypothesis.

Typically, survey research consists of the following characteristics (Fowler 2014;
Miller and Salkind 2002; Singleton and Straits 2017):

◆ Large and randomly chosen samples

◆ Systematic instruments

◆ Quantitative analysis

A large sample of respondents that is randomly chosen from the population of interest
produces survey findings that are more representative and generalizable than results from

stratified random
sampling
A random selection
of individual subjects
from sampling frame
subgroups, where each
subgroup is made up of
individuals who share a
characteristic of interest.

strata
Levels into which a
population or a sample
is divided on the basis of
selected characteristics.

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small, nonrandom groups. Survey research uses a systematic questionnaire or interview guide
to ask questions of respondents. Questions are carefully considered and written beforehand,
and they are asked in the same order for all respondents. Interviewers are trained to present
questions with exactly the same wording and in the same manner. Standardization of surveys
and their administration is of utmost importance because it enhances data reliability by
minimizing measurement error. These principles are illustrated in the For Your Consideration
box titled “An Example of Survey Research.”

FOR YOUR CONSIDERATION
An Example of Survey Research

The dual aims of this study presented by Bosch and colleagues (2017) were (1) to assess the
association between intimate partner violence (IPV) and health risk factors, health behav-
iors, and poor mental health and (2) to examine potential moderators of the relationship
between IPV and health risk factors or health behaviors by using secondary data from the
2005 Behavioral Risk Factor Surveillance System (BRFSS) survey data for the state of Missouri.

The BRFSS is a cross-sectional survey collected via telephone by the Centers for Disease
Control and Prevention (CDC) at the state level, which collects data about noninstitutional-
ized adults aged 19 or older regarding their health behaviors, health conditions, and use of
preventive services. The BRFSS includes a core questionnaire for every state but also optional
questions (such as questions on IPV). BRFSS data for 2005 were selected for this study because
it was the year in which IPV questions were investigated in Missouri. Demographics, IPV, health
risk factors, poor mental health, and health-compromising behaviors (including physical
inactivity, binge drinking, and cigarette smoking) for 3,110 female respondents aged 18–89
from the 2005 BRFSS were included in this secondary data analysis. In terms of statistical
analysis, chi-square analyses were performed to explore the relationship between IPV and
demographic indicators, health risk factors, and health behaviors; and logistic regression
analyses were conducted to assess the association between IPV and health risk factors, health
behaviors, and mental health, adjusted for demographics.

The study results revealed that women with a history of IPV were significantly more likely
than women without a history of IPV (p < .05) to be overweight or obese, smokers, and binge
drinkers, and to report poor mental health. The study also found that demographic vari-
ables moderated the association between IPV and obesity, smoking, high blood pressure,
and high cholesterol. Women with a history of IPV were usually younger, divorced, and more
often unable to work, and those who were unable to work were significantly more likely to
be obese and diagnosed with high blood pressure and high cholesterol. These study results
implied that clinics, community health centers, and other healthcare settings should provide
women who have a history of IPV with appropriate resources to reduce the health-related
consequences of IPV.

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Survey Types
Surveys may be cross-sectional (capturing one point in time) or longitudinal (providing a
series of observations over a period of time). The cross-sectional survey is by far the most
commonly used survey design. In a cross-sectional survey, data from a composite represen-
tation of respondents that reflect a target population are acquired within a short period.

The cross-sectional survey method has two major limitations. First, data collected
using these surveys do not reveal causal relationships because the data are acquired within
a short and limited period. Second, the risk of bias is inherent in study results because the
quality of cross-sectional survey data depends on the accuracy with which individuals recall
information.

One example of a cross-sectional survey is the Community Health Center User Survey,
conducted by the Bureau of Primary Health Care (BPHC) of the Health Resources and
Services Administration. The Community Health Center User Survey collected information
on demographics and health status, healthcare utilization, and quality of services received
among patients who visit community health centers. All health centers that received BPHC
funding and provided primary care at the time the Community Health Center User Survey
was administered were included in the survey’s sampling frame. The content and sampling
strategy of the survey produced a nationally representative snapshot of health centers’ char-
acteristics and those of the patients they served.

A longitudinal survey follows a single sample, or another similar sample with repeated
(at least two) surveys over a specified period. Data may be collected at predetermined intervals
(e.g., at three, six, and nine months over a one-year period) or continuously (e.g., monthly
over two years). Longitudinal surveys often are initiated when cross-sectional surveys or other
sources of data reveal new trends. They enable researchers to investigate questions about
causes and consequences associated with the data of interest and form stronger inferences
about causal direction, potentially providing a basis that can substantiate theory.

The use of longitudinal surveys is limited by two factors. First, they are relatively
expensive to conduct (due to the need for repeated follow-up), and continual implementation
requires long-term funding and a secure organizational base from which the researchers can
operate. Second, they are prone to attrition—the loss of subjects who drop out of the study
at some point during the study period. The difficulty with following individuals over time is
that the researcher is often left with a smaller subgroup at the completion of the study than
at its onset. This subgroup may not be representative of the full population, threatening
the validity of the study conclusions. Because of the expense associated with conducting
longitudinal surveys, many are designed to be multipurpose, asking a variety of questions
related to other topics in addition to a core set of questions addressing the topic of interest.

The two major types of longitudinal surveys are trend studies and panel studies.
A trend study includes a series of cross-sectional surveys used to collect data on the same
items within randomly selected samples of a single population. Trend studies can also take
on the appearance of cohort studies when the impact of an intervention or program on a

cross-sectional survey
A descriptive research
method used to examine
characteristics of a
population within a
short time frame.

longitudinal survey
A survey administered
to the same sample
or similar samples at
repeated intervals over
a predetermined length
of time.

attrition
Loss of participants
during a study that
measures outcomes over
time.

trend study
A series of cross-
sectional studies
examining how a
characteristic or set of
characteristics changes
over time through
repeated sampling from
the overall population.

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group is to be studied. A cohort is a group of indi-
viduals who experience the same significant event
within a specified period or who share some major
characteristic. See the Research from the Field box
titled “Survey Research: Longitudinal Survey, Trend
Study” for an example of a trend study.

Most national health surveys sponsored
by the federal government are trend studies. One
example is the National Health Interview Survey,
conducted by the National Center for Health Sta-
tistics, which is an annual survey of the US non-
institutionalized population that includes detailed
questions on health conditions, doctor visits, hos-
pital stays, and personal characteristics. Analyses
of data from the National Health Interview Survey
have informed policy decisions on health insurance
mandates and programs to increase access to care
for vulnerable populations.

