Healthcare Regulation

Regulation plays a major role in the healthcare industry and healthcare insurance coverage. Through various regulatory bodies, the Department of Health and Human Services (HHS) protects the public from a number of health risks and provides programs for public health and welfare. Together, these regulatory agencies protect and regulate public health at every level.


The Centers for Medicare and Medicaid (CMS), founded in 1965, oversee most of the regulations related directly to the healthcare system. CMS provides government-subsidized medical coverage through a number of programs:

  • Medicare for the elderly and disabled
  • Medicaid for lower-income individuals and families
  • State Children’s Health Insurance Program (SCHIP) for health insurance coverage for children under 19

CMS is also responsible for ensuring compliance to the Health Insurance Portability and Accountability Act (HIPAA). HIPPA is a major piece of healthcare regulation instituted to improve the efficiency and effectiveness of the healthcare system – to “cut the fat” while at the same time protecting patients and providing better medical care.

The Agency for Healthcare Research and Quality (AHRQ) is another agency that falls under the auspices of HHS. It conducts research aimed at improving the quality of healthcare, reducing its costs, and addressing patient safety and medical errors.

Non-profit organizations serving as watchdogs and accreditation institutions for healthcare in America:

  • The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is an NPO focused on ensuring that healthcare organization provide quality care. JCAHO employs a system in which healthcare organizations are examined and then given a score between 1-100, with higher scores being better. These scores are important to healthcare organizations as they are a factor in reimbursement from Medicare.
  • The National Committee for Quality Assurance (NCQA) is an NPO that ensures the quality of America’s managed care plans. It was established in 1991 to provide standard, objective information about HMOs.


Other Public Health Regulation

In addition to the CMS programs, the HHS has many regulatory departments that oversee other forms of public health regulation.

  • The Centers for Disease Control and Prevention (CDC) in Atlanta, GA, examines public health and warns of possible health threats from infectious diseases. The CDC monitors birth defects, disabilities, diseases and conditions, emergency preparedness and response, environmental health, genetics and genomics, health promotion, injury and violence, travelers’ health, vaccines and immunizations and workplace safety and health.
  • The Food and Drug Administration (FDA) is the federal regulatory agency responsible for the controlling the safety and effectiveness of the country’s drug supply for both humans and animals. The FDA regulates food safety, cosmetics, feed supply for animals, dietary supplements, biologics and the national blood supply, medical devices, food additives, product recalls, and restaurant inspection.
  • The United States Agency for Toxic Substances and Disease Registry (ATSDR) monitors and regulates the effects of hazardous materals on public health. The ATSDR responds to hazardous materal threats, educates the public on hazmat risks, and involves community members and organizations to encourage participation in ATSDR’s activities.

FierceHealthcare covers breaking healthcare news about industry regulation with a special emphasis on Medicare, Medicaid, HIPAA, and FDA regulation. Free daily updates from FierceHealthcare.

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