SYMPOSIUM ON CRITICAL PERSPECTIVESAND ISSUES IN HEALTH POLICYEDITORS' PREFACE

Readers of the Policy Studies Journal should be familiar withthe divergencies in goals and methods employed by policy analysts inevery substantive area. This collection of papers, and indeed anywork in health policy, is no exception. The contributors to this col-lection do share an interest in viewing the role of government inhealth care in a dynamic way—the essence of health policy analysis.This common interest, however, does not mask the sharp differencesin approach which reflect the variety of disciplinary and theoreticalorientations the contributors bring to their subjects. The editorshave sought papers which will explore different facets of healthpolicy from different ideological perspectives—varying from those wholook to market solutions for problems in health care to those whoapply a radical analysis from the " lef t . "

The symposium reflects the editors' judgment on the importantissues and arenas in health for policy analysis. The introductorysection contains two papers which review various approaches tohealth policy analysis and explore problems of definition. The nextfour sections deal in turn with the question of change and the healthsystem, planning and regulation, financing, and issues of compara-tive health care.

Ralph Straetz, Marvin Lieberman, and Alice SardeilHealth Policy ProgramNew York University

INTRODUCTIONHEALTH POLICY ANALYSIS: SOME REFLECTIONS ON THE STATEOF THE ARTDavid Falcone, Duke Universitty

Academics frequently are chided for their seeming preoccupationwith definitions but, as has been remarked of admen and execution-ers, somebody has to do i t . Moreover, as will be pointed out in theensuing discussion, definitional boundaries often have significarttimpacts, which is part of the reason they tend to provoke heated de-bate. The discussion sets forth some major definitional issues in de-limiting the field of health policy analysis. The emphasis on issuesreflects the fact that definitions will not be attempted. The field ismultifaceted and, partly because it is interdisciplinary, dynamic andrelatively new, it has not undergone much of the self-examination itwill have to endure as it matures. This paper is part of the initialstirrings of that effort and purports merely to convey a glimpse ofthe landscape. (When it is over, the reader might suggest a lookthrough a kaleidoscope would have been a more apt metaphor.)

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The f irst section deals with health; health policy; and healthservices research, planning and administration. Following this, apresupposition of this issue of the Policy Studies Journal—i.e., thatthere is validity (uti l i ty) in recognizing health policy analysis as afield—is treated as a working hypothesis. In so doing, questionsare raised about the distinctiveness of health as a policy area.Finally, the state of the art of health policy analysis is brieflyreviewed.

HEALTH POLICY. Several types of policy directly affect or seek toaffect health. Those that come readily to mind are primarily legisla-tive but also judicial and public administrative decisions dealing with:the rates of production, geographic and specialty distribution ofhealth manpower; health care financing; assurance of the quality ofhealth personnel, institutions and services; occupational safety andenvironmental protection; and attempts to limit consumption of pre-sumably destructive substances such as alcohol, tobacco and synthe-tic carcinogens. In some instances, the indirect effects on healthof housing, income maintenance or other welfare policies may be evenmore consequential than the direct effects of policies that patentlydeal with health. Nevertheless, it is useful to limit the conception ofhealth policy to the conventional notion of public decisions that seekprimarily to affect health or principal actors—professional andinstitutional—in their roles in the health arena. Indeed, employingthis restriction allows one to make statements such as the one abovepositing that some other policies may ultimately have a more tellingimpact on health than more strictly health policies, or that there isa need for integrating different policy areas (health and welfare areperhaps those most frequently c i ted) . '

HEALTH AND HEALTH CARE. If health policy analysis is boundedby its subject matter, then the question arises as to what is meant byhealth and health care. That there is no dearth of literature on thistopic is understandable in light of the fact that the prevalent societalconception of health at any given time obviously has profound conse-quences for policy. For the Creeks, health was a state of harmonyand some commentators such as Henry Sigerist think that "this isstill the best general explanation we have."^ To some extent thisconception is beginning to be institutionalized in the form of theholistic health movement.

