Politics and the Public Health Workforce: Lessons Suggested from a Five-State Study.

Policy Points The United States public health system relies on an inadequate and inefficient mix of federal, state, and local funding. Various state-based initiatives suggest that a promising path to bipartisan support for increased public health funding is to gain the support of local elected officials by providing state (and federal) funding directly to local health departments, albeit with performance strings attached. Even with more funding, we will not solve the nation's public health workforce crisis until we make public health a more attractive career path with fewer bureaucratic barriers to entry. CONTEXT: The COVID-19 pandemic exposed the shortcomings of the United States public health system. High on the list is a public health workforce that is understaffed, underpaid, and undervalued. To rebuild that workforce, the American Rescue Plan (ARP) appropriated $7.66 billion to help create 100,000 new public health jobs. As part of this initiative, the Centers for Disease Control and Prevention (CDC) distributed roughly $2 billion to state, local, tribal, and territorial health agencies for use between July 1, 2021, and June 30, 2023. At the same time, several states have enacted (or are considering enacting) initiatives to increase state funding for their local health departments with the goal of ensuring that these departments can deliver a core set of services to all residents. The differences in approach between this first round of ARP funding and theseparate state initiatives offer an opportunity to compare, contrast, and suggest lessons learned. METHODS: After interviewing leaders at the CDC and other experts on the nation's public health workforce, we visited five states (Kentucky, Indiana, Mississippi, New York, and Washington) to examine, by means of interviews and documents, the implementation and impact of both the ARP workforce funds as well as the state-based initiatives. FINDINGS: Three themes emerged. First, states are not spending the CDC workforce funding in a timely fashion; although the specifics vary, there are several organizational, political, and bureaucratic obstacles. Second, the state-based initiatives follow different political paths but rely on the same overarching strategy: gain the support of local elected officials by providing funding directly to local health departments, albeit with performance strings attached. These state initiatives offer their federal counterparts a political roadmap toward a more robust model of public health funding. Third, even with increased funding, we will not meet the nation's public health workforce challenges until we make public health a more attractive career path (with higher pay, improved working conditions, and more training and promotion opportunities) with fewer bureaucratic barriers to entry (most importantly, with less reliance on outdated civil service rules). CONCLUSION: The politics of public health requires a closer look at the role played by county commissioners, mayors, and other local elected officials. We need a political strategy to persuade these officials that their constituents will benefit from a better public health system.

Trump v. The ACA.

Before his incoherent response to the COVID-19 pandemic, the focus of President Trump's health policy agenda was the elimination of the Patient Protection and Affordable Care Act (ACA), which he has called a 'disaster'. The attacks on the ACA included proposals to repeal the law through the legislative process, to erode it through a series of executive actions, and to ask the courts to declare it unconstitutional. Despite these ongoing challenges, the ACA remains largely intact as the U.S. heads into the 2020 election. The longer term fate of the law, however, is uncertain and the outcome of the 2020 election is likely to have a dramatic effect on the direction of health policy in the U.S.

Getting The Price Right: How Some Countries Control Spending In A Fee-For-Service System.

Although the US has the highest health care prices in the world, the specific mechanisms commonly used by other countries to set and update prices are often overlooked, with a tendency to favor strategies such as reducing the use of fee-for-service reimbursement. Comparing policies in three high-income countries (France, Germany, and Japan), we describe how payers and physicians engage in structured fee negotiations and standardize prices in systems where fee-for-service is the main model of outpatient physician reimbursement. The parties involved, the frequency of fee schedule updates, and the scope of the negotiations vary, but all three countries attempt to balance the interests of payers with those of physician associations. Instead of looking for policy importation, this analysis demonstrates the benefits of structuring negotiations and standardizing fee-for-service payments independent of any specific reform proposal, such as single-payer reform and public insurance buy-ins.

Why Did the ACA Co-Op Program Fail? Lessons for the Health Reform Debate.

