Experiencing Politics: A Legislator's Stories of Government and Health Care / Edition 1 available in Paperback
Experiencing Politics: A Legislator's Stories of Government and Health Care / Edition 1
- ISBN-10:
- 0520224116
- ISBN-13:
- 9780520224117
- Pub. Date:
- 11/22/2000
- Publisher:
- University of California Press
- ISBN-10:
- 0520224116
- ISBN-13:
- 9780520224117
- Pub. Date:
- 11/22/2000
- Publisher:
- University of California Press
Experiencing Politics: A Legislator's Stories of Government and Health Care / Edition 1
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Overview
Product Details
| ISBN-13: | 9780520224117 |
|---|---|
| Publisher: | University of California Press |
| Publication date: | 11/22/2000 |
| Series: | California/Milbank Books on Health and the Public , #2 |
| Edition description: | First Edition |
| Pages: | 354 |
| Product dimensions: | 6.00(w) x 9.00(h) x 0.90(d) |
| Lexile: | 1380L (what's this?) |
About the Author
Read an Excerpt
experiencing POLITICS
A LEGISLATOR'S STORIES OF GOVERNMENT & HEALTH CAREBy JOHN E. McDONOUGH
University of California
Copyright © 2000 Regents of the University of CaliforniaAll right reserved.
ISBN: 0-520-22411-6
Chapter One
Agendas and Children's Health Care ... chance favours only the prepared mind.
Louis Pasteur
It was a gorgeous spring day, with luxuriant blossoms dressing the trees that lined the Hooker entrance to the State House. Imperturbably guarding the entrance is the equestrian statue of Joseph Hooker, the Civil War general who briefly commanded the Army of the Potomac in 1863. It was my first year in the House, 1985, and I wasn't paying much attention to the surroundings, thinking instead of the hell-on-wheels week just past. It seemed I could do nothing right. Issues kept popping up that threw me off balance, and everyone in sight was angry or disappointed in me for one reason or another. As I stood on the steps, the legendary Senate President William Bulger happened to walk by, wearing his familiar grin suggesting nothing got him down. "Boy, this is tougher than I thought," I said in response to his polite, "How's it goin' kid?" "Listen," he said, lowering his voice, "you get so wrapped up in the day-to-day issues around here, and you think if you don't do things the way people want, they'll never speak to you again. And you're always wrong, because they always come back for more."
His words were comforting relief I remember to this day. Nonetheless, the odd, unpredictable, and chaotic way that issues popped up on the public's and the legislature's radar screens was puzzling and troubling to me. It seemed too random and out of control to be real, not just in Massachusetts but everywhere I looked. Some issues, such as welfare and immigration reform, suddenly reach the center stage of public attention, become incessant topics of controversy in governmental corridors, newspaper columns, and policy discussions, and then result in the enactment of new laws. Other issues, such as universal health care and comprehensive national tobacco control, may reach the public agenda, generate substantial attention, and then collapse before enactment or implementation of any new policy or law. Still other issues that may reflect major public problems, such as homelessness, can languish offstage for many years with no significant public concern.
Is this just random luck of the draw? While it often seems that way from afar, the appearance of randomness is an illusion. Throughout many layers of society, all the time, individuals and groups inside and outside of government are hard at work setting up their next opportunities to create change. Those who understand the dynamics of a process called agenda setting and who operate according to its principles have a valuable advantage over those who do not. There is, indeed, an element of luck involved in this process. But, as Pasteur suggests, luck most often happens to those who prepare for it.
This chapter describes the dynamics of agenda setting, relying on a model developed by John Kingdon. In explaining his model, I use President Bill Clinton's ill-fated national health reform plan of 1993-94 to illustrate how the framework can be used retrospectively to analyze a successful or unsuccessful legislative campaign. I then describe how I used Kingdon's model prospectively to plan and promote major health care access legislation in Massachusetts in 1996.
AGENDA SETTING
Kingdon developed a simple and elegant model in the early 1980s to explain the emergence and recession of issues from the policy agenda. I have found this framework genuinely useful in real life and one that people can easily understand. Because politics is both science and art, no model can explain everything. Rather, good models work like helpful tools-a hammer, a saw, a screwdriver-that can be used by most of us to perform a necessary job. Of course, there is always more to a successful job, such as the skill of the craftsperson, the quality of the materials. But the tools can also help a lot.