A panel study follows a representative
sample of the group of interest over time by admin-
istering a series of surveys. Whereas trend studies

focus on variables and their changes over time, panel studies focus on individuals and how
they change over time. For example, the Medical Expenditure Panel Survey, conducted by the
Agency for Healthcare Research and Quality and the National Center for Health Statistics,
is a well-known panel study used to collect information on the financing and utilization
of medical services in the United States. The Medical Expenditure Panel Survey consists of
three major components: the Household Component (which collects medical expenditure
data at the personal and household levels), the Medical Provider Component (which surveys
medical providers and pharmacies identified by household respondents), and the Insurance
Component (which collects data on health insurance plans obtained through employers in
both the public and private sectors).

eva l u at i O n re s e a r C h

Evaluation research is most often used in HPR for needs assessment; program planning,
monitoring, and improvement; and policy implementation (Ammerman, Smith, and Calancie
2014). When researchers apply evaluation research to program monitoring and improve-
ment, they are usually interested in assessing the effectiveness of the program in terms of its
implementation, components, participation, cost-effectiveness, and areas for improvement. In

panel study
A study in which data
are collected repeatedly
over time within the
same sample selected
from the overall
population to examine
how individuals change
over time.

RESEARCH FROM THE FIELD
Survey Research: Longitudinal Survey, Trend Study

Beginning in 2006, a trend study type of longitudinal survey of
clinician attitudes toward the implementation, use, and impact
of electronic health record (EHR) systems was administered to a
network of health centers participating in Atrius Health, a multi-
center group practice (El-Kareh et al. 2009). The objective of the
longitudinal study was to examine whether clinician attitudes
toward the use of EHR would change over time. Clinicians, nurse
practitioners, and physician assistants practicing at selected health
centers that were implementing EHR systems were included in this
study. Cross-sectional surveys measuring perceptions of the EHR
system were administered to all participants 1 month following EHR
implementation and then again at 3, 6, and 12 months following
implementation. All participants experienced the same interven-
tion (EHR implementation) and were repeatedly surveyed on the
same measures to determine changes over the course of one year.

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contrast to program monitoring and improvement, which assess a program in one particular
setting, evaluation research performed for policy implementation is intended to assess how
well a policy can be applied to other settings (Bissell, Lee, and Freeman 2011). Investiga-
tors who engage in evaluation research are typically interested in studying organizational
cultures, target populations, resources, financing, or effects on communities.

Evaluation research is most useful when resource constraints exist and the need arises
to prioritize problem areas and select those programs that can most effectively and efficiently
address health or social problems.

It is also a key methodology by which to fulfill funding requirements. For example,
evaluation of health programs and policies is often required to receive funding (CDC 1999),
and to that end the Government Performance and Results Act of 1993 mandates that federal
agencies set performance goals and measure results. Private sources of funding routinely
require performance evaluations as well.

Evaluation research is a form of systematic, applied research conducted to assess programs
and policies or their components (Rossi, Lipsey, and Freeman 2004). When used in HPR, evalu-
ation is performed on a particular product (e.g., therapeutic drug), service (e.g., family plan-
ning), or health or social problem (e.g., lack of access to healthcare) to study policy or program
components, operation, overall impact, or generalizability to other settings and populations.

A hallmark of evaluation research is the objectivity with which it is performed. Typi-
cally, an outside investigator who has no involvement in the implementation of the program
or policy is charged with conducting an evaluation through the following steps:

1. Determine the scope of evaluation.

2. Become acquainted with the program.

3. Choose the methodology for evaluation.

4. Collect the data.

5. Analyze the data.

6. Report findings.

Often, working with the program or policy sponsor and staff, an investigator delin-
eates the general purpose of the evaluation, specific components to be assessed, goals and
objectives of the evaluation, study design, and evaluation budget. In addition, an investigator
may outline the respective roles of researchers and staff in conducting the evaluation and
delegate the responsibility for distributing evaluation results to an appropriate research team
member (Nelson et al. 2011).

When choosing a study design for evaluation research, both quantitative and qualita-
tive methods may be used, depending on the goals of the evaluation. Quantitative approaches

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(e.g., administering surveys, extracting information from administrative records) are used to
measure, summarize, and analyze outcomes or effects and to generalize program or policy
results to a population. Qualitative approaches (e.g., conducting focus groups) can offer
another dimension through which to get context-rich and in-depth understanding of a
program or policy, uncover nuances that may not be captured by quantitative data methods,
or identify unanticipated outcomes (Brownson et al. 2010; Tolley et al. 2016).

Whether using one or both of these approaches, the following measures are typically
examined:

◆ Participant characteristics

◆ Characteristics of the program structure or context that might affect the
intervention (e.g., staff characteristics, organizational setting, environmental
impact)

◆ Characteristics of program implementation or processes (e.g., types of
intervention, activities, staffing, resources)

◆ Characteristics of program outcomes, both long-term and short-term (e.g.,
measures of program goals and objectives, including health status, condition,
knowledge, satisfaction, behavior changes, and unanticipated outcomes—
positive and negative)

◆ Costs and benefits associated with the program and outcomes

Types of Evaluation Research
The main types of evaluation research are needs assessment, process evaluation, and outcome
evaluation (Brownson et al. 2010; Patton 2002; Rossi, Lipsey, and Freeman 2004).

Needs Assessment
The purposes of a needs assessment are to identify areas of weakness or deficiency (i.e., needs)
in a program that can be remedied and to anticipate future conditions to which a program
might need to adjust (Huber et al. 2015).

Needs assessments can be performed at the individual, organization, or community
level (Brownson et al. 2010; Huber et al. 2015). Data for a needs assessment can be obtained
from a variety of sources and are used to identify and prioritize problems and determine
which outcomes to pursue.

In an organizational needs assessment, investigators focus on the key components
of a program to identify any problems, such as the absence or inadequacy of necessary ser-
vices, a lack of efficiency, or the delivery of ineffective or superfluous services. Investigators

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must also carefully consider the effects of proposed
solutions on compatibility with program objec-
tives, staff, clients, and finances. Ultimately, it is
the responsibility of the investigator, working with
evaluation sponsors and program staff, to account
for the consequences of alternative solutions and
select the one that offers the greatest net benefit.

A community needs assessment is more
expansive than an organizational needs assessment in
terms of the scope of issues that must be considered.
Investigators must examine the social, medical, and
health characteristics of the population and under-
stand its relationship with the community’s health
system. When conducting a community needs
assessment of vulnerable populations, common
problems include gaps between services and needs,
a lack of knowledge of programs on the part of pro-
viders and patients, a lack of coordination between
health entities and providers, poor patient education,
and inappropriate distribution of necessary services.

Community needs assessments can be especially useful for policymakers. One example
is an assessment conducted in Louisiana in 2004. Researchers investigated tobacco use
among ninth-grade students in south-central Louisiana by surveying more than 4,800
students about their tobacco habits (Johnson et al. 2004). The study team confirmed self-
reported survey results by collecting saliva samples from a subset of students. According
to the study, more than half of all the participating students reported smoking a cigarette
at some point; additionally, researchers were able to identify which racial or ethnic groups
contained students most likely to smoke and what types of social relationships and attitudes
were associated with smoking. The results from this community needs assessment provided
state lawmakers with real-world evidence to guide tobacco-control efforts, focusing on poli-
cies and funding of programs targeted toward smoking prevention and cessation among
youth. See the Research from the Field box titled “Evaluation Research: Community Needs
Assessment” for another example.

