Public Policy

Basic Premises

In the United States, the basic value at the foundation of public policy concerning healthcare is that [Page 979]healthcare is not a legal right of citizenship. Instead, healthcare is considered to be a privilege usually associated with a benefit of employment. Only for those 65 years of age or older and those with very low incomes has the nation created a legal entitlement to health insurance coverage, thus establishing a right to healthcare for these citizens.

The basic model is that healthcare is an individual, private responsibility for all those in the age range of 18 to 65 whose incomes do not fall below the poverty line and who are not disabled, veterans, American Indians, or Alaska Natives.

The U.S. healthcare system stands out in two other ways, which also reflect mainstream values. The first is that it devotes the largest share of its gross domestic product (GDP) to healthcare in contrast to other developed nations. In the middle of the 20th century, less than 5% of its GDP was devoted to healthcare. That percentage rose to nearly 14% by the end of the century. Yet the system does not necessarily produce superior health outcomes (e.g., low infant morality or greater life expectancy). The second unique feature of the U.S. healthcare system is that it is not based on some form of universal healthcare. The system relies, for the most part, on private healthcare providers with a mix of private and public insurance as well as extensive government regulatory intervention.

Policy-Making Process

Policy is the product of a process consisting of the following stages: (a) problem definition; (b) formulating options for consideration; (c) debate and deliberation over the available options; (d) adoption of a particular option; (e) implementation of the selected option, including appropriation of resources to support the option; and (f) assessment or evaluation. This process may vary depending on which political institution or level of government is involved.

Legal and Regulatory Foundations

Much of public policy since World War II in the healthcare area can be traced to changes in laws and regulations related to healthcare. These policies relate to access, financing, organization, and service delivery. Taken together, these laws and regulations represent public policy in American healthcare.