"Fluid Structure" of Agenda-Setting. Reflections on President Clinton’s Attempt to Introduce a Universal Healthcare System and the Subsequent Reform of Healthcare Industry under Obama Administration
Term Paper 2010 16 Pages
TABLE OF CONTENTS
The Context of National Health Care Reform
Explaining Policy Change
Kingdon’s Model of Policy Making Process
Applying Kingdon’s Model to the Study of an Attempted National Health Care Reform
under Clinton’s Administration
Comparing Clinton’s NHS Initiative with PPACA Deliberation under the Obama Administration
For generations, America’s liberal tradition has stood “as a prime suspect in the demise of comprehensive national reforms to address the country’s negative consensus about the health care system” (Jacobs 2014). The list of Presidents who offered to reform the American healthcare industry includes Teddy Roosevelt (1я 912), Franklin Delano Roosevelt (1934), Harry Truman (1945), Richard Nixon (1970s), Bill Clinton in 1993-1994, and finally, President Obama (2004-2008). On March 23 2010, President Obama signed the Patient Protection and Affordable Care Act (H.R. 3590), which substantially extended the role of the state in healthcare regulation. This development created a “landmark of American social policy”, which disrupted “the familiar patterns of selectivity” (631) and promised to deliver “more and more economic help and prosperity to millions of lowand middleincome Americans” (Skocpol 2015).
Interestingly, the reasons for Obama’s success in setting the agenda for policy change in healthcare industry are not sufficiently examined. The nature and the speed of agendasetting progress in 2009 seems to be particularly puzzling in view of President Clinton’s failure to enact a very similar reform package of ‘managed competition’ fifteen years earlier. Based on the existing literature of policy continuity and change in American healthcare industry, my paper analyzes and compares the two reform efforts under Obama and Clinton’s administrations. First, I discuss the scope of national reform project offered by democrats during the early 1990s. Second, I question how and why similar ideas succeeded rather than failed fifteen years later. I conclude that policy proposals, which cut across the US value system, require policy entrepreneurs’ combined efforts to use some of the available levers of change, based on accurate assessment of problems and target populations and the right choice of policy instruments. None of these factors, however, suffice to advance anything close to comprehensive policy change in a context of decentralized management, such as the US healthcare system.
Keywords: agendasetting process, policy change, healthcare industry, decentralized management system, framing and persuasion
Running head: ‘fluid structure’ of agendasetting
The process of public policy making is commonly described as a course of action rooted in principles of rationality and logical progression from one step to another. This process consists of at least four stages - policy formulation, policy evaluation, policy implementation and policy appraisal - each requiring proper assessment and adequate incentives for behavioural change.
Sociological and psychological accounts repeatedly challenge the traditional definition of public policy making. Numerous examples suggest that time pressures, the quality of information and other factors significantly impede our ability to arrive at optimal outcomes. Rochefort (2009), for example, asserts that systematic mismatches exist between measures of the seriousness of a problem and the level of attention devoted to it. Controversy also surrounds how a given issue will be understood: perceptions of the origins, impact and significance of certain problems depend largely on how issues are formulated: “Even if one conception manages to attain dominance at a given moment, however, this interpretation can later be dislodged, effectively altering the substance of the problem being worked on” (56).
Shaping public policy is a complex and multidimensional process that involves the dynamic interaction between the context in which policy operates and numerous stakeholders (individuals and interest groups) promoting their own vision of a government’s agenda. Policy entrepreneurs (groups and individuals) often mobilize their resources to affect laws, regulations and funding priorities through education, mass media, lobbying and other methods. In this respect, we must pay special attention to the ways in which the national agenda is set and the relationship between various factors (such as context, actors, strategies, etc.) in this process.
