Week 14- Participation in Public Policy

This week will by my final blog posting and I would like to take this opportunity to reflect back on this semester. I have grown a great deal as a public policy student in the past few months. I am fortunate that I have the ability to share my growth through this blog to my readers and health policy professor Dr. Ross. Throughout this class I have learned strategies to increase consumer participation in the policy process. In the beginning of this semester Congresswoman Sinema spoke with our class and set the tone for rest of the semester. I have often thought back to her remarks as I have matured as a public policy student. One key theme that stands out from her presentation is that Rep. Sinema encouraged us as healthcare providers to get involved in public policy. She urged us to get our voices heard, write letters to legislators, make phone calls to their office staff, and network with policy experts in our area of interest. She mentioned that most legislators are not experts on healthcare and have little-to-no medical experience (Sinema, 2014). Legislators primarily rely on us to be their informants and to advise them of what healthcare policies are needed (Sinema, 2014). We cannot expect change or new policy development if we do not participate. Rep Sinema made it apparent that legislators are approachable and receptive to feedback from the public. Having the opportunity to listen to her lecture and the fact that she came and met with our class changed my perception that politicians are out of the public reach.

My perception of the out-of reach politician was further dispelled after my interview with policy consultant Mr. Chris Gallagher. Honestly, I was nervous about interviewing him because I felt unqualified to interview someone with his obesity policy expertise. I was afraid that he might be dismissive or annoyed by my questions. I was pleasantly surprised. Not only was he happy to talk with me, he spoke candidly to me on the telephone for over 45 minutes. He explained in detail obesity-related healthcare policies, including the policy that I have been focusing on, which is Treat and Reduced Obesity Act (TROA). Mr. Gallagher reviewed policy aspects that I was not familiar with. He also emailed a few articles that discussed obesity policy in further detail. Mr. Gallagher is the policy consultant for American Society of Bariatric Physicians (ASBP), which is a group that I am a member of. After we got to talk, we realized that we have been to a few of the same conferences and he presented at one of the last conferences I was at. He also was works as policy consultant with some of the bariatric surgeons that we consult with here Phoenix. Even though he works on Capitol Hill, we have similar connections. This demonstrates how important networking is in the public policymaking process. Mr. Gallagher also asked for my feedback as a FNP that specializes in bariatric medicine. This reiterated to me that policy consultants and legislators do want our feedback.

One of my apprehensions coming into this class is that I am a very politically neutral person, which I thought that would hinder my growth as a public policy student. I have realized now that being political neutral is beneficial because people with strong political opinions often create roadblocks to getting their policies passed. This concept stood out to me when Rep Sinema came and spoke with our class. She is a democrat, however she did not push her party or bash the other party. She presented information about the Affordable Care Act (ACA) in a completely bipartisan manner. Rep Sinema discussed the benefits and faults of the ACA and emphasized that neither party’s point of view is completely right. This makes me think of how Madison must have felt when dealing with Hamiltonians and Jeffersonians of his time. He came to the conclusion that the Constitution is a framework for argument rather than a set of solutions, which allows for debate and continuous modification (Padgett et al., 2013). Therefore, healthcare policies including the ACA are up for debate so we should be involved in this debate.
As consumers there is a lot that we can do to get involved in the policymaking process. A good place to start is by identifying a problem or a topic that we are passionate about. Then find an interest group or organization that shares similar views. Although it is possible for ideas to get heard as an individual, groups are substantially more effective because they have greater voice, expanded networking ability and multiple resources (Longest, 2010). We can also write to legislators, go to public forums, and vote of course. Moving forward, I plan to get involved further in obesity policies through the ASBP. Mr. Gallagher asked me to be local voice in Phoenix to speak with legislators here if needed to further educate and advocate for obesity polices. I still have a great deal to learn in public policy but I am taking small steps to support a cause that I am passionate about. Thanks again for reading this blog. I hope you enjoyed it.
References:
Gallagher, C.R. (personal communication April 2, 2014).
Longest, B. (2010). Health policymaking in the United States (5th ed.) Chicago: Health Administration Press.
Padgett, K, Bellinger, J., Ellis, J., Hollis, D., & Rosenkranz, N. (2013). Sex, ducks, and the founding feud. Retrieved on April 17th, 2014 from http://www.radiolab.org/story/sex-ducks-and-founding-feud/
Sinema, K (personal communication January 24, 2014).

Week 13 – Policy Innovation and Obesity Management

The policymaking process in the United States is a complex, dynamic process that continues to change and evolve over time. The key factor for sustaining an innovative environment for policymaking occurs in the policy modification phase (Longest, 2010). In this phase, policy development is stimulated by the performance and consequences of current policies (Longest, 2010). This is a constant feedback loop, which ensures that no policy is permanent and can always be modified to meet the needs of our ever-changing society. Policy outcomes may have a negative impact on a particular interest group, organization, and/or the public (Longest, 2010). Our policymaking process allows for those negatively impacted by a policy to request a modification or dissolution of that policy. There is also the ability to request modifications to a policy that would extend or increase it’s positive outcomes over a certain period of time (Longest, 2010).