A less romantic view is that health simply is freedom from disease.In either conception, however, as David Banta3 has put i t , "healthcare could become a tyranny" if defined too broadly, particularly inthe case of mental illness and chronic disease (e .g . , in some waysaging at a certain point could be viewed as an illness). Currently,the most widely cited definition of health, that posited by the WorldHealth Organization, if implemented, might invite the tyranny whichconcerns Banta. According to this definition, health is a "state ofcomplete physical, mental and social well-being and not merely theabsence of disease or infirmity.""* When one takes into considerationthe perceptual (e .g . , what is "pain") and social (e .g . , what is "dis-ability") factors involved in the determination of what constituteshealth and disease, there almost is no limit to the scope of healthcare. '^

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A new issue has been raised by the quantification of healthstatus indices, 5 incorporating social as well as biological factors,which would seem to require some decision about composite cut-offpoints to designate a threshold of health. The activism of one'sorientation then would determine where one would make the cut.

Related to the activism-passivism continuum on which health,and thus health care, can be conceived is the differentiation betweenpersonal health and public health services. This distinction ismore marked in the United States than in other countries, but it isubiquitous. Briefly, the public health perspective envisions healthin terms of populations or groups whereas, in the extreme, personalhealth services are delivered in a mythically unique doctor (or pre-sumably some other health professional) -patient relationship. ^ Thisdistinction is shaded in particular instances (e .g . , family practition-ers supposedly view their patients in the context of their families andcommunities, and the public health service does deliver health careto individuals) but it exists in reality and motivates profound dif-ferences in attitudes towards policy. For example, the AmericanPublic Health Association has traditionally supported comprehensiveuniversal and publically administered national health insurance pro-grams in opposition to representatives of the personal health caresector, such as the American Medical Association and, to a lesserextent, the American Hospital Association.

Generally speaking, those with a public health orientation alsotend to take a relatively more active stance on sumptuary policiessuch as those relating to tobacco and alcohol. With some oversimpli-fication, one could say that when the inevitable clashes between indi-vidual liberty and perceived public good occur, the public healthpersuasion tends to emphasize the latter. Health policy analysissubsumes both these schools of thought.

Overlapping to some extent the public-personal health dichotomyis another continuum on which conceptions of health care can be ar-rayed according to the degree to which health is recognized as aright. Until recently, the dominant view was that health was a publicgood; i.e., that society at large received a collective benefit fromthe provision of a minimal level of aggregate health, that it was ineach individual's best interest for government to impose a measure ofhealth care. The most clearly justifiable policies under this rubricwere those dealing with sanitation and communicable disease, towhich later were added programs targeted at the disablecl childrenand mothers. With the demise of classic liberalism and the ascend-ance of a reform liberalism holding that rights could be derived aswell as natural, health increasingly was recognized as a right. Thespread of this view was made possible by advances in the efficacy ofmedical care. The seemingly abated escalation of such advances andincreasingly constrained resources have probably subdued the enthu-siasm of some proponents of the notion that health care is a right.

Health and health care obviously are portmanteau terms, asillustrated by the foregoing catalog of conceptions. They are allwithin the ambit of health policy analysis and often underly scholarlyand public debate: e .g. , whether the "health" care of the elderly isbecoming "overmedicalized."

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POLICY. The problem of deriving a useful definition of health policyanalysis is further complicated by the problem of defining policy.The problem is imposing, not because of the scarcity of meaningswith some currency, but the lack of commonly accepted conceptions.If they have an underlying dimension, it would be that of an orienta-tion that forms the basis for decision rules, whether the decisionsare what Amatai Etzioni has called "bit" or "contextuating."' In thisview, a given policy may virtually preordain that all legislative, bu-reaucratic, judicial and administrative actions would be regarded asof the "bit" variety; I.e., serially incremental, but part of a shiftingpolicy context. The evolution of the welfare state—at least up untilthe mid-70's—is an example of this pattern. The policy toward socie-tal (via government) responsibility for the equality of opportunityand maintenance of a minimally acceptable standard of living has beenloosely formulated so as not to collide with the shibboleths of classicliberalism. Therefore, the actions (or outputs) that have occurredunder its aegis, such as the Maternal and Child Health/CrippledChildren Services Program under the Social Security Act, the Kerr-Mills federal-state conditional granting program to provide care forthe elderly poor, the Comprehensive Health Planning Program, Re-gional Medical Program, Medicare and Medicaid have been targetedto specific beneficiaries or problem areas as resources havepermitted and groups have "demanded."

