The Art of Structuring and Writing a Health Policy Analysis
Teitelbaum, J. B., & Wilensky, S. E. (2017). Essentials of health policy and law (3rd ed.). Burlington, MA: Jones & Bartlett Learning.
The Art of Structuring and Writing a Health Policy Analysis
Imagine you work for the governor of a state that recently received a large sum of federal money for anti-bioterrorism efforts and your boss asks you how it should be spent. How are you going to respond? Or, assume you are an assistant to the director of a state nutrition program for low-income children and the program’s budget was slashed by the legislature. The program’s director needs to reduce costs and turns to you for help. How will you approach this problem? Finally, pretend you work in the White House as a domestic policy advisor and the president is considering revising the administration’s methane emissions guidelines. What guidance will you offer? While the substance of health policy and law has been discussed in detail up to this point, this chapter teaches you what policy analysis is and the skill of addressing complex health policy questions through a written policy analysis.
POLICY ANALYSIS OVERVIEW
In this section we define policy analysis and review the purposes for developing one. In the following section, we provide a step-by-step process detailing how to create a written health policy analysis.
The client is the particular stakeholder that requests the policy analysis, and the analysis must be developed to suit the needs of the client. (The client could be a policymaker who hires you, a fictional policymaker in an exercise developed by your professor, an employer who asks you to analyze a problem, etc.) In general, a stakeholder refers to an individual or a group that has an interest in the issue at hand. There may be many stakeholders related to a particular policy issue. Of course, the client requesting an analysis is also a stakeholder because that person or entity has an interest in the issue. However, to avoid confusion, we refer to the person or group that requests the analysis as the client, and the other interested parties as stakeholders.
Providing informed advice means the analysis is based on thorough and well-rounded information. The information included in the analysis must convey all sides of an issue, not just the facts and theories supporting a particular perspective. If a decision maker is only presented with evidence supporting one course of action or one side of a debate, it will be impossible for the client to make a well-informed decision. In addition, to be effective in persuading others to favor the recommended policy, your client must be able to understand and, when necessary, refute alternative solutions to the problem.
Public Policy Decision
Policy analyses involve public policy decisions. A public policy problem goes beyond the individual sphere and affects the greater community.
Providing Options and a Recommendation
A key component of any policy analysis is providing the client with several options to consider, analyzing those options, and settling on one recommendation. In other words, a policy analysis is not simply a background report that identifies a variety of issues relating to a particular problem; instead, it gives the client ideas about what steps to take to address the problem and concludes by recommending a specific course of action.
Your Client’s Power and Values
Finally, the analysis should be framed by the client’s power and values. The first requirement is fairly straightforward and uncontroversial: the options presented and the recommendation made must be within the power of the client to accomplish. On the other hand, the notion of framing an analysis according to the client’s values is more controversial. In most conceptualizations of policy analysis, including the one discussed later in this chapter, the process is roughly the same: define the problem and provide information about it, analyze a set of alternatives to solve the problem, and implement the best solution based on the analysis.1(p3) As new information is uncovered or the problem is reformulated, analysts may move back and forth among these steps in an iterative process.2(p47) However, although there is general agreement that politics and values play a role in policy analysis, there is disagreement over at which stage of the analysis they come into play.
To understand this controversy, it is necessary to discuss two models of policy analysis: the rational model and the political model. The rational model was developed in an attempt to base policy decisions on reason and science rather than the vagaries of politics.2(p7) In the traditional rational model, the analyst does not consider politics and values. Instead, she should recommend the “rational, logical, and technically desirable policy.”2(p51) According to the rational model, the decision maker infuses the analysis with politics and values once the analyst’s work is complete.