The Treat and Reduce Obesity Act (TROA) is a great example of proposed policy modification. In 2011 the Centers for Medicare & Medicaid Services (CMS) implemented a policy to provide reimbursement to primary care providers (PCPs) for intensive behavior therapy for obesity treatment (Centers for Medicare & Medicaid Services [CMS], 2012). Although this is a great advancement for obesity management, several interest groups and organizations have identified negative outcomes of this policy. The main negative outcome is that this policy does not reimburse obesity management done by other qualified health care providers (HCPs), such as registered dieticians (RDs), and psychologists (H.R. 2415, 2013). TROA has been proposed as an innovative modification of a currently flawed policy. TROA is an example of an incremental policy modification because it is minor modification of the larger pre-existing Medicare policy. Incrementalism is the preferred method of policy modification because the policy changes are gradual, stable and allow for compromise amongst diverse groups (Longest, 2010).

The idea of policy modification and sustaining innovative environments can be traced back to when the Founding Fathers wrote the Constitution. At that time there was a major power struggle between federal and state governments (Padgett, Bellinger, Ellis, Hollis, & Rosenkranz, 2013). Hamilton wanted a strong federal government with no separate state power and a president to be elected for life. Jefferson wanted a limited federal government and most of the power to reside in the individual states. Madison realized that neither party was right and that both federal and state governments have a role in making the country successful (Padgett et al., 2013). There are certain issues that should be handled by the federal government such as military, international trade and treaties. Other issues such as healthcare and education are often more local issues and the states are better equipped to handle them (Padgett et al., 2013). The states also act as innovative labs for new policies to be developed. The argument between Jefferson and Hamilton was purposely left unresolved and open for debate. The Constitution is a framework for argument rather than a set of solutions (Padgett et al., 2013). If we were unable to debate over the Constitution and modify policies if needed, we would never progress as a country and ultimately fail (Padgett et al., 2013).

In my interview with Mr. Gallagher, he discussed creating innovative environments for policy development and also understanding the scope of certain policies. As a policy consultant, he often helps his clients propose new policy that will amend problems with existing policy (Gallagher, 2014). Obesity policy modifications such as the TROA often fall under the scope of both the federal and state governments. TROA would amend the federal Medicare policy, however individual states reimburse for CMS programs differently (Gallagher, 2014). Mr. Gallagher (2014) explained that the priority for TROA is to get obesity recognized under the chronic disease management category on the Essential Health Benefits (EHB) and then focus on State Exchanges. When obesity management is covered by the EHB the changes that TROA proposes will be included in that. The individual state exchanges will then create an innovative, competitive marketplace for obesity-related health care coverage (Gallagher, 2014).

Center for Medicaid and Medicare Services (CMS). (2012). Intensive behavior therapy (IBT) for obesity. Medicare Learning Network. Retrieved on February 16, 2014 from http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/ICN907800.pdf

Gallagher, C.R. (personal communication April 2, 2014).

Longest, B. (2010). Health policymaking in the United States (5^th ed.) Chicago: Health Administration Press.

Padgett, K, Bellinger, J., Ellis, J., Hollis, D., & Rosenkranz, N. (2013). Sex, ducks, and the founding feud. Retrieved on April 17^th, 2014 from http://www.radiolab.org/story/sex-ducks-and-founding-feud/

 

Treat and Reduce Obesity Act of 2013, H.R. 2415, S. 1184. 113^th Cong. (2013).

 

 

 

Week 12- Obesity Management and Health Care Financing.

Health care financing is complex process with many different interacting components. The Congressional Budget Office (CBO) has an influential role in the health care financial process and can help determine the ultimate fate of a bill. The CBO was established in 1974 as nonpartisan congressional agency that functions to provide objective cost analysis of proposed policies (Congressional Budget Office (CBO), 2014). The CBO evaluates proposed legislation and assigns a formal cost estimate of that bill on the federal budget. The formal cost estimate shows how the federal revenues and outlays would change if this bill was fully implemented. Federal outlays refer to spending that pay federal obligations and revenues refer to funds that the government collects from the public such as taxes (CBO, 2014). The formal cost estimate provides vital information to legislators about the budgetary consequences of the proposed bill if enacted (CBO, 2014).

The cost estimates also show how new legislation would affect the three components of the federal budget, which are discretionary spending, mandatory spending and changes to the tax code (CBO, 2014). Discretionary spending includes programs that are under the House and Senate Appropriations Committees such as defenses, education, and transportation programs. Mandatory spending deals with entitlement programs that are governed under permanent law such as Medicare, Medicaid and Social Security (CBO, 2014). The Treat and Reduce Obesity (TRO) Act of 2013 proposes changes to Medicare and will affect mandatory spending. Bills that deal with mandatory spending, like the TRO, are subject to the Statutory Pay-As-You-GO- (PAYGO) Act of 2010. The PAYGO requires that any increase to entitlement programs and/or cuts in taxes need to be completely offset (Longest, 2010). For example, since TRO will increase Medicare spending it will have to be paid for cutting spending on another entitlement program and/or by raising revenue. The CBO will take this into consideration when they assign a cost estimate to the TRO, which is yet to happen.    