When we think of policy as an orientation, however, we usually'think of a "contextuating" government action; viz., one which ex-plicitly initiates a new government strategy for attacking a problemand sets the stage for further predictable actions. The SocialSecurity Act is a prime example, although even it can be viewed asa pragmatic, episodic response to a perceived crisis. The distinc-tion between contextuating and bit policy is drawn here not so muchto set forth a rudimentary typology as to indicate that what we reallyare distinguishing are explicit and implicit policies. There has beenlittle in the way of distinctively contextuating policy dealing withhealth, although some have so regarded the 1946 Hospital Surveyand Construction (Hill-Burton) Act since it marked the legitimacy ofat least a measure of government induced health planning, and Medi-care since it was a "health" as opposed to welfare ( i .e . , it is notmeans-tested) program.

For this reason, there is a reigning claim that we have no na-tional health policy. (Related to this is the claim that we have nohealth system but rather a collage of modes of health services de-livery.) In the perspective suggested in the foregoing discussion,this claim turns into one that holds that the financing and organiza-tion of health care are not yet government priorities, that the U.S.has not decided to launch an articulated, coordinated movementtoward the assumption of societal responsibility for health and theattempt to make health services universally available and accessible.

HEALTH SERVICES RESEARCH. PLANNING AND ADMINISTRATION.Health policy analysis may or may not fall under the general headingof health services research depending upon the expansiveness ofone's conception of the latter term. But health services research,perhaps more than any other pursuit, lays the groundwork for healthpolicy analysis. Health services research has been defined as:8

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concerned with problems in the organization, staffing,financing, utilization, and evaluation of health services.This Is in contrast to biomedical research which isoriented to the etiology, diagnosis and treatment ofdisease. Health services research subsumes both medi-cal and patient care research. It could well be termed"socio-medical" research.

The field is by now advanced enough to be recognized by anacronym, HSR, and an entire volume9 and other literature have beendevoted to its meaning. This paper clearly cannot do justice to thefield. However, some of the major sub-issues involved in its develop-ment can be cursorily identified:^° i .e. , whether HSR should be"applied" or "basic," discipline-rewarding or policy oriented, " in "health (with the health field as the principal focus) or "of" health(with disciplinary exploitation of topics in the health area as a p r i -mary motivating factor). These largely coincident distinctions canbe consequential for research funding (applied research, by andlarge, is more attractive to dollars). However, whether research isapplied is fundamentally an empirical question and thus must, apr ior i , pose an impressive challenge to a grantor to divine themotives of the researcher. Otherwise, one does not know whetherresearch was basic or applied until its consequences have beenevaluated.

One aspect of the basic-applied distinction that surfaces inpolicy studies is in the form of policy advocacy versus analysis. 1^Perhaps this is a more frank and useful dichotomy than that usedin HSR because it self-consciously recognizes motives as its basis:basic becomes "objective" (or, at least, intersubjective) in orienta-t ion; applied can be termed "adversarial" or explicitly value laden.

HSR and health policy analysis dovetail in their focus; pos-sibly the distinguishing trait of the latter is a more macroscopic andgovernment program centered purview. And here it should be reaf-firmed that if policy is to have any meaning, it must be reserved togovernmental (or, to invoke a term commonly used in the health fieldto denote private agencies with some government sanctioning power,"subgovernmental") decisions.

With regard to the distinguishing features of health policyanalysis, planning and administration, John Kralewski, as chairmanof a Task Force (of the Accrediting Commission for Graduate Educa-tion in Health Services Administration) on Specialized Accreditationfor Policy Analysis, Planning and Administration Programs, hasattempted to, as he wisely puts i t , place some signposts to delimitthe boundaries of each field. ^2 yvhat emerges from his efforts is avision of boundaries that are hazy but discernible, with health ad-ministration occupying the acreage characterized by managementskills and an institutional focus, planning sharing this tur f butemphasizing different skills and outlooks (less institutionallydefensive, for example), and policy analysis nomadically coveringthese areas but moving towards a separate area sparsely populatedby traditional academic disciplines and increasingly inhabited by anew breed of hybrid health administration (or public health)discipline educated researcher. Kralewski's work is in the initial

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stages; it is cited here as representative of an effort, grounded inpragmatic considerations, to delimit fields of education that reflectareas of inquiry and practice. His preliminary writing suggests thatthe most problematic field to isolate may be health policy analysis.

