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CHAPTER
83
3THE PROCESS OF HEALTH POLICYMAKING Learning Objectives
After reading this chapter, you should be able to
• appreciate some of the important frameworks and theories about policymaking;
• define the stages heuristic policymaking framework; • draw a schematic model of the phases of the policymaking process; • understand the relationship between the policymaking process and its
external environment; • discuss the agenda setting and development of legislation activities of
policy formulation; • discuss the designing, rulemaking, operating, and evaluating activities
of policy implementation; • discuss the modification phase of policymaking; • discuss how the phases of policymaking interact with one another; and • appreciate the political nature of policymaking.
W hether health policies take the form of laws, rules or regulations, implementation decisions, or judicial decisions, all policies are authoritative decisions made through a complex process. The most
important thing to understand about policymaking is that it is a decision- making process. This chapter describes this process. As we will see, with certain variations policies at the federal, state, and local levels of government are made through similar decision-making processes (Bovbjerg, Wiener, and Houseman 2003).
Having considered the context in which health policies are made in the previous chapter (in particular the structure and operations of policy markets), and having identified the demanders and suppliers who interact in these markets and the important operational aspects of these interactions, consideration of the intricate process through which public policies are made is now possible. The discussion begins in this chapter at the conceptual level and includes a schematic model of the core policymaking process; applied
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C o p y r i g h t 2 0 1 6 . H e a l t h A d m i n i s t r a t i o n P r e s s .
A l l r i g h t s r e s e r v e d . M a y n o t b e r e p r o d u c e d i n a n y f o r m w i t h o u t p e r m i s s i o n f r o m t h e p u b l i s h e r , e x c e p t f a i r u s e s p e r m i t t e d u n d e r U . S . o r a p p l i c a b l e c o p y r i g h t l a w .
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H e a l t h P o l i c y m a k i n g i n t h e U n i t e d S t a t e s84
discussions of the component parts of the policymaking process follow in subsequent chapters.
Conceptual Frameworks and Theories of Policymaking
As a precursor to discussing any model of the public policymaking process, consideration of some of the important frameworks and theories that have guided inquiry about how the process works will be useful. Frameworks guide inquiry by organizing elements and relationships among elements that may lead to theory development (Ostrum, Cox, and Schlager 2014). Theories, which are more specific than frameworks, postulate testable relationships between variables (Walt et al. 2008).
Both frameworks and theories are useful devices, but it must be admitted at the outset that there is no universally agreed-upon framework or theory about how the public policymaking process works. Instead, there are many frameworks of and theories about the process (Sabatier and Weible 2014), each offering only a partial explanation of public policymaking. We will review some of the most important and enduring ones and select relevant and workable frameworks and theories around which to structure a model of the policymaking process.
Stages Heuristic The best known of the policymaking frameworks is the stages heuristic, which is attributable to early work by Lasswell (1956). The policymaking process model presented later in this chapter is heavily influenced by this framework. The framework essentially views policymaking as occurring in four stages: agenda setting, formulation, implementation, and evaluation. The framework has been legitimately criticized for oversimplifying reality but remains useful for thinking about the policymaking process.
Among alternatives to the stages heuristic, Walt and Gilson (1994) developed the policy triangle framework, which considers how actors, con- text, and processes interact to produce policy. Another framework, networks, evolved to help explain the way growing numbers of actors interact around policy issues (Sabatier and Weible 2014). Policy communities, described in Chapter 2, are simply tightly knit networks.
Multiple-Streams and Punctuated-Equilibrium Theories Theories, which as noted earlier are more focused than frameworks, have been developed to explain certain aspects of the policymaking process. Among the most important policymaking theories are Kingdon’s (2010)
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85C h a p t e r 3 : T h e P r o c e s s o f H e a l t h P o l i c y m a k i n g
multiple-streams theory and Baumgartner and Jones’s (1993) punctuated- equilibrium theory. The multiple-streams theory, which focuses on agenda setting, postulates that problems, possible solutions, and politics flow along in separate streams in our society. Sometimes the streams merge and the confluence creates a window of opportunity for government to engage in policymaking. The punctuated-equilibrium theory postulates that policy- making typically proceeds in small incremental steps that can be disrupted by bursts of rapid transformation. The enactment of Medicare and Med- icaid in 1965 and the passage of the Affordable Care Act (ACA) decades later are examples of the phenomenon of punctuated-equilibrium in the health domain.
