Strategies for Increasing Consumer Participation in Policy

Outcomes of the policy-making process are directly impacted by who participates in the process (Kraft & Furlong, 2013). With policymakers’ primary focus on the preferences of large interest groups, it is critical that citizens of the general public determine ways to participate in the policy process to ensure their interest are taken into account (Kraft & Furlong, 2013). According to one article, “Public participation enhances citizen ownership of developed processes, increases the sense of citizenship, and results in better implementation of developed programs” (Korona, Mbow, Pidluska, & Aziz, 2014). The following text will discuss strategies that can be utilized to increase citizen participation in the policy-making process.

Prior to identifying strategies to increase participation, it is important to discuss potential reasons for the disconnect between the general public and the policy process. Kraft and Furlong (2013) suggests that many citizens do not have a clear view of how policy decisions affect their daily lives, and also believe they lack the ability to change policies (loc. 12967). In rural communities, the demographic isolation of rural citizens creates even greater barriers to policy participation. A 2009 Arizona survey reported that only 10% of Arizonans believed that elected government officials represent their interests further supporting the need to address this disconnect (The Center for the Future of Arizona, 2011).

A strategy led by The Center for Rural Pennsylvania (2008), was to develop a guide to assist organizations and leaders in utilizing best practices for enhanced citizen participation. This guide suggests citizen engagement should involve five specific elements including: (1) increasing citizens’ knowledge about a community issue, (2) encouraging citizens to apply that knowledge, (3) using that knowledge to improve the community, (4) creating opportunities for citizens to engage each other, and (5) ensuring that these opportunities are regular and on-going (The Center for Rural Pennsylvania, 2008). In Arizona, The Center for the Future of Arizona has partnered with the National Conference on Citizenship to develop strategies for empowering citizen involvement in the policy process. These two organization have found significant success with a strategy called the Five Communities Project, with 96 Arizona communities responding (The Center for the Future of Arizona, 2011). This project invited Arizona communities to develop grant proposals that describe how they can achieve health improvements in their community. With continued efforts to increase citizen participation in the policy process.

 References

Korona, M., Mbow, P., Pidluska, I., & Aziz, A. (2014). Making democracy work. Retrieved from http://www.wmd.org/assemblies/sixth-assembly/workshops/making-democracy-work/how-ensure-citizen-engagement-policy-makin

Kraft, M. E., & Furlong, S. R. (2013). Public Policy, Analysis, and Alternatives (4th ed.). Thousand Oaks, CA: CQ Press.

The Center for Rural Pennsylvania. (2008). Developing effective citizen engagement; A how-to guide for community leaders. Retrieved from http://www.rural.palegislature.us/effective_citizen_engagement.pdf

The Center for the Future of Arizona. (2011). Arizona civic health index. Retrieved from http://www.thearizonawewant.org/assets/pdf/arizona_chi_report_2011.pdf

 

Innovation & Rural Health Policy

Although implementing a change within an environment is extremely difficult, the bigger challenge lies in sustaining the change and encouraging further innovation. A Gallup survey released earlier this month reported more than 60% of Americans expressed little to no confidence in current United States (U.S.) congressional leaders (Gallup Politics, 2014). With these statistics and no room for failure, policymakers may be resistant to engage in change and the risk-taking necessary for innovation to occur. However, innovation can be created within an existing structure as seen in the policymaking process (Longest, 2010). To sustain innovative environments, legislators must determine ways to spark creativity and support and implement new ideas.

Described by Longest (2010), the modification phase of the policymaking process is stimulated by a continuous cycle of policy consequences and new policy development. This modification phase provides endless opportunities for innovation leading to improved outcomes. Organizations, interest groups, and even individuals can contribute to this process by advocating and collaborating with policymakers.