HEALTH POLICY ANALYSIS AS AN AREA STUDY. Having attempted toexamine some of the issues involved in a definition of health policy, thequestion arises as to whether it is valid to classify a field of inquiry byits substantive target—the institutions and principle actors involved—as opposed as to some other basis such as its effects on the distribu-tion or allocation of resources. The question obviously has a logicaldimension, but it also has pragmatic and pedagogical overtones.

One way of addressing this dilemma is to inquire as to distinc-tive features of the health system as an object of government actionand then decide whether these characteristics warrant constitutinga subheading of policy study—eschewing the issue of whether thevolume of literature and the sheer numbers of persons engaged inhealth policy analysis require recognizing the field as a pursuitthat it would be appropriate to delimit. Undertaking this endeavor,of course, amounts to treating the assumption of this volume as anhypothesis.

With regard to process variables, there obviously are institu-tional actors distinctive to the health field—the four health subcom-mittees of Congress, for example, or health agencies of the Depart-ment of Health and Human Services. There also are myriad groupswith an overriding interest in health policy—such as the AmericanMedical Association, the American Hospital Association, the Federationof American Hospitals (representing proprietary hospitals), the Ameri-can Health Care Association (representing proprietary nursing homes),the American Nursing Association, the National League for Nursing,and the Association of American Medical Colleges—which can be ex-pected to exert influence on all major issues. However, this is a rela-tively trivial distinction since the same could be said for any policyarea. In fact, focusing health policy analysis on characteristics ofsuch institutions because they are putatively health policy centeredmight obscure generalizations about administrative behavior. Inshort, health policy studies are open to the same criticisms as thoseleveled against area studies in comparative politics.

Area studies have been defended in this regard on the basisof the special knowledge that accrues from an intensive interdisci-plinary understanding of a country or region. The same groundscould be used to justify health policy analysis if a lietmotiv forhealth policy can be demonstrated. One may be found in that, untilrecently, health policy has been unique in defying the liberal demo-cratic tradition which has been the mainstream of development forother types of policy. The specific form this has taken has beenthe appropriation of the authority of the State to sanction medicalprofessional dominance and autonomy. It is true that the presenceOf disproportionate power relations characterizes political struqqles

/J °''^^'•1f^r^'"!*'^'^" *̂ « ^̂ S--̂ ^ *° «hich this is the?!f '^J'^'"' ^"^ ̂ ^ ^̂ '̂ ^ *^^* 't ^^^ been explicit marks

? "'"•'"• Granted this is a distinctive trait doesa pohcy-area approach? Not logically, since, in faci, it

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is a trans-area perspective which highlights . t . However takinga trans-area policy approach toward health without the intensifiedfocus might not let us see that what we have termed professionaldominance is a significant aberration that touches the roots ofAmerican democracy.

In a functionalist vein, we would expect professional dominanceto wane since it is anomalous and, indeed, it shows signs of doingso. It seems that the United States is attempting to inject into thesystem a dram of classical liberal democratic spirit (which has re-surged in other policy areas, displacing reform liberalism, in thepast few years) via regulations such as Certificate-of-Need andPeer and Utilization Review.

If one accepts that the primary reason for segregating healthpolicy analysis is the marked deviance of health policy with respectto the balance of power of interested parties and, relatedly, therelatively low salience of health issues for the general public, thenit would seem that this facet of the field would be the most exploitedby research. This may be true of medical sociology, but except fora few outstanding studies (such as Robert Alford's Health CarePolitics which won the Woodrow Wilson award in 1976), ̂ ^ politicalscientists and economists have ignored this phenomenon and devotedtheir attention to aspects of the political process in which a healthfocus could be viewed as almost incidental.