Professor John Kingdon and others have moved away from the rational model and toward a political model. King-don suggests that policy analysis occurs through the development of three streams: problems, policies, and politics.3 The problem stream is where problems are defined and noticed by decision makers. The policy stream is where solutions are proposed. These proposals may be solutions to identified problems, but they are often favored projects of policymakers or advocates that exist separate from specific problems that have garnered attention. Finally, the political stream refers to the ever-changing political mood. As a general matter, these streams develop separately, only coming together at critical junctures when the problem reaches the top of the agenda, the solutions to that problem are viable, and the political atmosphere makes the time right for change.4(p87)
Kingdon’s approach discusses occurrences the rational model does not, such as why some problems are addressed and others are not, why some solutions are favored even if they are not technically the best approach, and why action is taken at some junctures but not at others.3 In addition, the rational model only refers to one cycle of problems. As King-don and others have noted, solutions to one problem often lead to unintended consequences that create other problems to be addressed, resulting in an ongoing policy analysis cycle instead of an event with a start and a finish.4(p260)
Professor Deborah Stone also focuses on the role of politics and values in analysis.2(pp1–14) She argues that the idea of the rational policy analysis model misses the point because “analysis itself is a creature of politics.”2(p8) According to Stone, everything from defining a problem, to selecting analytic criteria, to choosing which options to evaluate, to making a recommendation is a political and value-laden choice. “Rational policy analysis can begin only after the relevant values have been identified and … these values change over time as a result of the policymaking process.”2(p32) She contends that policy analysis should do the very things that the rational model does not permit—allow for changing objectives, permit contradictory goals, and turn apparent losses into political gains.2(p9) The goal of the rational model founders—to divorce analysis from the vagaries of politics—is simply not possible in Stone’s view.
Having differentiated these models, we now return to our definition of policy analysis: an analysis that provides informed advice to a client that relates to a public policy decision, includes a recommended course of action/inaction, and is framed by the client’s powers and values. You can see that this definition follows Stone’s political model of policy analysis, requiring the analysis to be developed with a particular client’s values in mind. After reviewing the numerous examples provided in the following section, it will be evident that client values permeate all aspects of a policy analysis. Only after you take into account your client’s values, combine it with the information you have gathered, place it in the prevailing political context, and understand your client’s powers, can you make an appropriate policy recommendation.
The ultimate product of a policy analysis is a recommendation to a specific client about how to address a problem. However, a policy analysis has several other purposes as well. It provides general information necessary to understand the problem at hand and may be an important tool to inform stakeholders about a policy problem. In addition, the analysis may be a vehicle for widespread dissemination of ideas and arguments. Although your analysis is targeted to the client requesting advisement, it may also be used to inform and persuade other supporters, opponents, the media, the general public, and others. Finally, it will help you, the policy analyst, learn how to think through problems and develop solutions in an organized, concise, and useful way.
Policy analyses can take many forms—a memorandum, an oral briefing, a report, and so on—and, correspondingly, have varying degrees of formality. This chapter explains how to construct a short, written analysis because it is a commonly used, highly effective, and often practical way to provide a policy analysis to your client. Whether you are aiding a governor, the director of a state program, the CEO of a private business, or any other decision maker, you often will not have the opportunity to discuss issues in person or for a significant length of time. Furthermore, given time pressures, the demands on high-level policymakers, the need for rapid decision making, and the variety of issues most policymakers deal with, many clients will not read a lengthy analysis. That is why it is essential for anyone who wants to influence policy to be able to craft a clear and concise written analysis.
STRUCTURING A POLICY ANALYSIS
We now turn to a five-step method for writing a thorough yet concise policy analysis. Regardless of the subject matter, you can use this structure to analyze the question your client is considering. As you review each part of the analysis, notice the various disciplines and tools that may be part of writing an effective policy analysis. Analysts draw from a variety of disciplines—law, economics, political science, sociology, history, and others—and use a number of quantitative and qualitative tools when explaining issues, analyzing options, and making recommendations.
Although policy analyses come in various formats and use different terminology, they will all contain these essential elements:
Problem statement: Defines the problem addressed in the analysis
Background: Provides factual information needed to understand the problem
Landscape: Reviews the various stakeholders and their concerns
Options: Describes and analyzes several options to address the problem
Recommendation: Offers one option as the best action to pursue
The following sections discuss each of these elements in detail.