In my interview with Mr. Chris Gallagher, policy consultant, he emphasized the influential role that the CBO has in whether a proposed policy will get passed or not. The CBO focuses mainly on the money that policy will cost upfront and not the future economic benefits that the policy will create (Gallagher, 2014). This causes a major roadblock for health care policies focused on prevention such as the TRO. The cost estimate score that the CBO assigns to the TRO will likely be the determining factor on whether the bill gets passed. The TRO is an evidence-based policy that has been well researched and been shown to have both health and economic benefits and because of this it has gained a great deal of support (Gallagher, 2014). However, the bottom-line is if the TRO causes any budgetary constraints, legislators will likely not approve the bill (Gallagher, 2014). Mr. Gallagher (2014) related that bills most effectively get passed if there is a major group lobbying for them and willing to provide financial funding. These large groups in healthcare policy are most often pharmaceutical companies. The TRO does have support from two pharmaceutical companies Vivus and Eisai because the proposed the legislation will amend Medicare part D to cover two of their prescription medications (Gallagher, 2014). However, the TRO is not any group’s number one priority, which makes it more challenging to get Congress to approve it (Gallagher, 2014).

The CBO has a high priority of reducing healthcare spending since in the past few decades it has more than doubled and continues to increase (Longest, 2010). The CBO has estimated that under current law federal spending on Medicare and Medicare will rise from 4 percent to 9 percent of the gross domestic product (GDP) by 2034 (Longest, 2010). The main cause of this problem is that healthcare spending has increased and is exceeding the growth of the economy (Longest, 2010). Since Congress is currently focused on saving money, especially in health care spending related to Medicare, it may take a few years for them to pass TRO (Gallagher, 2014). The future priority of TRO is over the next few years to build a solid list of supporters and increase financial funding (Gallagher, 2014).

References:

Congressional Budget Office (2014) Retrieved on April 8, 2014 from http://www.cbo.gov

Gallagher, C.R. (personal communication April 2, 2014).

Longest, B. (2010). Health policymaking in the United States (5^th ed.) Chicago: Health Administration Press.

Week 11- Characteristics of Innovators and Change Agents in the Healthcare Sector

I had the privilege of interviewing Chris Gallagher who is an expert policy consultant for obesity healthcare policies. Chris works with several groups to promote obesity policies including the Obesity Action Coalition (OAC), American Society of Bariatric Physicians (ASBP) and the American Society of Metabolic and Bariatric Surgery (ASMBS). This week’s blog is a great opportunity to highlight my interview with Chris because he is an excellent example of an innovator in the healthcare sector. My interview with Chris was quite comprehensive and he provided me with a wealth of information. He gave me insight on the Treat and Reduce Obesity Act (TROA) and on obesity policies in general. The content of my interview will be shared in this week’s blog and discussed further in my upcoming four blogs.

Chris Gallagher went into healthcare policy straight out of college 25 years ago. He started on Capitol Hill working for Senator Bill Bradley (D) from New Jersey. In this role he was a legislative aide with the primary focus on healthcare policy. He then went to work as a policy consultant for the American Academy of Otolarygnology- Head and Neck Surgery for a few years. Following that position, he took a policy consultant job for the American College of Surgeons (ACS) where he worked for 11 years a senior federal lobbyist and also managed the ACS State Affairs program. When he was doing Advocacy Days for the ACS he was connected with Georgeann Mallory who is the executive director for ASMBS. Through his relationship with Georgeann he became interested in obesity policy and began working with the ASMBS. In 2007, Chris decided to open his own policy consultant firm called Potomac Currents and the ASMBS was his first client. During Chris’s policy advocacy for the ASMBS he became connected with the OAC President Joe Nadglowski and began working on obesity policy with this group as well. He has also worked closely with Ted Kyle who is on the board of directors for the OAC in helping promote education and advocacy for obesity policy. Chris’s firm, Potomac Currents also represents the ASBP now. Chris’s expertise in obesity healthcare policy has made Potomac Currents one of the leading policy consultant firms for obesity policy. It was a definite honor to interview Chris because he is a main player in advocating for obesity policy and healthcare reform in this area. The information he provided regarding the politics of obesity was fascinating and reinforced the complexity of getting a bill passed.

Chris demonstrates essential characteristics that make him a successful policy consultant and advocate. He mentioned multiple times throughout the interview the importance of education. He stated that in order to have your policy issue heard you have to focus on educating legislators, government agencies, organizations and the public about why this topic is important. He believes in teaching his clients advocacy skills so that they can effectively propose their policy issues to key legislators also. Chris is proactive and constantly connecting with legislators on key health care committees and he encourages his clients to create strong relationships with their elected legislators as well. Chris uses strategies that help his client’s topic stay in the political stream and ready for open windows that will allow the policies to get heard and ultimately passed. Some of these strategies include brainstorming fresh ideas for a policy topic so that it stays relavent. Chris’s firm acts as an active voice in Capitol Hill and makes sure that the client’s policy issues are visible before policymakers. He also ensures that his client’s topic have adequate research and proper analysis supporting the policy so that it can withstand criticism from potential policy opponents. Policy monitoring is an important strategy to carefully observe for an policy window to open and quickly act before the window closes. Potomac Currents, appropriately named, emphasizes that healthcare policy is a constant changing stream and in order to successfully navigate the stream you need help from an expert guide.

