Cost, quality, access, patient safety, and racial disparity problems persist across U.S. health delivery systems. Although the causes of these problems are multiple, the U.S. stands out from its peers across the globe for having one of the most complicated health care delivery and health care finance systems in the world. It has a highly decentralized system of government with a health care finance system that includes a mix of public and private payers. What is most unique about the United States is that no single entity, authority, or government agency is ultimately responsible for health care. All of these facts lead to a complex patchwork of decision making, causing health care policy in the United States to be a highly complex and politically polarizing process. The current health care structure reflects policy decisions from the values of current society, together with residual policies from the colonial era. The U.S. Constitution does not specifically mention health care but the preamble indicates that the federal government should “promote the general welfare.” This lies at the heart of the current political debate between the Democrat and Republican Parties regarding the role of the federal government in health care.
Federalism is the system of government in which power is divided between a central authority (federal) and constituent political units (state governments).This division of power and authority, while purposely designed by the founding fathers, is the source of much tension, acrimony, and complexity in U.S. policymaking. The locus of tension between the states and federal government is very relevant to health care policy. Medicare, Medicaid, and CHIP are examples of federally driven policies that create a partnership with states to administer health care under federal guidance. Meanwhile, regulation of health professionals, private health insurance coverage and long-term care policies have long been the domain of the individual states. This complexity between the state and federal spheres illuminates the fragmented and seemingly chaotic approach to solving health care problems in the United States.
Many aspects of the Affordable Care Act (ACA) protect states’ rights to choose the degree to which they carry out some of its most important provisions, such as creating health exchanges to expand access to care. This built-in flexibility allows states to experiment with local solutions because, for example, what works in Minnesota may not work in Manhattan. The ACA escalated tensions between federal mandates and states’ rights as evidenced by the United States Supreme Court’s role in settling 64the dispute resulting from the multistate lawsuit challenging the constitutionality of the ACA’s mandate that every citizen purchase health insurance. Although the Supreme Court upheld the individual mandate as a federal law that states must accept, the court also ruled expansion of the Medicaid program constitutional, but protected the right of states by ruling that states cannot be penalized if they choose not to participate in the expansion (O’Connor & Jackson, 2012).
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The trend to allow states increased flexibility in recent decades adds complexity to health policymaking and amplifies the need for nurses to understand the policymaking process. Nurses must be knowledgeable regarding the appropriate authorities so that decision-making bodies are targeted appropriately. For example, there have been incidences of nurses who have approached federal legislators to persuade them to increase funding for school nursing, unaware that the issue was a state issue and funded at the state level.
The U.S. Constitution gives the federal government the power to block state laws when it chooses to do so. As noted earlier, state governments have authority to regulate health professionals as part of their charge to protect the public; although this is not in the Constitution, it has been the case since the formation of the United States (Safriet, 1992). This status quo is no longer appropriate as new forms of remote care delivery can render geographic boundaries irrelevant. Federalism is intended to create and sustain a highly decentralized locus of authority and is one of the most important dynamics in U.S. policymaking. This dynamic also, however, makes health care delivery systems complicated and difficult to reform.
Just as the federalist power structure creates tension between state and federal government policymaking, another outcome has been incremental policymaking. Historically, the most politically viable model, incrementalism, is used to describe policymaking which proceeds slowly by degrees. It represents a conservative approach to decision making and is viewed as a way to improve current policy. Within the U.S. Constitution, the three branches of government are designed deliberately to prevent one person or group from obtaining dictatorial powers. The disadvantage of this checks and balances structure is that it is very difficult for far-reaching policy reforms to succeed.
Once in a generation there is a major reform in U.S. health policy. The 1930s saw the implementation of Social Security, and 1965 saw the passage of Medicare and Medicaid. CHIP in the 1990s and the 2010 passage of the ACA are also examples. However, most health policy reform in the United States has been incremental. Fukuyama (2013) has described the U.S. system as a vetocracy which empowers political players who represent a minority viewpoint to block the actions of the majority resulting in paralysis. This vetocracy was illustrated in 2013, 3 years after the ACA was signed into law, when members of the House of Representatives shut down the government for 16 days (at an estimated cost of $24 billion) in an attempt to defund some of the provisions in the ACA.
Policies in the United States are far easier to stop and obstruct than pass and implement. Policymaking is largely a process of continuous fine-tuning of what already exists. A good example of incrementalism is the policy toward gays in the military. In the early 1990s it was highly controversial to implement the don’t ask, don’t tell mandate that allowed gays to serve. By the early 2000s, public opinion on homosexuality shifted dramatically and the military now accepts individuals with this sexual orientation.
Lindblom (1979) first described the concept of incrementalism in the early 1950s. When policymakers face a highly complex, theoretical, or resource-intensive decision and lack the time, capacity, or understanding to analyze all of the various policy options, they may limit themselves to a set of particular strategies instead of tackling the problem holistically. Policy solutions may be restricted to a set of familiar policy options that align with the status quo and lack a thorough evidence base (Lindblom, 1979). Therefore, incrementalism, although effective in limiting the power of any one person, group, or branch of government, also creates a process that is neither proactive, goal-oriented, nor ambitious; it ossifies timely policy, and limits innovation (Weiss & Woodhouse, 1992).