Policy And Politics For Nurses And Other Health

Professionals: Advocacy and Action

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Library of Congress Cataloging-in-Publication Data

Policy and politics for nurses and other health professions : advocacy and action / edited by Donna M. Nickitas,
Donna J. Middaugh, Nancy Aries.
p. ; cm.
Includes bibliographical references and index.
ISBN-13: 978-0-7637-5659-8 (pbk.)
ISBN-10: 0-7637-5659-8 (pbk.)
1. Medical policy–United States. 2. Nursing–United States. I. Costello-Nickitas, Donna M. II. Middaugh, Donna J. III. Aries, Nancy.
[DNLM: 1. Health Policy–United States. 2. Health Care Costs–United States. 3. Lobbying–United States. 4. Policy Making–United
States. WA 540 AA1 P766 2011]
RA395.A3P587 2011
362.10973--dc22
2010006367

6048

Printed in the United States of America

14 13 12 11 10 10 9 8 7 6 5 4 3 2 1
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Dedication

In memory of my parents, John and Anna Costello: Thank you for encouraging me to follow my
dream and discover my passion of becoming a registered professional nurse. For my husband,
Michael: Thank you for all your patience, love, and guidance on my journey promoting advocacy
and action for my patients, students, and colleagues.
Donna M. Costello-Nickitas

I dedicate this book to my husband Robert and our son Robert Guy, who have awakened my soul
and are my inspiration in everything I do and every choice I make. They have taught me to love
unconditionally, enjoy life and live with purpose. Also, to the memory of my mother, Alpha Duff,
a teacher, who taught me to never stop learning. Ex Deo familia. Ex pertinacia victoria.
Donna J. Middaugh

To the memory of my father, Leon J. Aries, a surgeon, who taught me that caring for one’s patients
was the fundamental job of all health professionals.
Nancy Aries

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Contents

Foreword ix
Richard H. Carmona, RN, MD, MPH, FACS
Preface xi
Contributors xiii

Section I Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

1 ToOther
Engage or Not Engage: The Choice Confronting Nurses and
Health Professionals 3
Nancy Aries

2 Health Status and Access to Care

Paula Lucey
25

Section II The Health Labor Force: Understanding

the Distribution of Power and Influence . . . . . . . . . . . . . . . . . . .51

3 Physicians 53
Nancy Aries and Barbara Caress

4 Nurses 75
Donna M. Nickitas

v
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vi Contents

5 Allied and Other Health Professionals

Donna M. Nickitas
103

Section III Healthcare Providers: Understanding

How Power, Markets, and Government Impact the
Organization and Delivery of Care . . . . . . . . . . . . . . . . . . . . . .121

6 Hospitals: The Power of Institutional Interests

Nancy Aries and Barbara Caress
123

7 Long-Term Care 143

Emma Kontzamanis and Keville Frederickson

8 Mental and Behavioral Health: Clinical and Policy Impact on

Mental Health Trends 155
Kunsook Bernstein and Joseph Saladino

9 Public Health Policy: Promotion, Prevention, and Protection

Mary Mincer Hansen and Mary Jones
181

Section IV Healthcare Finance: Understanding the Role

of Markets in Government . . . . . . . . . . . . . . . . . . . . . . . . . . . .209

10 Healthcare Costs: Follow the Money!

Jonathan Engel
211

11 The History of Health Insurance in the United States

Leah Curtin and Franklin A. Shaffer
237
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Contents vii

