Module 47: Health Policy

Health Policy

Actions taken by government bodies and other societal actors to attain specific health-related goals.
Includes laws, regulations, government agency guidelines, position statements, resolutions, judicial decrees, budget priorities.


Broad mandates with flexibility.
Give the administering executive branch agencies the authority to write regulations.


Describe in detail how the executive branch agency will carry out the law.
Must always refer to directly to the law it seeks to amplify, and an agency cannot write rules that exceed its statutory authority (Must honor the law's intent).

Executive Branch Agency

The part of the federal or state government that is responsible for administering a law.

Examples of Executive Branch Agencies

State Health Departments
State Boards of Nursing

State health departments have jurisdiction over. . .

Local health departments and boards of health, sanitarians, vital statistics.

Boards of Nursing are authorized to. . .

Implement the nurse practice act in their state.
And license or discipline license holders to protect the public.

Four major stages in policymaking

Agenda setting
Government response

Department of Health and Human Services (HHS)

Includes 11 separate divisions (notably the AHRQ, CDC, CMS, FDA, NIH).
HHS programs include those that improve maternal and infant health, protect mental health, promote better nutrition and physical activity, manage infectious.

Occupational Safety and Health Administration (OSHA)

Tasked with ensuring health and safety of Americans in the workplace.
Mission to provide assistance to employers, who are responsible for providing a safe workplace and for reducing or eliminating workplace hazards.

Who does the state department of health and human services report to?

The state's governor
They are also considered a part of the executive branch of state government.

What do state health departments regulate?

County health departments, and may license or register healthcare facilities (hospitals, LTC facilities), child care centers, clinical labs, X-ray suppliers.
Construction of medical facilities
Resolving complaints of facilities they regulate

Responsibilities of state offices of emergency medical services (OEMs)

Establishing training and certification standards for EMS personnel
Accrediting training programs
Overseeing state's trauma system
Licensing medical transport services.

What is the goal of state offices of emergency medical services (OEMs)?

Providing citizens with access to high-quality emergency medical care
Achieved by ensuring local EMS systems comply with applicable regulations.

Local Health Departments

Work at the county or municipal level
Oversee child care centers, food safety
Offer community-wide disease and injury prevention programs
Awareness to lead poisoning, smoke detectors, helmets, car seats.

Local social service departments are typically responsible for administering. . .

Medicaid; the Child Health Insurance Program (CHIP); and the Women, Infants, and Children (WIC) supplemental nutrition program.

What does the Women, Infants, and Children (WIC) supplemental nutrition program do?

Provides food assistance to pregnant women and children under age 5 who are at risk for malnutrition.

What three groups do International Health Agencies fall into?

Depending on their funding sources and location:
Multilateral organizations, bilateral organizations, and nongovernmental organizations (NGOs).

Who are multilateral organizations a part of?

The United Nations (UN).
e.g. The World Health Organization (WHO), the only international health organization with legal authority.

Who are bilateral agencies a part of?

A single country.
e.g. The U.S. Agency for International Development, who provides aid to developing countries.

Who are nongovernmental organizations (NGOs) a part of?

They are also known as private voluntary organizations (PVOs). They are independent of any government.
There are many (over 130).
e.g. Project Hope, who provides essential medicine, supplies, volunteers, medical training, and disaster response.


The process of gaining recognition through a peer review process that evaluates the quality of an organization on the basis of standards and criteria of the accreditation organization.
Established standards are evidence based.
Conducts on-site surveys

Achieving state/federal licensing/certification VS achieving Accreditation

Governmental VS Private and Voluntary
Achieving accreditation certifies that the organization meets quality criteria and is competent to provide the services or programs it offers.

Organization requirements for accreditation

Provides evidence it has continuously evaluated its own performance.
Has acted to correct deficiencies.
Continues to meet the accreditation standards.
Must be reevaluated at intervals by accrediting body.

The Joint Comission

An independent, nonprofit organization that sets standards for and accredits healthcare provider organizations (ambulatory care centers, behavioral healthcare providers, hospitals, LTC facilities).