References

C.R. Gallagher (personal communication April 2, 2014).

Potomac Currents LLC. Retrieved on April 4, 2014 from http://potomaccurrents.com/index.html

Week 10- Obesity- It’s Time for Change!

Change in health policy occurs when multiple factors are aligned just perfectly, allowing for the new policy to successfully be passed and implemented. These opportunities for change are often referred to as policy windows (Kingdon, 2013). Policy actors must be prepared and have their proposals ready for policy window openings because they don’t happen often and only remain open for short periods of time (Kingdon, 2013). Shifts in political streams have a significant impact on opening policy windows. Political streams in themselves are complex and composed of many variables including national mood, partisan distribution in Congress, and changes in administration (Kingdon, 2013). A change in administration offers a key opening in the policy window because initially a new administration is determining their priorities and ready to make changes. During this initial phase, legislators, interest groups, and the general public are able to advocate for the policy proposals that they were unable proposed with the prior administration (Kingdon, 2013). Shifts in distribution of partisan seats in Congress can significantly impacted the fate of a bill. A policy window can open even with any turnover of a policy actor, especially if the policy actor has a problem/issue that they are passionate about. Changes in national mood occur when a large portion of the country shares common beliefs/ opinions in regards to an issue and can directly impact the policy window (Kingdon, 2013).

As discussed in previous blogs, the Affordable Care Act (ACA) was successfully implemented in the Obama Administration because it acted within the open policy window. Policy advocates had already established a consensus on the basics of the ACA, so when Obama took office in 2009, the window opened briefly and this prepared policy was quickly proposed and ready to get passed and implemented (Kingdon, 2013). The ACA created a window for Medicare changes to be made and obesity policy advocates seized this opportunity and proposed the Treat and Reduce Obesity Act (TRO). Policy supporters of TRO took into account that although the window was open, Congress was still divided especially on health care policy. Therefore, they designed this policy so that it appealed to both sides and was effective in gaining bipartisan support in the both the House and the Senate when it was introduced into the 113th Congress  (OAC, 2013). The shift in national mood also created a favorable window for TRO to be introduced. A large number of the public is aging and are obese, which makes them concerned about how obesity will affect their health and medical costs. Components of the political stream have opened a favorable window for obesity policy change.

The concept of coupling is important when considering effective policy change in the open window of opportunity. Couplings occur when proposals are floating around continuously in the political stream waiting to find the right problem to attach to (Kingdon, 2013). A great example of coupling is the proposal of national health insurance, which has been floating around since the Carter administration waiting for the right problem to attach to. The recent Great Recession elevated the problem of health care cost and lack of access to health care. The national health insurance proposal now modified into the ACA was able to successfully couple to this problem and the new administration and shift in national mood opened the window for it to get passed (Kingdon, 2013). The TRO, which offers solutions to modify current Medicare law for improved management of obesity, effectively coupled with the problem of rising obesity rates in Medicare beneficiaries and obesity related Medicare spending (OAC, 2013). Coupling has become increasingly important as the country recovers from the recession and the need for effective evidence-based policies is critical (Liebman, 2013). Policymakers are pushing to reallocate funds from less-effective programs to programs that shown to be more-effective based on evidence. TRO is a policy that does offer research- based solutions that can be coupled to the high priority problem of Medicare spending (OAC, 2103).

While the window is currently open for obesity policies to be proposed and implemented, it will not stay open for long. Policy windows close for a variety of reasons and often unexpectedly. One reason a policy window may close is because policy actors may feel like the problem has sufficiently been addressed through decision or enactment (Kingdon, 2013). Policy actors may decide to close a window because they are unwilling to invest any additional political capital, other resources or time on the problem . An event that brought the problem to the forefront may fade from priority, which will also close the window. Lastly, the window will close when the policy actors change, which commonly occurs with a new administration or a shift in partisan seats in Congress (Kingdon, 2013). The political stream, like a real stream is constantly flowing and changing. It is vital to act when the stream is favorable and the window is open for obesity policy and that time is now.

 

References

Kingdon, J. (2010). Agendas, alternatives, and public Policies. (2^nd ed.). London: Longman Publishing Group.