Section V Drivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .261

12 Advancing the Use of Technology in the Organization and

Delivery of Health Care 263
Diane J. Skiba and Donna Dulong

13 Healthcare Quality
Donna J. Middaugh
287

14 Health Services Research 309

Donna M. Nickitas, Keville Frederickson, and Jonathan Small

15 Conclusions: A Policy Toolkit for Healthcare Providers and Activists

Roby Robertson and Donna J. Middaugh
327

Appendix A: Web Resources 353

Compiled by Lametria Wafford

Appendix B: Glossary of
Managed Care Terminology 357

Index 365

Photo Credits 377

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Foreword

I have been fortunate to have worked in the health field at every professional level through 5 decades.
Being a registered nurse has afforded me a unique vantage point and lens to view through the “ret-
rospectoscope” as well as peer into the future. Nurses by their nature and training view their pa-
tients, community and even the world with great refractive holistic clarity. Being a nurse first has
made me a better physician and surgeon general.
The core values of nursing are with me in all of my endeavors. In fact, I am most proud to al-
ways state, “once a nurse, always a nurse”! I have watched nursing evolve from a subservient role
where we could not write our nursing notes in the progress notes and our observations and con-
structive input were not always welcome. Today we have evolved as health leaders, consummate
patient advocates, and clinical and administrative experts, and public polls often demonstrate that
nurses are among the most trusted professionals.
Our nursing leadership is apparent at all levels of our healthcare systems to include advising on,
constructing, and implementing policy. Policy development and execution is complex and multi-
factorial while being essential to the orderly, efficient, and effective conduct of any organization.
Understanding the process and components of effective policy takes years of training and expe-
rience. Nurses are perfectly positioned to assume a growing role in policy by virtue of their train-
ing, experience, holistic approach, selfless service, and extraordinary public credibility.
We should require our nurses and all health professionals to be knowledgeable about the inter-
section of policy and politics and encourage them to take an active role in the policy arena.
Today more than ever we need well-informed nurses and health professionals to guide our non-
partisan discussions about health reform. As nurses, we serve a special interest group, but our spe-
cial interest group is often the forgotten constituent in the partisan political debate—the patient!
This textbook, Policy and Politics for Nurses and Other Health Professions, is a wonderful guide for
the novice or the professor and it will serve to improve policy health literacy for all.
Richard H. Carmona, RN*, MD, MPH, FACS
17th Surgeon General of the United States
Distinguished Professor, University of Arizona
Vice Chairman, Canyon Ranch
President, Canyon Ranch Institute
*Inactive

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Preface

Our vision and commitment in writing this book was based on the belief that healthcare policy is
centered on the notion that all healthcare professionals regardless of their discipline required a fun-
damental understanding of the healthcare system. No longer can healthcare professionals be pre-
pared solely for clinical practice. They must ready themselves to engage in the economic, political,
and policy debates in the field. This process of engagement requires knowledge about advocacy
and action. For meaningful influence to occur, health professionals must stand ready to inform, ed-
ucate, and advocate to leaders at their own institutions and to the insurance companies, government,
health suppliers such as the pharmaceutical industry and other players within the industry on health
policy, planning, and management.
The ideas presented in this book offer our combined thoughts about ways for nurses and allied
health professionals and other grassroots activists who have an interest in improving healthcare sys-
tems and services in local, state, national and global communities to become involved in health-
care advocacy and action. This book offers an interdisciplinary approach to understanding health
care, health finance, health professionals, and health policy.
We have sought contributions from a group of diverse experts who recognize the internal and ex-
ternal forces influencing healthcare in America. Our rationale for seeking a transdisciplinary ap-
proach was the understanding that no one individual or discipline has a comprehensive under-
standing of the challenges and complexities confronting the healthcare system and the potential
for healthcare reform. These challenges include, but are not limited to, increasing access to care
and improving quality by such actions as the reduction of medical errors and the promotion of health
and wellness, and last by improving efficiency and reducing costs.
As the nation explores ways to reform the healthcare system, health professionals recognize that
our healthcare system is broken and needs complete, comprehensive reform to assure that future gen-
erations may enjoy a delivery system that will ensure their health and well-being. With unreliable
quality, Americans on average receive only 55% of the recommended care they need for common
conditions. An estimated 44,000 to 98,000 people die every year from medical errors. With in-
consistent access, there remains 47 million who are uninsured; many uninsured are from working

xi
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xii Preface

families. Despite healthcare costs that exceed $7,000 for every citizen in this country, the uninsured
are 8 times more likely to skip medical care because they cannot afford it.
Every day, healthcare professionals exercise their clinical judgment and leadership skills to make
important and much-needed changes that increase access to and improve the quality and afford-
ability of health care. This textbook offers future healthcare practitioners and others who are com-
mitted to improving health disparities and healthcare equality, keen insight and understanding that
clinical practice is derived from regulation, laws, and policies that are initiated from public policy
and politics. This is just the starting point. As educators, and health professionals, we are commit-
ted to support nurses and other health professionals to gain leadership expertise as well as execu-
tive positions and ensure that they have a place and a voice at decision-making tables. For nurses, in
particular, the seat at the table has not always been that easy. They have had less influence on health-
care reform than physicians, institutional providers, government, insurance and pharmaceutical
executives and others. We believe that nurses must have increased influence and equity as compared
to other important decision makers or revenue generators on national issues relating to influenc-
ing health reform. This why we have placed nurses first in the title of the book. However, the les-
sons from this book are addressed to a broader audience of health professionals because together with
nurses they have insights that are not otherwise represented. Given their role as caregivers, they bring
a unique perspective to policy-making concerns. Our hope that in the not so distance future, nurses
and other health professionals will assume their rightful place at the table and speak with equal voice
and influence.