Process Evaluation
The purpose of a process evaluation is to monitor and improve ongoing program delivery
or policies. A process evaluation usually considers the components that are essential to the
implementation and success of a program. For example, it may be used to assess operations
by studying the staffing structure, budget, critical activities and services, and administration

RESEARCH FROM THE FIELD
Evaluation Research: Community Needs
Assessment

Following the World Trade Center terrorist attacks on September
11, 2001, a community needs assessment was done to assess the
health status and use of mental health services by New York City
residents (Boscarino, Adams, and Figley 2004). To collect data, the
researchers conducted a telephone survey of 2,368 adults selected
through the use of random-digit dialing. Participants were asked
a series of questions measuring service utilization, medication
usage, mental health status, and general health status. Research-
ers also asked participants a series of questions regarding their
demographic background and social support networks. By examin-
ing participants’ demographic, social, and health characteristics,
the researchers were able to identify gaps in service use among
resident subpopulations.

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of a program. It may also be used to ensure that resources are being allocated in the proper
and most efficient way or that a program is compliant with legal and regulatory requirements
(Rossi, Lipsey, and Freeman 2004; Moore et al. 2015).

The researchers Rossi, Lipsey, and Freeman (2004) noted the abilities of process
evaluation to

◆ help investigators assess the efficiency with which program administrators carry
out their day-to-day activities and identify ways to enhance the efficiency;

◆ help investigators identify unexpected problems with program implementation;

◆ provide evidence to funders, sponsors, and other stakeholders that a program is
being implemented according to predetermined goals and objectives;

◆ help researchers monitor costs and resource expenditures associated with a
program—information that can be crucial for conducting cost–benefit analyses;
and

◆ serve as a prerequisite for planning and conducting an outcome evaluation of a
program or policy.

Outcome Evaluation
The purpose of an outcome evaluation is to examine the impact and effectiveness of a service,
program, or policy in order to inform its planning and implementation (Kozica et al. 2015; Lee
et al. 2018). Program results are compared with either the status quo or an alternative program
with similar goals. To complete an outcome evaluation, a researcher must address many aspects
of a program by understanding how its goals and objectives are measured, how its essential
components are related to achieving those goals, and how its level of success in accomplishing
its intended results can be measured. With this information, the program can be compared with
an alternative. After changes that may lead to increased attainment of goals and objectives are
identified, a final decision can be made on whether to continue, expand, or modify a program.

Common outcome measures seen in the public health literature include health
status, health-related behaviors, performance (e.g., smoking cessation), and effectiveness
(e.g., participants’ satisfaction on completion of a program). Measures of health outcomes
can include short-term outcomes such as attitudes, knowledge, and beliefs; intermediate
outcomes such as health-related behavior and access to care; and long-term outcomes such
as mortality and morbidity as well as physical function, mental well-being, and other aspects
of quality (Lee et al. 2018).

A variety of structured instruments are available for assessing many dimensions of
health status, such as measures for general health, pain, social health, and quality of life.
These instruments are listed in the Research from the Field box titled “Health Status Dimen-
sions Assessment Instruments.”

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Outcomes research at the patient level, also
known as medical outcomes research or effectiveness
research, has grown in importance with the increases
in therapeutic options available to patients, their
healthcare costs, and the need for healthcare reform.
This research typically focuses on the most prevalent
or costly medical conditions for which more cost-
effective alternative clinical strategies or pathways
may be available. As explained in a classic paper
by Guadagnoli and McNeil (1994), at the patient
level, outcomes research involves linking positive
and negative outcomes to the type of care (e.g., drug
therapies, surgical procedures, diagnostic care, pre-
ventive care, rehabilitative care) received by a variety
of patients with a particular condition to identify
what treatment works best for which patients.

Both the public and private sectors are inter-
ested in outcomes research focusing on measuring
health-related outcomes and their predictors. In
both sectors, payers are responsible for controlling spending and helping to improve qual-
ity of care. This responsibility can be fulfilled in part by allocating resources to treatments
that are known to be effective, making outcomes research invaluable to both policymakers
and payers.

Results from outcome evaluations can also enable sponsors to decide whether to
continue, expand, or reduce the scope of programs or policies by providing information on
the financial implications of the alternative clinical strategies.

Such studies are key drivers in the continued support and funding of the nation’s health
center network (see the first case study at the beginning of this chapter). Community health
centers receive a significant portion of their operating budget from the federal government,
and outcome evaluations have shown that these health centers provide high-quality, cost-
efficient primary and preventive healthcare (Falik et al. 2006; Jones, Zur, and Elam 2016;
O’Malley et al. 2005; Shin, Markus, and Rosenbaum 2006; Stevens 2016). In addition,
outcome evaluations have shown that expansion of the health center network is a promising
strategy for reducing racial and ethnic disparities in health and healthcare (Earnshaw et al.
2013; Greene and Dawson 2016; Marino et al. 2016; Shi and Collins 2007; Shi, Tsai, and
Collins 2009; Shi et al. 2004).

Strengths and Weaknesses of Evaluation Research
The major strength of evaluation research is its potential for making an impact on policy.
Findings from evaluation research can lead to improved design and implementation of

medical outcomes
research
Research that examines
the comparative
effectiveness of
available treatments for
a patient with specified
characteristics.

RESEARCH FROM THE FIELD
Health Status Dimensions Assessment Instruments

The following are examples of assessment instruments used to
determine a variety of health status dimensions, along with the
names of these instruments’ creators. See the reference citations
that accompany each assessment for more information.

• Four Single Items of Well-Being: Andrews and Grandall (1976)
• McGill Pain Questionnaire: Melzack (1983)
• Medical Outcomes Study: Riesenberg and Glass (1989);

Tarlov et al. (1989)
• Nottingham Health Profile: Hunt and McEwen (1980); Hunt,

McEwan, and McKenna (1985)
• Quality of Life Index: Spitzer, Dobson, and Hall (1981)
• Sickness Impact Profile: Bergner et al. (1976, 1981)
• Social Health Battery: Williams, Ware, and Donald (1981)

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health programs and interventions in public health. Evaluation research offers practical and
tangible evidence for policymakers and other decision makers to act on.

Evaluation research can, however, suffer from selection bias and differential attri-
tion rates (i.e., subjects drop out of each study group at varying rates) due to an inability
to randomly assign subjects to study groups. In addition, results from evaluation studies
often have limited generalizability—that is, the success of a particular program or policy
may not be guaranteed in other environments or settings. Finally, time constraints, financial
constraints, and an unfavorable political climate are limitations that can affect the scope
and depth of program evaluation.