Benefits of Joint Commission accreditation

Greater consumer trust and respectability.
Credibility with private third-party payers.
Helps organizations meet qualifications for Medicare and Medicaid reimbursement.

What do the Joint Commission NPSGs and Sentinel Event reporting system offer for healthcare organizations?

They provide benchmarks for quality improvement processes.

What is the role of the nurse in the Joint Commission accreditation process

Developing/revising facility policy for nursing practice to be current and evidence based.
Participation in the organization's self-review.
Nurse's in mgmt. may be part of meetings with accreditation survey team; Survey teams are often interested in speak

The American Association of Colleges of Nursing

The national voice for baccalaureate and graduate nursing education.
Focuses on expanding federal funding streams to support nursing education; supporting policies that affect affordability, access, transparency, and diversity.

Can you sign up for AACN?

If you are a nursing student or BSN student, yes.
Bachelor and collegiate.

International Council of Nurses (ICN)

Mission to "represent nursing worldwide, advancing the profession and influencing health policy."
Worldwide, oldest org for health professionals.

Sigma Theta Tau International (STTI)

Mission to "advancing world health and celebrating nursing excellence in scholarship, leadership, and service."
Membership by invitation to baccalaureate and graduate nursing students who demonstrate excellence in scholarship and to nurse leaders who exhi

American Nurses Association (ANA)

Fosters high standards of nursing practice, promoting the rights of nurses in the workplace, projects a positive and realistic view of nursing, lobbies Congress and fed.
Represents US nurses.
Membership for the Federal Nurses Association is open to RNs wh

ANA (per lecture notes) (abridged)

Role: Foster high standards of nurse practice.
Know stuff for your job or profession, HIgh standards of practice.
Advocates for the nurse and nurses in workplace.
Lobby to congress and regulatory agencies.

National Student Nurses Association (NSNA)

Mentors nursing students preparing for initial licensing as registered nurses.
Membership is open to nursing students in associate, baccalaureate, diploma, and prelicensure (second-degree) graduate programs.

ANA Nursing Strategic Action Team (N-STAT program)

Unites nurses across the nation who aspire to let lawmakers know their position on bills moving through Congress.

Specialty Practice Nursing Associations

Advances nursing practice in the affiliated specialty area (Obstetrics, Med-Surg, Neonatal, Orthopaedic).
Provides support to practitioners and their patients.

National League for Nursing (NLN)

To promote excellence in nursing education to build a strong and diverse nursing workforce to advance the health of our nation and the global community."
Membership includes both nurses and non-nurses.
Member services include professional development, re

The American Association of Colleges of Nursing (AACN)

The national voice for America's baccalaureate and graduate nursing education"
Membership includes colleges, which includes students to faculty to administrative staff.
Leader in securing federal support, shaping policy on nurse education programs, and f

AACN Essentials

The standards for the education curricula of its member nursing programs.

The healthcare from the Social Security Act of 1935 . . .

Did not include healthcare coverage for all Americans

The healthcare from the Affordable Care Act (ACA) of 2010 . . .

Meant that those who did not qualify for Medicare or Medicaid, and who otherwise would not have had access to health insurance, gained improved access to health insurance coverage.
The ACA also offers additional community-based programs as an alternative

Three basic private insurance plan types

Employer-sponsored insurance
Self-employment-based plans
Direct-purchase plans

Employment-sponsored insurance (ESI)

Offered through one's employer or union.
Coverage may be extended to include the spouse, dependents, or domestic partner of the employee.
Benefits of group health insurance include lower premium costs (the amount paid for insurance coverage) and better co

Domestic Partner

An unmarried partner of the same or opposite sex.

If the employer pays nothing toward the premium, partial, or full payment . . .

The employee is responsible for the premium amount not paid by the employer.


Annual cost for medical care
Commonly $100-300 per individual, and $500-2000 per family.