Donna M. Nickitas
Donna J. Middaugh
Nancy Aries
56598_FMxx_000i_0xvi:56598_Nickitas 3/1/10 12:16 PM Page xiii

Contributors

Nancy Aries, PhD Barbara Caress

Interim University Dean for Undergraduate Director of Strategic Planning & Policy
Education SEIU Local 32BJ Benefit Funds
City University of New York New York, NY
New York, NY
Ellen Chesler, PhD
Steven L. Baumann, PhD, APRN-BC, RN Distinguished Lecturer
Professor Director, Eleanor Roosevelt Initiative at
Hunter College Roosevelt House
The City University of New York Hunter College
New York, NY The City University of New York
New York, NY
Kunsook Bernstein, PhD, RN, PMHNP-BC,
CASAC Leah Curtin, ScD(h), MA, RN, FAAN
Associate Professor Executive Editor
Hunter College Professional Outreach
Hunter-Bellevue School of Nursing American Nurse Today
The City University of New York Director
New York, NY Nurse Manager Bootcamp
Former Editor in Chief, Journal of Nursing
Claudia Beverly, PhD, RN, FAAN Management
Professor Cincinnati, OH
Director, Hartford Center of Geriatric Nursing
Excellence
University of Arkansas for Medical Sciences
Little Rock, AR

xiii
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xiv Contributors

Jessie Daniels, PhD Mary Mincer Hansen, PhD, RN

Associate Professor Associate Professor
Hunter College MPH Program and Global Health
Community Health, Department of Urban Department
Health Des Moines University
The City University of New York Des Moines, IA
New York, NY
Mary J. Jones, BSEMS, MA
Donna DuLong, RN, BSN Deputy Director
Professional Research Assistant Iowa Department of Public Health
College of Nursing Division Director
University of Colorado Denver Acute Disease Prevention and Emergency
Denver, CO Response Lucas State Office Building
Des Moines, IA
Jonathan Engel, PhD
Professor of Public Affairs Emma Kontzamanis, RN, MA
School of Public Affairs Assistant Professor
Baruch College Department of Nursing
The City University of New York New York City College of Technology
New York, NY The City University of New York
New York, NY
Nancy L. Falk, PhD, MBA, BSN
Adjunct Faculty Eileen Levy, MS, NP
College of Health and Human Services Huntington Hospital
George Mason University Huntington, NY

Keville Frederickson, EdD, RN, FAAN Paula A. Lucey, MSN, RN, CNAA
Professor and Director Research and Lamplighter Consulting, LLC
Scholarship Greenfield, WI
Lehman College
The City University of New York Donna J. Middaugh, PhD, RN
Director, Doctor of Nursing Science Program Associate Dean
Graduate Center, The City University of New Coordinator, Nursing Administration Master’s
York Specialty
New York, NY College of Nursing
University of Arkansas for Medical Sciences
Little Rock, AR
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Contributors xv

Donna M. Nickitas, PhD, RN, CNAA, BC Joseph Saladino, MSN, RN, NPP
Professor and Graduate Specialty Coordinator Instructor
Dual Degree MS/MPA Hunter College
Hunter College Hunter-Bellevue School of Nursing
Hunter-Bellevue School of Nursing The City University of New York
The City University of New York New York, NY
Deputy Executive Director, Doctor of Nursing
Science Program Franklin A. Shaffer, EdD, ScD(h), RN,
Graduate Center, The City University of New FAAN
York Sr. Vice President and Chief Nursing Officer
New York, NY Cross Country Healthcare, Inc.
Editor Chief Learning Officer
Nursing Economic$, The Journal for Health Care Cross Country University
Leaders New York, NY
Pitman, NJ
Diane J. Skiba, PhD, FAAN, FACMI
Kathleen M. Nokes, PhD, RN, FAAN Professor and Project Director
Professor I-Collaboratory: Partnerships in Learning
Hunter College College of Nursing
Hunter-Bellevue School of Nursing University of Colorado Denver
The City University of New York Aurora, CO
New York, NY
Jonathan Small, BA
Roby Robertson, PhD College Assistant
Director and Professor Doctor of Nursing Science Program
Institute of Government Graduate Center, The City University of New
University of Arkansas at Little Rock York
Little Rock, AR New York, NY