Several innovative leaders in rural health policy are members of the National Advisory Committee on Rural Health and Human Services (NACRHHS), comprised of both private and public sector members (National Advisory Committee on Rural Health and Human Services [NACRHHS], 2014). To support the innovative process, NACRHHS members come from varies healthcare backgrounds, with varies areas of expertise including, delivery, financing, research, development, and administration (NACRHHS, 2014). Together, committee members prioritise the most pertinent issues facing rural health, develop innovative solutions for addressing these issues, and then provide recommendations to the Secretary of Health and Human Services (NACRHHS, 2014).

Although innovative ideas require the willingness to change as well as risk-taking, the outcome potential for improving rural health is worth the risks. Policymakers who are reluctant to a change in processes and/or policies should consider this and embrace innovation as progression.

Reference

Gallup Politics. (2014). On economy, Americans less confident in federal leaders. Retrieved from http://www.gallup.com/poll/168560/economy-americans-less-confident-federal-leaders.aspx

Longest, B.B. Jr. (2010).  Health policymaking in the United States (5th ed.). Chicago, IL: Health Administration Press.

National Advisory Committee on Rural Health and Human Services. (2014). Advisory committees. Retrieved from http://www.hrsa.gov/advisorycommittees/rural/index.html

Federal Spending and Healthcare

With healthcare costs steadily on the rise, policymakers face the critical challenge of determining how to reduce spending while subsequently improving health care quality and reducing negative outcomes (Longest, 2010). Although the Congressional Budget Office (CBO) provides an analysis of federal spending as an informative tool to help guide policymakers spending decisions, the federal budget process is complex with multiple players (Longest, 2010). The following text will provide a summary of the federal budget process. Additionally, this blog will include a recent interview with Dr. Derksen, Center for Rural Health (CRH) Director, as he explains how the Affordable Care Organizations (ACOs) can reduce costs while providing efficient and effective care.

The Federal Budget Process

This complex process begins with the President’s submission of a budget request outlining what the federal spending policy should be for the upcoming fiscal year including; (1) how much should be spent on public purposes, (2) how much to collect in tax revenue, and (3) how much the difference should be between the two (Longest, 2010). Additionally, this request outlines how the President prioritizes spending on federal programs, including Medicaid and Medicare. Next, the President’s budget request is reviewed by Congress who subsequently develops a budget resolution (Longest, 2010). The budget resolution contains a set of numbers designating how much Congress should spend in each of the 19 spending categories (Longest, 2010). Finally, this budget resolution must pass through the House and Senate with a majority vote.

Accountable Care Organizations

 Accountable Care Organizations (ACOs) are based on a care delivery model aiming to link provider reimbursements to the quality of care and positive health outcomes of their patients (Centers for Medicare & Medicaid Services [CMS], 2013). Members and facilities active in ACOs aim to coordinate patient care not only to ensure high-quality, safe, and effective care, but also to avoid service duplications and reduce healthcare costs (CMS, 2013). In regards to ACO’s and rural residents, Derksen recommends that rural communities “execute as equal partners with ACO’s on expanding the marketplace, Medicaid expansion, meaningful use of technology, and the utilization of multi-payer networks“ (Center for Rural Health [CRH], 2014, “Rural Health News,” video 1). Derksen suggests that by partnering with ACO’s in these strategies, rural communities “could thrive and advocate for the health of all residents” (CRH, 2014, “Rural Health News,” Video 1). Although more time will be needed to determine the efficacy of ACO’s in reducing healthcare costs, it is a promising solution to unsustainable government spending pattern and should be seriously considered by policymakers.

Reference

 Centers for Medicare and Medicaid Services. (2013). Accountable care organizations. Retrieved from http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO/

 Center for Rural Health. (2014). Rural health news. Retrieved from http://crh.arizona.edu

 Longest, B.B. Jr. (2010).  Health policymaking in the United States (5th ed.).  Chicago, IL:  Health Administration Press.

Change Agents in Rural Health

Catalysts for change, or change agents, facilitate the change process and are a vital component for effective and progressive change implementation. Author Campbell (2008) suggests that “change within a health care organization means that individuals must transition from one identity to a new identity when involved in a process of change” (p. 23). So what identity characteristics make for an effective change agent? How can these characteristics be utilized to support change improvements to rural health?

