The policymaking process in the United States: The Executive Branch Sara Wilensky, JD, PhD

Session Overview Executive Branch Role of State and Local governments Administrative Agencies Role of State and Local governments Federalism

Learning Objectives At the end of this session, participants will be able to: Broadly understand the role of the Federal Executive Branch with respect to health care & CHCs 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                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    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 Key issues 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

Questions?