The Problem Statement
The first step in writing a policy analysis is to clearly define the problem you are analyzing. A problem statement should be succinct and written in the form of a question that identifies the problem addressed in the analysis. It usually consists of a single sentence, though it may be two sentences if you are analyzing a particularly complex issue. Although a problem statement is simple to define, it is often one of the most difficult parts of the analysis to do well. It is also one of the most important.
The problem statement is the key to your analysis because it frames the problem at hand. Indeed, some policy battles are won or lost simply by how the problem statement is crafted. For example, consider the different questions asked in these problem statements:
Problem statement 1:
What type of tax credit, if any, should the president include in the next budget proposal?
Problem statement 2:
What type and size of health insurance tax credit should the president include in the next budget proposal?
The first problem statement asks what type of tax credit, if any, should be considered. One possible answer to that question is that no tax credit of any kind should be considered. Another answer could involve a tax credit, but not one related to health insurance. The second problem statement suggests that the option of not proposing a health insurance tax credit is unacceptable. Instead, the second problem statement lends itself to an analysis of identifying the pros and cons of various health insurance tax credit options. In other words, one option that may be considered based on the first problem statement (no tax credit) is excluded based on the second problem statement.
Consider another example:
Problem statement 1:
Should the governor’s top priorities include initiating a new state program to reduce the number of obese residents?
Problem statement 2:
Should the governor’s priority of reducing the number of obese residents be accomplished by relying on currently existing programs?
Again, the first problem statement asks whether providing a new healthcare program relating to obesity should be at the top of the governor’s agenda. It is possible that the answer is “No, other priorities such as education and transportation should take priority.” The second problem statement starts with the governor committed to reducing the obesity rate and asks how to best accomplish that goal. These may sound like similar questions, but they lead to very different analyses and (most likely) different recommendations.
It is possible that your client’s values will be evident from the way the problem statement is phrased. For instance, in the second example, the second policy statement clearly reflects the governor’s desire to reduce the obesity rate. Consider another example. You have been asked to write a policy analysis about the merits of importing low-cost prescription drugs from Canada. How might the problem statement differ if your client is a pharmaceutical lobbying group, on the one hand, and an elder rights association on the other? Here are two possible problem statements.
Acceptable problem statement for the pharmaceutical lobbying firm:
How can this firm help improve medical care quality in the United States by reducing the importation of dangerous prescription drugs from Canada?
Acceptable problem statement for the elder rights association:
How can this association help seniors obtain low-priced prescription drugs from Canada?
The vast differences in these problem statements reflect differing viewpoints regarding the importation of prescription drugs. A pharmaceutical lobbying firm is more likely to be concerned about reduced profits for its drug company clients and therefore would want to deter or restrict importation, which could lead to more competition in the market. One way to accomplish that goal is to phrase the issue as a safety/quality-of-care concern. An elder rights association is more likely to be concerned with high-priced prescription drugs in the United States and would therefore want to promote drug importation (assuming there is no actual safety concern with the drugs, of course). One way to accomplish that goal is to phrase the issue as one of cost reduction.
It is also possible to write solid, yet neutral, problem statements. From the immediately previous example, analysts for both groups could use the following problem statement:
What action should [the client] take in response to recent congressional proposals relating to importing prescription drugs from Canada?
A neutral statement is not necessarily better or worse than a value-driven statement. The value-driven statement provides additional information about the direction of the policy analysis and clearly limits some of the options that might otherwise be considered. A neutral statement is often broader, leaving more options on the table at the outset. Yet, even if a neutral statement is used, the options the analyst considers and the recommendation the analyst makes will still be constrained by the client’s values and needs.
Because it is possible to create numerous problem statements for any issue, how do you develop the best one? Follow these guidelines.
Make the Problem Statement Analytically Manageable
Acceptable problem statements can be broad or narrow. One is not better than the other; they suit different purposes. Policy analyses with broad problem statements may require more diverse information in terms of background and may consider a wider range of issues in the paper’s landscape section. Also, the recommendations may promote “big picture” changes instead of specific and tailored ideas. Narrower problem statements may require less extensive background and landscape information, but they may not capture big picture, systemic concerns relating to the problem under consideration.
