1. Perspectives on health and social policy M6920 December 4, 2001

2. Columbia University School of NursingM6920, Fall, 2001 Where are we going in US policy-making? l Combined impact of welfare reform and recession just arriving l Immigration policy/attitude influenced by perceptions of terrorism l Health issues falling into background

3. Columbia University School of NursingM6920, Fall, 2001 The potential in health l Slow incrementalism in spending Rx drugs Special group coverage Support for research l Resurgence of interest in public health

4. Columbia University School of NursingM6920, Fall, 2001 Goals of current policy making l Correct for overly generous history? l Improve financial status of those in control? l Enforce fundamentalist moral codes? l Balance competing interests fairly?

5. Columbia University School of NursingM6920, Fall, 2001 Questions during this course: l What policies have positive impact? l What policies have negative impact? l What policy conflicts affect our ability to improve health? l What do I want to do to have an impact on policies?

6. Columbia University School of NursingM6920, Fall, 2001 What is policy? l A decision on how to allocate resources to accomplish a purpose l Ideally, deliberately adopted after a review of alternatives, and it is intended to be followed.

7. Columbia University School of NursingM6920, Fall, 2001 What is health policy? l Decisions that support health l Decisions to respond when health is threatened l Decisions to treat or cure illness l Decisions on who will benefit Decisions on how to organize and pay for benefits

8. Columbia University School of NursingM6920, Fall, 2001 What is social policy? l Decisions about community education work housingrecreation l Decisions that affect how groups relate to one another l Decisions about economic welfare

9. Columbia University School of NursingM6920, Fall, 2001 Other countries l Achieve universal coverage l Use various combinations of taxation regulation organization l Spend less and achieve higher health status

10. Columbia University School of NursingM6920, Fall, 2001 Comparing Health Systems* l Basic Policy (scope & goal) l Organizational Structure l Economic Support l Staffing l Facilities l Supplies l Delivery Patterns l Preventive Services l Regulations * Adapted from Roemer, Comparative Health Systems

11. Columbia University School of NursingM6920, Fall, 2001 Perspectives on policy-- the actors l the general welfare or the body politic l the intended beneficiaries l the stated beneficiaries l the managers or organizers l the decision-makers

12. Columbia University School of NursingM6920, Fall, 2001 Perspectives on policy-- time and place l time immediate short term long term l place neighborhood city state region nation global

13. Columbia University School of NursingM6920, Fall, 2001 Perspectives on politics l Distribution of power in a system l Define participants l Set agenda l Limit solutions

14. Columbia University School of NursingM6920, Fall, 2001 Ways to influence policy l Choose policy-makers (VOTE!) l Provide information l Expect information l Practice setting l Professional association l Interest association l Party politics

15. Columbia University School of NursingM6920, Fall, 2001 Vulnerable population l a group that is for some reason at higher risk of problems l not all members of the identified population will experience the problem l others outside the population will experience the problem

16. Columbia University School of NursingM6920, Fall, 2001 Possible reasons for vulnerability l Social prejudice racism age-ism able-ism genderism l geography l economics

17. Columbia University School of NursingM6920, Fall, 2001 Health is a product of l genetics l social environment l physical environment l behaviors l diseases l medical care

18. Columbia University School of NursingM6920, Fall, 2001 Select populations tracked in HP2010 l Race/Ethnicity l Gender l SES l People with disabilities

19. Columbia University School of NursingM6920, Fall, 2001 If you are in a vulnerable population you are l More likely to be dependent on public programs for some necessities l More likely to lack insurance l More likely to experience barriers to care l More likely to be sicker and die younger

20. Columbia University School of NursingM6920, Fall, 2001 Impact of welfare reform l In 1995, 88% of poor children received food stamps; in 1998, 70% l From 1995-1997, average incomes of poorest 20% of female headed families fell 2 million families, 6 million people drop of $580 per family; below 3/4 of poverty line

21. Columbia University School of NursingM6920, Fall, 2001 Income disparity l Top 1% of population (2.7 million people) have as much to spend as the bottom 40% of the population (100 million people) l The top 1/5 of the population has 50.4% of income. l The top 1/5 has had a 15% income increase; the bottom 1/5 only 10%

22. Columbia University School of NursingM6920, Fall, 2001 Public coverage for children United Hospital Fund, March, 2000

23. Columbia University School of NursingM6920, Fall, 2001 Percentage of Medicare Recipients, by age

24. Columbia University School of NursingM6920, Fall, 2001 Barriers to universality in US l American enterprise l Incrementalism l Political history

25. Columbia University School of NursingM6920, Fall, 2001 Possible forces for change l Balancing cost, quality and access l The public’s role l Economics

26. Columbia University School of NursingM6920, Fall, 2001 Health Status Goals Determinants of Health Policy Healthy People 2010

27. Columbia University School of NursingM6920, Fall, 2001 What do you do? l In planning clinical practice? l In choosing a practice setting? l In carrying out professional roles? l As a member of the community?

28. Columbia University School of NursingM6920, Fall, 2001 Remember... l Significant problems we face cannot be solved with the same level of thinking we were at when we created them* * Attributed to Einstein