HPAM Midterm

National Academy of Medicine Definition

- (NAM) an independent, nonprofit organization that works outside of government to provide unbiased and authoritative advice to decision-makers and the public a. Institute of Medicine (IOM) - Focuses on six areas to improve quality a. Safe care: avoiding injuries to patients b. Effective care: providing care based on scientific knowledge c. Patient-centered care: providing respectful and responsive care that ensures that patient values guide clinical decisions d. Timely care: reducing waits for both recipients and providers of care e. Efficient care: avoiding waste f. Equitable care: ensuring that the quality of care does not vary because of characteristics such as gender, ethnicity, socioeconomic status, or geographic location

Essential Public Health Services

- ***Assessment a. Assess and monitor population health status, factors that influence health, and community needs and assets b. Investigate, diagnose, and address health problems and hazards affecting the population - ***Policy Development a. Communicate effectively to inform and educate people about health, factors that influence it, and how to improve it b. Strengthen, support, and mobilize communities and partnerships to improve health c. Create, champion, and implement policies, plans, and laws that impact health d. Utilize legal and regulatory actions designed to improve and protect the public's health - ***Assurance a. Assure an effective system that enables equitable access to the individual services and care needed to be healthy b. Build and support a diverse and skilled public health workforce c. Improve and innovate public health functions through ongoing evaluation, research, and continuous quality improvement d. Build and maintain a strong organizational infrastructure for public health

Department of Health and Human Services (HHS) (graphic in S06 notes)

- ***Central public health agency of the federal government - Includes operating agencies: a. CDC b. NIH c. FDA d. Health Resources and Services Administration (HRSA) e. Agency for Healthcare Research and Quality (ARHQ) f. Substance Abuse and Mental Health Services Administration (SAMHSA) g. Indian Health Service (IHS)

Department of Health and Human Services (HHS)

- ***Enhance and protect the well-being of all Americans by providing effective health and human services and fostering advances in medicine, public health, and social services - 11 agencies that manage more than 100 programs a. Medical and social science research b. Preschool education services c. Health insurance programs d. Substance abuse and prevention services, etc.

Human Resources and Services Administration (HRSA) (graphic in S06 notes)

- ***Improve access to healthcare services for people who are uninsured, isolated, or medically vulnerable - Improve health by funding healthcare initiatives and systems - Four goals a. Achieve health equity b. Improve access to quality care and services c. Foster a health workforce and health infrastructure d. Optimize HRSA operations and strengthen program engagement - Six bureaus and ten offices a. Each bureau provides clinical and preventive services to vulnerable populations

Substance Abuse and Mental Health Services Administration (SAMHSA)

- ***Leads public health efforts to advance the behavioral health of the nation a. Provides federal funding to states, local communities, and private entities i. Does not directly deliver treatment services b. Supports activities that include education and training, prevention programs, early intervention activities, treatment services, and technical assistance c. Supports states' efforts in providing community-based behavioral health services d. Conducts surveillance and data collection of national behavioral health issues

Centers for Medicare and Medicaid Services (CMS)

- ***Medicare, Medicaid, and CHIP - Provide a healthcare system with better care, access to coverage, and improved health

Department of Veterans Affairs (VA)

- ***Provides comprehensive care to veterans who were not dishonorably discharged - Veterans Health Administration (VHA) a. Largest integrated U.S. health system b. Originally established to treat veterans with war-related injuries and to help rehabilitate past service members with war-related disabilities c. Service-connected illnesses and disabilities, low incomes, or special healthcare needs d. Eligibility: one must have served in the active military, naval or air service and separated under any condition other than dishonorable

Agency for Healthcare Research and Quality (AHRQ)

- ***Reducing the risk of harm from healthcare services by using evidence-based research and technology to promote the delivery of the best possible care - Transforming the practice of healthcare to achieve wider access to effective services and reduce unnecessary healthcare costs - And improving healthcare outcomes by encouraging providers, consumers, and patients to use evidence-based information to make informed treatment decisions

World Health Organization (WHO) (graphic in S06 notes)