Carol Roye, EdD, RN Alison P. Smith, BA, BS, RN

Professor Director
Hunter College C-Change
Hunter-Bellevue School of Nursing Washington, DC
The City University of New York
New York, NY Elizabeth Summy, MSc, CAE
Vice President, Personal Membership Groups
American Hospital Association
Chicago, IL
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xvi Contributors

Pamela Trevino, RN, BSN Lametria S. Wafford, RN, BSN, MNSc(C)

Staff Nurse IV Arkansas Children’s Hospital
Arkansas Children’s Hospital Little Rock, AR
Little Rock, AR
Helen Werner, PhD, RN
Ralph J. Vogel, RN, PhD Assistant Professor
University of Arkansas for Medical Sciences Hunter College
College of Nursing Hunter-Bellevue School of Nursing
Little Rock, AR The City University of New York
New York, NY
56598_CH01_0001_0024:56598_Nickitas 3/1/10 12:06 PM Page 1

Section
I
Introduction
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Chapter 1
To Engage or Not Nancy Aries

Engage: Choices
Confronting Nurses
and Other Health
Professionals
OVERVIEW
Healthcare professionals of the 21st century must understand how the government, together with
providers, consumers, and insurers, interacts in the health policy process. This chapter provides a
comprehensive overview of the essential elements that drive and shape health policy in America. By
understanding the politics of policy making and program implementation, health professionals will
be better prepared to advocate for a healthcare system that best meets the population’s needs.

OBJECTIVES

• To understand the formal definition of competing interests determine policy

health policy outcomes
• To understand the policy-making process, ° Recognizing the role that
which includes the following: implementation plays in the policy
° Describing the ways competing concepts process
of federalism create the structure within • To describe the opportunities and
which policy is determined constraints that health professionals and
° Explaining the role of the market and their patients face as a result of policy
the government in the framing of health decisions
policy • To recognize different ways that healthcare
° Identifying the competing interests that advocates can impact policy and
shape health policy and the ways these programmatic decisions

3
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4 Chapter 1: To Engage or Not Engage

KEY TERMS
❏ Advocacy ❏ Policy: Social policy, health policy
❏ Federalism ❏ Policy-making process
❏ Government programs: Taxation, provision ❏ The role of markets and government
or purchase of services, regulation ❏ Stakeholders and interest groups
❏ Implementation

Another Text on Health Policy costs and that they, as front-line workers, bear
the brunt of these cost-cutting measures when
and Politics: Why? their organizations are understaffed and the
Numerous text books are available that describe demand for productivity is increasing. If they are
the healthcare delivery system in the United going to act to improve this situation, they need
States or step back to explain how politics and to know exactly how the dots that define health
policy making influence the organization of care policy connect to the dots that define care and
delivery. Why are we putting another text on treatment. This book is intended to provide an
the market that purports to address many of the understanding of policy that is rooted in the per-
same questions? Our answer is both simple and spectives of nursing and other health profession-
complex. als but at the same time helps make students
Simply put, we believe that many of these conversant with the politics and economics that
books fail to address the reality of health care as generate the rules of the game under which they
experienced by nurses and other health profes- work with such skill and dedication.
sionals. Many of the students and practitioners In this book, we want to put the opportuni-
with whom we work are totally absorbed in the ties and constraints that confront our professions
day-to-day demands of their jobs. They work in a larger perspective. By developing a more
hard just to keep up with the needs of patients nuanced understanding of the ways policy shapes
and their families, health colleagues, physicians, the organization of the healthcare system, we
and administrators. Many describe themselves as hope to provide those working in healthcare
running up a down escalator that speeds up every delivery with the tools that they need to influ-
time they think that they might make some for- ence these decisions. One book cannot change
ward progress. One consequence of this con- how we conduct our professional lives, but it can
suming daily struggle is that there is no time or change how we understand our options. This
intellectual space to step back and reflect on the book demonstrates that we have options other
larger institutional, social, political, and eco- than hoping to get by or finding positions where
nomic forces that shape their professions and we do not experience the pain of those whose care
their industry. is compromised. To take no action is to allow
The more complex answer is that students decisions to be made by others. Engagement in
often recognize that the hospitals, community- the policy world can be an effective way to over-
based agencies, and other health facilities that come a sense of helplessness about the current
employ them are under severe pressure to cut state of the healthcare system. By more fully
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Another Text on Health Policy and Politics: Why? 5