The ACA created a new type of nonprofit health insurance entity, the "Consumer Operated and Oriented Plan" ("co-op"). Most of the newly created co-ops soon lost money, and only 4 of the original 23 remain. We interviewed key stakeholders and conducted in-depth case studies of 3 of these co-ops. We discovered that politicians and regulators made it unlikely the program could succeed, that most of the co-ops did not have the management capacity to overcome these political obstacles, and that even those with good managers lacked the needed fiscal resilience. We also considered lessons suggested for those proposing a newly created "public option." The main one is that a successful public option requires a supportive political environment, strong management, and significant fiscal capacity, none of which comes easily. A better route may be a quasi-public option in which the government subcontracts the operation of its newly created plan to a private firm. Although it is uncertain whether federal regulators have the capacity to hold such private for-profit firms accountable, pragmatism suggests that a combination of public-sector regulation and private-sector implementation may be the most direct path toward a US version of affordable universal coverage.

Single-Payer Health Care in the United States: Feasible Solution or Grand Illusion?

The adoption of a single-payer health care system, a recurring dream of progressive American reformers, now enjoys sustained attention in the run-up to the 2020 national elections. Some compelling arguments support the case for single payer, and its political prospects may indeed be on the rise, but myriad obstacles beset it, and a full-throated Democratic endorsement of it carries disquieting risks.

Health reform requires policy capacity.

Among the many reasons that may limit the adoption of promising reform ideas, policy capacity is the least recognized. The concept itself is not widely understood. Although policy capacity is concerned with the gathering of information and the formulation of options for public action in the initial phases of policy consultation and development, it also touches on all stages of the policy process, from the strategic identification of a problem to the actual development of the policy, its formal adoption, its implementation, and even further, its evaluation and continuation or modification. Expertise in the form of policy advice is already widely available in and to public administrations, to well-established professional organizations like medical societies and, of course, to large private-sector organizations with commercial or financial interests in the health sector. We need more health actors to join the fray and move from their traditional position of advocacy to a fuller commitment to the development of policy capacity, with all that it entails in terms of leadership and social responsibility.

Physician integration revisited-An exploratory study of monetary and professional incentives in three countries.

Discussions - and definitions - of "integration" in health services and systems are abundant, but little is known about the inducements that organizational leaders use to win the support of physicians within integrated systems. This paper, drawing on a qualitative exploratory survey of sources within 151 integrated care organizations in three nations (the U.S., England, and Germany), explores the mix of monetary and professional inducements these organizations employ to attract and retain physicians. The organizations we sampled do not rely exclusively, and seldom preponderantly, on selective monetary incentives, but rather employ a composite portfolio of the two types. These inducements appear with remarkable consistency at the "micro" level of organizations in our three nations, notwithstanding the marked differences in their "macro" health systemic contexts. Since public policy sets the framework for the design of inducements and individual organizations are in charge of their implementation, our findings call for closer attention to the big motivational picture, and especially to the importance of professional considerations within it, if healthcare organizations hope to deploy effectively the whole spectrum of available incentives for physician-organization integration in the future.

The political economy of rationing health care in England and the US: the 'accidental logics' of political settlements.

This article considers how the 'accidental logics' of political settlements for the English National Health Service (NHS) and the Medicare and Medicaid programmes in the United States have resulted in different institutional arrangements and different implicit social contracts for rationing, which we define to be the denial of health care that is beneficial but is deemed to be too costly. This article argues that rationing is designed into the English NHS and designed out of US Medicare; and compares rationing for the elderly in the United States and in England for acute care, care at the end of life, and chronic care.

Dynamics of device innovation: implications for assessing value.