Reflect on the following examples. They both may be acceptable problem statements, depending on the needs of your client.
A broad problem statement:
What action should the U.S. Department of Health and Human Services take to avoid another flu vaccine shortage?
A narrow problem statement:
How can the U.S. Department of Health and Human Services create incentives for additional manufacturers to supply flu vaccine to the United States?
The first problem statement could result in a variety of recommendations, such as improving surveillance to lower the incidence of flu in the future, developing new vaccines that have longer-lasting immunity, finding ways to entice additional manufacturers to provide supplies to the United States, and others. It is a broad problem statement that will lead to an analysis that could recommend a wide variety of actions. The second problem statement focuses on one particular way to decrease a flu vaccine shortage—increasing the number of suppliers. Although the analysis will also provide a number of options, all of the options will address the specific issue of increasing suppliers. Again, there is no single right or wrong problem statement. Whether it is more useful to have a broad or narrow problem statement will depend on the needs and concerns of your client.
However, it is possible to make a problem statement so vague that it will be impossible to write a sound policy analysis. Unfortunately, there is no easy way to differentiate an acceptably broad problem statement from an unmanageably vague one when you begin your analysis. You will know your problem statement is too vague, however, if you find it impossible to write a complete and concise policy analysis and you can think of many diverse options to include. Your paper will require too much information in the background and landscape sections if you draft an overly vague problem statement. In addition, you will find that you cannot devise a coherent series of options addressing the problem because the problem statement is too broadly defined. Instead of a concise and useful policy analysis, you will end up with a lengthy and unfocused paper.
If you believe your problem statement may be so vague that it is analytically unmanageable, ask yourself if you are addressing one specific problem that may be countered with a few specific options. If you are having trouble narrowing your problem statement, you can try including limitations based on geography (e.g., refer to a particular state or city), time (e.g., focus on the next year or over the next five years), or numerical boundaries (e.g., use a goal of reducing a figure by a certain percentage or a budget by a specific dollar amount). Consider this example:
An unmanageably vague problem statement:
What is the best use of Centers for Disease Control and Prevention’s resources to improve the health status of our citizens?
This problem statement is not analytically manageable. It is extremely broad and unfocused. Using this problem statement, your analysis could address any health issue, such as access to care problems, the need to improve vaccination rates, racial disparities in health care, or many others. The list is endless and your policy analysis will be as well.
A manageable problem statement:
What preventive health issue should be the top priority for the Centers for Disease Control and Prevention next year?
This problem statement is analytically manageable. It is focused on preventive measures specifically and is limited to determining the top priority. In addition, the problem is focused on what can be done in the upcoming year. The second problem statement allows for a much more concise and directed policy analysis.
Do Not Include the Recommendation in Your Problem Statement
Another pitfall in writing problem statements is crafting a problem in a way that suggests a particular solution to the issue. A problem statement should define a specific problem; it should not indicate how that problem should be solved. If the answer is preordained, why bother with the analysis? When drafting your problem statement, ask yourself if you can imagine four, five, or six potentially viable options to address the problem. If you cannot, then you have not defined the problem well.
For example, assume you’ve been asked to address how to reduce medical malpractice insurance premiums. Here is a problem statement that leads the reader to one conclusion:
To what extent should jury awards be limited in malpractice cases in order to reduce malpractice premiums?
This problem statement leads to one very specific solution (limiting jury awards) as a way to counter a broad problem (reducing malpractice premiums). The only question presented by this problem statement is what the award limit should be. It does not provide a range of options for reducing malpractice premiums (one of which may be limiting jury awards) for your client to consider. (Of course, if you were specifically asked to address how to limit jury awards in malpractice cases, this would be an appropriate problem statement.) A better problem statement would be “What action should be taken to stem the rise in malpractice premiums nationwide?”
This problem statement lends itself to an analysis that considers several options. Possible alternatives include limiting jury awards, enacting regulations that limit the amount insurance companies can increase premiums each year, and a host of other options. The problem statement also narrows the focus of the analysis to national solutions.
