Health Care Reform and the Decision Agenda
This memo analyzes how health care reform—more specifically the Patient Protection and Affordable Care Act of 2010—moved onto the decision agenda during the period in time from 2008 to 2010. By using Kingdon’s definition of the decision agenda and utilizing his conceptual framework of process streams and policy windows, this memo attempts to show how effective coupling of multiple process streams occurred in a policy window opened by the financial crisis of 2008 and the subsequent victories of the Democratic Party in the race for the House of Representatives, the Senate, and the Presidency.
The Decision Agenda and Process Streams
Kingdon defines the governmental agenda as a “list of subjects to which people in and around government are paying serious attention at any given point in time,” (Kingdon 166) while defining the decision agenda as a “smaller set of items that is being decided upon” (Kingdon 166)—or a subset—within the framework of the governmental agenda. Having established this, it is easy to imagine that a policy issue like health care reform has been on the governmental agenda for an extended period of time; however, because of the “problem of infinite regress” (Kingdon 73) the origin of health care reform ideas is not specifiable nor is it important in this analysis. What is important, however, is the movement of health care reform policies onto the decision agenda in light of the Obama campaign and presidency, and the questions that this movement presents about the path to prominence of health care reform legislation. Kingdon’s three process streams—those of problem recognition, formation and refinement of policy proposals, and politics (Kingdon 87)—help to address these questions and generate some understanding of a federal government system described as “organized anarchy” (Kingdon 85).
The Problem of Health Care
First, with respect to the problems stream, it is clear that health care reform has been on the governmental agenda for a long-time and that health care costs have—with minor exceptions—continued to steadily increase over the years (Census Report 22). Within the time period discussed, a look at a U.S. Census Bureau report from 2009 verifies the number of uninsured Americans at a shocking 46.3 million people, or over 15% of the population (Census Report 22). Furthermore, “while there is consensus that the American health care system is bloated with waste,” (Sack) there is also the reality that the necessary solutions to a host of problems “have proved intractable for decades” (Sack). Staggering figures such as the ones mentioned above and general consensus among experts makes it rather apparent that a problem existed in the American health care sector. Nonetheless, the problem stream in and of itself simply does not sufficiently explain why health care reform suddenly moved onto the decision agenda. By looking at the policy proposal and political streams, however, further understanding and insights can be gained.
Finding a Healthy Proposal
With respect to the formation and refinement of policy proposals, health care reform was no newcomer. Potential solutions to health care issues and health care reform had been proposed at least as far back as the 1920’s and had also been considered—but omitted—from the New Deal in 1934 (Goodridge). However, in the time frame relevant for this memorandum, June 5th 2009 marked the date when Senator Edward Kennedy began to float specific legislation that indicated the desire to reform the health care system in a way that would provide all Americans with access to “’essential health care benefits,’ with no annual or lifetime limits” (Pear). While it is not fully clear why this health care reform proposal arose as the most salient, this memorandum suggests that Edward Kennedy—as the policy entrepreneur behind the suggest proposal— identified the post-financial crisis timeframe as an opportune moment to tackle a controversial issue like health care. Of course, Edward Kennedy was not the only one among the “policy community of specialists” (Kingdon 87) concentrated on generating proposals that would address the nation’s health care problems. For example, the head of the Senate Finance Committee Senator Max Baucus—also a Democrat—was another one of the many politicians and bureaucrats at the forefront of a new push to reform health care (Pear). Typical of the policy stream, some of these proposals were ignored, while others were taken more seriously and eventually merged into what became Patient Protection and Affordable Health Care Act of 2010.