One key characteristic of an effective change agent is leadership. Leaders that are agents of change in health care need to have the ability to provide others with a vision of change and to ensure the appropriate response to the demand for change (Porter-O’ Grady & Malloch, 2011). A prominent leader and change agent for rural health in the United States southwest region, including Arizona, is Daniel Derksen, MD. In 2008, Dr. Derksen drafted federal legislative provisions to improve the nation’s distribution of health workforce to rural areas (Center for Rural Health, [CRH], 2014). Additionally, he is an advocate and innovative researcher aiming to improve health care coverage, access, and quality of health care for rural residents (CRH, 2014).

Another characteristic of an effective change agent is the ability to manage and emerge relationships. Porter-O’Grady and Malloch (2011) state “the key to mastering desired change begins with a focus on holistic systems and relationships among components in those systems” (p. 88). Simply put, change agents should encourage collaboration, collective wisdom, and teamwork to facilitate the change process. Another innovative change agent for Arizona’s rural health is Agnes Attakai, Director of Health Disparities Outreach and Prevention Education for the CRH’s Environment and Policy Division. Most recently, Attakai acted as the senior research specialist and evaluator for a community-engaged project coordinating education and training programs for medically and underserved populations in Arizona (CRH, 2014).

Leadership qualities and the ability to manage relationships are only a small selection of characteristics possessed by effective change agents. However, as demonstrated by the rural health leaders discussed above, individuals should identify and utilize their attributes to drive change in health care in a positive and progressive direction. Collaborative efforts of change agents in addressing the robust policy issues facing health care, can only lead to overall improvements in the system.

References

Campbell, R. J. (2008).  Change management in health care. The Health Care Manger, 27(1), 23-39.

Center for Rural Health. (2014). Faculty and staff. Retrieved from http://crh.arizona.edu/faculty-staff

Porter-O’Grady, T., & Malloch, K. (2011). Quantum leadership: Advancing information, transforming health care (3rd ed.). Sudbury, MA: Jones & Bartlett.

Change Theory & Rural Health Policy

The process of change is a necessary step preceding progression and transformation of any organization. Although this process can vary, it usually begins with the recognition of inadequacies supporting the need for change, followed by innovative change ideas (Kingdon, 2011). In regards to change and the evolution of public policy, Kingdon (2011) states, “Wholly new ideas do not suddenly appear. Instead, people recombine familiar elements into a new structure or a new proposal” (p. 124). More challenging than developing an innovative change proposal, is gaining support for the implementation, overcoming barriers to transformation, and ensuring sustainable adoption of the change. The following text will review Kotter’s Change Management Model and the utilization of this model in regards to rural health policy.

The first phase in Kotter’s model involves creating the proper environment to support change (Campbell, 2008).  This phase includes instilling a sense of urgency in others, creating a support team to guide the change, and developing and expressing a clear vision of the change direction (Campbell, 2008). In regards to rural health policy, the shortage of primary care providers along with the barriers to accessing healthcare led organizations, such as Southwest Rural Policy Network (SWRPN), to focus their efforts on improving healthcare for rural residents in Arizona (Center for Rural Health, 2014).  In the early 90’s, the failing healthcare system for rural Americans prompted congressional legislators to take urgent action to address this issue. They launched the State Offices of Rural Health grant program funding organizations, such as SWRPN, to support the team’s change efforts (Center for Rural Health, 2014). This organization set a clear vision with a mission “to improve the health and wellness of Arizona’s rural populations” (Center for Rural Health, 2014, para. 1).

The next phase of the Kotter’s model is to enable action by the entire organization by effectively communicating how each group and/or individual will be affected by the change, assisting in overcoming obstacles, and by celebrating the small successes the change is making along the way (Campbell, 2008). The SWRPN has demonstrated these steps to successful change most recently by celebrating a small, but important, success of developing and distributing a clear, culturally sensitive health brochure to rural residents living in the Southwest region. The brochure explains the benefits of health care coverage through the Affordable Care Act (ACA) and gives explicit instruction on signing up for coverage (Center for Rural Health, 2014).  The brochure has received national praise due to its readability and usefulness for assisting providers in explaining ACA to patients and is now being distributed throughout the United States.