- ***Specialized, non-political, health agency of the UN, with headquarters at Geneva - ***The objective of WHO is the attainment by all people of the highest possible level of health - WHO fulfills its objectives through its core functions: a. Providing leadership on matters critical to health and engaging in partnerships where joint action is needed b. Shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge c. Setting norms and standards and promoting and monitoring their implementation d. Articulating ethical and evidence-based policy options e. Providing technical support, catalyzing change, and building sustainable institutional capacity f. Monitoring the health situation and assessing health trends - Three principle organs: a. World Health Assembly i. Supreme governing body of the organization ii. Main functions 1. To determine international health policy and program 2. To review the work of the past year 3. To approve the budget T4. o elect member state for executive board

Food and Drug Administration (FDA)

- ***The FDA is responsible for promoting public health via the regulation and supervision of food safety, tobacco products, dietary supplements, medicine, medical devices, and a myriad of other products - The FDA inspects and reviews production facilities that make products like food, medicine, tobacco, and other items regulated by the agency - The FDA gives approval to regulated products before they can be sold in the U.S. FDA has the power to recall products on the market, if necessary, for safety and other reasons Regulate the approval process for new drugs development Four phases of clinical trials 1 - Tests drug on healthy individuals; tests for safety, dosage, and side effects 2 - Tests on larger group of affected individuals; tests for efficacy and side effects 3 - Tests on new and wider demographic; tests for long-term effectiveness and comparisons with other medications FDA Approval - treatment determined effective and safe for public use 4 - Continuous to test for effectiveness and safety; can be taken off the market if necessary - Role during the COVID-19 pandemic a. Responsibility to authorize drugs, treatments, and vaccines

Centers for Disease Control and Prevention (CDC)

- ***United States' primary health protection agency - Focuses on science and technology to prevent diseases - Manages the nation's biggest health problems

Legislative Process (map in S03 notes)

- A bill is introduced in the House of Representatives - If approved it is forwarded to the Senate - Sent to President after passing the House and Senate a. President can sign bill into law b. During congressional session, bill becomes law after 10 days without presidential signature c. When not in session, bill does not become law without presidential signature d. President vetoes bill; two-thirds vote in House and Senate can override veto - If signed it becomes law

Gonzales v. Carhart

- A landmark decision of the U.S. Supreme Court that upheld the Partial-Birth Abortion Ban Act (PBABA) of 2003 a. PBABA was not void for vagueness simply because the law prohibits performing intact D&Es b. PBABA did not impose an undue burden for being overly broad c. PBABA did not pose a substantial obstacle to obtaining an abortion under Casey's undeue burden test d. PBABA did not contain language protecting the health of the women and did not render the law unconstitutional

Key stakeholders

- A third way to conceptualize health policy and law issues is in terms of the stakeholders whose interests are impacted by certain policy choices or by the passage or interpretation of a law - Who are the key stakeholders? a. Patients, healthcare providers, governments, the public, managed care and traditional insurance companies, employers, the pharmaceutical industry, the medical device industry, the research community, interest groups, and others

Healthcare Access

- Access refers to ability to obtain needed services - Key barriers to access a. Lack of health insurance b. Inadequate health insurance c. Insurance coverage limitations d. Workforce issues

HHS Key Agencies

- Administration for Children and Families - Administration on Aging - Agency for Healthcare Research and Quality - Agency for Toxic Substances and Disease Registry - Centers for Disease Control and Prevention - Centers for Medicare and Medicaid Services - Food and Drug Administration - Health Resources and Services Administration - Indian Health Service - National Institutes of Health - Substance Abuse and Mental Health Services Administration

Federal Constitutions

- All legal rules of the land have to fit within the Constitution - Articles are mostly about the functioning of the government - First ten amendments to the Constitution make up the "Bill of Rights"

Physical and mental disability discrimination

- Americans with Disabilities Act (ADA) a. Prohibits discrimination against people with disabilities and guarantees that they have equal opportunity to participate in mainstream American life b. The act made it illegal to discriminate against a disabled person in terms of employment opportunities, access to transportation, public accommodations, communications, and government activities i. Title I prohibits discrimination against qualified individuals with disabilities during job application procedures, hiring, firing, the pursuit of career advancement, compensation, job training, and other aspects of employment ii. Title II applies to state and local government entities iii. Title III prohibits discrimination against people with disabilities regarding access to activities at public venues

