peterson slides.2.20.09
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Is This the Era of Health Care Reform?Is This the Era of Health Care Reform?Why This Time is Different from All Why This Time is Different from All
Other TimesOther Times
Mark A. Peterson, Ph.D.Professor of Public Policy and Political Science
Department of Public PolicyUCLA School of Public Affairs
Leonard Davis Institute of Health Economics Health Policy Seminar Series
University of PennsylvaniaFebruary 20, 2009
The easy out: This time is not different
But not so fast…is there a reason to anticipate that this time is different?
The Policy Window and Possible Triggers(Based on John W. Kingdon, Agendas, Alternatives, and Public Policies)
Po
licyP
olicy
Politics
Politics Problems
Problems
Policy Policy WindowWindow
Major Crisis?(health care system/economic system?)
Change in Administration
(2008)
Change in Congress (2006, 2008)
Viable Policy Options(but no consensus)
Systematic Signs of Decline or
Missed Opportunities
Swing in the National Mood
Social Movement?
Policy Image?
Power of Ideas?
Rearrangement of Interest Group
Alliances?
“Google” the term “health care crisis”:
Over 500,000500,000 hits
Costs Coverage Consequence
Int’lMea-sures
HCInfla-tion
Gov’tSpend
Bus.Spend
Indiv’lSpend
Un-insured
Under-insured
Dispar-ities
Quality/Outcomes
Int’lRank
PopHealth
1912 0 0 0 0 - 0 0 0 0 0 -
FDR 0 0 0 0 -- -/0 0 0 0 0 0
Truman 0 0 0 0 -+? -+ -+ 0 0 0 0
Nixon/Ford
0 - - -? -+ -(+) - 0 0 0 0
Carter 0? -- --? -? -+ -(+) - 0 0 0 0
Clinton -- -- -- -- -- -- - -- - - 0
Now -- -- -- -- -- -- -- -- -- -- -
0 = No evidence or limited perception of problem - = widely recognized evidence of problem-- = evidence of problem and getting worse -+ = evidence of problem but getting better
Rational Responses to Health Care System Problems?
© Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,” book manuscript.
Institutional-Political-Economic-Policy Contexts
• The Institutional Context
• The Political Context
• The Economic Context
• The Policy Context
• Presidential/Administration Leadership
From: Mark A. Peterson, Legislating Together: The White House and Capitol Hill from Eisenhower to Reagan (Harvard University Press, 1990).
Institutional-Political-Economic-Policy Contexts
• The Institutional Context– Congress
Mark A. Peterson, Legislating Together: The White House and Capitol Hill from Eisenhower to Reagan (Harvard University Press, 1990).
Types of Legislative Structure - Policy Effects
Policy Effects Centralized Decentralized Fragmented
Promotes Policy Change
Threatens Policy Change
Legislative Majority Favors
Change
Legislative Majority Opposes Change
Supportive Chairs and
Committees as Protocoalitions
Antagonistic Chairs
Exercise Baronial Veto
Multiple Coalition Strategies
Issue Complexity Reinforces
Fragmentation
© Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,” book manuscript.
Structure of the House of Representatives During Four Periods of Reform Debates
Decentralization
Centralization
Fragmentation
Fragmentation
Centralization
Decentralization
Fragmentation
Centralization
Decentralization
Centralization
Decentralization
Fragmentation
1940s (Truman) 1970s (Nixon/Ford/Carter)
1993-94 (Clinton) Now (Obama)
The Senate?The Senate?© Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,” book manuscript.
Institutional-Political-Economic-Policy Contexts
• The Institutional Context– Congress– Interest Groups
Mark A. Peterson, Legislating Together: The White House and Capitol Hill from Eisenhower to Reagan (Harvard University Press, 1990).
Changing Interest Group Communities
PolicyMonopoly(1940s)
Polarized(1970s)
Fragmented(Open to multiple
coalition strategies)
(1990s, Now?)
“The Challengers”
Poorly Mobilized Well Mobilized
“Th
e E
xis
tin
g S
tak
eho
lde
rs”
Allied
Split
© Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,” book manuscript.
Interest Group Positions on Clinton’s Health Security Act
0
10
20
30
40
50
60
70
Perc
ent
GOP Target Groups
Neither
Dem Target Groups
© Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,” book manuscript.
Institutional-Political-Economic-Policy Contexts
• The Institutional Context– Congress– Interest Groups
• The Political Context– Presidential Election Returns
Mark A. Peterson, Legislating Together: The White House and Capitol Hill from Eisenhower to Reagan (Harvard University Press, 1990).
Election Results Supporting the President
First Election of the President—Popular Vote Percentage
0
10
20
30
40
50
60
70
% Popular Vote
Perc
ent
FDR 1932Eisenhower 1952Obama 2008Clinton 1992
Institutional-Political-Economic-Policy Contexts
• The Institutional Context– Congress– Interest Groups
• The Political Context– Presidential Election Returns– Congressional Election Returns
Mark A. Peterson, Legislating Together: The White House and Capitol Hill from Eisenhower to Reagan (Harvard University Press, 1990).
