Policy Making Process and Policy Analysis FPMU120: Health Policy for healthy lifestyles Yuyan Shi, PHD Department of family medicine and public health University of California, San Diego Spring 2016

Lecture Outline Announcements This lecture: Download readings Public Health Research Day Individual presentation This lecture: Learning objectives Health policy making process Bardach 8-fold Path for health policy content analysis Acknowledgement: part of this presentation is derived from a presentation made originally by Dr. McMenamin in FPMU 120, Spring 2015 and 2016. These slides are used with Dr. McMenamin’s permission.

Announcements Public Health Research Day Individual short presentation April 6th 2-5pm Medical Education and Telemedicine (MET) 2-3 Panel Session in the Auditorium 3-5 Poster Session and Reception in MET 141-145 Individual short presentation A well-defined health policy that aims to address a well-defined health behavior problem Sign up before 4/5 or you get zero points. Starts from Tuesday 4/5

Lecture Learning Objectives Describe the steps to pass a law at federal and CA state level. Describe the basic function, structure, and powers of the legislative & executive branches of government To identify federal and state government organizations involved in public health policy making To differentiate between analysis of policy making process and analysis of policy content To identify the main steps in the policy making process To identify the main steps in the analysis of policy content (Bardach 8-fold Path)

Federal Government Policy Making Process https://www.youtube.com/watch?v=HJQoZtn9C3w

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*Legislative Branch Basic Function Structure of Congress Pass legislation Structure of Congress Senate (2 from each state, 100 total) House of Representatives (435 members allocated by population) Powers Granted by Constitution Levy taxes, collect revenue, pay debts, provide for the general welfare, regulate interstate and foreign commerce, establish federal courts, declare ware. Source: Teitelbaum and Wilensky, Essentials of Health Policy and Law

*Executive Branch Basic Function Structure Powers Provide leadership Implement legislation Structure The President 15 Member cabinet Administrative agencies Powers Manage the cabinet Appoint judges to supreme court Veto power on legislation passed by congress Issue regulations on implementation Source: Teitelbaum and Wilensky, Essentials of Health Policy and Law

Federal Government Policy Making Department of Health and Human Services AHRQ (Agency for Healthcare Research and Quality) CDC (Centers for Disease Control and Prevention) CMS (Centers for Medicare and Medicaid Services) FDA (Food and Drug Administration) NIH (National Institutes of Health) SAMHSA (Substance Abuse and Mental Health Services Administration) More Source: Teitelbaum and Wilensky, Essentials of Health Policy and Law

CA State Government Policy Making Process https://www.youtube.com/watch?v=fbk8ipnW7Ng http://senate.ca.gov/legislativeprocess

CA State Government Policy Making

State Government Policy Making “The Constitution gives states primary responsibility for protecting public’s health” Organizations involved in state health policy making Includes State Health Department Other organizations vary by state Local public health agencies Source: Teitelbaum and Wilensky, Essentials of Health Policy and Law

Idealized Process of Policy Making A troubling social condition comes to light and is documented. Public officials assess the problem and its causes and to respond as efficiently as possible through such means as new legislative enactments. Attention continues until the distressing concern is alleviated. Source: Rochefort and Cobb. Problem Definition, Agenda Access, and Policy Choice. Policy Studies Journal. 1993;21(1):56-71.

In Reality… Policy Making is Complicated Hundreds of actors Multiple levels of government Long time span Technical debates Most disputes include deeply held values, big money, and coercion at some level. Source: Sabatier. Theories of the Policy Process. (1999)

Health Policy is Like a Soap Opera Heroes Villains Victories Defeats

Current Health Policy Disputes Brain Break: Take a moment to think about a health policy disputes you are familiar with Take 2 minutes to share your interest with your neighbor Share with the class

*Public Policy Making Process Source: Texas Politics Policy Website: https://texaspolitics.utexas.edu/archive/html/bur/features/0303_01/policy.html

*Bardach Eightfold Path for Policy Content Analysis 1 Define the problem 2 Assemble evidence 3 Construct the alternatives 4 Select the criteria 5 Project the outcomes 6 Confront the trade-offs 7 Decide 8 Tell your story

Public Policy Making Process Source: Texas Politics Policy Website: https://texaspolitics.utexas.edu/archive/html/bur/features/0303_01/policy.html

*Policy Making: Step 1: Agenda Setting Agenda setting is the process by which problems and alternative solutions gain or lose public and elite attention. Group competition to set the agenda is fierce because no society or political system has the institutional capacity to address all possible problems that arise at any one time. Groups must therefore fight to earn their issues’ places.

*Policy Making: Step 2: Policy Formulation Policy Analysis to select best policy tool for given problem (Bardach 8-fold path) Economic Policy Tools Legal Policy Tools Regulatory Policy Tools Media Tools Healthcare Financing Tools

*Policy Making: Step 3: Policy Adoption Policy adoption can be influenced the same factors that affect the composition of policy agendas: the lobbying efforts of significant interest groups, crises, and public attention brought by the media. Governors and mayors can adopt policies on the state or local level. Congress plays a minimal role in policy adoption since it cannot initiate policies the way the president can. The president has the sole ability of initiating new national policies. Source: Boundless. “Policy Adoption.” Boundless Political Science. Boundless, 21 Jul. 2015.

