US HEALT

H POLIC

Y

DIMENSIO

NS OF

HEALTH, H

EALTHCARE, A

ND HEALT

H POLIC

Y

Dr. Lisaann GittnerSept 2012

HEALTH AND POLICYWhere does the money go?

US Health Spending 2007

INTERSECTION OF HEALTH AND POLICY

• Health is measured in life times with disease manifesting after many years (decades)

• Policy is measured in election cycles with results necessary in 2-5 years

• Health outcomes are measured in terms of the absence of disease states or the non manifestation of progressive deteriorating symptoms

• Policy outcomes are measured in active results that can be quantified

• HOW DO YOU QUANTIFY THE ABSENCE OR NON MANEFESTATION OF A DISEASE????

POLICY CRASHES INTO HEALTH

Policy can effect Healthcare in a policy cycle but can it effect Health?

Policy for healthcare are quantifiable in a policy cycle Policy for healthcare does achieve measurable results Policy for health may not be quantifiable in a policy

cycle or may not even be quantifiable Policy for health especially prevention is difficult, how

do you measure “who didn’t get sick??”

HEALTHY PEOPLE 2020

“The values of a nation are reflected in its willingness to secure better health, well being, and vitality for all. “ (Secretary’s Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020 7-26-2010)

Healthy People 2000, 2010 and now 2020 set the US public health policies and goals for the decade.

All US health funding is supposed to be designed to meet the Healthy People goals

DOES HEALTHY PEOPLE WORK?

Example from Health People 2010

According to the Healthy People 2010 Midcourse Review, pediatric obesity increased and moved away from the target by 5% (Healthy People 2010 Midcourse Review, 2007). Rather than a reduction in obesity that was predicted, obesity increased over and above the baseline threshold during the measurement period (2000-2005).

WHY?

HEALTH P

OLICY

HEALTH V

ERSUS HEALT

HCARE

HEALTH

World Health Organization Definition

“Health is not only the absence of infirmity and disease but

also a state of physical, mental and social well-being.”

HEALTHCARE

The prevention, treatment, and management of illness and the preservation of mental

and physical well-being through the services offered

by the medical and allied health professions

PUBLIC HEALTH: WHAT CAN HEALTH POLICY DO?

IS MEASURING HEALTH DIFFERENT IF YOU LOOK AT IT FROM AN INDIVIDUAL VS. A PUBLIC HEALTH LENS?

HEALTH VS HEALTHCARE

Health is an individual state of being

Healthcare is a provision of service

HOW CAN YOU MEASURE HEALTH VS. HEALTH POLICY?

When you design and evaluate health policies?

What are the domains, factors, variables?

What specifically can you measure?

WE MEASURESOCIAL DETERMINANTS OF HEALTH

SOCIAL ECOLOGICAL THEORY OF HEALTHUrie

Bronfenbrenner

SOCIAL ECOLOGICAL MODEL

Each person is significantly affected by interactions among a number of overlapping ecosystems. At the center of the model is the individual.

Microsystems are the systems that intimately and immediately shape human development. The primary microsystems for children include the family, peer group, classroom, neighbourhood, and sometimes a church, temple, or mosque as well. Interactions among the microsystems, as when parents and teachers coordinate their efforts to educate the child, take place through the mesosystem.

Surrounding the microsystems is the exosystem, which includes all the external networks, such as community structures and local educational, medical, employment, and communications systems, that influence the microsystems.

Influencing all other systems is the macrosystem, including cultural values, political philosophies, economic patterns, and social conditions.

LIFECOURSE THEORY OF HEALTHDavid Barker

LIFE-COURSE MODEL OF HEALTH

• Proposed by David Baker in the late 1980s states that characteristics and health of the infant and influences from the environment during infancy, toddlerhood, and early childhood are associated with the development of adult acute and chronic disease, disability and death (Barker, 1995b).

• Barker’s theory has also come to be known as the Life-course Model of Health (Forrest & Riley, 2004; Halfon & Hochstein, 2002; Hertzman, 1999).