Liebman, J. (2013) Building on recent advances in evidence-based policy making. The Hamilton Project. Retrieved on March 25, 2014 from https://myasucourses.asu.edu/bbcswebdav/pid-8843701-dt-content-rid-33354252_1/xid-33354252_1

Obesity Action Collation (2013). Obesity care continuum supports the Treat and Reduce Obesity Act of 201. Retrieved on January 30, 2014 from http://www.obesityaction.org/wp-content/uploads/0713-OCC-LOS-for-TRO.pdf

Week 9- Health Privacy Protection Policy and it’s Role in Obesity Management

 

 As health care continues to evolve with great advancements in science and technology, health policies that govern access to data and privacy protection have become necessary. Both federal and state governments have implemented many health policies to protect patient privacy and regulate access to health information. States have the main power and responsibility of health privacy regulations and every state has it’s own statutes governing the use and disclosure of health information (Pritts, 2007). Computer technology has increased and the use of electronic health records (EHRs) has been implemented and is now mandatory.  EHRs created new issues of privacy concern and a need for federal regulatory legislation (Schweitzer, 2012).  In response, Congress in 1996 established the Health Insurance Portability and Accountability Act (HIPAA), which created a minimal set of protections that each state must adhere to, but can expand on if that state choses to (Pritts, 2007).  Under the HIPAA privacy rule,  all health information, with the exception of psychotherapy notes, may be disclosed for payment, treatment, and health care operation without first obtaining the individual’s permission. There have been efforts for the federal government to impose one strict standard on health privacy policy for all states. However, this been extremely challenging to do since each state has different populations and health goals. Also Congress has not been able to agree on controversial issues, such as access to health information of minors (Pritts, 2007).

The advancement of genetic science has resulted in the need for policies to protect individual’s privacy and from being discriminated against.  The Genetic Information Non-Discrimination Act (GINA) was enacted in 2010 by Congress and replaced a patchwork of state laws with one uniform protection policy. GINA protects individuals against discrimination by employers or health insurance companies  based on genetic information including genetic tests or family health history (Bard, 2011).  Privacy rules under GINA do conflict with certain provisions made by the ACA to increase access to obesity management. One provision that was discussed in the last blog was the ACA’s promotion of  employer-based wellness programs in the private sector. Wellness programs are regulated by both federal and state laws and under HIPAA rules these programs must be available to all employees if the company choses to have one (Bard, 2011). Wellness programs have been successful in reducing obesity among employee participants  (Yang & Nichols, 2011).  However, family history remains a key component of risk assessment in most wellness programs, which directly collides with GINA privacy rules. GINA prohibits employers from requiring employees in a wellness program to discuss family history and prevents employers from discriminating based on genetic conditions that could affect wellness (Bard, 2011).

Currently there are no complaints that GINA has conflicted with the benefits of the ACA modifications to HIPAA for wellness programs. There is also speculation amongst genetic scholars about the reliability in genetic testing and family health history as a predictor of future health risks (Bard, 2011).  However, in the future when genetic information gets more accurate, there will likely be conflict between controlling health care costs and genetic privacy. For example, if a gene ever gets discovered for obesity, under current GINA rules that person would likely be exempt from having to meet certain health goals of an employer-based wellness program (Bard, 2011). There is also now direct-to-consumer (DTC) genetic testing, which a major public health and privacy concern since it widely unregulated in the United States and not necessary subject to health privacy regulations under HIPAA (Caulfield & McGurire, 2012). As DTC gets more accurate it could be used as tool by wellness programs to do health risk assessments. Undoubtedly, in the future genomics will play a role in health care that involves wellness programs and obesity management. The main issue is to what extent should individuals be held responsible for paying more for health care based on their chronic disease risk factors including obesity and genetics (Bard, 2011).

References

Bard, J. (2011). When public health and genetic privacy collide: positive and normative theories explaining how ACA’s expansion of corporate wellness programs conflicts with GINA’s privacy rules. Journal of Law, Medicine, & Ethics, 3, 469-482.

Caulfield, T. & McGuire, A. (2011). Direct-to-consumer genetic testing: perceptions, problems, and policy responses. Annual Review of Medicine, 63, 23-33. doi:10.1146/annurev-med-062110-123753.

Schweitzer, E. (2012). Reconciliation of the cloud computing model with US federal electronic health record regulations. Journal of the American Medical Informatics Association, 19, 161-165, doi:10.1136/amiajnl-2011-000162

Yang, T. & Nichols, L. (2011). Obesity and health system reform: private vs. public responsibility. Journal of Law, Medicine & Ethnics, 3, 380-386.

Week 8- Private Sector Innovation and Policy Advancement in Obesity Management

 

The obesity epidemic is affecting not only the health of millions of Americans but also costing the United States billions of dollars in additional health care spending. Private and public sectors both are impacted by the rising costs of medical expenditures attributed to obesity. The annual medical cost associated with obesity is averaged at 147 billion per year and private insurance companies pay for about half of the total cost (Yang & Nichols, 2011). Studies have shown that medical cost are more than $1500 per year for class two (BMI 35-39.9) obese female workers compared to non-obese female workers. Class III (BMI 40+) obese female workers missed almost one week more of work per year compared to females of normal weight.  Current research indicates that obese workers are less productive while at work, which has been referred to as ‘presenteeism’ (Yang & Nichols pp. 381, 2011). Presenteeism is defined as the average frequency the employee engages in five specific behaviors, which are lack of concentration, repeating a task, working slower, feeling fatigued, and not performing job duties while at work. It is estimated that the extra cost of presenteeism and absenteeism is 11.7 billion per year compared to normal weight workers.(Yang & Nichols, 2011).