The For Your Consideration box titled “Two Examples of Evaluation Research”
illustrates some strengths and limitations of this type of research.

FOR YOUR CONSIDERATION
Two Examples of Evaluation Research

Outcomes Research
Evidence indicates that health promotion programs can help people with disabilities better
manage their secondary health conditions. However, access to those programs is limited for
people who are unemployed or people with disabilities who live in rural areas. The Health
Plans to Employment (HPE) program consists of low-cost interventions that can be remotely
delivered to people with disabilities through electronic means. The purpose of a research
study by Ipsen and colleagues (2014) was to assess the comparative effectiveness of three
variations of the HPE program that were given to a Factsheet group (to receive a series of
four electronic fact sheets), an HPE group (to receive access to an online interactive health
promotion website), and an HPE+MI group (to receive the online health promotion website
access plus two motivational interviewing calls) for improving health in a sample of vocational
rehabilitation (VR) consumers.

Study participants were recruited from two state VR agencies in Washington and North
Carolina. The agency personnel mailed recruitment postcards to 600 randomly selected
consumers who were aged 21–65 and had a primary physical disability. The postcards asked
about their interest in this internet-based health promotion program and outlined inclusion
criteria; thus, participants all volunteered to be in the study. Among the 142 participants from
Washington and 80 participants from North Carolina, each person was randomly assigned
to one of the three groups (Factsheet, HPE, or HPE+MI). Data on health and health behavior
outcomes were collected before the three interventions began and again at two, four, and six
months into the interventions. The primary outcomes variables included the Sum of Secondary
Conditions Surveillance Instrument measures of the prevalence and severity of 32 secondary
health conditions (e.g., fatigue, weight, depression, urinary tract infection); the Behavioral Risk
Factor Surveillance System Health-Related Quality of Life Module measures of the prevalence

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FOR YOUR CONSIDERATION
Two Examples of Evaluation Research (continued)

of health problems; and the Health Promoting Lifestyle Profile II measures of the six dimen-
sions of lifestyle behavior (e.g., physical activity, nutrition, interpersonal relations). Data
were analyzed using repeated measures analysis of variance to compare changes over time.

Contrary to the researchers’ hypothesis, the study results did not find differences between
the Factsheet, HPE, and HPE+MI groups based on intervention intensity. Participants in all
groups experienced statistically significant reductions in secondary health conditions (p < .001)
and health-related quality of life symptom days (p < .004) and significant improvements in
health-related behaviors (p < .017) over six months.

Policy Analysis
As presented in a study by Kehler and Hahn (2016), Kentucky has had one of the highest
smoking rates of all states in the United States. Particularly, exposure to secondhand smoke
(SHS) has led to significant public health and financial burdens (smoking-related illness and
smoking-attributed productivity cost) on Kentucky. Evidence showed that comprehensive
smoke-free laws are the most effective approach to fully protect people from exposure to SHS.
In 2010, the comprehensive smoke-free legislation that bans smoking in public places and
employment settings was introduced in the Kentucky House of Representatives. However, the
comprehensive smoke-free bill named HB145 in 2015 (similar to bills filed in the previous four
years) failed to receive a hearing in the Kentucky Senate after passing the House with amend-
ments that significantly weakened it. Kehler and Hahn conducted a policy analysis of HB145.

The researchers used Kingdon’s three streams model for agenda setting (see, e.g., Kingdon
2011) to guide the analysis of the legislation and to illustrate how and why HB145 failed to
pass into law. The Kingdon model consists of three independent streams: problems (which
come to the attention of the government and public attention), policies (policy communities
develop alternatives and policy proposals), and politics. Specifically, the Kehler and Hahn
(2016) study focused on the leadership team, the context of partisanship, and the support-
ing and opposing business and organizations of the smoke-free legislation. In the problem
stream, the researchers evaluated the components of indicators and focus events, feedback,
and problem definition. In the policy stream, the researchers examined the criteria of policy
communities, survival criteria, the short list of ideas, available alternative, fiscal impact, and
unintended consequences. In the politics stream, the factors of state mood, organized forces,
consensus building, and coupling were assessed in analyzing the failure of HB145.

The policy analysis found that smoke-free legislation in Kentucky obtained public support
and was feasible, but policymakers were divided on whether the issue should be determined at
the state level or by the individual business owners. The failure of HB145 was strongly associated
with partisanship, fragmentation of advocacy groups when amendments were made to the bill,
lack of political negotiation and compromise, and conflict of values (Kehler and Hahn 2016).

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Key Health Services Evaluation Studies
Examples of important evaluation research for the health services abound in the literature.
One of the most notable is the Women’s Health Initiative, which evaluated the health risks
and benefits of hormone replacement therapy (HRT) for postmenopausal women (Writing
Group for the Women’s Health Initiative 2002). For decades, HRT was routinely prescribed
to this population to help prevent coronary heart disease, despite the lack of evidence of its
long-term effects. Beginning in 1993, the Women’s Health Initiative conducted a rigorous
randomized controlled trial that enrolled more than 16,000 women to assess the associa-
tions between HRT and coronary heart disease, breast cancer, stroke, pulmonary embolism,
endometrial cancer, colorectal cancer, and hip fracture. After approximately five years of
follow-up study, the trial was abruptly halted in response to the finding that women using
HRT experienced unacceptably high rates of invasive breast cancer.

CO s t–Be n e f i t an a ly s i s a n d CO s t-ef f e C t i v e n e s s an a ly s i s

Cost–benefit analysis (CBA) and cost-effectiveness analysis (CEA) are methods used to
analyze or ascertain the efficiency and impact of programs. These analyses, each of which is
a type of efficiency analysis, are particularly useful when evaluating policies or programs
and when considering alternative programs. The following paragraphs provide definitions of
CBA and CEA (Rossi, Lipsey, and Freeman 2004), and exhibit 9.1 compares the methods
on the basis of key characteristics.

CBA is a type of efficiency analysis in which a program’s benefits are compared with its
costs (direct and indirect) in monetary terms. The benefits and costs may be projected into the
future, or the future benefits and costs may be discounted to convert them into their present values.

CEA is a type of efficiency analysis in which a program’s benefits are compared with its
costs, but only the costs of the program are monetized. Program benefits in CEA are expressed
in outcome units, such as the quality-adjusted life year, which measures quality or desirability
of a health state for the duration of survival (Haddix, Teutsch, and Corso 2003). CEA is often
used to compare the efficiency of programs that share similar goals and outcome measures.

Because both CBA and CEA provide insight on efficiency levels of programs, these
analyses are both crucial for decisions related to planning, implementing, continuing, and
expanding health programs. Resource constraints force program directors to measure pro-
grams’ effectiveness to determine whether they should be continued. See the Research from
the Field box titled “Cost-Effectiveness Research” for an example of research using CEA.