Once you have written your concise and precise problem statement, you have set the framework for your analysis. Every other section of the analysis should relate directly to the problem statement. Remember that writing a policy analysis is an iterative process; you must review, revise, and tighten the information and arguments throughout the writing process. As you review the other components of your policy analysis, it may become evident that what you thought was the best problem statement can be further improved. There is nothing wrong with revising your problem statement as you craft your analysis, as long as you remain true to your client’s values and power.
The Background Section
The first substantive information your analysis provides is in the background section. The background informs the reader why the particular problem has been chosen for analysis. This section should make clear why the issue is important and needs to be addressed now. In addition to providing general information about the topic, your background and landscape (discussed next) sections provide the information necessary to assess the options you lay out.
Much of the information in the background will be relevant regardless of who assigned the analysis. However, because the background provides information necessary to understand the problem, it is essential to understand the knowledge level of your client when constructing the background. For example, assume you are writing an analysis relating to state preparedness planning for smallpox vaccination in the event of a bioterror attack. Regardless of your client, your background would likely include information about why a smallpox attack is a threat, including (but not limited to) the following:
• Reference to the September 11, 2001, attacks on the World Trade Center and subsequent events
• The belief that although smallpox has been eradicated as a natural disease, it is likely that samples of the virus still exist
• Reference to any information provided by the federal government or other sources relating to the possibility of a bioterror attack
If your client does not have knowledge relating to smallpox, you would also include details about smallpox transmission, the effects of the disease, the vaccination procedure, and the risks associated with vaccination.
In addition, your background should include whatever factual information is necessary to fully assess the options discussed. Remember, your client needs a complete picture, not just the information that supports the recommended action or your client’s viewpoint. By the time the reader reaches your paper’s options section, all of the information necessary to evaluate the options should have been presented in your background or landscape.
For example, assume one of your options for the smallpox vaccination state preparedness analysis is immediate compulsory vaccination of all first responders and establishment of a protocol for vaccinating the remaining population if there is a smallpox outbreak. In that case, your background (and possibly the landscape) should provide information regarding who first responders are, where they are located, how many there are, legal issues relating to compulsory vaccination, and so on.
Because the background section is an informational—not analytical—part of the analysis, the material provided in it should be mostly factual. The tone of the background is not partisan or argumentative. It should simply state the necessary information.
The Landscape Section
Together, the background and landscape sections frame the context of the analysis for your client. Whereas the background provides factual information to assist the client in understanding what the problem is and why it is being addressed, the landscape provides the overall context for the analysis by identifying key stakeholders and the factors that must be considered when analyzing the problem. In the following discussion, you will read about numerous types of people, groups, and issues that might be included in a landscape. These examples are meant to provide suggestions and provoke thought about what should be included in an analysis. It would be impossible to include everything discussed here in any single landscape section. It is the job of the policy analyst to choose among these options—to be able to identify whose views and which factors are the most salient ones in creating a complete landscape.
Identifying Key Stakeholders
Up to this point, the policy analysis discussion has focused on just one stakeholder: the client who asked for the policy analysis. The landscape brings in other stakeholders who have an interest in the issue. Although it is often impossible to include every possible stakeholder in a single analysis, it is necessary to identify the key stakeholders whose positions and concerns must be understood before a well-informed decision can be made.
How do you identify the key stakeholders particular to your issue? Unfortunately, there is no magic formula. The best approach is through research and thinking. Also, bear in mind that the stakeholders and issues discussed in the landscape must relate to your overall policy analysis. Your options must address the problem identified initially, and all of the information necessary to assess the options must be presented in the background and landscape. As you learn about the problem to be analyzed and think about options for addressing the problem, it should become apparent which stakeholders have a significant interest in the issue.
For example, assume your analysis relates to proposed legislation regulating pharmacists and pharmaceuticals. Who are possible key stakeholders regarding this issue? They may include several parties:
• Democratic and Republican politicians (you might need to distinguish among those in Congress, state legislatures, and governors)
• Pharmaceutical industry
• Health insurance industry
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