The final phase in Kotter’s model is implementing and sustaining the change (Campbell, 2008).  Kotter recommends that the change team continue instilling a sense of urgency in organization members, reminding them that change is a continuous process towards improvement (Campbell, 2008).  For continued improvement of healthcare for rural Arizona residents, as well as all rural Americans, SWRPN, along with legislators and several other organizations, must continue efforts focused on these vulnerable populations.

References

Campbell, R. J. (2008).  Change management in health care. The Health Care Manger, 27(1), 23-39.

Center for Rural Health.  Programs and initiatives. Retrieved from http://crh.arizona.edu/topics

Kingdon. (2010). Agendas, Alternatives, and Public Policies, Update Edition (2nd ed.). London: Longman Publishing Group.

 

 

 

Policy for Access to Healthcare Data

Included in the Affordable Care Act (ACA) is the key provision for healthcare providers to adopt and demonstrate meaningful use of electronic health records (EHR) in order to receive adequate Medicare and Medicaid reimbursements rates (McDonough, 2014). Additionally, enhanced efforts are being taken to increase patient involvement in their care through improved access to medical records. With increased utilization of technology in healthcare, it is critical for policymakers to develop and implement laws ensuring the privacy of personal health information.

 Historically, individual states have had primary control over the regulation of health information and have managed medical records for more than 150 years (Pritts, 2007). Currently, each state has a specific set of laws and regulations regarding how health information is utilized and disclosed, generally requiring informed and written consent for access (Pritts, 2007). Outweighing similarities between state laws regulating health information are law inconsistencies resulting in both a lack of interoperability for the exchange of health information as well as privacy vulnerability for some states. In 1996, the privacy issue facing some states sparked the need for federal intervention leading Congress to develop the Health Insurance Portability and Accountability Act (HIPPA) (Pritts, 2007). The initial purpose of HIPPA was to develop an electronically based system for medical records followed with subsequent development of national health information privacy laws (Pritts, 2007). With failure by Congress to develop these privacy laws in a timely manner, the task fell to the U.S. Department of Health and Human Services (HHS). To address the states privacy issue, HHS placed emphasis on establishing minimal federal privacy laws, aiming to provide supplemental protection to state privacy laws already in place instead of one federal standard (Pritts, 2007). Although these federal laws improved the protection of consumer health information, varies state health policies continue to create barriers to interoperability of electronic health information.

Cloud computing is one proposed solution to the current lack of EHR interoperability with the potential to “achieve acceptable privacy and security through business associate contracts with cloud providers that specify compliance requirements, performance metrics and liability sharing” (Schweitzer, 2013, p. 161). Cloud computing would allow for connectivity and access to EHR systems wherever Internet is available enhancing both interprofessional collaboration as well as patients’ access to their personal health information. To address the healthcare needs and barriers to healthcare access for rural citizens in China, a cloud-computing EHR system was developed and tested over a three year time period demonstrating that this system was not only effective for improving providers ability to care for and monitor rural patients, but also enhanced preventative care efforts (Lin et al., 2014). Continued collaboration and efforts are required by policymakers to determine methods for effective utilization of technology to improve healthcare while also protecting the privacy of health information.

References

Lin, C. W., Abdul, S. S., Clinciu, D. L., Scholl, J., Jin, X., Lu, H., . . . Li, Y. C. (2014). Empowering village doctors and enhancing rural healthcare using cloud computing in a rural areas of mainland China. Computing Methods Programs Biomed, 113(2), 585-592. doi: 10.1016/j.cmpb.2013.10.005 

Pritts, J. L. (2007). Federal efforts to promote uniformity on health information privacy laws. Health Law and Policy, 20.