A Core Model of the Public Policymaking Process
Incorporating some of the frameworks and theories noted previously and adding other components, we can diagram the complex and intricate process through which public policymaking occurs. Remember, the most important attribute of this process is that it is a decision-making process. Although such schematic models tend to be oversimplifications, they can accurately reflect the component parts of the process and their interrelationships. Exhibit 3.1 is a model of the public policymaking process in the United States. This model depicts the policymaking process as it occurs at federal, state, and local levels of government. We discuss the component parts of the model in the following sections and then in greater detail in subsequent chapters. As can be seen in the model, policymaking occurs in three interrelated and cyclical phases: formulation, implementation, and modification. Each of these phases of policy making at the federal level is described in the following sections.
Formulation Phase
The formulation phase of health policymaking is made up of two distinct and sequential parts: agenda setting and development of legislation. Each part involves a set of activities in which policymakers and those who would influence their decisions and actions engage. The formulation phase results in policy in the specific form of new public laws or the far more likely result of amendments to existing laws. In other phases of the process, policies emerge in the forms of rules and regulations and other implementation decisions; policies in the form of judicial decisions can emerge from throughout the entire process.
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H e a l t h P o l i c y m a k i n g i n t h e U n i t e d S t a t e s86
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87C h a p t e r 3 : T h e P r o c e s s o f H e a l t h P o l i c y m a k i n g
Agenda Setting The public laws or amendments pertaining to health are initiated by the inter- actions of diverse health-related problems, possible solutions, and dynamic political circumstances that relate to the problems and to their potential solutions. Before the policymaking process can progress, some mechanism must initiate the emergence of certain problem–solution combinations and their subsequent movement through the development-of-legislation process. In essence, this step is deciding what to make decisions about within the policymaking process.
At any given time, there are many problems or issues related to health. Many of them have possible solutions that are apparent to policymakers. Often these problems have alternative solutions, each of which has its sup- porters and detractors. Diverse political circumstances surround the actual problems and potential solutions. Agenda setting, a crucial initial step in the policymaking process, describes the ways in which particular combinations of problems, possible solutions, and political circumstances emerge and advance to the next stage. Agenda setting is discussed in depth in Chapter 5.
Development of Legislation Once a problem or issue that might be addressed through public policy rises to a prominent, possibly actionable place on the policy agenda—through the confluence of the problem’s identification, the existence of possible policy solutions, and the political circumstances surrounding the problem and its potential solutions—it can, but does not necessarily, proceed to the next point in the policy formulation phase, development of legislation. Kingdon (2010) describes the point at which problems, potential solutions to them, and political circumstances converge to stimulate legislation development as a window of opportunity (see Exhibit 3.1).
At this second step in policy formulation, policymakers propose spe- cific legislation. One can think of these proposals, or bills as they are techni- cally called, as hypothetical or unproven solutions to the problems they are intended to address. The proposals then go through carefully prescribed steps that can, but do not always, lead to policies in the form of new public laws or, more often, amendments to previously enacted laws. The steps in the develop- ment of legislation, also called the legislative process, are listed in Exhibit 3.2.
Only a small fraction of the problems, health-related or otherwise, that might be addressed through public policy ever emerge from agenda setting with sufficient impetus to advance them to legislation development. And even when they do, only some of the attempts to enact legislation are success- ful. The path of legislation—that is, of policy in the form of new public laws or amendments to existing laws—can be long and arduous (Hacker 1997). The details of this path that pertain to agenda setting are described more fully
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H e a l t h P o l i c y m a k i n g i n t h e U n i t e d S t a t e s88
Introduction
Anyone may draft a bill; however, only members of Congress can introduce legis- lation, and by doing so become the sponsor(s). There are four basic types of leg- islation: bills, joint resolutions, concurrent resolutions, and simple resolutions. The official legislative process begins when a bill or resolution is numbered— H.R. signifies a House bill and S. a Senate bill—referred to a committee and printed by the Government Printing Office.
Step 1. Referral to Committee
With few exceptions, bills are referred to standing committees in the House or Senate according to carefully delineated rules of procedure.
Step 2. Committee Action
When a bill reaches a committee it is placed on the committee’s calendar. A bill can be referred to a subcommittee or considered by the committee as a whole. At this point, a bill is examined carefully and its chances for passage are deter- mined. The committee not acting on the bill is the equivalent of killing it.
Step 3. Subcommittee Review
Often, bills are referred to a subcommittee for study and hearings. Hearings provide the opportunity to put on the record the views of the executive branch, experts, other public officials, supporters and opponents of the legislation. Testi- mony can be given in person or submitted as a written statement.