Everything is Politics
Nevertheless, the politics stream played and continues to play a major role in all things related to the movement of policy concerns onto the decision agenda. The political stream—“composed of things like swings of national mood, vagaries of public opinion, election results, changes of administration, shifts in partisan or ideological distributions in Congress, and interest group pressure campaigns” (Kingdon 87)—profoundly impacted the emergence of health care reform as a top priority in the decision agenda. The electoral cycle of 2008 saw a massive ideological shift within both houses of Congress that drastically changed the partisan and ideological distribution, and brought to power an administration that sharply broke from the policies of the Bush administration that preceded it. Policymakers had every opportunity to latch on to this evident swing in the national mood following a presidency marked by two unpopular wars and an economic crisis. Thus, Democrats effectively exploited the events within the political stream and were able to win majorities in both the House and Senate, along with the presidency.
The Window of Opportunity
While the three process streams discussed above developed quite independently of one another, it is arguable that “the key to understanding agenda and policy change” (Kingdon 88) is through the coupling of two or more of these process streams. With this concept in mind, a clearer understanding of why health care reform suddenly became an issue that was “really getting hot” (Kingdon 166) can be explained by the concept of a “policy window”—or the appearance of an “opportunity for advocates of proposals to push their pet solutions, or to push attention to their special problems” (Kingdon 165). The eventual passage of the Patient Protection and Affordable Health Care Act renders it clear that a policy window indeed existed that allowed for the coupling of multiple process streams and resulted in sweeping reform legislation. First, the fact that “the economy faltered, and attention focused on Wall Street and Detroit” (On Health) created the political space necessary for the major political and ideological shift that swept Washington in the wake of the 2008 elections. Second, the opening of this policy window allowed for the subsequent coupling of all three of the process streams. The fact that the Obama administration was able to elevate the problem of health care costs onto the decision agenda by prioritizing it publicly, the fact that this administration then embraced policy proposals and experienced policy entrepreneurs such as Hillary Clinton and Edward Kennedy, and the fact that it brought into office majorities in both Houses of Congress, were made possibly only by the opening of this window. The notion that “policy windows open infrequently, and do not stay open long” (Kingdon 166) is also evidenced by the media’s surprise at the pace of movement of this policy and the suggestion that “few in the Obama administration would have predicted late last year that they would be this well positioned by June to achieve a major victory on health care” (On Health). Moreover, many in Washington, including White House budget director Peter Orszag, were quick to recognize that “politics and economics have converged to spark such momentum” (On Health) and that “you have industry groups that are cognizant of the need to make changes, members of Congress who have been preparing for this moment and a president quite committed to doing it. It is a rare alignment of forces” (On Health).
Ultimately, it seems that the policy window opened by the economic crisis of 2008 and the subsequent election created the necessary—and rare—coupling of multiple process streams that resulted in the eventual signing of the Patient Protection and Affordable Health Care Act on March 23, 2010.
Works Cited
Goodridge, Elisabeth. "A History of Overhauling Health Care - Interactive Feature - NYTimes.com." The New York Times - Breaking News, World News & Multimedia. 08 Apr. 2011. Web. 08 Apr. 2011. <http://www.nytimes.com/interactive/2009/07/19/us/politics/20090717_HEALTH_TIMELINE.html>.
"Income, Poverty, and Health Insurance Coverage in the United States: 2008." Census Bureau. Web. 8 Apr. 2011. <http://www.census.gov/prod/2009pubs/p60-236.pdf>.
Kingdon, John W. "Chapter 4, Chapter 8." Agendas, Alternatives, and Public Policies. Print.
"On Health Care, Obama Tries to Seize the Moment." New York Times. Web. 8 Apr. 2011. <http://www.nytimes.com/2009/06/19/us/politics/19reform.html>.
Pear, Robert. "Sweeping Health Plan Is Drafted by Kennedy - NYTimes.com." The New York Times - Breaking News, World News & Multimedia. 08 Apr. 2011. Web. 08 Apr. 2011. <http://www.nytimes.com/2009/06/06/health/policy/06health.html>.
Sack, Kevin. "Health Plan From Obama Spurs Debate - NYTimes.com." The New York Times - Breaking News, World News & Multimedia. 08 Apr. 2011. Web. 08 Apr. 2011. <http://www.nytimes.com/2008/07/23/us/23health.html?_r=1>.