One way to categorize the body of health policy analysis thatpermits some contrasts to be drawn with other policy area studiesand points up needed research is according to whether the relation-ships stressed (if this is done with any measure of explicltness) areinput-process, process-output, output-outcome, or whether the sys-tems approach Is employed wherein input-process-output-outcomelinkages (or the f irst two of them) are assessed simultaneously.There are probably fewer of the latter in health policy than ineducation and welfare and those studies that have been "systemic"seem to be primarily disciplinary: i .e. , in the policy analysis "of"health mode.

There hardly is a voluminous literature in health policy analy-sis, but relative to other policy areas, with the possible exceptionof education, a disproportionate amount of it seems to focus on thedeterminants of outcomes. A substantial body of program evaluationresearch has been conducted. Unfortunately, the resulting storeof verifiable generalizations does not strike much optimism for thoseother policy areas with an, as yet, scarce amount of such research.For one thing, the debate noted earlier about what constituteshealth clouds the definitiveness of outcome evaluation. For another,outcome evaluation in health shares the problems of multicollinearitythat plague similar research in other areas. For example, althoughscreening programs are thought to have been efficacious in re-ducing cervical-uterine mortality, the disease already was decliningas a linear function of time. I"* Or, since so many diseases are self-limiting or of unknown etiology. It is difficult to attribute reductionin morbidity to programs with this intention. Nevertheless, thesestudies have uti l i ty, if only because they raise such questions,forcing implicit assumptions into the open.

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Perhaps as surprising as the comparatively large amount ofattention devoted to outcomes in health policy analysis is the rela-tive lack of process-output studies. The legislative process in healthpolicy has been the subject of some research—for example, TedMarmor's Politics of Medicare, 1^ Richard Redman's Dance of Legisla-tion^^ and David Price's "Policy Making in Congressional Com-mittees" 17—but major pieces of legislation, or the fact that therehas been a lack of them, have gone largely unexplored. And, re-turning to the issue discussed earlier about the distinctiveness ofhealth policy, in the three works cited it Is not the "health" aspectsof the policies that are highlighted for their roles in the legisla-tive process but expected redistributed impact (Marmor), degreeof salience and conflict (Price), and personalities and characteris-tics of the congressional process (Redman). Whether this istrue generally of health legislation is problematic but, so far, theburden of proof would seem to be on those who would argue thatvariables intrinsic to the health field are significant determinantsof the legislative process regarding health issues.

The bureaucratic/administrative process in health policy remainsa largely unchartered domain. Studies such as Judy Feder's Afed/-care, 18 which attempts to show that the implementation of this policywas affected in large part by the fact it was administered by in-surance rather than health-oriented officials, are rare. There evenIs a paucity of descriptive literature in this area, notwithstandingthe number of government publications of this nature.

The courts and health law have been more extensively studiedbut, again, there is very little that Is specific to the health fieldthat would distinguish this literature. Possible exceptions In lightof earlier discussion, are those works which deal with the incon-gruity of professional dominance.

Health Systems Agencies, (quasi-governmental in the sense thatthey have delegated review powers that are subject to administrativeappeal and that they are expected to work with local and regionalgovernment entities) seem to have been studied more extensively—if nowhere near adequately—than the legislature or the bureaucracyfor their role in health policy determination. This may signal thattheir actions are more significant in the policy process or, simply,that they (and their forerunners, the Comprehensive Health Plan-ning Agencies) are more accessible research sites. Research onHSAs has been largely concerned with the relations between state,local and federal agencies, and board representativeness and degreeof consumer participation. Therefore, the focus has been on processwith, at least implicitly, a presumed effect on outputs and outcomes.

Inputs and processes have been the subject of considerableresearch, characterized generally by a more or less explicit "group"approach. Congruent with what was said earlier about the distinc-tiveness of certain groups to policy fields ( i .e . , excluding the busi-ness labor, civic action, partisan-ideological and consumer qroupswhich can be expected to air views on any or all issues), the healthpolicy process has been dominated by their sentiments and interestsThe policy relevance of these studies depends on one's judgment 'about the importance for outputs and outcomes of the group

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struggle. There is little doubt in the case of the health field thatgroup interests have affected policies. But whether the effectshave been determining still seems a matter of speculation.