Executive Offices

- Assist and advise President (i.e., White House Office, Council of Economic Advisors, Office of Management and Budget) - 15 cabinet departments and independent agencies a. Interpret and implement laws passed by Congress b. 15 cabinet departments i. Led by individuals selected by the President and subject to Senate confirmation c. Independent Agencies i. Responsible for exercising a specific form of autonomous authority over some area of human or supervisory activity ii. Funded by outside organizations or private donors and are held separately iii. i.e., NASA, USPS, National Science Foundation

President

- Chief of State - symbol of the country and its citizens - Chief Executive Officer - manages cabinet and executive branch - Commander in Chief of the Armed Forces - top-ranking military official in the country - Other powers - agenda setting, budget proposals, persuasion, sign or veto bills, executive orders - Can veto - Executive orders a. May not be as unilateral b. Could be overturned by the courts c. Congress d. Can be revoked

Recommendation for Options Analysis

- Choose one of the options as the recommended course of action for the client a. Status quo/inaction may be an option b. Discuss why this option is better than the others despite the cons associated with the option c. If possible, identify any action that may be taken to ameliorate the cons associated with the option d. In almost all cases, do not choose a hybrid option that mixes two or more of your options

Legislative Branch

- Congress is lawmaking body of federal government - 3 Powers: a. Power to enact laws b. Power to tax c. Power to spend (allocate resources)

Insurance Coverage Limitations

- Cost-sharing a. Co-payments, deductibles, premiums - Reimbursement and visit caps a. Insurance plays may limit the $ amount/# of visits they will reimburse for a specific service during the year - Service exclusions a. It may not cover all health services

Common law/case law/judge-made law/decision law

- Court opinions interpreting and applying law to specific cases - Based on the traditions and customs of society, yet heavily influenced by legal precedent and the doctrine of stare decisis (the principle that lower court rulings should be governed by the precedent rulings of higher courts)

The Role of Courts

- Courts have responsibility to determine what the Constitution means, permits, and prohibits 1. Protect and enforce individual legal rights a. Courts are expected to uphold and enforces is the constitutional right to due process b. Due process is a requirement that legal matters be resolved according to established rules and principles, and that individuals be treated fairly c. Procedural due process requires that when the federal government acts in a way that denies a citizen of a life, liberty, or property interest, the person must be given notice, the opportunity to be heard, and a decision by a neutral decision-maker d. Substantive due process is a principle allowing courts to protect certain fundamental rights from government interference 2. Determine whether the political branches of government have violated the Constitution a. Arguments about the meaning of laws, how they are applied, and whether they violate the Constitution b. Judicial review i. Ability to decide if a law violates the Constitution ii. Actions of the executive and legislative branches of government are subject to review and possible invalidation by the judiciary iii. Provide checks and balances on the legislative and executive branches iv. Marbury v. Madison - Established a precedent of judicial review; notion that laws passed by Congress could be reviewed by the judicial branch of government 3. Maintain stability in the law through the application of legal precedent a. Application of "stare decisis" b. Benefit i. Court need not continuously reevaluate the legal underpinnings of past decisions and accepted doctrines ii. Predictability afforded by the doctrine helps clarify constitutional rights for the public c. Downside i. Permits erroneous decisions to continue influencing the law ii. Encumbers the legal system's ability to quickly adapt to change

Regulations

- Created by executive branch administrative agencies (state or federal administrative agencies) to implement statutes and clarify their ambiguities - Administrative agencies are organized and created to deal with specific policy subject matters (time and expertise) - Administrative Procedure Act (APA) a. Remedial statute designed to ensure uniformity and openness in the procedures used by federal agencies b. Governs the process by which federal agencies develop and issue regulations

Judicial Branch

- Defining Law a. Think of "law" not just as words on a page, but as the many interacting parts that are involved in drafting those words in the first place, and in bringing them to life once they have been enacted as laws b. Consider "law" as a system that entails regularly interacting and independent parts and subparts coming together to form a functional, unified whole c. Law - that which is laid down, ordained, or established; a rule or method according to which phenomena or actions coexist or follow each other; law, in its generic sense, is a body of rules or action or conduct prescribed by controlling authority, and having binding legal force, that which must be obeyed and followed by citizens subject to sanctions or legal consequences is a law (Garner, 2014)