Democratic and Republican Seats in the U.S. House
Democratic and Republican Seats in the U.S. Senate
Cloture (1917-74)
Cloture (1975 - )
Party Unity U.S. House and SenateFrom Nolan McCarty, Keith T. Poole, and Howard Rosenthal, Polarized America: The Dance of
Ideology and Unequal Riches (MIT 2006) [http://polarizedamerica.com/]
Comparison of Three Democratic Presidents and “Solid Votes” (Majority = 218)
President First Year Democratic SeatsDemocratic Party
Unity“Solid Votes”
Carter 1977 292 X .67 195
Clinton 1993 258 X .85 219
Obama 2009 257 X .96(110th Congress)
247
Economic Stimulus: 246
© Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,” book manuscript.
Net Change in Number of Democratic Congressional Seats
-10
0
10
20
30
40
50
60
Net Change House Seats Net Change Senate Seats
Nu
mb
er o
f S
eats
1990+1992 2006+2008
Institutional-Political-Economic-Policy Contexts
• The Institutional Context– Congress– Interest Groups
• The Political Context– Presidential Election Returns– Congressional Election Returns– Public opinion
Mark A. Peterson, Legislating Together: The White House and Capitol Hill from Eisenhower to Reagan (Harvard University Press, 1990).
Timing—Dynamism of Domestic Policy Mood Updated from James A. Stimson, Public Opinion in America: Moods, Cycles, and Swings, 2nd Ed.
Boulder: Westview 1999 (updated data set—Mood5204.xls—at www.unc.edu/~jstimson)
Most individuals in the United States currently get health insurance coverage through their employer or through a family member’s employer. Some people believe that employer-based health insurance is an effective way to provide health coverage and will remain so in the future. Other people believe that the employer-based approach will not continue to work in the future because of changes in our economy. When thinking about the future of employer-based insurance, for each of the following statements do you think the issue is--Not a problem for employer-based insurance; A potential threat to employer-based insurance; Certain to lead to the failure of employer-based insurance; or Don’t know? (Pre-Election Survey)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Multiple Employers inCourse of Work Life
Rising Cost of HealthCare
Decline of LargeManufacturers
Fewer EmployersProvide Coverage
Not a Problem Potential Threat Certain Failure Don't Know
Source: Blue Sky module, UCLA Team, 2006 Cooperative Congressional Election Survey, N=1,000
Public Support for Major Health Care System Change
0
10
20
30
40
50
60
70
80
90
100
1982 1984 1988 1990 1993 1994(9/94)
1998 2000 2006
Per
cent
Defeat of Clinton’s HSA
People have different views about what affects their own health and the health of their families. Some people believe that health is an individual matter, determined by their own preferences, decisions, and actions (“we’re on our own”). Let’s say that they are 1 on a five-point scale. Other people believe that health is a community matter, with their own health affected by the health and well-being of others (“we’re in this together”). Let’s say that they are 5 on the five-point scale. On the scale below, please indicate where you would place yourself. (Pre-Election Survey)
0
5
10
15
20
25
30
35
40
We're on OurOwn
2 3 4 We're in thisTogether
Perc
en
t
11%
Source: Blue Sky module, UCLA Team, 2006 Cooperative Congressional Election Survey, N=1,000
The truly Rugged
Individualists
When you consider the best way to think about health care services (provided by doctors, nurses, other health professionals, clinics, hospitals, etc.), which one of the following three statements comes closest to your own opinion? Health care services are “private goods” that people should buy somewhat like cars and televisions, and based on what they can afford; Basic health care services that should be available to everyone, like public education, but people who can afford to should be able to buy more or better care, similar to paying for private schools; or All effective health care services should be universally available, provided to everyone as a right of citizenship and based on the services they need. (Pre-Election Survey)
11
34
50
5
0
10
20
30
40
50
60
Private Goods Basic Servicesfor All
Provided as aRight
Don't Know
Perc
en
t
Source: Blue Sky module, UCLA Team, 2006 Cooperative Congressional Election Survey, N=1,000
Institutional-Political-Economic-Policy Contexts• The Institutional Context
– Congress– Interest Groups
• The Political Context– Presidential Election Returns– Congressional Election Returns– Public opinion
• The Economic Context– Growing Resources vs. 0-sum constraint vs. Crisis
Mark A. Peterson, Legislating Together: The White House and Capitol Hill from Eisenhower to Reagan (Harvard University Press, 1990).
Resources and the Politics of Policy Change
Growing Economy/Rising Revenues
Economic CrisisStagnant Economy/ Budget Deficits
Pro
spec
ts f
or
Maj
or
Po
licy
Ch
ang
e
LBJ
Nixon,Carter,Clinton
(1993-94)
FDR,[Reagan],
Obama
© Mark A. Peterson
Institutional-Political-Economic-Policy Contexts• The Institutional Context
– Congress– Interest Groups
• The Political Context– Presidential Election Returns– Congressional Election Returns– Public opinion
• The Economic Context– Growing Resources vs. 0-sum constraint vs. Crisis
• The Policy Context-- Regulatory & Redistributive: high conflict
• Presidential LeadershipMark A. Peterson, Legislating Together: The White House and Capitol Hill from Eisenhower to Reagan (Harvard University Press, 1990).