Two questions are seriously considered in the contemporary literature: (1) why some issues and solutions feature prominently on the policy agenda and others do not; and (2) how exactly policy change occurs. Authoritative scholars (Sabatier 1988, 2015; Baumgartner and Jones 2005, 2011; Kingdon 1994; Pressman and Wildawsky 1973) suggest that the mechanism by which some issues are brought into prominence rests on a series of developments that occur either as a result of political will or a number of other important factors coming together to produce policy change. Describing the impact of a fragmented institutional structure in the US on the process of policymaking and our ability to predict outcomes, Kingdon asserts that ‘there [...] is a lot of complexity and fluidity in this real world, and a model of that world should capture that complexity. One reason that a probabilistic model is more satisfying than a deterministic one is its recognition of that residual randomness. In fact, I tried my best along the way to specify necessary and sufficient conditions and to figure out some tight laws of causation. I found that there were too many exceptions, and that the specifications got unduly complex. I concluded that we do better quote the odds’ (225).
The discussion of the US healthcare initiatives is complicated by the existing institutional context, where health care delivery system appears to be made up of a “fragmented network of public and private financing, health care delivery, and quality assurance structures” (Health Industry Forum Brief, 2009). Until 2010, there has been no single national entity or a unified set of policies guiding the healthcare system. Filed (2007), in this respect, observed the following:
The array of regulations that govern health care can seem overwhelming to people who work in the industry. Almost every aspect of the field is overseen by one regulatory body or another, and sometimes by several. [Thus] health care professionals may feel that they spend more time complying with rules that direct their work than actually doing the work itself.
The observed nature the decisionmaking process, which includes national, state, and community levels, is held to account for the poor quality of healthcare delivery process observed in the US over the last several decades. Shih et al. (2008) assert that fragmentation of healthcare industry results in the absence of common standards, poor communication, medical errors, waste, duplication and other undesirable features, which contradict the mission of healthcare system per se. Field (2007) describes the history of the US healthcare industry as a “result of historical accidents and bureaucratic turf wars ”, which may not necessarily serve any purpose in modern life. In this system, different levels of government “vie with each other for supremacy” in line with an established tradition going back to at least a few centuries earlier. On the one hand, these actors appear to be entrenched in a system of checks and balances, promoting competition and preventing the state from the unnecessary intrusion. On the other hand, the system of checks and balances contributes to patients’ confusion, lack of efficiency and the deteriorating quality of healthcare service.
The failure of the US Presidents to transform the national healthcare system, produced at least two major explanations of policymaking paralysis: firstly, state leaders may have no levers necessary for change (in this case, the institutional structure of the American political system would matter); secondly, they may use the available structure of opportunity, or policy tools inappropriately. It is true that political institutions, parties and interest groups significantly constrain the range of options available to policy makers in their reform efforts. Meanwhile, the choice of instruments and approaches to dealing with those constraints is also extremely important, and it depends largely on the type of policy process in which policy entrepreneurs engage.
This paper analyses the complex nature of agendasetting process in area of health care regulation over the last twenty years. Based on the existing literature of agendasetting and policy change, I compare and analyze the two reform efforts taken by undertaken by President Clinton in 1994 and President Obama in 2009. I suggest that each time the national healthcare initiative advanced to the realm of agendasetting, there was a peculiar, structurally repetitive constellation of factors, which either did not allow the project to reach implementation stage or challenged the fate of it via contested policy implementation discourse. Specifically, President Clinton’ Health Security Act (HSA) failed due to mistakes made at the stage of policy formulation, whereas ‘Obamacare’ project, launched in 2009, proceeded more smoothly due to policymakers’ ability to learn from their past mistakes. Some of the most important lessons learned by the new generation of democrats after the failed policy initiative included effective management of issues such as stakeholder involvement, transparency of policy formulation stage, and finally, ‘framing’ effects, which have reflected an effort made by policy actors to accurately evaluate their target populations. The fate of this reform, however, is far from clear due to pressures launched in a contested political arena.
The paper proceeds as follows. First, I elaborate on the existing theories of agendasetting process, questioning the scope, instruments and communication strategy employed by American democrats in effort to advance their ‘managed competition’ framework. Second, I question how and why similar ideas succeeded rather than failed fifteen years later. I conclude that policy proposals, which cut across the US value system, require policy entrepreneurs’ combined efforts to use some of the available levers of change, based on accurate assessment of problems and target populations and the right choice of policy instruments. None of these factors, however, suffice to advance anything close to comprehensive policy change in a context of decentralized management, such as the US healthcare system.