Policy and the Policymaking Process

- Defining Policy a. 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 (Longest, 2016) b. A course of action adopted and pursued by a government, party, ruler, statesman, or other individual or organization (Subcommittee on Health and Environment, 1976) c. Authoritative decisions and guidelines that direct human behavior toward specific goals either in the private or the public sector (Hanley, 1999) - *Authoritative decisions are decisions made by an individual or group with the power to implement the decision and there are a variety of levels where these kinds of decisions can take place - *Private vs. public a. Public policy problems i. Beyond individual concerns ii. Determine if a "decision" represents a "policy" b. Structuring policy options i. Mandatory/voluntary ii. Take action/refrain from acting c. Health policy i. Aggregate of principles, stated or unstated ii. Characterize distribution of resources, services, and political influences impacting the population

Federal Health Bureaucracy

- Department of Health and Human Services (HHS) - Department of Veterans Affairs (VA) - Department of Defense (DOD)

Federal Public Health Agencies

- Department of Health and Human Services (HHS) - Human Resources and Services Administration (HRSA) - Substance Abuse and Mental Health Services Administration (SAMHSA) - Food and Drug Administration (FDA)

Executive Branch

- Enforces laws - White House

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

- Federal and state policy and law shape virtually all aspects of the health care system, from structure and organization, to service delivery, financing, and administrative and judicial oversight - Topics include: advertising and marketing of health services and products, health care contracting, employment issues, patents, taxation, health care discrimination and disparities, consumer protection, bioterrorism, health insurance, prescription drug regulation, and more - Policy and law in individual health care: a. Health care access b. Practice of medicine - In public health (the aggregate): a. Food inspections (FDA, food recalls) b. Regulation of public health agencies c. Occupational safety standards - One main focus of policy and law in the realm of public health is on locating the appropriate balance between public regulation of private individuals and corporations and the ability of those same parties to exercise rights that allow them to function free of overly intrusive government intervention - The competing interests at the heart of public health are mainly addressed through two types of policies and laws a. Those that define the functions and powers of public health agencies b. Those that aim to directly protect and promote health

Healthcare Finance: Direct Service

- Federal, state, and local governments fund programs that directly provide care to individuals a. Federally Qualified Health Centers (FQHCs) i. Located in medically underserved areas and provide primary ca services to individuals on a sliding fee scale ii. Funding for these centers usually comes from the federal and state governments b. Ryan White HIV/AIDS programs i. Provide services to patients with HIV or AIDS who do not have health insurance coverage or the financial resources to pay for needed care

Interest Groups

- General term for a variety of organizations that focus on an issue or issues and have the goal of influencing and educating policymakers and the general public - Do not make policy - Types: trade associations, think tanks, advocacy groups, lobbying firms

Generalists and Specialists

- Generalist (primary care physicians): trained in family medicine/general practice, general internal medicine, and general pediatrics a. Most PCP provide preventive services and treat frequently occurring and less severe problems b. Refer patients with less frequently or require complex diagnostic or therapeutic approaches to specialists, after an initial evaluation - Specialist a. Seek certification in an area of medical specialization b. Specialty board examinations is often required c. Six major functional groups: i. The subspecialties of internal medicine ii. A broad group of medical specialties iii. Obstetrics and gynecology iv. Surgery of all types v. Hospital-based radiology, anesthesiology, and pathology vi. Psychiatry

Publicly financed, privately delivered national health insurance (NHI)

- Government finances healthcare through general taxes - All citizens enroll in the national health insurance - Healthcare is delivered by private providers - Cheaper, simpler - Long waiting lists, delays in treatment

Socialized health insurance (SHI) system with mandatory contributions and private delivery

- Government-mandates contributions from employers and employees finance healthcare - Employers and employees are responsible for funding their health insurance system through "sickness funds" - Healthcare services are delivered by private providers - Shorter waiting times, higher quality of healthcare - Mandatory employment taxes are high in order to keep healthcare affordable

Stakeholders

- Groups, organizations, individuals that are inverted in the program and how it will be solved - What is their stake in the issue? - How much influence do they have to impact the solution?

Healthcare Finance: Insurance (graphic in S04 notes)

- Health insurance acts as an intermediary between patients and providers - Insurance: a mechanism for protection against risk a. Risk: possibility of a substantial financial loss from an ever whose probability of occurrence is relatively small

Topical domains of health policy and law

- Healthcare policy and law -> access, quality, and financing of care - Public health policy and law -> why and how the government regulates private individuals and corporations in the name of protecting the health, safety, and welfare of the general public - Bioethics (ethical issues raised in the context of medical practice or biomedical research)

Elements of a Health Policy Analysis

- Identify concrete operational measures of the problem - Determine magnitude and scope (how big is the problem?/what is the impact of the problem?) - Identify who is impacted by the problem - Identify how long the problem has existed - Identify how the problem might change over time (projections? will it be bigger?)