Political Hurdle #1:Ideological Positions on House Roll Call Votes, 93rd Congress (1973-74)
0
10
20
30
40
50
60
70
-1 -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8 1
DW-Nominate Scores (1st Dimension)
Num
ber
of R
epre
sent
ativ
es
RepublicansDemocrats
Source: Gary Jacobson, “Public Opinion and the Impeachment of Bill Clinton,” 1999.
About 1/3 could be either Dem or GOP
Political Hurdle #1:Ideological Positions on House Roll Call Votes, 110th Congress (2007-08)
(Source: Poole and Rosenthal, http://voteview.uh.edu/dwnomin.htm)
0
10
20
30
40
50
60
70
-1 -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8 1
DW-Nominate Scores (1st Dimension)
Num
ber
of R
epre
sent
ativ
es
RepublicansDemocrats
4 of the 5 defeated in 2008
15 of the 26 defeated/departedIn 2008
Political Hurdle #2:The Fear Arc
Time
© Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,” book manuscript.
IssueVisible “Polled” Attitude
Model CModel C
Implication 9
Implication 7
Implication 8
Model BModel B
Implication 6Implication 6
Implication 4Implication 4
Implication 5Implication 5
Model AModel A(current dominant)(current dominant)
Implication 3Implication 3
Implication 1Implication 1
Implication 2Implication 2
© 2006 Frameworks Institute—Susan Bales and Frank Gilliam
Strategy: Without Framing and Reframing—People Default to the Dominant “Pictures in their heads”
IssueVisible “Polled” Attitude
PreventionPrevention
Healthy others mean healthier me
Stay healthy
Self financing
Inter-dependent
Current system inefficient and unreliable
Every one is in this togetherEvery one is in this together
Need an infrastructureNeed an infrastructure
ConsumerConsumer
Reform: “Do me no harm”Reform: “Do me no harm”
Private goodPrivate good
Personal cost issuePersonal cost issue
© 2006 Frameworks Institute—Susan Bales and Frank Gilliam (amended)
Strategy: Without Framing and Reframing—People Default to the Dominant “Pictures in their heads”
The Individual Cognitive Process
• Duality of Individuals’ Information ProcessingBased on Drew Westen, The Political Brain (PublicAffairs, 2007)
– “Rational”
But also…
– “Emotional”• Kahneman and Tversky: “Prospect Theory”
People Need Values Cues(Based on George Lakoff)
Level One: Big ideas (and Emotional Connectons), like freedom, individual rights/responsibilities, justice, prevention, family, equality, security, and opportunity
Level Two: Issue-types, like women’s rights, the environment, children’s issues, work, health care
Level Three: Specific proposals, like the earned income tax credit, day care, minimum wage, individual health insurance mandate
© 2006 Frameworks Institute—Susan Bales and Frank Gilliam
Th
is D
irec
tio
n D
oes
No
t W
ork
Retooling Obama's campaign machine for the long haulThe vast network that helped elect Obama will be tapped to lobby lawmakers on behalf of the president, with an eye toward reelection. A service organization as a nonprofit arm is also considered.
By Peter Wallsten
January 14, 2009
Reporting from Washington — As Barack Obama builds his administration and prepares to take office next week, his political team is quietly planning for a nationwide hiring binge that would marshal an army of full-time organizers to press the new president's agenda and lay the foundation for his reelection.
The organization, known internally as "Barack Obama 2.0," is being designed to sustain a grass-roots network of millions that was mobilized last year to elect Obama and now is widely considered the country's most potent political machine.
Organizers and even Republicans say the scope of this permanent campaign structure is unprecedented for a president. People familiar with the plan say Obama's team would use the network in part to pressure lawmakers -- particularly wavering Democrats -- to help him pass complex legislation on the economy, healthcare and energy.
Retooling Obama's campaign machine for the long haulThe vast network that helped elect Obama will be tapped to lobby lawmakers on behalf of the president, with an eye toward reelection. A service organization as a nonprofit arm is also considered.
By Peter Wallsten
January 14, 2009
Reporting from Washington — As Barack Obama builds his administration and prepares to take office next week, his political team is quietly planning for a nationwide hiring binge that would marshal an army of full-time organizers to press the new president's agenda and lay the foundation for his reelection.
The organization, known internally as "Barack Obama 2.0," is being designed to sustain a grass-roots network of millions that was mobilized last year to elect Obama and now is widely considered the country's most potent political machine.
Organizers and even Republicans say the scope of this permanent campaign structure is unprecedented for a president. People familiar with the plan say Obama's team would use the network in part to pressure lawmakers -- particularly wavering Democrats -- to help him pass complex legislation on the economy, healthcare and energy.
© Los Angeles Times
Presidents in Political Time(Stephen Skowronek, The Politics Presidents Make: Leadership from John Adams to Bill Clinton)
• Reconstruction of the political order– FDR– [Reagan]
– Obama?• Articulation of the political order
– LBJ
• Preemption of the political order– Nixon– Clinton
• Disjunction of the political order– Hoover– Carter– [Bush II?]
http://www.blueskyhealthinitiative.org/