Kingdon's model was adapted from organizational theory that describes decision making in firms, whether for profit or not, governmental or nongovernmental. The model's basic premise is that leaders and managers in organizations and in politics are at the receiving end of a constant stream of disconnected, random, and chaotic information and feedback, flowing together in a form that makes little sense on its own. Creating some degree of order from all this varied input, finding a path through it, and then crafting an agenda for action are the essential challenges facing leaders both in organizations and in politics.
According to Kingdon's model, change can only happen when a "window of opportunity" for that change opens up-no open window, no change. For the window to open, three streams or dynamic processes must be moving at roughly the same time. The first stream is the problem stream, the sense among those with the power to act that a legitimate problem exists that deserves to be addressed. No genuine sense of a problem most often equals no action. Who are those with the power to act? That depends entirely on the forum in which the issue is being pursued. Changing a state insurance policy may require acceptance of legitimacy by the insurance commissioner and his or her appointing authority. Changing a university policy may require belief in the legitimacy of the issue by the president, the dean, and the board of trustees. If the issue requires action in a legislative body, then key legislative leaders and committee chairs are the ones who must recognize the legitimacy of the problem. Change in the regulatory structure governing managed care was a major issue in the Massachusetts legislature in 1997 and 1998 (as in many other states), with many bills and lots of interested organizations involved in the fray. Ultimately, nothing happened, largely because the Speaker of the House, in his gut, did not believe that the dispute represented a genuine problem and thus used his power to delay any consideration until very late in the session. In this example, the political and policy streams were moving well, while the problem stream was halted by a critical person with the power to act.
The second stream is the political stream, the sense among those with the power to act that the timing for action is right in relation to public sentiment and consistency with other policy objectives. This stream combines the mood of the electorate, election results (who has been put into positions of power), the process by which groups are mobilized, and more. Promoting a major public spending proposal during a recession when budgets are being cut and pushing a major antiabortion bill in a state with high levels of pro-choice support are two examples where there may be an implementable policy and even officials who strongly support it. But progress will be held back by the political stream.
The third stream is the policy stream, the existence of an implementable policy that fits the scope of the problem, is understandable to those who need to understand it, and can attain sufficient support. At all times, so-called policy networks in every conceivable area and microarea of public policy are at work developing, refining, and promoting policy ideas and proposals. These networks are composed of government officials, academics, industry leaders, consultants, journalists, and more. They argue and test out ideas with each other, hungrily anticipating the moment when a problem will emerge to which their favored solution or policy can be applied. Indeed, policy solutions often precede the emergence of problems; effective policy entrepreneurs work hard to spot emerging problems to which their new policy ideas can be applied.
When all three streams are flowing at a sufficient pace, the window of opportunity opens, creating the possibility for substantive policy change. Implicit in the model are several important caveats. First, having only one or two of the three streams in motion is usually insufficient, particularly on matters that generate substantial controversy and attention. Retrospective analyses of failed attempts to change policy can usually reveal deficiencies in one or more of the streams. Second, just as surely as windows of opportunity open, they close, making it important for advocates to move before an opening vanishes. Timing is not everything, but often it will be pretty close. Third, all window openings are not the same size. A policy proposal can easily be of a scale too large to fit through the size of the open window, either because the policy addresses far more than the perceived problem or because political limitations cannot permit a solution of the scale proposed.
President Bill Clinton's ill-fated national health reform proposal in 1993 and 1994 is a strong example of how Kingdon's model can be used retrospectively to analyze a failed policy initiative. At the time of Clinton's presidential inauguration in January 1993, the problem stream was moving with terrific force. Throughout the 1980s, analysts in numerous health policy networks had demonstrated that out-of-control health spending and rapidly increasing numbers of uninsured Americans were symptoms of a growing systemic crisis. Throughout the decade, the cost of health insurance, public and private, rose at a rate far greater than general inflation or the growth of the overall economy. Health spending rose from less than 10 percent of the gross national product in 1980 to more than 14 percent in the early 1990s, with projections that spending would rise as high as 20 percent by the year 2000 if trends continued (the rate stabilized around 14 percent through the middle and later 1990s). Business and labor leaders, consumer groups, state and federal lawmakers, and media voices concurred that health spending was out of control with no end in sight. During this same period, the numbers of Americans with no health insurance coverage at all began to increase by about a million persons per year, from twenty-five million uninsured in 1980 to more than thirty-eight million by 1993 (and forty-four million by 1999). As both sets of numbers worsened, health policy researchers began paying closer attention to various dimensions of the problem, media began publishing stories describing the human aspects, and state and federal commissions, such as the Pepper Commission chaired by U.S. Senator Jay Rockefeller, further documented the problems and the needs.