Obesity in the private sector negatively impacts obese and non-obese employers and employees. The higher medical cost associated with obesity that is paid out by private insurances subsequently is transferred to employers and employees through higher premiums, copayments and deductibles for medical services (Yang & Nichols, 2011). The affect of presenteeism and absenteeism has resulted in a less productive U.S. workforce and gradually has declined our overall industrial competitiveness (Yang & Nichols, 2011). Obese co-workers may affect normal weight co-workers directly because they have the burden of carrying an extra workload to make up for those who are absent or non-productive. The success of private employers relies heavily on the efficiency of their staff, which may be negatively impacted by obesity (Yang & Nichols, 2011).

There is both a public and private interest in reducing obesity since it is associated with increased social and economic cost to employees, employers, and taxpayers in general.  The newly enacted Affordable Care Act (ACA) contains a number of provisions that encourage increased private sector involvement in obesity reduction. One provision is that it allows for employers to lower insurance premiums up to 30% for employees who meet certain health standards or for employee participation in certain health promotion and disease prevention programs (Yang & Nichols, 2011). There are now many employment-based anti-obesity efforts being implemented that take advantage of this provision from the ACA.  A successful method of employment based obesity reduction is the creation of wellness programs that feature health risk assessments, feedback to participants and health education (Yang & Nichols, 2011). It is also important to have a supportive corporate culture that makes healthy living a priority starting for the top management all the way down to frontline employees. Employee participation in these wellness programs should be encouraged and incentivized in order for the program to be successful (Yang & Nichols, 2011).

An excellent example of a successful private sector innovative wellness program is the program being implemented by Johnson & Johnson (Yang & Nichols, 2011). Their program consists of a combination of health risk assessment, coaching, and financial incentives. Johnson & Johnson does not single out obese employees, but rather encourages all employees to participate in the health management program. They have a 94% participation rate and employees are incentivized by a $500 discount off annual employee premiums. This is an ongoing program so the results are still being compiled but so far Johnson & Johnson has saved over $200 per enrolled worker every year since 1995 (Yang & Nichols, 2011). This wellness program illustrates the major role that private sectors have in combating obesity

Obesity policy reform is a large issue with many influencing variables. The government and private sectors need to work in collaboration with each to other to create and implement policies and programs targeted at obesity management. The federal government does recognize the importance of private sector involvement in obesity reduction and has made provisions to encourage them to be involved. The ACA has relaxed existing non-discrimination restrictions allowing for the private sector to create further obesity reduction incentive programs without being deemed as discriminatory (Yang & Nichols, 2011).  It is important to note that the while the private sector needs to take an aggressive role in reducing obesity, it needs to be done humanely and appropriately with no one group of people feeling singled out or discriminated against. This can be done effectively in the private sector and is already being successfully implemented in multiple companies. 

Yang, T. & Nichols, L. (2011). Obesity and health system reform: private vs. public responsibility. Journal of Law, Medicine & Ethnics, 3, 380-386.  

 

 

 

Week 7- Medicare, Medicaid and the Affordable Care Act as examples of public policy implementation.

Medicare, Medicaid and the Affordable Care Act are excellent examples of the highly complex implementation process of health policy in the United States. Multiple Presidents starting with Theodore Roosevelt have tried to implement some sort of health care reform with marginal success (Kingdon, 2011). In health policy, there are many policy actors and variables that influence the implementation process and often halt this process altogether. Health policy changes are often done in small incremental changes rather than major health care reform, which is why the enactment of Medicare, Medicaid and Affordable Care Act have been so monumental (Kingdon, 2011).

For several years, the goal of health policy reform has primarily focused on achieving health care coverage for all U.S. citizens. The first major health care reform to be implemented was Medicare and Medicaid in 1965 under the Johnson Administration (Kingdon, 2011). Medicare was established to provide health insurance for U.S. citizen aged 65 and older and those who qualify for disability. Medicaid was created as a federal and state entitlement program that provides medical coverage for low-income citizens (Longest, 2010). The most recent changes to health care policy have been the enactment of the Affordable Care Act, which has just recently been implemented under the Obama administration. The central goal of this complex health care reform is that all U.S. citizens will be mandated to have health insurance and that affordable options must be available (Kingdon, 2011).

Close examination of the Affordable Care Act and the many factors involved in its successful implementation, is helpful in understanding the implementation process in general.  The main focus of this blog has been access to obesity management, in particular, the Treat and Reduce Obesity Act of 2013.  This bill proposes changes to current Medicare law that would improve access to obesity treatments including weight loss counseling and prescription medications (H.R. 2415, 2013).  This bill is a minor policy change but its potential implementation process can still be compared to the implementation of the Affordable Care Act. A significant determinant of a bill being passed and successfuly implemented is based on the timing of the policy change.  One reason that the Affordable Care Act was successfully implemented in the Obama Administration was because it had good timing.  Health care cost and lack of access to health care have been significant problems since the Great Recession (Kingdon, 2011).  The problem has to be great enough both economically and socially for the change to occur. This concept can be applied to the Treat and Reduce Obesity Act. Obesity in the past 20 years has become a major health and financial problem. In Medicare beneficiaries the rate of obesity has doubled from 1987 to 2002 and health care spending on patients with obesity has more than doubled. The problem of obesity is rapidly getting worse and it is predicted that by 2030 almost half of Medicare beneficiaries will be obese (Cai, Lubitz, Flegal, & Pamuk, 2010). Therefore, public policy that focuses on obesity management is needed now, making the timing of H.R. 2415 critical.

