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Quiz: Health Policy and Management

Test your understanding of the US health system, policy processes, health economics, and program planning with these review questions.

1. Kingdon's "multiple streams" model of the policy process proposes that policy change occurs when:

  1. Scientific evidence accumulates sufficiently to make the case for legislative action
  2. A policy window opens allowing the problem, policy, and politics streams to converge
  3. A regulatory agency completes a formal cost-benefit analysis supporting new regulation
  4. Public opinion shifts above a threshold that makes inaction politically untenable
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The correct answer is B. Kingdon's multiple streams framework describes three relatively independent streams — the problem stream (recognition of a condition as a public problem), the policy stream (available policy solutions), and the politics stream (political environment, election cycles, public mood) — that normally flow separately. When these three streams align at a "policy window," usually triggered by a focusing event, policy entrepreneurs can couple them to advance significant policy change.

Concept Tested: Kingdon's Multiple Streams Framework

2. Adverse selection in health insurance markets occurs when:

  1. Insurers select against high-risk individuals by denying coverage
  2. Higher-risk individuals are more likely to purchase insurance, raising average costs for insurers
  3. Employers choose less comprehensive benefit packages to reduce premiums
  4. Government mandates require insurers to cover pre-existing conditions regardless of cost
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The correct answer is B. Adverse selection is a market failure in insurance markets: when individuals have better information about their own health risk than insurers, higher-risk individuals are more likely to seek coverage (and more coverage), while lower-risk individuals may forgo it. This raises the insurer's average cost, leading to premium increases, which further drives out lower-risk individuals — a "death spiral." Mandatory coverage or community rating policies are regulatory responses to adverse selection.

Concept Tested: Adverse Selection in Health Insurance

3. The primary mechanism by which the Affordable Care Act (ACA) expanded health coverage was:

  1. A national public option that competed with private insurers
  2. Mandated employer provision of health insurance to all full-time employees
  3. Medicaid expansion and subsidized marketplace plans through health insurance exchanges
  4. A single-payer system replacing private insurance for Americans under 65
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The correct answer is C. The ACA's major coverage expansions came through two mechanisms: expanding Medicaid eligibility to adults with incomes up to 138% of the federal poverty level (in states that adopted the expansion), and creating Health Insurance Marketplaces with income-based subsidies for individuals purchasing private insurance. These two pathways together reduced the uninsured rate from approximately 16% to below 9% by 2016.

Concept Tested: ACA Coverage Expansion Mechanisms

4. In the PRECEDE-PROCEED program planning model, "predisposing factors" include:

  1. The skills and resources required to perform a health behavior
  2. Reinforcements (rewards and punishments) that follow a behavior
  3. Knowledge, attitudes, beliefs, and values that motivate or inhibit behavior
  4. Environmental factors that make a behavior easier or harder to perform
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The correct answer is C. Green and Kreuter's PRECEDE-PROCEED model distinguishes three categories of factors influencing health behavior: predisposing factors (cognitive/affective antecedents — knowledge, attitudes, beliefs, values, self-efficacy), enabling factors (skills, resources, accessibility that allow behavior to occur), and reinforcing factors (consequences that reward or punish behavior). This taxonomy guides which interventions to design for which mechanism of change.

Concept Tested: PRECEDE-PROCEED Model

5. The concept of "moral hazard" in health insurance refers to:

  1. The ethical obligation of insurers to cover all medically necessary services
  2. Reduced incentive for individuals to avoid health risks or moderate healthcare use when insured
  3. The risk that insurance companies will engage in fraudulent billing practices
  4. The tendency for patients to seek second opinions before major procedures
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The correct answer is B. Moral hazard describes the tendency for insurance coverage to alter behavior: when individuals are insulated from the full cost of healthcare, they may use more services than they would if paying out-of-pocket, and may take less precaution to avoid health risks. Cost-sharing mechanisms (deductibles, copayments, coinsurance) are designed to mitigate moral hazard by preserving some price sensitivity, though they also create barriers to necessary care for low-income individuals.