Rights under Healthcare Laws: Examination and treatment for Emergency Medical conditions and women in labor act (EMTALA)

- In the case of a hospital that has a hospital emergency department, if any individual...comes to the emergency department and a request is made...for examination or treatment for a medical condition, the hospital must provide an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department to determine if an emergency medical condition exists - Hospitals must perform a medical screening examination (MSE) on any person who comes to the hospital and requests care to determine whether an emergency medical condition (EMC) exists -If an EMC exists, hospital staff must either stabilize that condition to the extent of their ability or transfer the patient to another hospital with the appropriate capabilities - Hospitals with specialized capabilities or facilities are required to accept transfers of patients in need of such specialized services if they have the capacity to treat them a. Legal rights established under EMTALA are accompanied by heavy penalties for violation

Writing a Health Policy Analysis Background

- Informs the reader why a problem has been chosen for analysis a. Provides much of the facts and information necessary to understand the problem being addressed b. Develops the fact based and body of existing evidence (i.e., use of statistics/data, use tables and graphs) c. Generally, decision maker could change and background would look the same d. May have to tailor some background information based on the knowledge base of the client

Social Context

- Is the problem an individual problem or societal problem? - Are these equity issues?

Uninsured

- Key characteristics a. Low income, low education, racial/ethnic minority, location, age, gender - Problems with being uninsured a. Less access to care, less timely care, less likely to follow treatment recommendations due to cost b. Safety net providers serve many uninsured and underinsured

Underinsured

- Key characteristics a. Poor, low education, non-native, racial/ethnic minority, location, age, gender - Problems with being uninsured a. Less access to care, less timely care, less likely to follow treatment recommendations due to cost - Underinsured do not have financial resources to cover the gap between what their insurance covers and their medical bills - Safety net providers service many uninsured and underinsured

Statutes

- Laws written by legislative bodies at all levels of government that command or prohibit something - Two hallmarks: prospectivity (forward-looking) and generality (apply to large number of people) - As broad policy statements, statutes are often ambiguous as applied to specific cases or controversies, requiring courts to interpret them through the practice of "statutory construction" - process by which courts interpret and apply legislation

Federal Policymaking Structure

- Legislative branch a. House b. Senate - Executive branch a. White house b. Administrative agencies - Judicial branch

Global Public Health Organization Limitation

- Limited ability to enforce global recommendations - Limited funding - Complex international administration

Options Analysis (example in S02 notes)

- Media - Scholarly articles - Interest group recommendations - Think tanks/experts in the field - Congressional testimony - Legislation (passed or proposed) - Agency reports - The policy analysis should provide three to five options for a client to consider, and all options must: a. Be within the power of the client to do b. Be consistent with the client's values c. Address the issue identified in the problem statement - Identify pros and cons for each option (there is no perfect option) - Identify criteria that will be used to evaluate the option - Sample options criteria - Identify criteria that will be used to evaluate the option (three to five) - Side-by-side table may assist in analyzing the options a. Descriptive or analytical tables may be appropriate

Presidential Constituents

- Nation (all voters) - Public who voted for President - Political party - Other nations - International organizations

The right to make informed healthcare decisions

- Nuremberg Code - roots of U.S. informed consent law a. Derived from the Nuremberg trails b. 10 principles to guide physician-investigators in experiments involving human subjects c. "The voluntary consent of the human subject is absolutely essential. This means that the person involved should have legal capacity to give consent..." - Canterbury v. Spence a. Duty to disclose requires more than just answering patient questions; it demands voluntary disclosure on the part of the physician of pertinent medical information b. Actual scope of the disclosure required? Patient has sufficient information to make an intelligent choice i. A proposed treatment's inherent and potential risks ii. Any alternatives to a proposed treatment iii. The likely outcome of the not being treated at all

Nurse Practitioners and Physician Assistants

- Nurse practitioners a. A NP is a registered nurse (RN) with advanced clinical training and education b. Practice autonomously c. Provide a wide range of health care services including the diagnosis and management of acute, chronic, and complex health problems, health promotion, disease prevention, health education - Physician assistants a. "Part of the healthcare team... [who] work in a dependent relationship with a supervising physician to provide comprehensive care"