Qu a l i tat i v e me t h O d s

Qualitative research can serve as a critical complement or an alternative to quantitative
research. It is particularly useful as an exploratory study method when little is known about

efficiency analysis
Thorough examination
of the overall direct
and indirect costs
and benefits of an
intervention; can
be used to compare
interventions or
programs that have
similar goals.

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Steps Considerations CBA CEA

Specify the accounting per-
spectives to influence what
items are chosen and how
items are valued

Decide whether to consider costs and
benefits from the perspective of pro-
gram participants, the program spon-
sor/funder, or society as a whole

Identify costs and benefits Include all relevant cost and benefit
components to ensure valid results

√ √

Measure costs and benefits (in
terms of a common monetary
unit) and specify measure-
ment method

Consider opportunity costs (to reflect
alternative ways that resources can be
used) and externalities (unintended
spillover consequences)

√ √

Value costs and benefits;
compare total program costs
to total program benefits

May employ discounting, a technique
used to reduce costs and benefits that
are spread out over time to their pres-
ent or future values

√ √

Assess effectiveness of the
program and compare results
to similar programs

Measure program benefits in terms
of whether the program reached its
substantive goals

Sources: Adapted from Blaney (1988); Drummond et al. (2015); Patrick (1993); Pearce (1981); Rossi, Lipsey, and Freeman
(2004); Rowland (1995); Stokey and Zeckhauser (1978); Svensson and Hultkranz (2017); VA (1989); Veney and Kaluzny
(2005).

exhiBit 9.1
Comparisons
Between Cost–
Benefit Analysis
(CBA) and Cost-
Effectiveness
Analysis (CEA)

RESEARCH FROM THE FIELD
Cost-Effectiveness Research

The Health Disparities Collaborative (HDC) is a program that was initiated by the BPHC to
improve the quality of care for chronically ill patients receiving primary care services at
Health Resources and Services Administration (HRSA) health centers. Various HDCs have
been established to focus on specific chronic conditions. To examine the efficiency of the
Diabetes HDC, researchers conducted a cost-effectiveness study of the program, using data
collected between 1998 and 2002 on 80 randomly chosen patients with diabetes from selected
health centers (Huang et al. 2007). The data included information on patient demographics
and receipt of services as well as clinical information. Using these data and a simulation
model, the researchers determined the resulting quality-adjusted life years (QALYs) and the
costs associated with the patients’ treatments. The QALYs and costs were then compared to
determine the cost-effectiveness of care received through the Diabetes HDC.

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a program or its outcomes. In contrast to quantitative research, in which numbers represent
the bulk of an analysis, qualitative research focuses on observations and analyses made from
concepts identified in open-ended responses and statements from participants.

The goal of qualitative research is to gain individual accounts of actions, knowledge,
thoughts, and feelings. The focus of qualitative research is not to generalize findings to predict
future events but, rather, to provide context-rich information and gain in-depth understand-
ing of a particular research problem (Petty, Thomson, and Stew 2012a, 2012b). Researchers
attempt to understand the perspective of a program insider by capturing the participants’
view of reality and their perceived experiences. By examining the program from this per-
spective, qualitative researchers hope to gain insight into a complicated event or problem.

ty P e s O f Qu a l i tat i v e re s e a r C h

Many types of qualitative methods are used in research (Isaacs 2014). In fact, a number
of terms are commonly applied to qualitative research methodological approaches (Patton
2002). For example, qualitative research is often referred to as field research because it often
takes place in a natural social setting to allow researchers to directly and closely interact with
subjects and situations under study.

The three most widely used qualitative approaches are participant observation, in-
depth interview (including focus groups), and case study (Babbie 2006; Patton 2002; Petty,
Thomson, and Stew 2012a; Singleton and Straits 2017; Yin 2003).

Participant Observation
Direct participation and close observation are critical methodologies by which to under-
stand a program, enabling researchers to go beyond the selective perceptions of others and
experience a program firsthand. Qualitative observation differs from other forms of scientific
observation, because it takes place in a natural setting (rather than a controlled setting or
laboratory) and requires the researchers to be physically present for direct observation (rather
than participating in an indirect capacity, such as through a survey). Participant observa-
tion generally involves fieldwork, which allows the researchers to experience the lives of the
people they are studying as much as possible.

Often referred to as observational research, participant observation allows researchers to
become part of the group or setting of interest. Participation can either be open, with inves-
tigators making known their role as researchers, or disguised, with only group leaders or the
heads of organizations being made aware that the observation is taking place. The selection
of open versus disguised participation depends on whether the knowledge that an observer
is present would be expected to significantly alter the usual behavior of the participants.

As participants, researchers pay close attention to the physical, sociocultural, and human
environment; formal and informal interactions; and unplanned activities surrounding the

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topic under study. By directly observing activities and operations within the research setting,
researchers gain a better understanding of the context and process of the study environment.

In-Depth Interview
An in-depth interview can take one of three forms: (1) the informal conversational interview;
(2) the general interview guide approach, or semistructured interview; or (3) the standard-
ized open-ended interview, or structured interview (Patton 2002).

All kinds of interviews extend along a continuum of structuredness, from highly
unstructured to highly structured. The informal conversational interview is the least
structured of the three types. Often occurring during the course of fieldwork, informal
conversational interviews do not include specific predetermined questions or presentation
of general topics. The interaction is organic, allowing researchers to spontaneously generate
questions depending on the flow of conversation.

The general interview guide approach or semistructured interview is in the middle
of the structuredness continuum—more structured than the informal conversational interview
but less structured than the standardized open-ended interview or structured interview in that it
allows the researcher some flexibility while conducting the interview. Under this methodology,
a researcher follows an outline listing the issues to be explored during the interview; however,
the interviewer’s approach to raising the issues is unstructured, and the questions asked are
open-ended and vary in length. The outline ensures that no major issues are omitted. The
general interview guide approach or semistructured interview often yields new findings that
may determine subsequent interview questions. It also allows the interviewers full control
over what they seek from the interview but not excessive control of the interview flow.

The standardized open-ended interview or structured interview is the most struc-
tured of the three in-depth interview types—at the opposite end of the spectrum from the
informal conversational interview. The interviewer follows a set of explicit instructions and
uses a questionnaire that contains a set of carefully worded and ordered questions. Each
respondent is asked the same set of questions in the same sequence. Although the standard-
ized open-ended interview or structured interview affords the researcher less flexibility and
spontaneity than the other two types, it minimizes variation in the questions asked and thus
reduces the potential bias introduced by the interview process.

