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

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

3. 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  

4. Federal Executive Branch
Key Players
President
White House Staff
Administrative Agencies
Departments
Agencies
Sub-agencies/divisions/centers

5. Federal Executive Branch
Key Powers
Agenda setting
Private persuasion
Fundraising
Budget process
Interact with legislative process
Veto
Executive Orders/Presidential Directives
Constituents?

6. 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?

7. HHS Organizational Chart
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
HHS Organizational Chart

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. Questions?