Separation of Powers

- One of the most important aspects of both federal and state constitutional design - To guard against a concentration of political power, governmental powers and responsibilities are divided among three separate, co-equal branches - Checks and balances system a. Each branch of government with individual powers to check the other branches and prevent any one branch from becoming too powerful b. Branches with some power to appoint or remove members from the other branches i. Article 1: Legislative Branch - Congress makes the laws Article 2: Executive Branch - President enforces the laws Article 3: Judicial Branch - Supreme Court interprets the law

Department of Defense (DOD)

- Operates a large and complex healthcare program - For active duty and retirees, dependents, survivors, and former spouses - Each branch operates its own medical facilities - TRICARE is the insurance plan a. Healthcare program service members, retirees, and their families around the world b. Provide health care through DOD's medical facilities or civilian providers

Stenberg v. Carhart

- Partial birth abortion (D&E Procedure) - Nebraska law - "partial-birth abortion" illegal, without regard for the health of the mother - Court invalidated the state law because it lacked an exception for the preservation of the health of the pregnant women - Court concluded that the statute created an undue burden on women seeking pre-viability abortion

Political Landscape

- Politically hot topic? - Are there differences in how politicians define the problem and the causes of the problem? - Is there a reason to act now or to delay?

Basic Health Insurance Terminology

- Premiums: monthly fee to insurance company - Cost sharing: people usually need to pay a portion of the actual the care cost out of their own pockets a. Deductible: the amount people pay each year for most eligible medical services or medications before health plan begins to share in the cost of covered services b. Copayment: a flat fee that people pay on the spot each time they go to their doctor or fill a prescription c. Coinsurance: the portion of the medical cost people pay after the deductible has been met d. Out-of-pocket maximum: the most people could pay for covered medical expenses in a year

Quality Assessment and Assurance

- Processes that improve quality a. Clinical practice guidelines: guideline to provide preferred clinical processes b. Cost-efficiency i. Important concept in quality assessment ii. Benefit received is greater than the cost incurred to provide the service c. Risk management i. Review clinical processes and establish protocols for the specific purpose of reducing malpractice

Prevailing historical factors

- Professional autonomy perspective: 1880-1960 a. Legal oversight of the practice of medicine was delegated to the medical professional itself - Social contract perspective: 1960-1980 a. Public policy and law can and sometimes should enforce a social contract at the expense of physician control b. Enhancing access to care, creating new health insurance programs - Free market perspective: 1990s-today a. Market for healthcare services and health insurance operate best in a deregulated free market environment. Commercial competition and consumer empowerment will lead to the most efficient healthcare system.

State Constitutions

- Provide for the organizational structure of the particular state's government - Some measure of a state bill of rights - State constitutions go further than federal law in conferring rights or extending

Overview of the U.S. Healthcare System

- Provides a general understanding of how the healthcare system works in the U.S. - Focuses on... a. Healthcare finance b. Healthcare access c. Healthcare quality d. Comparative health systems

Goals of Governmental Public Health Agencies

- Public Health - Goals a. To prevent epidemics and the spread of disease b. To protect against environmental hazards c. To prevent injuries d. To promote and encourage healthy behaviors e. To respond to disasters and assist communities in recovery f. To ensure the quality and accessibility of health services - Health promotion is the process of enabling people to increase control over, and to improve, their health (WHO). - Three core functions a. Assessment: collecting and analyzing information about health problems b. Policy development c. Assurance

Three common types of healthcare systems

- Publicly financed, privately delivered national health insurance (NHI) - Publicly financed and delivered national health systems (NHS) - Socialized health insurance (SHI) system with mandatory contributions and private delivery

Healthcare Quality

- Quality of care a. Quality: the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge - The U.S. spends more per person on healthcare but often ranks poorly on preventive and primary care healthcare measures

The right to be free from unlawful discrimination when accessing or receiving healthcare