SUMMARY. This paper has attempted to air some major issues inhealth policy analysis through a discussion of definitional problemsand a consideration of the distinctiveness of the field. In sur-veying the scope of health policy analysis, health policy has beenlimited to its conventional usage—i.e., government decisions andactions that have the overt intention of affecting the healthsystem—while noting the significant impact on the system thatpolicies in other areas may have. For example, changes in lawsregarding the tax treatment of non-profit institutions would haveimportant consequences for hospitals, the majority of which fallin this category, but if hospitals were not the chief concern ofthese policies, one would not label them health policies. This re-striction allows for a comparison of the relative influence on healthcare of different policy areas.

In a brief examination of the meaning of policy, it was arguedthat this term usually is equated with explicit contextuating policywhen, in fact, the nature of a policy may not really be apparentuntil the flow of decisions that issue from it has occurred. Thus,it mayjuQt be entirely correct to say that the United States hasno health policy; rather, it may have a health policy consonantwith the vestiges of classical liberalism in our political culture.

Since health policy analysis Is not a methodological or func-tional but a subject matter-oriented field, some of the protean con-ceptions of health and health care were explored. It was pointedout that the shape and direction of health policy are inextricable fromthe prevailing societal view of what constitutes health.

The closest thing to a disciplinary basis for health policyanalysis is, in fact, an interdisciplinary amalgam called health serv-ices research. In identifying HSR, the paper reviewed a preliminaryeffort to differentiate health policy analysis, planning and adminis-tration as fields of education, inquiry and practice.

Finally, the literature in health policy analysis was assessed inlight of its relative attention to input-process, process-output, andoutput-outcome linkages. Hopefully somewhat short of breast beat-ing, the question was raised as to whether a subject matter focussuch as health is an appropriate subclassificatlon of policy analysis.It was contended that the resolution of this issue rests on whetherhealth policy is distinctive with respect to the processes involvedin its formulation, and that this has not been demonstrated by theresearch to date. In fact, a trans-area policy focus is needed tosettle this question.

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NOTES

1. See, for example, Gechen DeJong, "Interfacing NationalHealth Insurance and Income Maintenance: Why Health and WelfareReform Go Together," 1 Journal of Health Politics, Policy andLaw 405-432 (Winter, 1977).

2. Medicine and Human Welfare (McGrath, 1970), 46, cited inDavid Banta, "What Is Health Care?" in Steven Jonas (ed . ) . HealthCare Delivery in the United States (Springer), 14.

3. Banta, 21.

4. World Health Organization, "The Constitution of the WorldHealth Organization," 1 WHO Chronicle (1944).

5. See W. Balinksy and R. Berger, "A Review of Researchon General Health Status Indices," 13 Medical Care (1975).

6. The distinction is highlighted in an exchange in theJournal of Health Politics, Policy and Law 2 (Sprfng, 1977);Sagar Jain, "Whither Education in Public Health?" and Cecil Sheps,"Reply to Jain."

7. "Mixed Scanning: A 'Third' Approach to Decision-Making,"27 Public Administration Review 385-92 (December, 1967).

8. E. Evelyn Flook and Paul Sanazaro, "Health ServicesResearch: Origins and Milestones," in Flook and Sanazaro (eds . ) .Health Services Research and R&D in Perspective (Ann Arbor,Mich.: Health Administration Press, 1973), 1.

9. Ibid.

10. For amplification of these issues see Robert Eichorn andThomas Bice, "Academic Disciplines and Health Services Research,"in Health Services Research, 136-149.

11. See, for example, Thomas Dye, Understanding PublicPolicy, 3rd ed. (Prentice-Hall, 1978), chapter 1.

12. "The Health Administration Domain," paper delivered at thethe 1980 meeting of the Association of University Programs in HealthAdministration, Washington, D.C., May 10.

13. (University of Chicago Press, 1975).

14. U.S. National Center for Health Statistics, "Age AdjustedCancer Death Rates for Selected Sites, 1930-1975."

15. (Aldine, 1973).

16. (Simon and Schuster, 1973).

17. 72 American Political Science Review 548-74 (June. 1978).18. (D.C. Heath, 1977).

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