Health is an integral part of our lives, on a personal level especially, but also at the meta level. Many of us are concerned with the state of our personal health—weight, habits, chronic conditions, exposure to infectious disease, and the like. Health at the meta level, however, is a different matter. This concept aggregates personal health to the quantity of population health and the health status of communities or their subsets.
The beginning of this broader conversation invites a wide-ranging consideration of the factors that have an impact on health at the population level. Certainly, such health determinants as tobacco use, diet, and exercise have the greatest impact on an individual’s health. Health policy, however, can alter those determinants and, sometimes, the behavior that affects an individual’s health as well as the health status of larger populations. Health policy is composed of authoritative decisions made throughout all three branches of the federal government as well as the branches of state and local governments.
And therein, in part, is the reason to study health policy. If we see that our healthcare system is inefficient in delivering high-quality care, if we see that our healthcare system is inequitable because it perpetuates disparities in health among people living in the United States, and if we see that our healthcare system is ineffective because too many people live with chronic diseases that often become acute conditions, what are we to do? What will you do as a healthcare administrator? Because of your profession, do you have an obligation to the common good or to the community in which you live? If the answer to that ethical question is yes, then your understanding of health policy becomes your tool to serve others—to serve something beyond your own career and self-interest.
This book is intended to help the reader understand the process of health policy. Health policy is a key external factor that can threaten any healthcare organization. Or it can be an opportunity for a healthcare organization to extend its breadth and depth of care into the larger community. In short, it can limit our work or it can expand our reach. Understanding how policy decisions are made will provide background for healthcare leaders to turn threat into opportunity, to turn limits into expansions.
In summary, this book is intended to help emerging healthcare leaders develop competency in the domain of health policy. The well-rounded healthcare leader should be willing and able to become an effective advocate. Understanding the process is a baseline requirement of that competency. In other words, the book seeks to help the reader understand what is important about the process of policymaking without editorializing on any particular policy position. The real-world examples included on these pages demonstrate the health policy process in both political and jurisprudential terms.
This seventh edition continues to rely on the policy process model originally developed by Professor Beaufort Longest in the first edition. Professor Longest developed the model for his students some 30 years ago and refined it multiple times through six editions of the book. This edition builds on Professor Longest’s well-considered and time-honored theoretical foundations. It also, however, incorporates a few changes. While remaining true to Professor Longest’s concepts, I have expanded the practical applications of the theory, including real-world examples of the major concepts, and have taken a slightly different approach to the structure presenting those concepts.
First, the book is divided into four parts to facilitate the focus on core aspects of the policy process model. Second, after each part’s introduction, a policy snapshot captures the key elements addressed in that part of the book. Third, appendixes have been placed at the end of each part to help reinforce the model’s framework with examples, many of them documents produced by government agencies or by parties interested in governmental policy, showing how that part’s principles are being addressed. Finally, a new chapter, on federalism, has been added, delineating the dynamic nature of the relationship between federal and state governments and how that relationship affects health policy, health determinants, and, ultimately, our health.
Part 1, “Health and Its Policymaking Context” (chapters 1, 2, and 3), explores the meaning of health and health status. Material here compares the US health system with the rest of the industrialized world to provide a context for the cost and quality of the US healthcare system. This part also introduces the reader to the concept of federalism, which forms the basis of the frequently used federal and state “partnerships” that determine multiple aspects of health policy.
Part 2, “Legislative Policymaking” (chapters 4, 5, and 6), explores the introductory elements of the model—the beginnings of how health policy is made—with a focus on the legislative process. Here we begin to see the influence of politics and the political process on health policy. Indeed, the snapshot introducing part 2 speaks to the triumph of politics in one dramatic gambit resulting in a fundamental change in the US healthcare system: the creation of Medicare and Medicaid.
Part 3, “Policy Implementation and Judicial Review” (chapters 7 and 8), goes into further detail about how policy is made, as this part includes a discussion on the administrative implementation of legislative enactments. Policy is not fully a policy until it is implemented. While part 2 delves into the legislative process of policy pronouncements, part 3 is where the rubber hits the road, examining how those pronouncements are put into operation. Moreover, part 3 further elaborates on how American courts affect health policy.
Part 4, “Charting the Future” (chapters 9 and 10), wraps up all the other material pertaining to policy modification and discusses the competency of a healthcare executive as an advocate. This last part of the book takes an approach different from that of the first three parts, which focus on policymaking and emphasize the legislative process, administrative implementations, and court decisions. Unlike the other three policy snapshots, this part’s snapshot does not address legislative actions or Supreme Court decisions. Rather, it invites the readers to consider their future role as advocates in the policymaking arena and encourages them to consider the right-versus-commodity question.
Throughout the book, the appendixes provide examples of legislation, executive orders, administrative rules, and regulations, along with congressional or administrative agency testimony. Although the appendixes are located in their respective parts of the book, readers are encouraged to jump between parts to find appendixes that may well reflect an issue in a different part of the book. For example, appendixes 1.1, 1.2, and 1.3 no doubt have application throughout the book but are placed with part 1 because they specifically relate to issues in the first three chapters.
As you study the health policymaking process and, indeed, as you move throughout your career, you will be confronted with the foundational question of whether healthcare is a fundamental right for all or a commodity available to those who can afford it. This is a question we have not fully answered as a society. History demonstrates that both sides of the coin seem to wax and wane over time. You will have the opportunity to consider this question in detail in the policy snapshot in part 4. You will, however, confront this question in a number of other ways throughout your career. The question as it is presented in this book invites you to consider the obligation a healthcare administrator has to the community at large. What is the role of the common good in your consideration of advocacy?
What are your personal and professional obligations to the common good as a part of your role as a healthcare professional and advocate?
This book’s Instructor Resources include a test bank, presentation PowerPoint slides, and answer guides to the in-book discussion questions.
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