In-depth interviews may be conducted with an individual or a group of individuals.
The latter is often referred to as a focus group study or, simply, focus group. Focus groups
are conducted to gather in-depth knowledge about individuals’ attitudes, perceptions, and
opinions regarding a specific topic (Clow and James 2014). A focus group typically consists of
8 to 12 people who are brought together to engage in a guided discussion of a topic (e.g., see
the For Your Consideration box titled “An Example of Qualitative Research: Focus Group”).
Participants are selected on the basis of their experience with the topic rather than through
the use of probability sampling methods, as in experimental and quasi-experimental research.

informal conversational
interview
A face-to-face in-depth
interview, conducted
in person during
observational studies,
that does not adhere
to a prescribed set of
questions.

general interview
guide approach or
semistructured interview
A method of conducting
an in-depth interview
that provides an
outline of issues that
the interviewer must
explore but allows the
interviewer flexibility
with regard to the type
and order of questions
asked.

standardized open-
ended interview or
structured interview
An in-depth interview
that is conducted by a
researcher asking each
respondent the same set
of predetermined open-
ended questions, recited
verbatim in a specified
order.

focus group
A small group (8–12
people) whose reactions
to a given topic are
studied to provide an
in-depth understanding
of the topic.

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FOR YOUR CONSIDERATION
An Example of Qualitative Research: Focus Group

The college or university years represent a critical period for potential unhealthy lifestyle
changes in eating behaviors among students. The purpose of this study conducted by Deliens
and colleagues (2014) was to explore which factors influenced the eating behavior of Belgian
university students, using a qualitative research design centered on focus groups.

Participants were asked to complete a questionnaire beforehand about their demograph-
ics, height, weight, and perceived health. Then, based on a semistructured interview guide,
five focus group discussions were conducted with 36 university students ranging in age from
about 18 to 22 and coming from a variety of academic disciplines. The students were asked to
share their thoughts and ideas for health promotion and interventions to counter unhealthy
eating behaviors. The focus group moderator (interviewer) also asked additional side questions
about these topics, with flexibility to encourage open discussions and more in-depth answers.

During subsequent data analysis, the students’ statements were examined for recurrent
themes, which were grouped by coding (content analysis) into general concepts (subcatego-
ries) and then into main categories. To ensure reliability, two rounds of analyses of the data
were carried out independently by two researchers, and disagreements were discussed with
two other researchers until consensus was reached.

Students reported that they were influenced by individual factors, social networks, the
physical environment, and society in making their food choices. Furthermore, these influ-
ences on the students’ eating behavior seemed to be moderated by university characteristics,
including residency, student societies, campus lifestyle, and exams. Recommended actions
for university administrators and researchers included the following:

• Providing students with information and advice to enhance healthy food choices and
preparation

• Encouraging students’ self-discipline and self-control
• Helping students develop effective time-management skills
• Enhancing students’ social support
• Changing the campus food environment by offering healthful foods at lower prices

than unhealthful food and by stocking vending machines with more healthful
products

This was the first European study to examine the perceived determinants of eating behavior
in university students and to collect ideas and recommendations for healthful eating inter-
ventions in a university setting. University characteristics influenced the effect of individual
and social environmental determinants on students’ eating behavior. These findings should
be considered when designing multilevel intervention programs to improve healthful eating
behaviors in university students.

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Conducting a focus group can be an efficient way to gather information that would
be difficult to capture through a survey or an individual interview, because a focus group
establishes a context for the perspectives of its members and allows researchers to assess
whether these perspectives are consistent among the target population. Focus groups are
often used to assess outreach efforts of programs and policies, such as health insurance
coverage programs aimed at vulnerable populations (Jones et al. 2016). In addition, data
obtained through focus groups are useful to inform future quantitative research, such as
questionnaire development.

The use of in-depth interviews offers several advantages, including flexibility in how
and where an interview is conducted, high validity in interview responses, and low costs
(Patton 2002). However, in-depth interviews also have several limitations. Time limits
may affect the number of questions asked or issues explored. The less structured formats
of the informal conversational interview, the general interview approach or semistructured
interview, and the focus group give the researcher minimal control of the group and lead to
discussion of irrelevant issues more frequently than when using more-structured methods.
Furthermore, data from in-depth interviews can be a challenge to analyze, because the pro-
cess of conducting and transcribing the interview demands considerable time and intensive
training for the interviewers and requires that the investigator remain objective and record
the participant’s statements with high accuracy to reduce bias (i.e., avoid asking leading
questions). See the Research from the Field box titled “Qualitative Research: In-Depth
Interviews” for two examples of in-depth interviews.

RESEARCH FROM THE FIELD
Qualitative Research: In-Depth Interviews

Two examples of qualitative research using in-depth interviews are provided here. The first
study assessed the capabilities of community health centers (CHCs) in responding to emergency
and disaster situations. Researchers conducted a series of focus groups between 2006 and
2007 with CHC staff in New York City (Ablah et al. 2008). Participants were not randomly chosen
but instead recruited from among center administrators and medical director members of the
Community Health Care Association of the New York State Emergency Preparedness Advisory
Committee. They were then assigned to one of three focus groups of 6 to 12 participants each.
A predeveloped script of questions was used to direct the conversation toward discussion of
New York CHCs’ competency in responding to emergency situations and the use of or further
need for emergency preparedness training. This method enabled the researchers to gain an

( c o n t i n u e d )

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Case Study
A case study is an empirical inquiry that draws on multiple sources of data to study a real-
world organization or phenomenon (Yin 2003). A case study typically takes place in a single
social setting, such as an organization, a community, or an association. Case studies can be
especially valuable when the researcher is trying to distinguish between environments, as
they can provide rich detail for an in-depth, comprehensive understanding of programs.

The case study method is flexible and diverse; the type and quantity of data collected
and analyzed can vary greatly. Researchers typically rely on several methods of data collec-
tion, including administrative record analysis, in-depth interviews, structured surveys, and
participant observation. Multiple data sources enable researchers to obtain a more complete
understanding of issues than a single data source does, which makes case studies useful in
both qualitative and quantitative research.

The ways that researchers define cases are as diverse as the potential data sources for
a case study. Types of cases may include a person, an event, a program, a critical incident,
or a community.

During a case study of an individual, interviews are typically conducted over an
extended period to obtain detailed accounts of a personal history. Individual case studies are
commonly used to study ethnic or cultural groups with distinctive experiences. In addition
to the individual’s account, interviews of family and friends and observations of relevant
settings or events can provide an enhanced picture of an individual’s history.

In contrast, case studies that focus on a social entity or group seek to describe certain
aspects of community life. For example, a community case study can provide a detailed

RESEARCH FROM THE FIELD
Qualitative Research: In-Depth Interviews (continued)

in-depth understanding of the capacity of multiple CHCs and collect information to inform
future programming and training.

The second study assessed US older adults’ experiences and perspectives of the over-
use of healthcare. Researchers conducted focus groups in Baltimore senior centers in 2016.
Participants were not randomly selected but instead recruited from among residents aged
66 or older at selected senior centers through flyers soliciting volunteers, using purposive
sampling to include those who were representative in race and socioeconomic status. Five
focus groups consisting of six to nine participants each were conducted in four senior centers.
A predetermined brief questionnaire helped direct the conversation toward discussion of
participants’ experiences and perceptions, consequences, and factors of healthcare overuse.
This method helped researchers to gain an in-depth understanding of healthcare overuse by
older adults in the United States and to collect information that informed the construction
of a framework to understand and reduce such overuse.