- Race/ethnicity discrimination - physical and mental disability discrimination

Federalism

- Refers to the allocation of federal and state legal authority - Under the Constitution, the federal government is one of limited powers, while the states more or less retain all powers not expressly left exclusively to the federal government - Individual states play a significant role in the development and implementation of health policies a. There is too much state control in regards to health policy changes - Federal government also plays a role in regulating health care and public health through the ability to tax, spend, and regulation - Structure of the US courts a. Jurisdiction - kinds of cases courses are able to hear i. Federal - Types of cases listed in the Constitution and specifically provided for by Congress ii. State - Broad jurisdiction i.e., robberies, traffic violation, broken contract, and family disputes

Sources of Law

- Regardless of how "law" is defined, at the core of the legal system lays a body of enforceable written rules a. Constitutions b. Statutes c. Regulations d. Common law/case law - Constitutions are the most fundamental of the sources of law

Healthcare rights are categorized in three ways

- Rights related to receiving services explicitly provided under healthcare, health financing, or health insurance laws a. Rights under Healthcare Laws: Examination and treatment for Emergency Medical conditions and women in labor act (EMTALA) b. Rights Under Healthcare Financing Law: Medicaid c. Rights Under Health Insurance Laws: the ACA

Congress consists of Senate and House

- Senate: statewide; two senators from each state - House: by district; proportional to population, at least one representative per state

Key Features of the U.S. Legal System

- Separation of powers - Federalism - The Role of Courts

Safety Net Providers

- Serve disproportionately high numbers of uninsured, underinsured, and publicly insured patients - Public and private hospitals, community health centers, family planning clinics, and public health agencies challenges a. Demand that exceeds supply b. Financial challenges

Types of Health Insurance Systems

- Single-payer system a. A national healthcare system that is usually the primary payer, the government - The United States has many payers; company can choose different plans a. A billing and collection nightmare - System becomes more cumbersome a. Difficult for providers to track various health plans b. Providers must hire claims processors c. Payments can be denied d. Government programs have complex regulations

Landscape Potential Elements

- Stakeholders - Political landscape - Economic factors - Legal context - Social context - Administrative practicality, feasibility - Others

Is this legal?

- State and local governments exercise this authority through police powers, or the authority to regulate individuals and private business for public health promotion and protection a. Police powers have been a critical component of state sovereignty - The Federal government is constitutionally authorized to tax and spend, and to "provide for the general welfare" a. Examples: "sin" taxes, income tax penalty for the uninsured, any expenditure on public health or allocation to state and local agencies for health purposes

State and Local Policymaking and Health Bureaucracy

- State-level policymaking is important a. Key decisions are made on state level b. The Constitution gives states primary responsibility for protecting the public's health c. There is variation among states in how policy-making process is structured - State and local health bureaucracy a. State-level agencies (e.g., Medicaid, public health) b. Local public health agencies

Griswold v. Connecticut

- The court considered the constitutionality of a state law criminalizing the provision of contraception to married couples - After the Griswold decisions -> how is the right to privacy applied in the context of abortion?

The right to personal privacy

- The court has taken a more or less two-pronged approach to the right a. The first approach defines the protected personal interest as "informational privacy" b. The second approach is concerned with individual autonomy and freedom from governmental interference in making basic personal decisions

Definition of Health

- The medical model defines health as the absence of illness or disease - Sociologists define health as the state of optimal capacity - Society for Academic Emergency Medicine: state of physical and mental well-being that facilitates the achievement of individual and societal goals - WHO: a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity - Healthcare system: all the activities whose primary purpose is to promote, restore, or maintain health

Rights concerning freedom of choice and freedom from government interference when making healthcare decisions

- The right to make informed healthcare decisions - The right to personal privacy

Roe v. Wade

- The supreme court ruled that women had a constitutional right to abortion - Woman's right to an abortion was implicit in the right to privacy protected by the 14th Amendment to the Constitution - The court divided pregnancy into three trimesters a. First: solely up to the woman b. Second: the government could regulate abortion, although not ban it, in order to protect the mother's health c. Third: the state could prohibit abortion to protect a fetus that could survive on its own outside the womb, except when a woman's health was in danger - Galvanized political forces opposed to abortion and prompted a movement to create ways to discourage the practice through state policies designed to regulate the factors involved in the abortion decision

Conceptualizing Health Policy and Law

- There are multiple ways to conceptualize the many important topics that fall under the umbrella of health policy and law - Three conceptual frameworks a. Topical domains of health policy and law b. Prevailing historical factors c. Key stakeholders