understanding the healthcare system and the healthcare systems—yet it ranked twenty-sixth
levers for change, it becomes possible to influ- internationally for mortality of children under
ence more actively the direction that the system 5 years of age (State of the World’s Mothers,
takes. 2007).
This plea for engagement is shaped by our Although it is critical that we describe the
own experiences of the healthcare system. There ways that health policy has shaped the healthcare
has not been a time in recent history when the system, it is equally important to understand that
problems of healthcare costs, access, and quality policy making is an interactive process. In some
were not serious concerns. In the early 1970s, we instances, government dictates the response
achieved greater access to care after the imple- of providers. In other cases, providers dictate
mentation of Medicare and Medicaid, but the response of government. Then there is the
healthcare costs began to escalate. Access was business sector, insurance companies, public
expanded, but no one was sure how it could be health organizations, professional associations,
sustained. In the mid 1980s, healthcare expen- and advocacy groups. Each one is trying to be
ditures topped 10% of gross domestic product heard and push the system to become more
(GDP), and the concept of managed care gained responsive in its needs and the needs of its con-
salience as a way to control costs while main- stituents. In this book, we want you to recognize
taining quality. Cost control, but not necessarily that as health professionals you can play a simi-
quality improvement, was achieved, whereas lar role in this process. You are in a position to
access declined as the number of uninsured advocate for your professions and for the patients
increased. In the early 1990s, President Clinton’s that you serve. Your voice can and should be
healthcare reform proposal reached Congress. heard. The combination of describing the health
Through a complicated system labeled managed system and explaining how complex policy
competition, the plan was purported to increase processes shape it and the ways you can become
access, control costs, and improve quality. The instrumental in that process distinguishes this
bill was defeated. Healthcare costs stayed flat book.
through most of the 1990s, as managed care In order to provide the context for under-
became the predominant insurance model; how- standing the policy and the policy-making
ever, access became more restricted, and there process, this chapter addresses the following
were growing concerns regarding quality of care. issues. In the first section, we define policy and
We cannot continue on our present course. consider how it shapes our experience of the
Healthcare expenditures reached $2.3 trillion in healthcare system. When we are successful in our
2008, or 16% of GDP. That amounted to jobs, it is often because of policies. When we fail,
$7,681 per person. The health share of the GDP it is often the case that policies have created an
is projected to reach 19.5% by 2017 (National environment in which it is difficult to operate.
Health Expenditure Data Fact Sheet, 2008). The Policy, as will be explained, can have many
number of uninsured Americans was nearly 47 meanings. In this book, the term policy is used
million, or 16% of the population in 2005, the to refer to government programs. The second
latest government data available (DeNavas-Walt section highlights the different ways that gov-
et al., 2007). This is an increase of almost nine ernment policy and programs intervene in the
million people since 2000. The United States organization and delivery of health services in
probably has one of the most sophisticated order to assure greater social equity in the
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6 Chapter 1: To Engage or Not Engage

distribution of goods and services. This involves work for better understanding how to become
understanding the competing concepts of feder- more effective players within the field.
alism and the ways that it impacts the develop-
ment of government programs. After this Health Policy Defined
framework is established, we can consider the
actual programmatic tools available to govern- Policy in the broadest sense is the manifestation
ment to achieve its goals. The choice of tools is of ideology or belief systems about how the
determined by the balance established between world should work (Rushefsky, 2008). For exam-
the market and the government in overseeing the ple, as a nation, we have watched our beliefs
organization of healthcare delivery.1 Although about foreign relations shift from being highly
we have a mixed system, each presents a differ- isolationist to becoming the protector of demo-
ent set of opportunities and constraints for pol- cratic values. We have strong beliefs about the
icy makers. Next, we examine the actual process value of rugged individualism, which is manifest
by which government policy is made. This in rags-to-riches stories. One way our beliefs are
involves understanding which groups have a manifest is in government actions. This means
stake in the development of government pro- we should be able to analyze government actions
grams, how their interests get expressed in the in terms of the ways that they are reflective of
political process, and whose interests are ulti- dominant social values or ideology. The ideolog-
mately reflected in the government programs. ical justification for the Iraq War put forward by
This chapter does not explain the legislative President Bush was our nation’s responsibility to
process. That is better left to a civics text. promote democracy. Similarly, the passage of
Rather, it explains how interest groups influence welfare reform in the 1990s can be rooted in a
that process in order to achieve what they per- social value of financial independence.
ceive to be a more favorable outcome. Policy Public policy, the term used to describe gov-
making, however, does not stop with the passage ernment actions, is typically divided into three
of legislation. Implementation is equally impor- areas: foreign policy, economic policy, and social
tant, although sometimes overlooked. Imple- policy (Lowi & Ginsberg, 1998). The objective
mentation is also an opportunity to influence of foreign policy is to defend national sover-
how policy is realized on a day-to-day basis. The eignty. Economic policy is designed to promote
final section of the chapter brings this discussion and regulate markets. Although foreign and eco-
back to the nurses and other health professionals nomic policy seeks to improve the overall well-
for whom this text is written. We reconsider why being of society by promoting the political and
a better understanding of policy not only economic well-being of American society, typi-
impacts our work and the experiences of those cally policies in these areas do not have equal
seeking health care but also provides a frame- impact on all sectors of society. Some groups may