Kingdon points out that there are many unfortunate conditions in life that are not recognized as public policy problems. "Conditions become defined as problems when we come to believe that we should do something about them," he observes. By the end of 1992 no credible voice anywhere in the nation doubted the existence of a serious problem in our nation's health system.
Policymakers' sense that the political stream was moving adequately to justify action had evolved over several years. In 1988, Democratic presidential candidate and Massachusetts Governor Michael Dukakis used health care concerns as a central policy plank in his national campaign. He had established his credentials on the issue with the signing of a so-called universal health care law in his own state in April of that year, a law that included a mandate for most employers to cover their workers and that was scheduled for implementation in 1992. While the Dukakis campaign floundered badly in the late summer and early fall in the face of an aggressive and negative campaign by then Vice President George Bush, it was widely agreed in campaign postmortems that the health issue had given Dukakis a late campaign lift, though not enough to overcome other weaknesses. The health care issue would increase in prominence in future presidential campaigns, several analysts wrote, though probably not until 1996.
The event that changed policymakers' perceptions about the political stream occurred in Pennsylvania in November 1991. Republican U.S. Senator John Heinz had been killed in an air crash in April of that year. Richard Thornburgh, the sitting U.S. attorney general at the time, resigned his cabinet position to run for Heinz's seat and began the campaign more than forty points ahead of his little-known rival, Democrat Harris Wofford, who had been appointed to the seat until a special election could be held. While Thornburgh publicly dismissed the notion that the health system was in crisis, Wofford made health reform his major issue, running television ads proclaiming, "If criminals have the right to a lawyer, I think working Americans should have the right to a doctor." When Wofford won the nationally watched contest, political observers widely agreed that health care was the issue that turned the election in his favor, even though his reform prescription was thoroughly undefined.
Democratic presidential candidate Bill Clinton made health cost control and access expansion central parts of his campaign, though once again in an undefined form embracing an untested, ambiguous concept called managed competition. After his victory, health reform was viewed as an electoral mandate issue, a point he emphasized repeatedly during his transition, most prominently at an economic summit he hosted in Little Rock, in December 1992. By inauguration day, 1993, with Democrats in control of the presidency and both houses of Congress, few doubted that the political stream was moving strongly in the direction of comprehensive, national health system reform.
But two streams are not enough to make change, especially big change, happen. It was the third stream, the existence of an implementable and understandable policy, that created the nascent administration's greatest challenge. Deborah Stone discusses how broad labels such as "liberty," "security," "efficiency," and "equity" can be used to mask gaping differences in real policy preferences. By January 1993, the time for discussion of broad and abstract concepts-managed competition, health care reform, universal coverage-had passed. Instead, it was time to talk turkey.
Kingdon's model suggests that early 1993 was the time to take a policy off the shelf and move it through Congress while the problem and political streams were optimal. Instead, President Clinton appointed the much-maligned Health Care Task Force, headed by First Lady Hillary Rodham Clinton, that quickly ballooned to about 500 participants whose job was to figure out what his policy should be. It was not until late September 1993 that the president announced his Health Security Plan to Congress (not delivering an actual bill until late October), after deciding that the plan would follow consideration of his budget package, narrowly approved in August, and ratification of the North American Free Trade Agreement, approved later in the fall.
by the time Congress readied itself for serious deliberation, the size of the open window of opportunity was already narrowing.
Continues...
Excerpted from experiencing POLITICS by JOHN E. McDONOUGH Copyright © 2000 by Regents of the University of California. Excerpted by permission.
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