The Impact of Federalism on U.S. Health Policy Formulation, Implementation, and Evaluation Público
Ogden, Lydia L (2010)
Abstract
Abstract
The Impact of Federalism on U.S. Health Policy Formulation,
Implementation, and Evaluation
By Lydia L. Ogden
This dissertation comprises three interrelated articles examining the impact of federalism on health care and public health in the United States. The American federalist system of governance is characterized by ambiguity and dynamism, distinguished by a constant polarity between centralizing and decentralizing forces. In the realm of health policy, federalism fosters cyclical, iterative evolution, a diffuse policymaking environment, and tradeoffs between local, state, and federal governments.
"From Poorhouse to Warehouse: Institutional Long-Term Care in the United States" assesses how federalism has shaped American nursing home policy and politics. Over time, institutional long-term care for frail elders has shifted from local government funding and administration to state-level oversight and support to a shared federal-state concern. The unsystematic approach to U.S. long-term care policy, a result of federalism, produces haphazard results in terms of quality, equity, and efficiency. The graying of the American population will increase the demand for long-term care, resulting in pressure for a more coherent policy response.
"Public Health Funding Formulas: Policy, Political, and Practice Considerations in the U.S. Federalist System" examines a specific tool of federal grant-in-aid programs: funding formulas for grant allocations. As a tool of fiscal federalism, formulas for funding allocations are used widely in federal health and social welfare programs, but are generally limited in federal public health. Federalism structures financing and disbursement options; funding formula designs affect allocations and program outputs. Funding choices - e.g., financing, allocation structures, definitions of need, and targets - affect perceptions of program efficiency, effectiveness, and utility.
"Punctuation Marks: Can Punctuated Equilibrium Explain Federal Health Budgeting in the United States?" tests Jones' and Baumgartner's policymaking theory in the realm of federal health budgeting and assesses the array of health policy system inputs, including national and state-level party control, policy, and sociodemographic variables. This framework offers a model for understanding the correspondence - or lack thereof - between what the public wants regarding health care, how public servants understand and act on those wants, and the effects on health entitlement policy and spending.
The Impact of Federalism on U.S. Health Policy Formulation,
Implementation, and Evaluation
By
Lydia L. Ogden
B.S., Middle Tennessee State University, 1981
M.A., Vanderbilt University, 1984
M.P.P., Kennedy School of Government, Harvard University,
1998
Advisor: Walter M. Burnett, Ph.D.
A dissertation submitted to the Faculty of the
James T. Laney School of Graduate Studies of Emory University
in partial fulfillment of the requirements for the degree of
Doctor of Philosophy
in Health Services Research and Health Policy
2010
Table of Contents
Table of Contents
1. From Poorhouse to Warehouse: Institutional Long-Term Care in the United States...1
Exhibits
1. Nursing Home Expenditures by Payer (in Millions of Dollars),
1968-2008...30
2. Growth in the Over-65 Population, 1900-2050, with Support
Ratios...31
3. Federal Legislative Milestones in Nursing Home Care...32-33
2. Public Health Funding Formulas: Policy, Political, and Practice Considerations in the U.S. Federalist System...42
Exhibits
1. Selected Federal-Level Government Initiatives Addressing
Childhood Obesity...87-89
2. Health Provisions of the 1935 Social Security Act (Public Law
271)...90-91
3. Trends in Federal Grants to State and Local Governments for
Non-Defense Services, Outlays in Billions of Dollars, Selected
Years, 1965-2008...92
4. Centers for Disease Control and Prevention Formula-Based Grants,
Fiscal Year 2009...93-94
5. Example Adjustors and Effects on Proportionality of
Allocation...95
6. Federal Public Health Funding Formula Allocations: An
Examination of Current and Hypothetical Allocations and
Adjustors...96
7. State and Local Public Health Responsibilities...97
8. State Public Health Program Areas Funded Through Formula
Allocations...98
9. States' Use of Funding Formulas Is Associated with Both the
Proportion of Federal Funding and the Number of Local Health
Agencies...99
10. Public Health Spending as a Portion of National Health
Expenditures, Selected Years, 1960-2007(Levels in
Millions)...100
Appendix--Survey of State Chief Financial Officers: Methodology and
Instrument...102-108
3. Punctuation Marks: Can Punctuated Equilibrium Explain Federal Health Budgeting in the United States?...123
Exhibits
1. Public Spending on Medicare and Medicaid, 1965-2018...150
2. Histogram of Annual Inflation-Adjusted Health Entitlement
Spending, 1968-2008...151
3. Annual Percentage Changes in Inflation-Adjusted Health
Entitlement Spending, 1968-2008...152
Appendix--Policy Milestones in Medicare and
Medicaid...153-157
Appendix--Technical Information on Databases, Variables,
Regression
Results...158-182
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