Influencing Health Care in the Legislative Arena

Sheila Abood, PhD, RN


Online J Issues Nurs. 2007;12(1) 

In This Article

The Policy Process and the Politics of Health Care

Health policy is a set course of action (or inaction) undertaken by governments or health care organizations to obtain a desired health outcome (Cherry & Trotter Betts, 2005). The overall health care system, including the public and private sectors, and the political forces that affect that system are shaped by the health care, policy-making process. Public health-related policies come from local, state, or federal legislation, regulations, and/or court rulings which govern the provision of health care services. In addition to public policies, there are institutional or business policies related to health care. These policies are developed in the private sector by agencies, such as hospitals, accrediting organizations, or managed care organizations. Nurses are very familiar with institutional policies including those developed and implemented by the Joint Commission on Accreditation of Healthcare Organizations.

Policy making takes place in a wide variety of settings ranging from fairly open and public systems involving a relatively large number of actors to a closed system involving just a few actors. The location of decision making in the public or the private sector, the scope of the issue, and the nature of the policy all have an impact on the characteristics of a policy (Thurber,1996). Since a basic understanding of the policy process is the first step in strategizing how to activate potential power and influence meaningful changes in the health care system, this section will discuss the three phases of policy making, as well as the connection between policy and politics.

The policy process refers to all the specific decisions and events that are required for a policy to be proposed, considered, and finally either implemented and/or set aside. It is an interactive process with multiple points of access providing opportunities to influence the multiple decision makers involved at each stage. Basically there are three phases of policy making: the formulation phase, the implementation phase, and the evaluation phase. During the formulation phase there is input of information, ideas, and research from key people, organizations, and interest groups. At this point the issue is framed; the purpose and desired outcomes are clearly identified; strategies most appropriate to the desired outcome are selected; and needed resources are identified and planned for.

The implementation phase involves disseminating information about the adopted policy and putting the policy into action. In this phase, the proposed policy is transformed into a plan of action (International Council of Nurses, 2005). Public policy enacted by local, state, or federal governmental bodies is usually implemented through the regulatory process that translates the policy into a written set of rules issued by the government agency which has the responsibility for administering the policy.

The policy process also includes an evaluation and modification phase when existing policies are revisited and may be amended or rewritten to adjust to changing circumstances (Longest, 2006). Most major public policies are subject to modifications in this incremental fashion. Making smaller changes in existing policies are usually less controversial than making major changes as they require less understanding of comprehensive relationships and less effort to achieve. An example of incrementalism in health policy can be seen in the many changes that the Medicare Program has undergone since its enactment in 1965. A change to the program of importance to advanced practice registered nurses came in 1998, when the U.S. Congress added nurse practitioners and clinical nurse specialists as providers who can bill for Part B services they provide to Medicare beneficiaries. Since then, Congress has tweaked Medicare program many times and added a number of preventive services to the Medicare program. Most recently Medicare Part D, an optional prescription drug program available for Medicare beneficiaries, has been added.

As any health care issue moves through the phases of the policy process, from a proposal to an actual program that can be enacted, implemented, and evaluated, the policy process is impacted by the preferences and influences of elected officials, other individuals, organizations, and special interest groups (Longest, 2006). These different factions do not necessarily view the issue through the same lens and often have diverse and competing interests. Added into the mix are the partisan agendas of the two political parties, the Democrats and the Republicans. The political party holding the majority usually has the political advantage.

Decision makers rely mainly on the political process as a way to find a course of action that is acceptable to the various individuals with conflicting proposals, demands, and values. As a general rule, any policy involving major change, significant costs, or controversy will be relatively more time consuming and difficult to achieve and will require the use of more political skills and influence than will policies involving less complex changes. Throughout our daily lives, politics determines who gets what, when, and how. Politics has been defined as "the process of influencing the authoritative allocation of scarce resources" (Kalisch & Kalisch, 1982, p.31).

Political interactions take place when people get involved in the process of making decisions, making compromises, and taking actions that determine who gets what in the health care system. Special interest groups and individuals with a stake in the fate of a health care policy use all kinds of influencing, communication, negotiation, conflict management, critical thinking, and problem solving skills in the political arena to obtain their desired outcome (Cherry & Trotter Betts, 2005; Kalisch & Kalisch, 1982).


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