Transcript Policy Analysis - University of Florida
Policy Analysis
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What is Policy Analysis?
Multi-element process of assess and analyzing components of a plan of action Not an exact science, more of an art Reviews the component parts of an issue or problems Considers new options. 2
What is Policy Analysis?
Multi-element process of assess and analyzing components of a plan of action Not an exact science, more of an art Reviews the component parts of an issue or problems Considers new options. 3
Policy Analysis New discipline Dates to early 1960s Policy analysis should Improve decision making Consideration of broad sets of alternatives Use of more systematic tools 4
Policy Analysis Neutral analysts Consider all options Advocates for best options serving “national interest” 5
1970s Amendments to the Legislative Reorganization Act “Congressional declaration of analytic independence from the administrative branch” Created CBO, CRS, and OTA 6
Think Tanks Originally, U.S. Now world-wide Have blended policy outside of political environment Established by interest groups Interest groups can adapt models developed by official sources 7
Evolution of Policy Analysis Clients not only decision makers Individuals stewarding institutional governance Planning Budgeting Regulation 8
Office of Assistant Secretary for Planning and Evaluation (ASPE) ASPE Principal policy advisor to the secretary Policy coordination, legislation development, strategic planning, policy research and evaluation and economic analysis 9
Office of Assistant Secretary for Planning and Evaluation (ASPE) Use of office has varied with Administrations Staff vary, initially Ph.D. economists…many from DoD Over time staff has varied Staff now serves entire department Also, other units have policy analysts, so ASPE is only one voice to Secretary 10
Office of Assistant Secretary for Planning and Evaluation (ASPE) Early methodology and analytic techniques relied on economic models Evolution to reliance upon policy expertise of office vs. policy analysis 11
Needed skills for ASPE Program knowledge Statistics Microeconomics Cost-benefit analysis 12
Congressional Research Service CRS Part of the Library of Congress Most recent incarnation dates to 1970 Legislative Reorganization Act Act allowed CRS to triple staff Now @ 700 individuals New staff teamed with experienced individuals 13
CRS What is the legislative hook?
High volume, quick turnaround “a reference factory” Emphasis on legislative consultation, interdisciplinary work, & anticipatory work 14
CRS Provision of background papers to the committee Assistance in design of congressional hearings Suggestions of witnesses for hearings Possible questions for Members to ask witnesses Attend hearings to supplement questions 15
CRS Consultation at mark-ups Hearing testimony Consultation on the floor as requested Prepare conference agendas Consultation at conferences 16
CRS Most important role may be participation in creation of new legislation Work not available to the public Unless released by a Member 17
CRS Varied products Electronic briefing books Background reports on topics CRS staff also interacts with Members and staff 18
CRS In-house capacity Modeling Create microsimulation models Fiscal analyses Culture emphasizes qualitative approaches and oral tradition 19
Heritage Foundation Founded in 1973 Formulate and promote conservative policies based on principles of free enterprise, limited government, individual freedom, traditional Americans values and strong national defense Seeks to differentiate itself from other conservative think tanks by focusing on influencing decisions very early in the process 20
Heritage Foundation Established in 1973 with 9 staff 1997 staff of 180 Added research staff in 1980 Funding from individual sponsors 21
Heritage Foundation Has pushed boundary of tax exempt organizations Replaced the Kennedy School orienting new conservative congressman Focus on Congress --- members and staff 22
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Health Policy Peters (1999) Pubic policy “sum of government activities, whether acting directly or through agents as it has influence on the life of citizens” Birkland (2001) “ a statement by government of what it intends to do or not do, such as laws regulation, ruling, decision, or order as a combination of these” 24
So, What is Health Policy?
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Health Policy Cochran and Malone (1995) “policitical decisions for implementing programs to achieve societal goals Longest 2002 “authoritative decisions made in the legislative, executive, or judicial branches of government that are intended to direct or influence the actions, behaviors, or decisions of others.