Step 4. Mark Up
When the hearings are completed, the subcommittee may meet to “mark up” the bill, that is, make changes and amendments prior to recommending the bill to the full committee. If a subcommittee votes not to report legislation to the full committee, the bill dies.
Step 5. Committee Action to Report a Bill
After receiving a subcommittee’s report on a bill, the full committee can conduct further study and hearings, or it can vote on the subcommittee’s recommenda- tions and any proposed amendments. The full committee then votes on its rec- ommendation to the House or Senate. This procedure is called “ordering a bill reported.”
Step 6. Publication of a Written Report
After a committee votes to have a bill reported, the committee chairman instructs staff to prepare a written report on the bill. This report describes the intent and scope of the legislation, impact on existing laws and programs, posi- tion of the executive branch, and views of dissenting members of the committee.
Step 7. Scheduling Floor Action
After a bill is reported back to the chamber where it originated, it is placed in chronological order on the calendar. In the House there are several different
EXHIBIT 3.2 The
Development of Legislation or
the Legislative Process at the
Federal Level
(continued)
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89C h a p t e r 3 : T h e P r o c e s s o f H e a l t h P o l i c y m a k i n g
legislative calendars, and the Speaker and majority leader largely determine if, when, and in what order bills come up. In the Senate there is only one legislative calendar.
Step 8. Debate
When a bill reaches the floor of the House or Senate, there are rules or proce- dures governing the debate on legislation. These rules determine the conditions and amount of time allocated for general debate.
Step 9. Voting
After the debate and the approval of any amendments, the bill is passed or defeated by the members voting.
Step 10. Referral to Other Chamber
When a bill is passed by the House or the Senate, it is referred to the other chamber, where it usually follows the same route through committee and floor action. This chamber may approve the bill as received, reject it, ignore it, or change it.
Step 11. Conference Committee Action
If only minor changes are made to a bill by the other chamber, the legislation commonly goes back to the first chamber for concurrence. However, when the actions of the other chamber significantly alter the bill, a conference committee is formed to reconcile the differences between the House and Senate versions. If the conferees are unable to reach agreement, the legislation dies. If agreement is reached, a conference report is prepared describing the committee members’ recommendations for changes. Both the House and the Senate must approve of the conference report.
Step 12. Final Actions
After a bill has been approved by the House and Senate in identical form, it is sent to the President. If the President approves of the legislation he/she signs it and it becomes law. Or, the President can take no action for ten days, while Con- gress is in session, and it automatically becomes law. If the President opposes the bill he/she can veto it; or, if he/she takes no action after the Congress has adjourned its second session, it is a “pocket veto” and the legislation dies.
Step 13. Overriding a Veto
If the President vetoes a bill, Congress may attempt to “override the veto.” To override the veto requires a two-thirds roll call vote of the members who are present in sufficient numbers for a quorum. See more at congress.org/ advocacy-101/the-legislative-process.
Source: Congress.org (2014). Reprinted with permission.
EXHIBIT 3.2 The Development of Legislation or the Legislative Process at the Federal Level (continued)
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H e a l t h P o l i c y m a k i n g i n t h e U n i t e d S t a t e s90
in Chapter 5, and those that pertain to the development of legislation are discussed more fully in Chapter 6.
Implementation Phase
When the formulation phase of policymaking yields a new or amended public law, enactment of legislation marks a transition from formulation to imple- mentation, although the boundary between the two phases is porous. The bridge connecting formulation and implementation in the center of Exhibit 3.1 is intentionally shown as a two-way connector.
The implementation phase of policymaking, including a discussion of the responsibility for implementation, is described here and in more depth in Chapters 7 and 8. As can be seen in Exhibit 3.1, policy implementation unfolds in a series of interrelated steps: designing, rulemaking, operating, and evaluating. These steps are briefly described in this section. First, however, a few words about responsibility for implementation.
Implementing organizations, primarily the departments and agencies in the executive branch of federal and state governments, are established and maintained and the people within them employed to carry out the intent of public laws as enacted by the legislative branch. Legislators rely on implementers to bring their legislation to life. Thus, the relationship between those who formulate policies and those who implement them is symbiotic.
In short, health policies must be implemented effectively if they are to affect the determinants of health. Otherwise, policies are only so much paper and rhetoric. An implemented law can change the physical or social environment in which people live and work, affect their behavior and even their biology, and an implemented law can certainly influence the availability and accessibility of health services.