BACKGROUND: In recent years, there has been growing interest in evaluating the health and economic impact of medical devices. Payers increasingly rely on cost-effectiveness analyses in making their coverage decisions, and are adopting value-based purchasing initiatives. These analytic approaches, however, have been shaped heavily by their use in the pharmaceutical realm, and are ill-adapted to the medical device context. METHODS: This study focuses on the development and evaluation of left ventricular assist devices (LVADs) to highlight the unique challenges involved in the design and conduct of device trials compared with pharmaceuticals. RESULTS: Devices are moving targets characterized by a much higher degree of post-introduction innovation and "learning by using" than pharmaceuticals. The cost effectiveness ratio of left ventricular assist devices for destination therapy, for example, decreased from around $600,000 per life year saved based on results from the pivotal trial to around $100,000 within a relatively short time period. CONCLUSIONS: These dynamics pose fundamental challenges to the evaluation enterprise as well as the policy-making world, which this paper addresses.

Introduction: evaluation in analytic theory and political practice.

The development of professional policy analysis was driven by a desire to apply "science" to policy decisions, but the vision of apolitical policy analysis is as unattainable today as it was at the inception of the field. While there is powerful evidence that schemes to "get around" politics are futile, they never seem to lose their popularity. The contemporary enthusiasm for health technology assessment and comparative-effectiveness research extends these efforts to find technical, bureaucratic fixes to the problem of health care costs. As the benefits and costs of health care continue to grow, so too will the search for analytic evidence and insights. It is important to recognize that the goal of these efforts should not be to eliminate but rather to enrich political deliberations that govern what societies pay for and get from their health care systems.

Stealing on insensibly: end of life politics in the United States.

Because the United States often seems (and seems eager to present itself as) the home of the technological imperative and of determination to brand all challenges to it in end-of-life care as a descent into death panels, the prospects look unpromising for progress in US public policies that would expand the range of choices of medical treatments available to individuals preparing for death. Beneath this obdurate and intermittently hysterical surface, however, the diffusion across US states and communities of living wills, advanced directives, palliative care, hospice services and debates about assisted suicide is gradually strengthening not so much 'personal autonomy' as the authority, cultural and formal, of individuals and their loved ones not merely to shape but to lead the inevitably 'social' conversations on which decisions about care at the end of life depend. In short, the nation appears to be (in terms taken from John Donne's mediations on death) 'stealing on insensibly'--making incremental progress toward the replacement of clinical and other types of dogma with end-of-life options that honor the preferences of the dying.

The fox and the grapes: is real reform beyond reach in the United States?

As the challenges of maintaining (or, in the US case, attaining) affordable universal coverage multiply, the debate about what constitutes "real" reform intensifies in Western health care systems. The reality of reform, however, lies in the eyes of myriad beholders who variously enshrine consumer responsibility, changes in payment systems, reorganization, and other strategies -- or some encompassing combination of all of the above -- as the essential ingredient(s). This debate, increasingly informed by the agendas of health services researchers and health policy analysts, arguably serves as much or more to becloud as to clarify the practical options policy makers face and remains severely imbalanced with respect to the institutional sectors on which it concentrates, the fields of knowledge on which it draws, and the roles it envisions for markets and the state.

A consideration of user financial incentives to address health inequalities.

Health inequalities and user financial incentives to encourage health-related behavior change are two topical issues in the health policy discourse, and this article attempts to combine the two; namely, we try to address whether the latter can be used to reduce the former in the contexts of the United Kingdom and the United States. Payments for some aspects of medical adherence may offer a promising way to address, to some extent, inequalities in health and health care in both countries. However, payments for more sustained behavior change, such as that associated with smoking cessation and weight loss, have thus far shown little long-term effect, although more research that tests the effectiveness of different incentive mechanism designs, informed by the findings of behavioral economics, ought to be undertaken. Many practical, political, ethical, and ideological objections can be waged against user financial incentives in health, and this article reviews a number of them, but the justifiability of and limits to these incentives require more academic and public discourse so as to gain a better understanding of the circumstances in which they can legitimately be used.

We all want it, but we don't know what it is: toward a standard of affordability for health insurance premiums.