A set amount paid at the time of service
e.g. $20 for a primary-care physician office visit.
Payments for specialty care are usually higher than primary care.

Out-of-pocket maximums

Protects the patient from catastrophic healthcare costs
If medical expenses reach a certain amount during a 12-month period, the plan covers all usual and customary fees for the remainder of the year.

Issues with individual health policies

The individual is responsible for paying the premium as well as copayments and deductibles.
Usually more expensive and coverage is more restricted than under group health coverage.
Medical examination may be required to determine eligibility.

Health maintenance organizations (HMOs)

Insurance plans that limit coverage to care from physicians who contract with the specific HMO.
Out-of-network care is not generally covered, except in emergencies.
May require person live or work in service area.
Must often select a PCP.

Primary Care Provider (PCP)

Gatekeeper to care. Refers the patient to in-network hospitals and specialists when additional care is needed.

Preferred-provider organization (PPO)

Does not require a patient to select a PCP.
Larger networks of providers than HMOs.
Provides financial incentives that encourage insured persons to seek care from in-network providers.
Less restrictive than HMOs, but typically have higher copayments.

Point-of-service (POS) plan

A hybrid of an HMO and a PPO.
Can decide between HMO or PPO when seeking healthcare.
Can pay less if they use in-network physicians, hospitals, and other healthcare providers.
Otherwise, out-of-network providers means higher copayments, coinsurance, and d

Indemnity plans

Allow the insured to self-select health-care providers; meaning, that there is no network.
Plans may use some managed-care techniques to control costs (e.g., preauthorization of MRIs)

Consumer-driven healthcare plan (CHDP)

Employer-sponsored coverage that combines a private insurance plan with a health savings account (HSA) or health reimbursement account (HRA).
Higher deductible, but lower monthly premiums.
Money is saved in the HSA or HRA to pay for deductibles and noncov

Medigap policy

i.e. Medicare supplemental insurance
A private health insurance that supplements Medicare coverage (Covers noncovered health care costs).
Medicare pays its share first, then the Medigap policy pays its share.
These policies are required to state they are

Examples of Federally Funded Public Healthcare

The Centers for Medicine and Medicaid Services (CMS) administers Medicare, Medicaid, and CHIP.
VA; Defense Health Program (TRICARE) for military personnel, their families, and military retirees.
Indian Health Service (Am. Indians and Alaskan Natives).


Federally funded
For 65 or older who worked in a Medicare-covered job.
Young people with disabilities.
People with end-stage renal disease or amyotrophic lateral sclerosis (ALS)

What does Medicare not cover?

Long-term care, routine dental and eye care, hearing aids and the exams for fitting them, and cosmetic surgery.
People of purchase Medigap policies from private companies to supplement or fill gaps in coverage.


Made in 1965, jointly funded and administered by states and the federal government.
Available to certain lower-income individuals and families, the elderly, and people with disabilities who meet eligibility.

Under Medicaid, federal mandates require coverage which services?

Hospitalization, physician services, prenatal care, nursing home and home health services, and medically necessary transportation.

Supplemental Security Income (SSI)

A federal and state program funded by general taxes.
Helps the aged, blind, and disabled people who have little or no income, including children who are blind and disabled.
Provides cash for basic needs such as food, clothing, and housing.

Children's Health Insurance Program (CHIP)

Previously SCHIP (S = State)
Covers children under 19 y/o whose families earn more than Medicaid limits, but cannot afford to purchase private healthcare coverage.

Federal requirements for CHIP

Mandate that states include routine checkups, immunizations, dental and vision care, inpatient and outpatient hospital care, and laboratory and x-ray services in their benefits.

Examples of local/county level healthcare for the indigent (poor)

New York City's Health and Hospitals Corporation
Chicago's Cook County Hospital

Affordable Care Act (ACA) includes measures that . . .

Ensures consumers receive value for the cost of their premiums.
Restricts insurers charging unreasonable premiums.
Holds insurance companies accountable for unjustified premium increases.
Banned dollar limits on essential coverage (hospitals, physician, p