Concept Tested: Moral Hazard in Health Insurance

6. A cost-effectiveness analysis (CEA) in health economics evaluates interventions using which primary metric?

  1. Total intervention cost compared to total disease cost averted
  2. Cost per unit of health outcome gained (e.g., cost per life-year saved or QALY gained)
  3. Net monetary benefit in dollars calculated from a societal perspective
  4. The ratio of direct medical costs to indirect productivity costs
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The correct answer is B. Cost-effectiveness analysis measures the ratio of net costs to net health effects — most commonly expressed as cost per quality-adjusted life year (QALY) gained or cost per life-year saved. This allows comparison across interventions affecting different conditions. A conventional (though contested) threshold of \(50,000–\)100,000 per QALY gained is used in the US; the UK's NICE uses approximately £20,000–£30,000 per QALY. CEA differs from cost-benefit analysis, which converts health outcomes into dollar values.

Concept Tested: Cost-Effectiveness Analysis

7. Public health law's "10 Essential Public Health Services" framework is primarily used to:

  1. Define the minimum benefits that health insurance plans must cover
  2. Specify the legal penalties for violations of communicable disease reporting laws
  3. Guide governmental public health agencies in fulfilling their core responsibilities
  4. Establish international treaty obligations for pandemic preparedness
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The correct answer is C. The Ten Essential Public Health Services framework, developed in 1994 and revised in 2020, describes the fundamental obligations of governmental public health systems: monitoring health status, diagnosing and investigating health hazards, informing and educating the public, mobilizing community partnerships, developing policies and plans, enforcing laws and regulations, linking people to needed services, assuring a competent workforce, evaluating services, and researching innovative solutions. It provides a framework for public health practice assessment and accreditation.

Concept Tested: Ten Essential Public Health Services

8. The Institute for Healthcare Improvement's "Triple Aim" framework for healthcare improvement includes:

  1. Cost reduction, quality improvement, and workforce satisfaction
  2. Improving population health, enhancing patient experience, and reducing per capita cost
  3. Evidence-based practice, patient safety, and equitable access
  4. Prevention, treatment, and rehabilitation across the continuum of care
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The correct answer is B. The IHI Triple Aim, developed by Berwick and colleagues, proposes simultaneously pursuing three dimensions: improving the health of defined populations, improving the individual experience of care, and reducing the per capita cost of healthcare. The "Quadruple Aim" later added improving the work life of healthcare providers. The Triple Aim has become the dominant framework for healthcare system redesign in the US and internationally.

Concept Tested: Triple Aim Framework

9. Certificate of Need (CON) laws in healthcare are designed to:

  1. Require all healthcare providers to demonstrate clinical competency before licensure
  2. Control healthcare capacity and costs by requiring state approval before building or expanding facilities
  3. Mandate minimum nurse staffing ratios in hospital settings
  4. Ensure that all patients receive written consent documentation before procedures
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The correct answer is B. Certificate of Need laws require healthcare facilities to obtain state approval before making major capital expenditures — building new hospitals, adding beds, or purchasing expensive equipment. The rationale is that excess capacity drives up costs (if the equipment exists, it will be used) and that CON review ensures that new services address documented community need. Critics argue CON laws reduce competition and may protect incumbent providers without meaningfully controlling costs.

Concept Tested: Certificate of Need Laws

10. The primary goal of quality improvement (QI) methodology in public health settings is to:

  1. Document performance deficiencies for regulatory compliance purposes
  2. Systematically improve processes and outcomes through rapid cycle testing of changes
  3. Compare individual provider performance for merit-based compensation
  4. Identify malpractice risks and reduce institutional legal liability
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The correct answer is B. Quality improvement in public health applies methods developed in manufacturing (Deming's Plan-Do-Study-Act cycle, Lean, Six Sigma) to systematically identify problems, test changes, measure results, and scale successful improvements. The PDSA cycle allows rapid iterative testing without the delay of formal research protocols. QI focuses on system performance rather than individual blame, recognizing that most quality failures arise from system design rather than individual error.

Concept Tested: Quality Improvement Methods