The Context of National Health Care Reform
In 1975, R. Alford opened his book on health care reform in the United States with the following words: “Health care in the United States is allegedly in a state of crisis. High and rising costs, inadequate numbers of medical and paramedical personnel, a higher infant mortality rate, a lower life expectancy, poor emergency rooms and ambulatory care that were documented more than several decades ago are among the diverse facts or allegations which have justified a wide variety of proposed reforms. And yet nothing has changed in recent decades” (xi). Indeed, if we look at the 1932 healthcare assessment reports and reports issued since 1960s, we’ll notice a striking similarity between them. Quite recently, the New York Times Magazine published an article suggesting that “the United States spends twice as much per capita on health care as many other nations, yet achieves inferior outcomes by such varied measures as life expectancy, preventable deaths from specific illnesses, and infant mortality” (Robert H. Frank, 2009). The economist Eli Ginzberg, accordingly, concluded that “While changes have occurred in response to emergences, opportunities, and alternatives in the market place, the outstanding finding is the inertia of the system as a whole” (Alford, ixxi).
The way the system handles its problems is indicative of predominant ideologies, structural constraints and normative boundaries that exist within a given society at a particular point of time. Unlike most European countries, where health care system has come to be understood as a “social right of citizenship”, attracting the largest share of budget expenditures, the US’ welfare system is commonly described as the “liberal model” of welfare state development, where social policy is more residual in nature, and the role of the market is more prominent (Esping-Andersen 1990). This model is underpinned by the neoliberal political ideology which limits the functions of the national government. It emphasizes the values of individual opportunity and responsibility.
In line with a neoliberal ideology, the prevailing approach to health care reform in the United States has been the expansion of private health insurance and the extension of federal funds to cover costs for the poor and the elderly. This approach inspired harsh criticisms on behalf of international policy communities, and yet very little change, until recently, was achieved in terms of institutional and ideational transformation. Various structural and ideological barriers have successfully resisted any kind of change, and even ‘Obamacare’ project, which emerged out of nowhere to address social, economic and political crises, experienced severe resistance on behalf of those who wanted to repeal it altogether and maintain the status quo.
Most health care in the United States is covered by the private sector, and because so much of it becomes the income stream of private sector providers, health care policy makers engage in bargaining, lobbying and other strategies aimed at influencing public health care policy. One result of this process has been that public health tends to be shrinking over time. Weissert&Weissert (2006) observe that in the decades since the passage of Social Security Amendments, which resulted in creation of Medicare and Medicaid, the nation has witnessed a gradual decline of the reach, scope, and funding of public health (1-2).
Given the fact that US Presidents have tried but repeatedly failed to transform the national healthcare system, two explanations may be offered: firstly, state leaders may have no levers necessary for change (in this case, the institutional structure of the American political system would matter); secondly, they may use the available structure of opportunity, or policy tools inappropriately. It is true that political institutions, parties and interest groups significantly constrain the range of options available to policy makers in their reform efforts. Meanwhile, the choice of instruments and approaches to dealing with those constraints is also extremely important, and it depends largely on the type of policy process in which policy entrepreneurs engage themselves.
Shneider and Ingram (1990) provide an interesting framework to analyze the implicit and explicit behavioural theories found in laws, regulations and programs. According to this framework, policy instruments chosen on behalf of decisionmakers have to be correlated with underlying assumptions about human behaviour . Authority tools are used when people expect to conform to the rules set up by the national government (normative socialization); incentive tools apply in a situation when people make rational calculations concerning their benefits and costs; finally learning tools attempt to inform and socialize. In each case, knowledge about recipients (target group) of a specific project is crucial.
The discussion of policy instruments must not be confused with the discussion of similar analytical categories, such as political influence, political capital, power, and others. Political authority, for example, may be utilized as an effective instrument to achieve a broad set of goals; however, there are numerous ways in which political power may be applied. Policy instruments provide just the range of options to choose from at the decisionmaking stage.
Standard political science theories offer conflicting accounts of human behaviour. Pluralist theories revolve around the model of comprehensive rationality (interestbased politics); the new institutionalism studies (historical institutionalism and sociological institutionalism in particular) assume that human rationality is essentially bounded, while people are socialized (“normalized”) throughout their life spans; ideational accounts attribute greater value to sociolinguistic and psychological effects of policy processes, such as framing. These theories are accordingly correlated with the incentive and authority, learning and symbolic policy tools.