Race/ethnicity discrimination

- Title VI: "No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity that receives federal funds or other federal financial assistance." a. Failure to comply with Title VI could result in a loss of federal or state funding for the healthcare entity

Planned Parenthood of Southeastern Pennsylvania v. Casey

- Trimesters were replaced by fetal viability as the regulatory touchstone - The pregnant women makes the abortion decision - State's interest in protecting pregnant women and fetuses now attaches from the outset of the pregnancy - Court's invalidation of the trimester framework enabled the establishment of a new "undue burden" standard for assessing the constitutionality of state abortion regulations - The court did not alter its decision in Roe decision that, post-viability, a state may proscribe abortion except when pregnancies endanger a woman's life or health

Comparative Health Systems

- Type of health insurance design relates to key issues for patients a. Affordability of health insurance b. Differences in access by income level c. Waiting lists/wait times d. Complexity of interacting with insurance system/paperwork

Partial Birth Abortion Ban Act of 2003

- U.S. law prohibiting a form of late termination of pregnancy called "partial birth abortion", referred to in medical literature as intact dilation and extraction - This statute prohibits a method of abortion; the statute calls the prohibited method "partial birth abortion" - The procedure described in the statute is used in the second trimester, from 50 to 26 weeks of which occur before viability

A Global Perspective

- United States is one of the only high-income nations that does not guarantee healthcare as a fundamental right - Some two-thirds of constitutions worldwide address health or healthcare - Including language respecting health rights in a constitution does not guarantee that the right will be recognized or enforced

Structuring the Options Section

- Use headings or bullets delineating each option - Headings should clearly label each option - Separate out the options by paragraph instead of having a continuous page - The first sentence or two of each options paragraph should be a clear description of that option - Assess the pros and cons of the option; explicitly state the criteria prior to your options description

What is Health Policy?

- Uses of policy a. Regulatory tools i. Market-entry restrictions* ii. Rate- or price-setting controls on health services providers* iii. Quality controls on the provision of health services* iv. Market-preserving controls v. Social regulation *economic regulation b. Allocative tools i. Distributive policies spread benefits throughout society ii. Redistributive policies are designed to benefit only certain groups of people by taking money from one group and using it for the benefit of another

Economic Context

- What are the economic causes of the problem? - Are certain subgroups disproportionately bearing the burden of the cost? - What is the economic impact of addressing/not addressing the problem?

Global Public Health Organization

- World Health Organization (WHO) - World Bank (WB)

Publicly financed and delivered national health systems (NHS)

- i.e., Canada - National Health Insurance = Medicare and does not = US Medicare - Financing for health benefits varies by benefit type a. Hospital services, physician services, and public health services are financed through public taxation b. Certain services (i.e., prescription drugs, home care and institutional care) are financed through a combination of public taxation and private insurance coverage c. Other goods and services, (i.e., dental and vision care) are covered only through private insurance - Government finances healthcare through general taxes or premiums - Government manages the infrastructure for the delivery of healthcare - Most healthcare providers are either government employees or are tightly organized in a publicly managed infrastructure - Same access to care - No out-of-pocket fees for patients - Overutilization - i.e., U.K. a. Cost containment strategies to address its budgetary concerns: freezing wages, increasing use of generic drugs, reducing hospital payments, lowering administrative costs, and improving hospital management b. People select a general practitioner in their service area, and this provider is the gateway to NHS service -> Gatekeeper c. Several plans to address challenges to the healthcare system i. i.e., focus on improving early identification of high-risk patients

Workforce Issues

1. Provider shortages - Supply of medical professionals a. Supply of primary care physicians i. Less medical students are aiming to become a primary care physician b. Demand of primary care physicians i. Increasing number of people with chronic conditions ii. A large influx of newly insured individuals c. Retirement 2. Uneven distribution of providers a. Maldistribution: either a surplus or a shortage of the type of physicians needed to maintain the health status of a given population at an optimal level i. Specialty maldistribution ii. Geographic maldistribution - medically underserved area/population

National Institutes of Health (NIH)

Conducts and supports medical research

World Bank (WB) (graphic in S06 notes)

Goals: end extreme poverty and promote shared prosperity in a sustainable way

Secretariat

Provide member states with technical and managerial support for their national health development programs

Landscape

Provides the overall context of the analysis by identifying key stakeholders and the issues that must be considered when analyzing the problem