Government and Nongovernment Actors in US Health Policy

Introduction: The Structure of Health Policy Actors

The governmental actors discussed in Chapter 10 of Health Policy Analysis: An Interdisciplinary Approach are federal government actors, state governments, and local governments. These are the entities that form policy and pass laws that protect and enforce it. The United States, during its infancy, established a system of checks and balances designed to prevent one-sided political agendas from taking hold, and that design continues to influence recent legislation. As McLaughlin and McLaughlin (2015) note, "The Constitution that took effect in 1789 created a stronger national government, but it established a three-headed state with legislative, executive, and judicial branches and a system of checks and balances to ensure that no one branch would dominate" (p. 28).

Governmental Actors and the Affordable Care Act

The Affordable Care Act (ACA) is one example of a step governmental actors have taken to reduce healthcare spending. States like Maryland have acted to implement sustainable ways to curb spending and promote wellness. The 2010 Patient Protection and Affordable Care Act essentially required states to create and maintain a health insurance exchange by a 2014 deadline, or to participate in a type of federal exchange. In response, Maryland elected to establish Maryland Health Connection — a marketplace Marylanders can use to shop for and enroll in health plans.

Through the ACA, people who were previously uninsured could now obtain coverage. However, the act itself did not directly reduce healthcare spending; rather, the changes resulting from its passage did. As Wartman (2015) observed, "Changes resulting from the Affordable Care Act can reduce treatment disparities, but the law's provisions do relatively little to restrain runaway costs" (p. 10). People soon began to recognize that budget awareness and higher-quality medical care were urgently needed, and that the system had to change to meet that need.

Maryland's All-Payer Hospital Payment Model

Across the nation, various groups have been piloting creative new payment methods and models. One such experiment was conducted in Maryland, where the hospital payment system was overhauled in ways that carried significant implications for Johns Hopkins Medicine, the hospital at the center of the experiment. As Wartman (2015) explains, "Rates at Maryland hospitals are set by a state agency known as the Health Service Cost Review Commission or HSCRC. Since 1977, Medicare waived payment rules it uses in the rest of the country, paying Maryland hospitals according to HSCRC rates" (p. 10). This arrangement enabled uninsured patients to receive adequate medical care and made treatment more affordable for all. However, the old fee-for-service model provided no real incentive to keep people healthy or limit health expenses.

The new all-payer model, approved in January 2014, gave Maryland residents something closer to a "population health" system. The new policy provided the state with a mechanism to establish a global budget — a universal budget under which hospitals charge the same rate to all patients for the same procedures.

Rather than competing to attract more patients, hospitals operating under the new plan are incentivized to stay on budget and prioritize quality and efficiency over volume. This means reductions in preventable conditions and hospital readmissions. The shift is, in essence, from volume to value. Maryland's experiment, though difficult to implement, signals that hospitals and other healthcare facilities are willing to adapt in order to meet current needs, and it may serve as a progressive model for other states pursuing reductions in healthcare spending.

Nongovernmental Actors and Their Influence

The nongovernmental actors discussed in Health Policy Analysis: An Interdisciplinary Approach include the public, interest groups, the media, and scientists and other experts. These groups — often funded by corporations and wealthy individuals — influence the way government behaves. They may organize into lobbying coalitions or interest groups in order to persuade political figures to vote in particular ways or to pass policies that deregulate the system. As McLaughlin and McLaughlin (2015) note, "Interest groups do more than just attempt to sway votes in their favor; they can be critical partners with government actors in policy development from inception to implementation" (p. 282).

Nongovernmental actors such as members of the public can also undermine policy by committing fraud or disregarding the rules and regulations established by federal law. While Maryland complied with the Affordable Care Act, the state soon experienced serious problems brought on by nongovernmental actors — specifically, contractors involved in building the state's health exchange portal.

Conclusion

The government has a role to play in how the country pursues its goals, as demonstrated through the passage of acts like the Affordable Care Act and related policy reform. States like Maryland have attempted to adhere to the new rules of the ACA; however, nongovernmental players — such as contractors — have made the creation of an online insurance application portal more expensive than initially anticipated. Nevertheless, Maryland has taken meaningful steps toward reducing medical spending by adopting a higher-quality, more efficiency-oriented model through the all-payer system.

References

McLaughlin, C., & McLaughlin, C. (2015). Health policy analysis. Burlington, MA: Jones & Bartlett Learning.

Wartman, S. (2015). The transformation of academic health centers. Academic Press.