It would be naive to suggest that policy leaders contemplate any theory of human rationality before taking decisions. However, mistakes that they make at the stage of agendasetting reflect their conflicting understandings of human behaviour, i.e. incentives, motivations and the preferences of policy recipients. If state decisionmakers do not possess full information about the social groups affected by their policies, they may fail to understand the nature of the problem that these people are facing. Alternatively, they may be unable to come up with an appropriate solution to the identified problem or simply miscalculate their message to the recipients of a policy project. Thus, nearly all mistakes, which arise at the policy formulation stage, relate, in one way or the other, to limits on rationality, which affect the choice of instruments, or policymakers capacity to appropriately assess their target populations.
Building upon the Kingdonian approach (1984) to the study of the US national health care system, I further argue that the mechanism by which some issues become prominent and get resolved in a system as ‘stubborn’ as the US Congress, include not only social crises (as it was commonly observed by a wide range of healthcare policy analysts), but also unique constellations between structures and personalities, their strategic and tactical choices, and their ability to appeal to the wider public. The ultimate progress of any project is viewed as a result of policy entrepreneurs’ combined efforts (accurate assessment of problems/ target populations, issues of timing and the right choice of policy instruments), whereas none of these factors suffice to advance anything close to comprehensive policy change in a context of decentralized management (such as the US healthcare system).
Explaining Policy Change
Howlett (2002) identified two types of policy change: incremental, where all new policies represent the simple continuation of old ones; and paradigmatic, involving a dramatic reconceptualization and restructuring of policy content. Paradigmatic change “involves periods of stability and incremental adaptations interspersed by periods of revolutionary upheaval”; this process results “in what has often been referred to as ‘punctuated equilibrium’ pattern of policymaking dynamics” (Heyes, 242). The best way to describe linkages between the two models of policy transformation is to stress their evolutionary qualities. It is observed that procedural policies may have profound substantive effects over an extended period of time, leading to a comprehensive transformation. Kingdon (1995) quotes one of his sources as saying: “These things proceed in small, incremental steps. Something is enacted, everybody concludes that it’s not so bad, and that gets people ready for the new bite” (Weissert&Weissert, 306).
The reasons behind the infrequency of policy change are often debated in the contemporary political science. All explanations of this process may be grouped into three categories: ideational accounts that link policy transformations to the profound role of ideas and various sociolinguistic effects; institutional (structural) accounts that look at the impact of pathdependency on social and political institutions, and finally, pluralist theoretical models that describe policy transformations as a compromise between various interest groups.
A wave of recent scholarship, embracing both rational choice and cultural approaches, highlights the importance of collective ideas in explaining politics (Legro, 419). Howlett, for example, asserts that the crucial factor for policy change is the significant adaptation in episteme or way of looking at and dealing with the problem; however ideas and the way of looking at appropriate solutions may be quite durable (and resistant to change):
‘Observers have always noted how in the course of interaction aiming themselves and in their dayto-day dealings with a public problem, policy makers tend to develop a common episteme or way of looking at and dealing with a problem . Slight adaptations and adjustments of views on the basis of experience is possible but understandings of the nature of public problems and the acceptable or feasible solutions to them are often remarkably durable and, once in place, are difficult to change’ (Howlett, 243).
 I observe that neither the frame nor the scope of reforms were appropriate at the time.
 This discussion is grounded in public policy literature, which combines the discussion of various types of change (Hall 1996, Wilsford 1994, Ruger 2007, Howelett 2002) with insights from John Kingdon’s ‘policy streams’ approach (1994).
 Field R. I. 2007. Health Care Regulation in America: Complexity, Confrontation and Compromise. New York: Oxford University Press, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2730786/
 The paper concludes with the discussion of President Clinton’s health care reform initiative during the early 1990s. This initiative is compared and contrasted to the development and deliberation of the Affordable Health Care for America Act and the subsequent enactment of the Patient Protection and Affordable Care Act (H.R. 3590) under Obama administration.