• Thus, infancy and toddlerhood are critical periods for health status across the life-span (Barker, 2001). The theory of Developmental Origins of Adult Disease was developed using a geospatial model that pinpointed later life heart disease in relationship to geographic areas that had high neonatal mortality and low birth weight infants (Barker, 2003; Barker, Forsen, Eriksson, & Osmond, 2002; Phillips et al., 2001; Robinson & Barker, 2002)

LIFECOURSE MODEL OF INDIVIDUAL AND COMMUNITY HEALTH

Glass and McAtee 2006

INTERSECTION OF HEALTH AND POLICY

• Health is measured in life times with disease manifesting after many years (decades)

• Policy is measured in election cycles with results necessary in 2-5 years

• Health outcomes are measured in terms of the absence of disease states or the non manifestation of progressive deteriorating symptoms

• Policy outcomes are measured in active results that can be quantified

• HOW DO YOU QUANTIFY THE ABSENCE OR NON MANEFESTATION OF A DISEASE????

WHAT WAS THE FIRST US HEALTH POLICY?

• Public Health Service originated with an Act of Congress “Act For The Relief Of Sick And Disabled Seamen” that was signed into law by President John Adams on July, 16, 1798

• Creating a system to provide care to merchant seamen, Marine Hospital Fund to be administered by the Treasury Department.  Twenty cents a month was deducted from the pay of each seaman to fund a system of hospitals in major port cities to treat sick and injured seamen. 

HEALTH POLICIES WERE THE JURISDICTION OF THE STATES

• Responsibility for quarantine for infectious diseases originally rested with the states

• In1877 yellow fever epidemic that spread from New Orleans up the Mississippi River resulted in the passage of the National Quarantine Act of 1878, which began a process of transferring responsibility for quarantine from the states to the Federal Government utilizing the Marine Hospitals. 

•US Federal Health Policy for ~ 100 years was only for the military.

EXPANDED TO VETTING IMMIGRANTS

• Under the immigration act of 1891, the Marine Hospital Service was assigned the responsibility for the medical inspection of arriving immigrants. 

• Immigration legislation prohibited the admission of individuals suffering from “loathsome or dangerous contagious diseases,” those who were insane or had serious mental deficiencies, and anyone likely to become a public charge (because of a medical disability). 

CHANGES AT THE TURN OF THE 19TH CENTURY

The name was changed in 1902 to the Public Health and Marine Hospital Service and also defined increased cooperation between Federal and state health authorities, including directing the Surgeon General to prepare and distribute to state health officers forms for the uniform compilation of vital statistics. 

Another law passed in 1902, the Biologics Control Act, extended the Service’s reach in yet another direction, giving it regulatory authority over the production and sale of vaccines, serums, and other biological products.

Another name change in 1912;  “Marine Hospital” was dropped from its title, and the organization became simply the Public Health Service (PHS).  

US HEALTH POLICIES

• World War I changed the scope of the PHS; it was responsible to work with local health departments to keep the areas around military training camps in the United States free from disease. 

• The threat of venereal disease (VD) to servicemen and essential war workers was of particular concern to the military, and a Division of Venereal Disease was created in the PHS in 1918 to help control the spread of VD. 

• The influenza pandemic that emerged in 1918 led to increased funding and staff for the PHS to fight the flu.

US HEALTH POLICIES

• In the period between the two world wars, the PHS assumed responsibility for the care of lepers when it converted the state leprosy facility in Carville, Louisiana into a national leprosy hospital; responsibility for the health of American Indians and Alaska Natives (1928); health of Prisoners (1930).

• Veteran Health was split off and the VA established (1921).

• As a result of a government reorganization in 1939, the PHS was taken out of the Treasury Department and given a new administrative home in the Federal Security Agency. 

US HEALTH POLICY

• The PHS expanded significantly during WWII, doubling its personnel between 1940 and 1945. 

• The war also increased the involvement of the PHS in international affairs, leading to the creation of an Office of International Health Relations. 

• A 1943 law reorganized the Service, consolidating its programs into four subdivisions: 1. the Office of the Surgeon General, 2. the National Institute (later Institutes) of Health, 3. the Bureau of Medical Services 4. the Bureau of State Services. 

Finally US Health Policies were consolidated/ Coordinated by an agency that was solely responsible for the health of the Nation.