Schweitzer, E. J. (2012). Reconciliation of the cloud computing model with US federal electronic health record regulations. Reconciliation of the cloud computing model with US federal electronic health record regulations, 19(2), 161-165. http://dx.doi.org/10.1136/amiajnl-2011-000162

Private Sector Policy Innovation & Alignment of Public & Private Sectors

Despite the growing role of the government in health policy and health services, the majority of United States (U.S.) health resources are controlled in the private sector (Longest, 2010). For example, public dollars are used to purchase services in the private sector for beneficiaries of the Medicare and Medicaid programs. With the private sector acting as a major player in health policy, it is important to identify how these organizations and local businesses successfully adopt, implement, and advance governmental policies. Additionally, importance must be placed on aligning public and private sector efforts to improve the nation’s health.

An essential component to successful achievement of policy goals involves utilization of managers within the implementing organizations to ensure support for the process (Longest, 2010).  Following a thorough understanding of policy objectives, managers of implementing organizations must think strategically of innovative ways to adapt the organization environment, making it adequate for policy implementation (Longest, 2010). This is accomplished through situational analysis. Adequate situational analysis identifies external strategic issues as well as internal strengths and weaknesses in order to determine the potential immediate and future effects of policies on the organization processes (Longest, 2010). The next activity of managers is to design. This process involves the establishment of relationships between organizational members and resources in order to properly design a functional organizational structure (Longest, 2010). Finally, the most important role of managers in guiding the policy implementation process is to act as transformational leaders. This requires decision-making about “organizational mission and structure, resources, priorities, quality and other performance standards, and acquisition of new technologies” (Longest, 2010, p. 139).

Although successful health policy advancements are dependent on efforts of both private and public sectors, competing demands on both providers and health care organizations can create barriers to this success.  According to the Agency for Healthcare Research and Quality (AHRQ), “To raise the quality of health care across the country, both the public and private sectors will need to maintain a strong commitment to aligning their efforts” (2014, para. 4). Currently, activities of the National Rural Health Association (HRHA) are bringing together rural residents, representatives of the state, local, and national governments as well as a wide range of private sector rural health organizations to address rural health issues and improve healthcare in these underserved areas (National Rural Health Association, [NRHA], 2014).

References

Agency for Healthcare Research and Quality. (2014). Principles for the national quality strategy. Retrieved from http://www.ahrq.gov/workingforquality/nqs/principles.htm#principle4

Longest, B.B. Jr. (2010).  Health policymaking in the United States (5th ed.). Chicago, IL:  Health Administration Press.

National Rural Health Association. (2014). NRHA programs overview. Retrieved from http://www.ruralhealthweb.org/go/left/networking

Factors of Successful Public Policy Implementation

Successful implementation of public policy programs such as Medicare, Medicaid, and the Affordable Care Act (ACA) are dependent on the development of the program’s details serving to ensure that policy goals and objectives will be attained (Kraft & Furlong, 2013). These details include organization of the program’s resources and processes, translation of program laws and regulation into comprehensive terminology, and finally, applying the program laws into action (Kraft & Furlong, 2013).

Until the recent passing of the ACA, implementation of public policy programs, in attempt for U.S. health care reform, have faced significant opposition resulting in multiple failed attempts. With millions of Americans uninsured and unable to access quality health care, why has comprehensive health reform taken this long? One frequently cited reason is the complexity of the U.S health system which consists of consumers, patients, providers, hospitals, specialty clinics, pharmaceuticals, several interest groups, and other entities (Kingdon, 2011). As discussed in previous posts, varies and competing interests as well as governmental separation of power, make it difficult to pass major reform. Another barrier to health reform results from the political culture in America. In comparison with citizens of other industrialized countries, “Americans trust government less, want limited government more, and prefer lower taxes” (Kingdon, 2011, p. 232). A final obstacle historically challenging health reform advocates was that 85 percent of the U.S. population already had some source of health coverage, although primarily through governmental programs (Kingdon, 2011).