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account of a community’s organization and needs for assessing a community-based health-
care network.

A case study may also be conducted for organizations or institutions, such as health
services organizations, schools, or regulatory agencies (see the For Your Consideration box
titled “Example of Qualitative Research: Case Study” to learn how this research method
was used for a governmental public health system). For example, a case study of a health
insurance organization may assess its impact on cost and quality of care, while a case study
of a political interest group can help measure its influence on health policies.

Qu a l i tat i v e st u d y de s i g n

Similar to quantitative methods, qualitative research should begin with a review of litera-
ture and background information so that researchers become familiar with the relevant

FOR YOUR CONSIDERATION
An Example of Qualitative Research: Case Study

According to Jacobson and colleagues (2015), the local health department workforce in the
United States decreased by nearly 19 percent from 2008 to 2010. In response, the governmental
public health system developed an innovative strategy called Public Health Entrepreneurship
(PHE), which applied entrepreneurial skills to supplement public funds with other revenues
from other sources. The Jacobson group’s study examined the feasibility and desirability of
PHE in governmental public health efforts.

The researchers used multisite qualitative case design for their study. Semistructured
interviews were conducted at 32 local health departments in 18 states across the United
States. Specifically, the respondents included chief health officers and senior management
staff, other public health representatives, health authorities, and members of national health
organizations. The local health departments were identified through literature review, consul-
tation with experts, and examination of survey data from the National Association of County
and City Health Officials. Further sampling identified additional entrepreneurial programs
or individuals’ contacts. Narrative and descriptive analyses were performed to compare the
interview data and documentary evidence across sites.

Generally, respondents identified three PHE practices: strategic planning, operational
efficiency, and generation of revenue. Most respondents reported that clinical services were
the strongest revenue-generating opportunity; traditional public health services provided
inconsistent revenue sources and therefore only limited entrepreneurial opportunities. Some
major barriers facing PHE consisted of strict civil service rules, a risk-averse culture, and the
primary concern that movement toward profit-oriented PHE strategies would compromise
core public health values. These barriers would need to be overcome for PHE to succeed.

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population, setting, and issues in a field study. Investigators must also ensure that they can
obtain the desired level of access to the study participants and research setting of interest.
In qualitative research, investigators often work closely with program administrators and
other staff, who are crucial to facilitating access to study participants.

The primary difference between quantitative research and qualitative research is that
in the latter, investigators do not attempt to manipulate the research setting. Qualitative
study—and thus qualitative study design—depends on the changing nature of the setting.
In many cases, the design is not finalized until the major issue of study and potential oppor-
tunities and obstacles are identified.

The following paragraphs describe a number of design considerations unique to
qualitative study, including the unit of analysis, preliminary sampling procedures, the role
of researchers, ethical implications, data collection, and analysis strategy.

Unit of Analysis
In qualitative research, the unit of analysis selected depends on the research goals for the
study. Units of analysis may include individuals; groups; incidents or longer-term actions,
such as events and activities; or the research setting itself. The unit of analysis in turn deter-
mines the researcher’s strategies for data collection, analysis, and reporting.

Preliminary Sampling Procedures
The sites and subjects from which the qualitative research investigator can select a sample are
typically determined by their availability and accessibility. Researchers must rely on alterna-
tives to probability sampling to choose a sample that is as representative as possible of the
population. One such method is purposive sampling or quota sampling, which is used
to ensure that a small sample of individuals or entities is similar to its target population in
terms of important characteristics. For example, for qualitative research of statewide hospital
conditions, limitations on funding and other resources may only allow for a few sites to be
included. A purposive sampling technique may help researchers choose hospitals that share
certain characteristics with average hospitals in the state, such as an urban or rural location,
socioeconomic status of the patients in the community, or size. Thus, the use of purposive
sampling improves the generalizability of the qualitative research results.

Other commonly used qualitative sampling methods are time sampling, typical case
sampling, extreme (deviant) case sampling, intensity sampling, and stratified purposeful
sampling (Patton 2002). Time sampling is based on sampling time periods (e.g., months of
the year) or units of time (e.g., hours of the day) and is used when activities are believed to
vary significantly from one period to the next. Typical case sampling enables the researcher
to compile a profile of one or more typical cases to determine the major characteristics of
the study. In contrast, extreme (deviant) case sampling focuses on atypical cases, providing
examples of unusual or extreme situations. Intensity sampling uses the most information-rich

purposive sampling or
quota sampling
A nonprobability
sampling technique
whereby the investigator
selects the study sample
from among accessible
sites or participants to
establish proportions
of characteristics in the
sample that are similar
to the proportions found
in the population.

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cases to provide researchers with detailed accounts of events or situations. Stratified purposeful
sampling combines typical and extreme case sampling to produce samples that fall along an
entire spectrum of characteristics.

Role of Researchers
The role of investigators and the degree to which they reveal themselves during the study
must be clearly defined during the preliminary stages of a study. The researcher’s role may
range from solely observation (i.e., the investigator simply watches events) to full participa-
tion (i.e., the investigator interacts with the study participants as a member of the group).

Ethical Implications
Ethical considerations are extremely important when designing and implementing qualitative
research. Potential risks—such as bodily harm, side effects, legal liabilities, and ostracism
by colleagues—must all be taken into account. (Refer back to the discussion in chapter 8
on the ethical framework of HPR.)

Data Collection
In general, qualitative researchers rely on multiple sources of evidence to address a range
of issues related to a topic and to validate study findings. As previously described, the most
commonly used methods of data collection are observations, interviews, and case studies.

To properly collect data, researchers must be familiar with administering interviews.
Even during informal conversational interviews, certain protocols must be followed. Prior
to the interview, the interviewer must have a general understanding of the topic and issues
under study as well as the type of information being sought. During the interview, the
investigator must maintain neutrality by avoiding asking leading questions or expressing
personal opinions. Finally, the interviewer must listen to complete, detailed answers while
understanding that the interview setting may influence those answers.

Technology is becoming increasingly useful in the data-collection process, which
has important implications for qualitative research. First, a larger amount of data for future
analysis can be collected by technological means than can be gained manually, allowing for
a more comprehensive qualitative study (Peacock et al. 2011). Technology can also facilitate
the participation of program staff and support future evaluation efforts.

Analysis Strategy
Through descriptions, field notes, and coding schemes, researchers must not only produce
detailed descriptions of subjects’ perspectives through anecdotes, examples, and quotes
but also further organize these descriptions into a comprehensible framework for analysis.

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Descriptions may be organized by the periods and processes they cover, the level of impor-
tance to the study, the extent to which they focus on critical events, or the category they
fall in within the major unit of analysis.