US HEALTH POLICIES

Another expansion of PHS grew out of a wartime program to control malaria in areas around military bases. 

The PHS-administered Malaria Control in War Areas program, based in Atlanta, expanded its responsibilities over the course of the war to include the control of other communicable diseases such as typhoid fever, dengue, and typhus. 

By the end of the war, the program had demonstrated its value in the control of infectious disease so successfully that it was converted in 1946 to the Communicable Disease Center (CDC).

The mission of the CDC expanded over the succeeding decades to include areas such as nutrition, chronic disease and occupational and environmental health. 

US HEALTH POLICY• The other 1946 law that had an influence on the activities

of the PHS was the Hospital Survey and Construction Act, more commonly referred to as the Hill-Burton Act.  It authorized the PHS to make grants to the states for surveying their hospitals and public health centers, for planning construction of additional facilities, and to assist with construction costs.

• The establishment of a National Institute for Mental Health, as a part of the PHS happened in 1949. 

US HEALTH POLICY

FINALLY, in 1953, the Federal Security Agency was elevated to cabinet status as the Department of Health, Education, and Welfare (DHEW), but this change in status had little direct impact on the PHS at the time. 

US HEALTH POLICY

• The PHS continued to expand in the 1960s.  Two agencies that were also housed in DHEW were incorporated into the PHS in this decade.  • St. Elizabeths Hospital, which had begun in 1855 as the

Government Hospital for the Insane, in 1967.• The Food and Drug Administration, whose predecessor

organization dates back to 1906, was made a part of the PHS in 1968, thus involving the Service much more

heavily in the area of regulation.

As You Can See US Health Policy bas been addressed since the beginning of the Nation but it is difficult to characterize the FOCUS of the Policy Stream

“IN AN IDEAL WORLD, HEALTH POLICY WOULD BE FORMULATED IN A RATIONAL, LINEAR PROCESS, MOVING FROM DATA COLLECTION, TO INTERPRETATION, TO SCIENTIFIC CONSENSUS.” (SOMMERS 2001)

FORMULATION OF US HEALTH POLICY

“By definition, health policy is made in the public arena. The process is, therefore, subject to a complex array of considerations and influences, only some of which, sometimes none of which, have anything to do with data or with the public’s health.” (Sommer 2001)

US HEALTH POLICY

Who are the stakeholders?Which stakeholders are named?Who are the un-named stakeholders?What is the power structure of the stakeholders?

Which if any stakeholders have veto power?What are the stakeholder’s agenda? (Is there a hidden agenda?)

How vested is each stakeholder in the program?

POLICY VS. PROGRAM

• Policies are made up of numerous programs

• Programs form the bulk of the activities when policies are implemented

• The failure of one program does not mean the policy is a failure

• It gets even more complicated in health because many policy streams develop health programs so you need to be aware that there could be programs from other policies that could interfere with the program you are working with

• Health care policy determines the institutional framework but not the direct provision of health care

• As you move up the public health pyramid you shift from policies to programs to individual interactions

“WHAT DO WE NEED TO DO IN THE FUTURE TO ENSURE THE HEALTH OF OUR SOCIETY.”

Health Policy Direction

“WHAT DO I NEED TO DO RIGHT NOW FOR THIS SPECIFIC PATIENT TODAY TO MAINTAIN HEALTH.”

Health Program Direction

BREAK IN

TO S

MALL G

ROUPS

EXER

CISE

POLICY STREAMS

• How is knowing the history of a policy stream helpful?

• What can it tell you? Who controls the agenda What type of evaluation/ analysis is necessary for change or termination

How you should frame the debate and your recommendations

FEDERAL AGENCIES THAT CONTROL POLICY STREAMS

LOOK AT EACH DEPARTMENT’S STREAMS• Look at the websites for the different agencies and write a

brief list of what they oversee

• Especially note, any policies that might affect HEALTH

• You will find this very interesting and it will give you clues about why some policies seem illogical

• Then try to classify what type of policy model (Bureaucratic, Political, Social Movement, Collaborative) each agency operates under

• Sometimes policy streams mature and change as their agency matures

• You have ½ hour and your group will be presenting your findings

POLICY CRASHES

INTO HEALTH