Another important step in public policy implementation is establishing a consensus on the policy solutions before the window opens. That way when the window is briefly open for this policy to be addressed, a plan has already been agreed on and implementation can begin. In the Obama administration, policy advocates had already established a consensus on the basics of the Affordable Care Act when he took office in 2009 (Kingdon, 2011). In H.R. 2415 a consensus on policy changes has already been established among policy advocates including interest groups, large organizations, legislators and the public before the window opened. When the bill was introduced in the Congress 113^th it quickly gained bipartisan support and was introduce in both House and Senate. The window to implement Medicare policy changes is now open. The  Affordable Care Act has helped opened this window by mandating a large health care reform. Also issues of health care cost and access to health care are at the forefront. Therefore, this is the perfect opportunity to address the cost of obesity and limited access to obesity management for Medicare beneficiaries.  Although the implementation process of any public policy change is very involved, H.R. 2415 should have a smoother implementation process when compared to major health care reforms such as Medicaid, Medicare and the Affordable Care Act.

References:

Cai, L., Lubitz, J., Flegal, K., & Pamuk, E. (2010). The predicted effects of chronic obesity in middle age on medicare costs and mortality. Medical Care, 48, 510-517.doi: 10.1097//MLR.0b013e3181dbdb20

Kingdon, J.  (2011). Agendas, alternatives, and public policies. (2^nd ed.). London: Longman Publishing Group.

Longest, B. (2010). Health policymaking in the United States. (5^th ed.). Chicago: Health Administration Press

Treat and Reduce Obesity Act of 2013, H.R. 2415, 113^th Cong. (2013).

Week 6- Public Sector Influence on Obesity Health Care Policy in Vulnerable Populations.

 

The topic of access to obesity management has a significant impact on vulnerable populations such as the underinsured, uninsured, older adults and disabled. This blog has focused on the lack of access to obesity care among Medicare beneficiaries. Medicare was established in 1965 to meet the demands of the public sector to provide health care coverage for our aged and disabled citizens (Longest, 2010). Medicare currently covers citizens who are age 65 and older and those who qualify as disabled. There are a multiple disabilities that may make a person eligible for Medicare (Social Security, 2013).  The Social Security law defines disability as anyone that has a medically determinable physical or mental impairment, which results in the inability to engage in any substantial gainful activity (SGA).  This disability must be chronic and expected to last for a continuous period of a least 12 months or expected to result in death (Social Security, 2013). Disabled citizens qualifying for Medicare are unable to work and often are not able to care for themselves independently, which makes them especially vulnerable for health care disparities. The public sector’s role in advocating for health care policies for this population is critical, because they usually lack the mental or physical ability to advocate for themselves.

Since Medicare was enacted in 1965, it has been revisited and modified multiple times to meet the growing needs of our nation’s older and disabled citizens (Longest, 2010). One significant need in this population is access to quality obesity management and prevention programs. The rate of obesity among Medicare beneficiaries has doubled in the past 30 years and this population has a higher rate of morbidity and morality related to obesity (Cai, Lubitz, Flegal, & Pamuk, 2010).  Both the public and private sector have recognized that controlling obesity will be produce substantial public health and economic benefits. The Treat and Reduce Obesity Act (H.R. 2415, 2013) if passed, will be a good example of the positive affect that public’s influence can have on amending health policy to provide improved obesity related health care to this vulnerable population.

The Treat and Reduce Obesity Act (H.R. 2415, 2013) includes improved access to intensive obesity counseling and coverage for new weight-loss medications. However, it does not adequately address the needs of obesity management in the learning disabled population.  Adults with learning disabilities that are in residential or support homes have a high risk for obesity and are often overlooked by the public and private sector (Shoneye, 2012). This population is especially vulnerable to health care inequalities, and as health care providers we have a responsibility to advocate health policy change for this group. The process of problem analysis is useful in exploring policy issues and in the creation new or amended health policies (Kraft & Furlong, 2011).  The steps of this problem analysis include defining the problem; measuring and determining the magnitude of the problem; thinking about the problem’s causes; setting goals and finding solutions (Kraft & Furlong, 2011).

This process is can be applied to the issue of obesity in the learning disabled.  The problem is defined as obesity in adults with learning disabilities. This problem is measured by statistics that indicate learning-disabled adults have higher rates of obesity and experience greater risk of morbidity and mortality related to obesity than the general population (Shoneye, 2012). The extent of obesity in the learning disabled is a nation-wide problem. There are several potential causes of this problem which include restricted income, limited access to food choices, and decreased ability to understand health education Also the staff at residential homes often lack training in nutrition and physical education and have a limited budget (Shoneye, 2012). Goals of this new policy change would be to prevent and reduce obesity in learning disabled adults. Possible solutions include reducing sedentary behavior, increasing physical activity, establishing regular eating patterns, staff not using food as rewards, and getting this group of adults involved in the food preparation and meal planning.  There is a need for health policies that are focused on treating and reducing obesity in the learning disabled population and public sector involvement is vital.  