So what are the primary goals and objectives of the ACA to achieve successful health reform? Currently, the ACA federal law outlines ten, separate titles to clarify the program’s scope. One key title that has the potential to significantly and positively impact U.S. rural communities is the title of “Prevention of Chronic Disease and Improving Public Health” (McDonough, 2013, p. 2). When compared with urban areas, rural communities in America have higher rates of preventable conditions such as obesity, diabetes, cancer, and injury, as well as higher rates of high-risk health behaviors such as smoking, inactivity, poor diet, and lack of seatbelt use (Crosby, Wendel, Vanderpool, & Casey, 2013). These rural health disparities have been attributed to both proximity to health care facilities as well as limited resources and inadequate education on disease and injury prevention (Crosby, Wendel, Vanderpool, & Casey, 2013). New ACA health reform structures strongly emphasize health promotion and disease prevention showing promise for decreased rates of chronic disease and injury rates in rural communities (McDonough, 2013).

References

Crosby, R. A.,  Wendel, M. L., Vanderpool, R. C.,  and Casey, B. R. ( 2013). Rural population and health: Determinants, disparities, and solutions. Retrieved from http://www.cdc.gov/pcd/issues/2013/13_0097.htm

Kingdon. (2010). Agendas, Alternatives, and Public Policies, Update Edition (2^nd ed.). London: Longman Publishing Group.

Kraft, M. E., & Furlong, S. R. (2013). Public Policy, Analysis, and Alternatives (4^th ed.). Thousand Oaks, CA: CQ Press.

McDonough, J. E. (2014).  Health system reform in the United States, International Journal of Health Policy Managing, 2, 1-4.

Poverty, Health, & The Role of the Public Sector in Policy

Perspectives regarding poverty and its cause in the United States have long been conflicting. Our nation places emphasis on self-sufficiency, hard-work, and optimization of opportunities to lead to success. However, the argument lies within opportunity equality, or inequality, according to some (Kraft & Furlong, 2013). Is poverty the result of circumstance or behavior? Some believe both to be contributing factors. Regardless of the differing views on poverty, it is hard to argue against income inequality among American citizens. According to Kraft and Furlong (2013), “the more unequal the distribution of income, the greater the potential poverty problem” (loc. 8351). In other words, as long as the wealthy continues making the majority of U.S. income, more and more individuals will become at risk of poverty. 

With limited resources, individuals living in poverty are at increased risk for adverse health events and are more likely to experience significant barriers to accessing quality healthcare (Berenson, Doty, Abrams, & Shih, 2012). The nation’s rural communities are at even greater risk for the negative health consequences of poverty. Currently, 69% of Americans in rural communities are living below the poverty level (Center for Rural Health [CRH], 2014). In rural Arizona, the poverty level is estimated to be greater than 29.8% in comparison to the 18.4% level in urban areas of the state (Rural Assistance Center [RAC], 2011). So what is being done to aid these vulnerable populations in decreasing health disparities?

With the government at its core, the public sector consists of all publicly controlled and funded agencies that deliver programs, goods, and services to the public (Kraft & Furlong, 2013). In regards to healthcare, the public sector assists in the delivery of health services to the poor, elderly, and disabled. Examples of this include both the Medicare and Medicaid programs, previously discussed in earlier posts, and most recently, the Affordable Care Act (ACA). The primary goal of the ACA is to restructure the U.S. healthcare system so that all citizens and legal residence have access to affordable health insurance (McDonough, 2014). Although millions of uninsured will now be covered, there is still a significant obstacle to accessing health care, especially in rural areas. At the start of the year, the National Governors Association met to discusses innovative approaches to improve health care delivery to rural communities (CRH, 2014). Some of these strategies included giving rural health professionals a tax credit, moving the primary care training pipeline to rural areas, implementing more efficient and timely health data collection and analysis, establishing medical homes in rural areas, and providing reimbursements for rural telemedicine services (CHR, 2014).

(Housing Assistance Council, 2012)

References

Berenson, J., Doty, M. M., Abrams, M. K., & Shih, A. (2012). Achieving better quality of care for low-income populations. The Commonwealth Fund Issue Brief, 1-19. 

