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Policy Analysis. 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. What is Policy Analysis?.

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Policy analysis

Policy Analysis

What is policy analysis

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.

What is policy analysis1

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.

Policy analysis1

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

Policy analysis2

Policy Analysis

  • Neutral analysts

    • Consider all options

  • Advocates for best options serving “national interest”

1970s amendments to the legislative reorganization act

1970s Amendments to the Legislative Reorganization Act

  • “Congressional declaration of analytic independence from the administrative branch”

    • Created CBO, CRS, and OTA

Think tanks

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

Evolution of policy analysis

Evolution of Policy Analysis

  • Clients not only decision makers

    • Individuals stewarding institutional governance

      • Planning

      • Budgeting

      • Regulation

Office of assistant secretary for planning and evaluation aspe

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

Office of assistant secretary for planning and evaluation aspe1

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

Office of assistant secretary for planning and evaluation aspe2

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

Needed skills for aspe

Needed skills for ASPE

  • Program knowledge

  • Statistics

  • Microeconomics

  • Cost-benefit analysis

Congressional research service crs

Congressional Research ServiceCRS

  • 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

Policy analysis


  • What is the legislative hook?

  • High volume, quick turnaround

    • “a reference factory”

  • Emphasis on legislative consultation, interdisciplinary work, & anticipatory work

Policy analysis


  • 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

Policy analysis


  • Consultation at mark-ups

  • Hearing testimony

  • Consultation on the floor as requested

  • Prepare conference agendas

  • Consultation at conferences

Policy analysis


  • Most important role may be participation in creation of new legislation

  • Work not available to the public

    • Unless released by a Member

Policy analysis


  • Varied products

    • Electronic briefing books

    • Background reports on topics

  • CRS staff also interacts with Members and staff

Policy analysis


  • In-house capacity

    • Modeling

    • Create microsimulation models

    • Fiscal analyses

    • Culture emphasizes qualitative approaches and oral tradition

Heritage foundation

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

Heritage foundation1

Heritage Foundation

  • Established in 1973 with 9 staff

    • 1997 staff of 180

  • Added research staff in 1980

  • Funding from individual sponsors

Heritage foundation2

Heritage Foundation

  • Has pushed boundary of tax exempt organizations

  • Replaced the Kennedy School orienting new conservative congressman

  • Focus on Congress --- members and staff

Health policy

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”

So what is health policy

So, What is Health Policy?

Health policy1

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.

Policy and health

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

Health policy2

Health Policy

  • Authoritative

    • refers to decisions made in any part of government

      • all three branches

Health policy3

Health Policy

  • In the US: Consists of many decisions, rather than one large decision

  • Other countries have integrated, coordinated health systems (Great Britain, Canada)

Health policy4

Health Policy

  • Laws

  • Rules

  • Regulations

  • Judicial Decisions

Health policy by levels

Health Policy by levels:

  • Law

    • PL 89-97 1965 law establishing Medicare

  • Rule

    • Executive order establishing federally funded health centers

Health policy by levels1

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

Policy analysis


  • 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

Health policy and markets

Health Policy and Markets

  • Capitalist countries such as the USA assume

    • markets are critical to production

    • consumption of health services

Health policy interventions

Health Policy Interventions

  • intervention needed when markets fail

  • party models have differing tolerance for market imperfection

Conditions for the market

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

Health policy categories

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

Health policy categories1

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

Health policy categories2

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

Regulatory market entry restrictions

RegulatoryMarket-Entry Restrictions

  • State licensing laws

  • Planning programs

  • CON

Regulatory price setting

Regulatory Price Setting

  • Out of vogue

  • Electric and gas utility control

  • PPS

Regulatory quality

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

Regulatory market preserving

Regulatory Market Preserving

  • Health markets are not true markets; this class of regulatory action addresses market imperfections

  • Sherman Anti-trust laws

State health policy

State Health Policy

  • Dynamic balance between state and federal policy

  • Recent ascendance of state policy

    • failed national reform in 1994-1995

    • Medicaid growth

State health policy roles

State Health Policy Roles

  • Lipson (1997)

    • financing or paying for several categories of people

    • public health

    • regulating health professions licensing and practice.

State health policy roles1

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

State health policy roles2

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

State health policy roles3

State Health Policy Roles

  • Professional Regulation

    • license various professionals

    • write practice acts

    • license and monitor compliance

State health policy roles4

State Health Policy Roles

  • States regulate the content, pricing and marketing of insurance plans

  • Under the McCarran-Ferguson Act (P.L. 79-15)

Erisa 1974

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



  • 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



  • For 1st 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



  • 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.

1995 travelers insurance decision

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.

1995 travelers insurance decision1

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

Erisa allowable state legislation

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

Erisa pay or play

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.

Policy analysis

  • 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

State laboratories

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

State roles increasing

State roles increasing

  • States may be too idiosyncratic

  • States still face large problems and increasing problems

Health policy policy vs policy objectives

Health Policy Policy vs Policy Objectives

  • Policies developed to achieve someone’s policy directives

  • The objectives shape health policy

Current us health policy objectives

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

Current us health policy objectives1

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

Domain of health policy

Domain of Health Policy

  • Remarkably broad

    • physical Environment

    • biology

    • social

    • tax issues

Domain of health policy1

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

Personal responsibility and work opportunity reconciliation act p l 104 193

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

Personal responsibility and work opportunity reconciliation act p l 104 1931

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

Political negotiation

Political Negotiation

  • Involves two or more parties bargaining

    • win/win

    • competitive -- win/lose

Political negotiation1

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

Political negotiation2

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.

Economic markets vs political markets

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

Policy analysis

Sellers Economic Exchanges in Market Transactions Buyers



Economic markets vs political markets1

Economic Markets vs. Political Markets

  • Demand for health policy markets

    • knowledgeable individuals

    • organizations

    • organized interest groups

      • AMA

      • AARP

      • AAHP

      • PhRMA

Benefits of interest groups ambiguous

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

Pluralist perspective

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

Pluralist perspective1

Pluralist Perspective

  • Groups must rely on political power bases

  • Groups representing concentrated economic interests must have money

  • Groups representing consumer groups must have members

Interest groups

Interest Groups

  • More than 22,000 in US

    • concern with pluralist perspective

      • all 22,000 groups given legitimacy

Interest groups have power

Interest Groups Have Power

  • Lowi labeled “interest group liberalism”

    • to address excessive deference to interest groups

  • Edwards, Wattenberg & Lineberry, 2001

    • Hyperplualism

Interest groups have power1

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



  • 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

Elitist model

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



  • Protect power base

What must health care reform accomplish

What Must Health Care Reform Accomplish?

  • Restrain cost

  • Create access and equity

  • Improve quality

  • Promote health

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