The 2010 Patient Protection and Affordable Care Act (P.L. 111-148), or ACA, requires that U.S. citizens either purchase health insurance or pay a fine. To offset the financial burden for lower-income households, it also provides subsidies to ensure that health insurance premiums are affordable. However, relatively little work has been done on how such affordability standards should be set. The existing literature on affordability is not grounded in social norms and has methodological and theoretical flaws. To address these issues, we developed a series of hypothetical vignettes in which individual and household sociodemographic characteristics were varied. We then convened a panel of eighteen experts with extensive experience in affordability standards to evaluate the extent to which each vignette character could afford to pay for one of two health insurance plans. The panel varied with respect to political ideology and discipline. We find that there was considerable disagreement about how affordability is defined. There was also disagreement about what might be included in an affordability standard, with substantive debate surrounding whether savings, debt, education, or single parenthood is relevant. There was also substantial variation in experts' assessed affordability scores. Nevertheless, median expert affordability assessments were not far from those of ACA.

Incentivizing professionals and patients: a consideration in the context of the United Kingdom and the United States.

We are at the beginning of an era in which the pressure to secure the biggest possible "bang" for the health care "buck" is perhaps higher than it ever has been, on both sides of the Atlantic, and within the health policy discourse, incentives, for both professionals and patients, are occupying an increasingly prominent position. In this article, we consider issues related to motivating the professional and the patient to perform targeted actions, drawing on some of the evidence that has thus far been reported on experiences in the United Kingdom and the United States, and we present an admittedly somewhat speculative taxonomy of hypothesized effectiveness for some of the different methods by which each of these two broad types of incentives can be offered. We go on to summarize some of the problems of, and objections to, the use of incentives in health and health care, such as those relating to motivational crowding and gaming, but we conclude by positing that, following appropriate consideration, caution, and methodological and empirical investigation, health-related incentives, at least in some contexts, may contribute positively to the social good.

Pedestrian paths: why path-dependence theory leaves health policy analysis lost in space.

Path dependence, a model first advanced to explain puzzles in the diffusion of technology, has lately won allegiance among analysts of the politics of public policy, including health care policy. Though the central premise of the model--that past events and decisions shape options for innovation in the present and future--is indisputable (indeed path dependence is, so to speak, too shallow to be false), the approach, at least as applied to health policy, suffers from ambiguities that undercut its claims to illuminate policy projects such as managed care, on which this article focuses. Because path dependence adds little more than marginal value to familiar images of the politics of policy--incrementalism, for one--analysts might do well to put it on the back burner and pursue instead "thick descriptions" that help them to distinguish different degrees of openness to exogenous change among diverse policy arenas.

Assessing technological change in cardiothoracic surgery.

Technological innovation--broadly defined as the development and introduction of new drugs, devices, and procedures--has played a major role in advancing the field of cardiothoracic surgery. It has generated new forms of care for patients and improved treatment options. Innovation, however, comes at a price. Total national health care expenditures now exceed $2 trillion per year in the United States and all current estimates indicate that this number will continue to rise. As we continue to seek the most innovative medical treatments for cardiovascular disease, the spiraling cost of these technologies comes to the forefront. In this article, we address 3 challenges in managing the health and economic impact of new and emerging technologies in cardiothoracic surgery: (1) challenges associated with the dynamics of technological growth itself; (2) challenges associated with methods of analysis; and (3) the ways in which value judgments and political factors shape the translation of evidence into policy. We conclude by discussing changes in the analytical, financial, and institutional realms that can improve evidence-based decision-making in cardiac surgery.

Active living as an institutional challenge: lessons from the Robert Wood Johnson Foundation's "Celebrate Fitness" program.

Native American youth suffer disproportionately from a range of adverse health conditions. Empowering youth leaders to work on community-based solutions has proved effective in reducing tobacco use and gun violence and is now emerging as a promising approach to improving fitness and health. This article, based on direct observation and interviews with key informants, examines the implementation of a Robert Wood Johnson Foundation-funded project that gave tribal youth councils minigrants to design and run diverse projects that encourage physical activity in their communities. The article highlights the institutional challenges that confront health-promotion strategies for disadvantaged populations. Unless they take proper account of organizational, political, environmental, and cultural forces, funders' interventions have limited chances for success and sustainability.