Center for Rural Health. (2014). Rural health disparities. Retrieved from http://crh.arizona.edu/topics/disparities

Housing Assistance Council. (2012). Taking stock; Rural people, poverty, and housing in the 21^st century. Retrieved from http://www.ruralhome.org/storage/documents/ts2010/ts_full_report.pdf

Kraft, M. E., & Furlong, S. R. (2013). Public Policy, Analysis, and Alternatives (4^th ed.). Thousand Oaks, CA: CQ Press.

McDonough, J.E. (2014). Health system reform in the United States. International Journal of Health Policy and Management, 2(x), 1-4.

Rural Assistance Center.(2011). State guides. Retrieved from http://www.raconline.org/states/arizona

Policy Formation & Rulemaking Influences for Implementation

As mentioned in previous posts, the policy-making process is complex with multiple influences and a course that encompasses formulation, implementation, and revision (Longest, 2010).  Although the policy model has been reviewed briefly, the purpose of this post is to provide a more in-depth look into the process of healthcare policy- -making including both statutory and regulatory mechanisms.

Policy formation is the first phase in policy-making and is made up of two parts, including agenda setting and legislation development (Longest, 2010). Agenda setting must precede legislation development, describing the process in which problems emerge and move through critical stages prior to advancing. In order for an identified problem on the agenda to advance to legislative development, there must be aligning perspectives that the problem exists and is significant, on potential solutions to the problem, and in regards to the political circumstances related to the problem and solutions (Longest, 2010). With alignment of these three agenda streams, the legislative development process can begin by drafting a proposed bill and presenting it to the Legislature for approval. The lengthy process continues in either the House or Senate with the bill being introduced, reviewed, debated, and potentially amended prior to approval (Longest, 2010). These steps are repeated once more, as both the House and Senate must approve the bill before it can be sent and signed into law by the governor.

Following the policy formation process resulting in enacted laws, policy implementation occurs. However, before a policy can be implemented, there must be a guide for the law’s operations (Longest, 2010). This is accomplished utilizing the method of rulemaking. Federal agencies develop rules and regulations for enacted laws by following an outlined process to ensure that those affected by a policy have the opportunity to influence the regulatory effects of its final implementation. According to Longest (2010), “because rules established to implement health-related public laws often target members of interest groups, these groups routinely seek to influence rulemaking” (p.118). This is accomplished through lobbying, marketing, and other forms of influence.

Currently, multiple interest groups around the nation are lobbying for Medicaid expansion into rural regions in response to the foreseeable effects of the Affordable Care Act (ACA) (National Rural Health Association [NRHA], 2014). To financially assist rural hospitals with taking care of a significant percentage of uninsured patients, the federal government issues Disproportional Share, or DISH payments, to these organizations. Since the ACA is based on the idea that all individuals will now have insurance or be on Medicaid, DISH payments from the government are expected to be cut within the next two years. Loss of DISH payments will be problematic in those  states who opted out of Medicaid expansion to their states rural areas. Without expansion, multiple rural individuals will remain uninsured and hospitals will not be reimbursed for their care causing great concern over hospital closures in rural regions (NRHA, 2014). In a recent interview with Dr. Jonathan Oberlander, a professor teaching social medicine at the University of North Carolina, “It’s one thing to be opposed to Obamacares’ ideologically, but when that opposition means that the state is not extending Medicare and is threatening the finances of your local hospital, you’re going to see the Medicaid expansion in a very different light” (National Public Radio [NPR], 2014).

 

References

Longest, B.B. Jr. (2010).  Health policymaking in the United States (5th ed.).  Chicago, IL:  Health Administration Press.

National Public Radio. (2014). Rural regions lobby for state Medicaid expansion. Retrieved from http://www.npr.org/2014/01/20/264250008/rural-regions-lobby-for-state-medicaid-expansion

National Rural Health Association. (2014). Medicaid updates. Retrieved from http://www.ruralhealthweb.org/go/left/government-affairs/medicaid-news