 

References

Cai, L., Lubitz, J., Flegal, K., & Pamuk, E. (2010). The predicted effects of chronic obesity in middle age on medicare costs and mortality. Medical Care, 48, 510-517.doi: 10.1097//MLR.0b013e3181dbdb20

Kraft, M.E., & Furlong, S.R. (2013). Public policy: politics, analysis and alternatives (4^th ed.). Thousand Oaks, CA: CQ Press

Longest, B. (2010). Health policymaking in the United States (5^th ed.) Chicago: Health Administration Press

Shoenye, C. (2012). Prevention and treatment of obesity in adults with learning disabilities. Learning Disability Practice, 15, 32-36.

Social Security (2013). Disability evaluation under social security. Retrieved on February, 17, 2014 from http://www.ssa.gov/disability/professionals/bluebook/general-info.htm

Treat and Reduce Obesity Act of 2013, H.R. 2415, 113^th Cong. (2013).

 

 

Week 5- Statutory and Regulatory Mechanism involved in Healthcare Policy-Making

The process of healthcare policy-making is highly complex and involves all three branches of the federal government, interest groups and the general public. This blog addresses the topic of access to obesity management and has been specifically focusing on the Treat and Reduce Obesity Act of 2013 (H.R. 2415). This blog will follow H.R. 2415 throughout the policymaking process as it hopefully progresses from bill to enacted law and then to new healthcare policy.

The Treat and Reduce Obesity Act of 2013 (H.R. 2415, 2013) is currently in review committees in both the House of Representatives and the Senate. Once both the House and the Senate pass this bill it will become statutory law and will be sent to the President to sign into public law. Even though the newly formed law will primarily be implemented in the executive branch, the legislative branch will continue to have an active role in the implementation process.  The Legislative Reorganization Act of 1946 mandates the role of the legislative branch in the policy implementation process through statutory mechanisms (Longest, 2010). One statutory mechanism includes ensuring that policy implementation reflects public interest and adheres to the original congressional intent of the policy. Another legislative responsibility is ensuring that the health policy improves the effectiveness, efficiency, and economy of Federal governments operations (Longest, 2010). Statutory mechanisms also include assessment of the federal agency assigned to the policy and elevated their ability to successfully implement this new policy (Longest, 2010).

The executive branch has the main responsibility of policy implementation and will assign the policy to a federal agency where it will be created into regulatory law (Georgia State University, 2014).  Since the Treat and Reduce Obesity Act will amend current Medicare law, it will be assigned to the Centers for Medicare and Medicaid Services (CMS) for implementation. The CMS is a federal agency within the Department of Health and Human Services (DHHS) that was created in 1977 specifically to administer Medicare and Medicaid programs (Longest, 2010). The CMS must establish a set of regulations for this new policy in order for the policy to get implemented. There are certain rules and protocols that must be followed by the CMS in the rulemaking processes, which are mandated in Federal Register Act of 1935 (Longest, 2010). Once the CMS has created the rules to carry out the newly enacted statutory law it must propose and announce these regulations in the Federal Register (FR). The FR is the official daily publication for proposed rules, final rules and notices of Federal agencies and organizations (Georgia State University, 2014). It can be accessed at www.gpoaccess.gov/fr/index.html.

Proposed rule is a draft that is open to all policy actors to react and give feedback before it becomes final.  Proposed rule can be modified, deleted or added to. When/if the Treat and Obesity Act gets passed the CMS will propose a set of regulations for this policy and publish it the FR. At this time, the legislative branch has the authority to determine that a proposed rule must be returned to an earlier point in the process for further action or be deleted completely (Longest, 2010). It is also possible for the public, interests groups and large professional organizations to review this new regulatory policy and ensure that it supports their original purpose. After the proposed rules are reviewed and approved it then becomes final rule and permanent policy. The policy will then receive a codification and be published in the Code of Federal Regulation (CFR), which can be read at www.gpoaccess.gov/cfr.

This is just a brief summary of the statutory and regulatory mechanisms that occur in the implementation process. The judiciary branch can also change policy through court decisions referred to as case law (Georgia State University, 2014). There are many stages that the Treat and Reduce Obesity Act will go through if it gets passed into law. This policy will likely get modified multiple times before actual implementation. It will be interesting to follow throughout this semester.

References:

Georgia State University (2014). Introduction to legal research. Retrieved on February 10^th, 2014 from http://libguides.law.gsu.edu/introductiontolegalresearch

Longest, B. (2010). Health policymaking in the United States (5^th ed.) Chicago: Health Administration Press

Treat and Reduce Obesity Act of 2013, H.R. 2415, 113^th Cong. (2013).