Researchers are also responsible for explaining and interpreting the participants’
actions, activities, and beliefs described and assigning significance to the results, themes,
and concepts identified as possible components of grounded theories.

The frequent review and editing of field notes is one way to facilitate subsequent data
analysis. The coding can begin with a small segment of data (e.g., interview or observational
notes) for which the researcher identifies each unique response, theme, or concept. Coding
strategies act as a foundation for analyzing the next segment of data and can be refined with a
better understanding of the data. When new categories no longer present themselves during
data collection, the researcher can develop instructions for coding. After this step, all of the
data should be recoded using the same coding instructions and framework.

Although an exhaustive overview of the approaches for analyzing qualitative data is
beyond the scope of this book, two central methods—constant comparative analysis and
narrative analysis—are described in the sections that follow.

Constant Comparative Analysis
Glaser and Strauss (1967) first developed the process of constant comparative analysis in their
seminal text The Discovery of Grounded Theory. The constant comparative process involves
comparing pieces of data (e.g., an interview or a statement) to understand the relationships
between the distinct pieces of data (Thorne 2000). This method enables the researcher to
identify similarities and differences across data sets and develop theories about relationships
and patterns that emerge from the data. The use of constant comparative analysis produces
an enhanced understanding of a human phenomenon within a specific context, enabling
the researcher to develop theories about basic social processes and factors that may account
for variation in people’s experiences of these processes (Heidari et al. 2016; Thorne 2000).

One example of this type of analysis is a study conducted at the Washington Diabetes
Care Center in Seattle by researchers who used constant comparative methods to explore
issues of trust and collaboration in the healthcare setting (Ciechanowski and Katon 2006).
First, 27 diabetic patients completed a self-reported measurement of “attachment style,”
which captured the level of trust patients felt toward the healthcare system. The set of patient
responses was used to obtain a wide range of attachment styles among the group, allowing
for comparisons within the group. Researchers then interviewed the patients, asking ques-
tions about their experiences within the healthcare setting and interactions with providers.
By comparing the interview results of patients with varying levels of attachment style, the
investigators were able to develop theories about how patients with particular levels of trust
in the healthcare system could be better served.

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Narrative Analysis
Narrative analysis is a process that involves the generation, interpretation, and representation
of people’s stories (Thorne 2000). Narrative analysis as a method of qualitative research is
distinguished by its ability to “highlight the uniqueness of each human action and event
rather than their common properties” (Chase 2005, 657). In contrast to constant comparative
analysis, which aims to identify similarities across groups, narrative analysis aims to identify
patterns and themes within each individual narrative. Thus, rather than create generalizations,
the goal of narrative research is to emphasize the uniqueness of each particular narrative and
to place it into a broader frame (Chase 2005).

In HPR, narrative analysis can help improve understanding in specific areas such as
patients’ personal experiences with disease. For instance, noting the small amount of literature
that addressed living with lupus (a chronic autoimmune disease) at that time, one researcher
conducted a narrative analysis using interview data from lupus patients (Mendelson 2006). Seven
women with lupus participated in three interviews, conducted one month apart, and maintained
a daily symptom journal. Interviews were also conducted with 23 additional women. Using
narrative analysis, the researcher identified patterns and themes within each narrative and noted
many overlapping themes across the narratives, such as feelings of uncertainty, a shifting sense of
identity, and experiences of financial stress related to living with lupus. This type of research is
important in shaping programs and funding therapies both in and beyond the healthcare setting.

en s u r i n g ri g O r i n Qu a l i tat i v e re s e a r C h

In the late twentieth century, Devers (1999) and Bowling (1997) cited several criteria for
ensuring the rigor and quality of qualitative research. The research question, theoretical
framework, process methods, and context should be clearly defined. The research study design
should reflect the researcher’s understanding of the implications of choosing a particular
sample. Similarly, researchers must choose an appropriate sample size that will ensure that
useful information is collected, while avoiding the saturation point, at which similar ideas
are repeated by study participants. In fact, qualitative researchers have called for a more
rigorous definition of saturation, as this concept has been invoked to justify small samples
with inadequate data for explanation (Charmaz 2006).

Data-collection methods, data types and sources, and data-analysis methods must also
be described and justified. Ideally, an independent investigator should be able to replicate
the data collection and analysis in a study to produce the same or similar results. The validity
and reliability of qualitative research can also be improved through triangulation methods, in
which several quantitative and qualitative methods are used together to investigate the same
research topic. Other strategies for enhancing the rigor of qualitative research include searching
for evidence that may disprove the results, archiving the data, and conducting a peer review.

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Finally, researchers must carefully consider the information they and their colleagues
present in a final report and how that information may be interpreted by sponsors and other
stakeholders. For example, presenting adequate amounts of raw data (e.g., transcripts of
interviews) in the final report supports the researcher’s claim that interpretations of the data
are based on evidence rather than subjective impressions.

➤ Quantitative methods in health policy research include experimental or quasi-
experimental research, survey research, evaluation research, and cost–benefit analysis
and cost-effectiveness analysis.

➤ The main difference between experimental and quasi-experimental research is that
in the latter, there is no random assignment of participants to treatment groups; thus,
researchers must use other methods to ensure that the study groups are comparable.

➤ Survey research is a popular approach to studying health policy. It provides a
systematic way to capture data from a large sample.

➤ Evaluation in health policy research allows researchers to objectively assess policy
or program components, operations, or impacts associated with a particular product,
service, or problem.

➤ Qualitative research is performed to capture and categorize observations and thoughts
into cohesive themes and concepts; the most widely used types are participant
observation, the in-depth interview, and the case study.

Ca s e st u d y 1

On the basis of your research of health centers and the fight against health disparities, answer
the following questions:

1. What prompted the establishment of health centers in the United States?
2. What services do health centers provide to address health disparities?

Ca s e st u d y 2

On the basis of your research of Vermont’s Accountable Communities for Health Learning Lab,
answer the following questions:

k e y P O i n t s

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

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1. For what purposes was the Vermont Accountable Communities Model established?
2. What are the core elements that were shown to improve through the Peer Learning Lab?

Using one quantitative and one qualitative health policy research method described in this
chapter, design a study to examine whether health centers are able to reduce or eliminate
health disparities (i.e., differences in access, quality, and health outcomes) across racial or
ethnic and socioeconomic subpopulations.

1. What methods are commonly used in health policy research?
2. What are the conditions for a causal relationship?
3. What are some types of experimental research and situations in which such methods

are most appropriately used?
4. What is survey research?
5. What is the difference between a cross-sectional survey and a longitudinal survey?
6. What is a panel study?
7. What is evaluation research?
8. How would you differentiate among needs assessments, process evaluations, and

outcome evaluations?
9. What are the differences between cost–benefit analysis and cost-effectiveness

analysis?
10. What methods are commonly used in qualitative research?
11. Through what process is a qualitative study designed?
12. How can rigor in conducting qualitative research be enhanced?

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

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