Sara Wilensky, JD, PhD

The policymaking process in the United States:

The Executive Branch

Session Overview

• Executive Branch– Administrative Agencies

• Role of State and Local governments

• Federalism

Learning Objectives

At the end of this session, participants will be able to:

1. Broadly understand the role of the Federal Executive Branch with respect to health care & CHCs

2. Appreciate the role of State and Local government related to health care & CHCs  

Federal Executive Branch

• Key Players– President– White House Staff– Administrative Agencies

•Departments •Agencies •Sub-agencies/divisions/centers

Federal Executive Branch

• Key Powers– Agenda setting– Private persuasion

•Fundraising

– Budget process– Interact with legislative process– Veto– Executive Orders/Presidential Directives

• Constituents?

Federal Executive Branch

• Administrative Agencies– Part of Executive Branch– Under President’s authority

• Key Power– To issue/promulgate regulations

•Administrative Procedures Act•Proper scope•Political constraints

• Constituents?

HHS Organizational Chart

                            

                                                                                                                                                                                                                                                                                                                                                                                                                                                                  

   

Bureau of Primary Health Care

• Administers Health Center program• Policies announced through Policy Information Notices (PINs) and Program Assistance Letters (PALs)

• Technical Assistance• Information about program requirements, applying for grants, and operating health centers

• UDS data• FTCA deeming

State Government

• Generally same structure as federal– Executive, legislative, judicial branches– State constitutions vary– Authority and structure of each branch varies by state• Data, cooperation challenges

• Traditional focal point of health care– 10th amendment

• Complex relationship with federal government– Varying levels of federal intervention over time

State Government

• Key Powers– Police powers– Poor Law descendents– Create state health departments and agencies– Tax and spend– Licensing and regulation (providers, insurance)

– Create sub-units• Delegate power• Home rule

Local Government

• Local Public Health Agencies (LPHA)– Created by referendum or legislation resolution

• Defined by state law– Part of state network, shared responsibility

• Common Structures– Usually formed and managed by local gov’t– May share oversight of local agency– May directly operate local agency

• Counties are primary sub-unit– 75% LPHAs on county level

Intergovernmental Relations

• How various levels of gov’t work together– None has absolute authority or autonomy

• Trickle down: Fed State Local• Types of revenue

– Direct expenditures– Intergovernmental revenues– Intergovernmental assistance– Mandates

Federalism

• Defined– Shared sovereignty among levels of government

• Key issues– Who pays for a public service?– Correspondence principle

• What level of government should deliver the service?

• Distribution of costs and benefits• Nature of the problem (local or national)• Best delivery level• Effect of political pressures• Pragmatism

Federalism in Health Policy

• Arguments for federal primacy– Health care requires national perspective– State autonomy leads to “race to the bottom”

– Federal government has necessary resources– Others?

• Arguments for state primacy– Laboratories for democracy– Some programs work better if decentralized– One size does not fit all– Others?

Questions?