1The terms “market” and “government” are short-hand expressions to describe the two alternative ways in which society conducts its
business. “Market” means reliance on generally voluntary exchanges between private parties. Sometimes these exchanges are mandated
and regulated by government, as is the case with mandatory liability insurance to own a motor vehicle. “Government” means reliance
on the direct provision of a service by government employees, as is the case with Veterans Affairs hospitals. It is not uncommon to use
a combination of markets and government, as is the case with Medicare and Medicaid, where government makes payments to private
providers to care for individuals who the government is seeking to service.
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The Framework for Public Policy Making 7

benefit, whereas others might find themselves not risk poverty in old age because of high
suffering undue consequences. The North Amer- healthcare costs. For those over 65 years of age,
ican Free Trade Agreement benefited the econ- health care was deemed a right. The opposite
omy overall, but many persons who held holds true for the working-age population and
manufacturing jobs found themselves unem- their dependents. No universal health insurance
ployed as production moved from the United program is available to Americans under 65
States to countries with lower production years of age. Either they can obtain health insur-
costs. Social policy often becomes the means by ance as a benefit of employment, or they can pur-
which the unintended consequences of policies chase health insurance out of pocket. Health
that seek to better the overall condition of insurance, however, is costly. The average pre-
American society are addressed. Government mium in 2007 was $2,613 for an individual
actions become the means by which we ensure health insurance policy. For those who cannot
the provision of the basic necessities: food, afford to purchase insurance, there is an array of
shelter, health care, and education (Midgley & safety net programs that provide marginal care
Livermore, 2008). Social policy is redistribu- and have been unable to address the needs of the
tive by its very nature. Its goal is to achieve rising number of uninsured (Center for Policy
greater social equity. and Research, 2007). How did this situation
Health policy can be located within the larger come to pass? To get the answer, we need to
realm of social policy. Because policy generally is understand how policy in this area evolved. We
rooted in social values and ideologies, our dis- begin by understanding the nature of our federal
cussion of health policy begins with the recog- system of policy making.
nition of the values and ideology that are
reflected in the organization of the healthcare The Framework for Public
system. The historic course of American health Policy Making
policy is best described in terms of our shifting
beliefs about how access to care is provided.
Sometimes we have stridently pursued health Federalism
care as a right for all. Sometimes we have treated In order to understand the process of policy for-
it as a privilege (Knowles, 1977). In fact, these mation in the United States, it is necessary to
competing values (i.e., a right versus a privilege) grasp the meaning of federalism in the American
are simultaneously and continually at work in context (Bovbjerg et al., 2003). American fed-
the outcomes of our health policy. Therefore, to eralism is a system of governance in which the
understand health policy requires that we delve exercise of sovereign power is split between the
further into explaining how values can shape a 50 states and the national government. Hence,
complex set of actions. the federal government is limited in its actions
The American approach to health insurance in several important ways. First, there is the dual
provides a good illustration of this duality. On nature of our system of state and federal gover-
one hand, we have a health insurance program nance. When the nation was founded, the states
that covers practically all Americans over the age ceded certain responsibilities to the federal gov-
of 65 years. One argument underscoring the cre- ernment but retained others for themselves. In
ation of Medicare was that the older population addition, within the federal government, there is
had worked for the benefit of society and should a separation of powers among the legislative,