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Policy and Health When public policies or authoritative decisions refer to health it is health policy Includes federal, state, and local government Health policy affects classes of citizens physicians, providers, consumers, the poor, the elderly 27
Health Policy Authoritative refers to decisions made in any part of government all three branches 28
Health Policy In the US: Consists of many decisions, rather than one large decision Other countries have integrated, coordinated health systems (Great Britain, Canada) 29
Health Policy Laws Rules Regulations Judicial Decisions 30
Health Policy by levels: Law PL 89-97 1965 law establishing Medicare Rule Executive order establishing federally funded health centers 31
Health Policy by Levels Judicial Decision Court ruling that an integrated delivery system’s acquisition of another hospital violates federal anti-trust Regulation County health department’s procedure for inspecting restaurants City government’s ordinance banning smoking in public places 32
Laws Laws enacted at any level of government create policies Laws passed at federal or state levels federal laws: 1983 Amendments to the Social Security Act (P.L. 98-21) state laws govern professional practice 33
Health Policy and Markets Capitalist countries such as the USA assume markets are critical to production consumption of health services 34
Health Policy Interventions intervention needed when markets fail party models have differing tolerance for market imperfection 35
Conditions for the Market True markets require: buyers and sellers have adequate information to make informed decisions large numbers of buyers and sellers easy entry to the market competitive products that can replace each other adequate quantity of products 36
Health Policy Categories Allocative Policies provide net benefits to some at the expense of others subsidies for medical education rural hospital support Medicare and Medicaid 37
Health Policy Categories Regulatory Policies policies designed to influence actions, behaviors, and decisions of others market-entry restrictions rate or price setting controls quality controls market preserving controls social controls 38
Health Policy Categories Regulatory Policies market entry, rate controls, quality controls, market preserving controls are all economic regulation social controls seek socially desired outcomes: smoke free workplace, nondiscriminatory hiring practices 39
Regulatory Market-Entry Restrictions State licensing laws Planning programs CON 40
Regulatory Price Setting Out of vogue Electric and gas utility control PPS 41
Regulatory Quality Food safety and quality standards Medical Devices Amendments (P.L. 94 295) to the Food, Drug and Cosmetic Act (P.L. 75-717) placed medical devices under FDA 42
Regulatory Market Preserving Health markets are not true markets; this class of regulatory action addresses market imperfections Sherman Anti-trust laws 43
State Health Policy Dynamic balance between state and federal policy Recent ascendance of state policy failed national reform in 1994-1995 Medicaid growth 44
State Health Policy Roles Lipson (1997) financing or paying for several categories of people public health regulating health professions licensing and practice. 45
State Health Policy Roles Financing Medicaid about 15% of most state budgets State employee health benefits (large group when you consider teachers, employees, etc) uninsured 46
State Health Policy Roles Public Health oldest most fundamental state health responsibility States granted constitutional authority to establish laws to protect public’s health and welfare engages states in environmental protection Federal government delegates to states responsibility for monitoring the environment monitoring workplace and food safety 47
State Health Policy Roles Professional Regulation license various professionals write practice acts license and monitor compliance 48
State Health Policy Roles States regulate the content, pricing and marketing of insurance plans Under the McCarran-Ferguson Act (P.L. 79-15) 49
ERISA 1974 Enacted in 1974 to remedy fraud and mismanagement in private-sector pension plans. ERISA preempts state’s regulation of pensions and self-insured plans ERISA preemption broad language that supercedes all state laws relating to employee benefit plans sponsored by private sector employers or unions 50
ERISA ERISA preempts state’s regulation of insurance ERISA creates self-insured plans which states cannot regulate Insured health plans that states can affect indirectly through insurance regulation Both are ERISA plans that states cannot directly regulate 51
ERISA For 1 st 20 years after passage, courts expansive view of ERISA Court noted the reemption clause was “expansive in its breadth” Overturned state laws that had any impact or referred to private sector employee plans 52
ERISA 1995 Travelers Insurance decision Narrowed ERISA preemption provision Limiting types of state law that impacts the “relate to” private sector employer sponsored plans Court held NY’s hospital rate-setting law imposed surcharges on bills paid by insurers other than BCBS even though it increased costs for ERISA plans buying coverage from these insurers.
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1995 Travelers Insurance decision ERISA preemption Designed to minimize employer-sponsored plans’ administrative and financial burdens of complying with conflicting local and state law Court said the NY surcharges as having indirect, at best, economic effect on employer sponsored plans.