*Policy Making: Step 4: Policy Implementation Includes all the activities that result from the official adoption of a policy. Implementation is what happens after a law is passed. We should never assume that a passage of the law is the end of policy making process. Sometimes laws are passed and nothing happens.

*Policy Making: Step 5: Policy Evaluation Is the Policy addressing the problem? How is the policy implementation proceeding? If the problem is not fixed: Revise the policy? Issue new regulations?

Bardach Eightfold Path for Policy Content Analysis 1 Define the problem 2 Assemble evidence 3 Construct the alternatives 4 Select the criteria 5 Project the outcomes 6 Confront the trade-offs 7 Decide 8 Tell your story

*Policy Analysis: Step 1: Define the Problem Problem definition decides… Who will be interested and affeted (Individuals vs. marijuana producers) Where policy debates should take place (Health care system vs. state regulation vs. federal regulation) What policy options should be used to solve the problem (do nothing vs. legalization)

*Policy Analysis: Step 2: Assembling Evidence Evidence should: Assess the nature and extent of the problem. Examine the policy environment - what is operationally and politically feasible? Help identify policy alternatives. Help assess proposed alternatives and project outcomes.

Policy Analysis: Step 2: Assembling Evidence Evidence comes from: Conducting literature searches. Conducting a targeted search of the web. Reading bill analysis and hearing testimony. Reviewing public opinion polls. Interviewing people by phone or in person.

*Policy Analysis: Step 3: Constructing Alternatives Identify potential policy options to solve the problem. Make a list of all alternatives you may want to consider. Always include in your first approach the alternative of “Take no action.” Research policies in other countries, states, counties Identify policies used to address similar problems In the FINAL stages limit the alternatives to 2 or 3.

Policy Analysis: Step 3: Constructing Alternatives An example for marijuana regulation Policy Type Definition Countries Example Full prohibition Marijuana use is criminal offense and subject to criminal control. Most countries in the world Depenalization Marijuana use is criminal offense, but the severity of punitive consequences is reduced by various alternatives. Canada, France, UK Decriminalization Marijuana use is regulated by non-criminal statues or interventions; criminal processing and punishment are replaced with civil or administrative sanctions. Belgium, Denmark, Italy, Russia, Australia, US Partial prohibition Criminal laws associated with marijuana use are selectively enforced, or marijuana use is allowed at select spaces or populations. Canada, US, Netherlands Commercialization Marijuana production, sale, and use are legal. Uruguay, US

Policy Analysis: Step 3: Constructing Alternatives What could be alternatives to control unprotected sex among teens?

Policy Analysis: Step 4: Select Criteria Goals/values Equity/Equality Efficiency Security/safety Liberty Practical Considerations Politically feasible Technically feasible Effectiveness Socially acceptable Cost

*Policy Analysis: Step 4: Select Criteria Relevance: does the intervention contribute to the health needs of the target population? Is it consistent with policies and priorities? Progress: how do actual results compare with projected or scheduled results? Efficiency: what are the results in relation to resource expenditure of the intervention? Effectiveness: to what degree does this particular intervention attain its objectives? Impact: what is the effect of the activity on overall health and related socio-economic development? Collins, T. "Health policy analysis: a simple tool for policy makers." Public Health 119.3 (2005): 192-196.

*Policy Analysis: Step 5: Project the Outcomes Think through what the potential outcomes are for each policy Review existing evidence Examine similar policies elsewhere Be REALISTIC! Explore both intended and potential unintended consequences.

Policy Analysis: Step 5: Project the Outcomes An example of marijuana legalization Recreational marijuana use remains illegal: costs for law enforcement efforts, fines for possession, no tax revenue, no impacts on marijuana use. Recreational marijuana use becomes legal: increase tax revenues by X million, increase marijuana use in adolescents and adults, people from nearby states likely to purchase from CA as well.

*Policy Analysis: Step 6: Confront the Trade-offs Determine which criterion is most important? Equity? Liberty? Safety? Create a matrix to see if one policy alternative is the clear winner Eliminate any policy alternative which is dominated by another alternative across criteria

Policy Analysis: Step 6: Confront the Trade-offs An example of recreational marijuana legalization. https://www.youtube.com/watch?v=z14GhhHmuMM https://www.youtube.com/watch?v=7PMK90di9gI

*Policy Analysis: Step 7: Make Decision What would you do if you were the decision maker? Which policy would you recommend, and justify your choice! Example: why legalize recreational marijuana? Tax revenue increases Big support from voters Politically feasible in California Respect individual liberty Opens many opportunities to regulate marijuana Example: why not legalize recreational marijuana?

*Policy Analysis: Step 8: Tell Story Effective communication of first 7 steps is key! Think about who your audience is Think about what medium you will use to convey your message Keep it brief and clear

Next lecture Policy Making Process Policy Strategies Policy Evaluation Mass media tools Pre-post and RCT Policy process and analysis Economic tools Quasi-experimental design Problem definition and agenda setting Legal tools Cost-effectiveness Regulatory tools Interest group Cost-benefit Healthcare financing