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1995 Travelers Insurance decision This case and several that followed: Show ERISA preemption does not condemn all types of state health legislation As long as the state legislation is not directed at ERISA plans Even if the law has an effect on an ERISA plan Still prohibits states from mandating employers offer coverage 55
ERISA Allowable State Legislation 1998 Massachusetts enacted pay or play >5 employees must pay a payroll finance
tax
Credit for costs the employer actually funded No effect on plans, but on the employer Challenged by state restaurant association Law was repealed 56
ERISA Pay or Play Do not require employers to offer health coverage to their workers Establish universal coverage funded in part by employers taxes Do not refer to ERISA plans Remain neutral on payroll tax or tax credit Impose no conditions on employer coverage Minimize administrative impacts on ERISA plans. 57
COBRA 1985 – allows employees to purchase health coverage for 18 months post employment 1996 HIPPA (P.L. 104-191) allows employees guaranteed access to health coverage
company must provide benefits premiums can be renewed assuming payment
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State Laboratories State viewed as “health coverage laboratories” ability to implement local solutions to coverage little evidence the laboratories actually design experiments with national implications 50 individual markets all politics are too local 59
State roles increasing States may be too idiosyncratic States still face large problems and increasing problems 60
Health Policy Policy vs Policy Objectives Policies developed to achieve someone’s policy directives The objectives shape health policy 61
Current US Health Policy Objectives Adding years and quality to life Eliminating disparities in health and access to health services Improving quality of health services Reducing cost of health services 62
Current US Health Policy Objectives Eliminating environmental threats to health Improving housing and living conditions Improving economic conditions Improving nutrition Moderating consumption of food, drink and chemicals Modifying unsafe sexual practices 63
Domain of Health Policy Remarkably broad physical Environment biology social tax issues 64
Domain of Health Policy Personal Responsibility and Work Opportunity Reconciliation Act (P.L. 104 193) AKA Welfare Reform Act modified welfare eligibility also modified Medicaid eligibility for key welfare benefit AFDC 65
Personal Responsibility and Work Opportunity Reconciliation Act (P.L. 104 193) Replaced AFCD with Temporary Assistance to Needy Families (TANF) TANF provided in state block grants states provided broad flexibility to design support and work programs states must impose time limits on support 66
Personal Responsibility and Work Opportunity Reconciliation Act (P.L. 104 193) Allows AFDIC eligible families to enroll in Medicaid, but new identification methods are needed 67
Political Negotiation Involves two or more parties bargaining win/win competitive -- win/lose 68
Political Negotiation Cooperative Negotiating Strategies Work best when: goal of both negotiators is to attain fair, specific outcome sufficient resources are available both negotiators believe they can achieve fair outcome 69
Political Negotiation Competitive Negotiation works best when: each negotiator want to achieve the most possible.
resources are not sufficient for both negotiators to achieve their goals.
both negotiators think it is impossible for both to succeed.
the intangible goal of both negotiators is to beat the other.
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Economic Markets vs. Political Markets Health policies– all policy– is made within political markets operate much like traditional markets Differ from traditional markets no money exchanged less direct relationship than traditional markets 71
Sellers Economic Exchanges in Market Transactions Buyers (Suppliers) (Demanders) 72
Economic Markets vs. Political Markets Demand for health policy markets knowledgeable individuals organizations organized interest groups AMA AARP AAHP PhRMA 73
Benefits of Interest Groups Ambiguous James Madison “The Federalist Papers” in 1788 described groups he labeled “factions” Madison felt factions were inherently bad “mischiefs of the factions” must be contained by setting it against other groups ambitions 74
Pluralist Perspective Everyone’s interests represented in one or more interest groups View interests groups as positive Interest groups provide linkages among people and government Interest groups compete for outcomes; creates counterbalanced vectors No group will become too dominant 75
Pluralist Perspective Groups must rely on political power bases Groups representing concentrated economic interests must have money Groups representing consumer groups must have members 76
Interest Groups More than 22,000 in US concern with pluralist perspective all 22,000 groups given legitimacy 77
Interest Groups Have Power Lowi labeled “interest group liberalism” to address excessive deference to interest groups Edwards, Wattenberg & Lineberry, 2001 Hyperplualism 78
Interest Groups have Power Critics: Interest groups too influential responding to interest groups creates conflicting policy Government tries to satisfy conflicting groups with policy satisfying all groups 79
Elitist Models argues those who control key institutions have power act as gatekeepers for public policy process take powerful roles in nation’s economic and social systems thereby overly controlling policy 80
Elitist Model Real power lies within only a few groups Members of the power elite share a consensus or near consensus on basic values private property rights preeminence of markets best way to organize limited government role of individual liberty 81
Elitist Protect power base 82
What Must Health Care Reform Accomplish?
Restrain cost Create access and equity Improve quality Promote health 83