The implementation phase of public policymaking involves managing human, financial, and other resources in ways that facilitate achievement of the goals and objectives embodied in enacted legislation. Policy implementa- tion is primarily a management undertaking. That is, policy implementation in its essence is the use of resources to pursue the objectives inherent in public laws. This type of management is typically called public administration (Abramson and Lawrence 2014).
Depending on the scope of policies being implemented, the manage- rial tasks involved can be simple and straightforward, or they can require mas- sive effort. For example, President Johnson, who played a major role in both formulation and implementation of Medicare, observed that implementing the Medicare program represented “the largest managerial effort the nation
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91C h a p t e r 3 : T h e P r o c e s s o f H e a l t h P o l i c y m a k i n g
[had] undertaken since the Normandy invasion” (Iglehart 1992, 1468). More recently, implementation of the ACA is proving to be a monumental management undertaking (Jacobs and Skocpol 2012; Thompson 2013). No matter the scale, however, the implementation of public laws always involves the set of interrelated activities shown in Exhibit 3.1: designing, rulemaking, operating, and evaluating.
Designing The relationship among the activities in the implementation phase is essen- tially cyclical and interactive. As shown in Exhibit 3.1, implementation begins with designing, which entails establishing the working agenda of an implementing organization (e.g., the Food and Drug Administration), planning how to accomplish the work, and organizing the agency to per- form the work. This activity is rather straightforward management, which is defined as “the process, composed of interrelated social and technical functions and activities, occurring within a formal organizational setting for the purpose of helping establish objectives and accomplishing the predeter- mined objectives through the use of human and other resources” (Longest and Darr 2014, 255).
More detail about the designing activity is provided in Chapter 8, but suffice to say here that this implementation activity entails the traditional management functions: planning, organizing, staffing, directing (motivating, leading, and communicating), controlling, and decision making (Daft 2014). These interrelated functions, including how decision making intertwines with all the other functions, are shown and briefly described in Exhibit 3.3.
Rulemaking Again following Exhibit 3.1, the next step in the implementation phase of policymaking is rulemaking. Rules, which may also be called regulations, are specific detailed directives developed by implementing organizations in the executive branch. Rules are themselves policies because they are authoritative decisions made in the executive branch to implement laws and amendments. Recall from Chapter 1 that authoritative decisions refer to those made any- where within the three branches of government that are under the legitimate purview (i.e., within the official roles, responsibilities, and authorities) of those making the decisions. For example, rules promulgated to implement a law are as much policies as are the laws they support. Similarly, operational decisions made by implementing organizations, to the extent that they require or influence particular behaviors, actions, or decisions by others, are policies. Furthermore, decisions made in the judicial branch regarding the applicability of laws to specific situations or the appropriateness of the actions of implementing organizations are policies. By definition, policies
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H e a l t h P o l i c y m a k i n g i n t h e U n i t e d S t a t e s92
are established in both the formulation and implementation phases of the policymaking process.
The Clean Air Act, the Food and Drug Act, the Civil Rights Act, and, more recently, the ACA are all examples of landmark legislation requiring extensive rulemaking to guide their implementation. The rules promulgated to implement laws and amendments can undergo revision—sometimes exten- sive and continual revision—and new rules can be adopted as experience dictates. This characteristic of policymaking tends to make the process more dynamic than it would be otherwise.
The promulgation of rules is itself guided by certain rules and proto- cols set forth in legislation. Key among the rules of rulemaking is the require- ment that implementing agencies publish proposed rules, which gives those with interests in the issue an opportunity to participate in the rulemaking prior to the adoption of a final rule. Proposed and final rules are published
EXHIBIT 3.3 The Manage ment
Functions in an Implementing Organization
Source: Longest, B. B., Jr., and K. Darr. 2014. Managing Health Services Organizations and Systems, sixth edition. Baltimore, MD: Health Professions Press, 259. © 2014 by Beaufort B. Longest, Jr., and Kurt Darr. Reprinted by permission of Health Professions Press, Inc.
PLANNING Deciding in advance what is to be done
ORGANIZING Developing intentional patterns of relationships among people and other resources
CONTROLLING Regulating activities in accordance with plans
DIRECTING Initiating work in the organization
STAFFING Acquiring, maintaining, and retaining human resources
DECISION MAKING Choosing
between or among
alternatives
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93C h a p t e r 3 : T h e P r o c e s s o f H e a l t h P o l i c y m a k i n g
in the Federal Register, a daily publication of important official documents. The rulemaking process is discussed in more detail in Chapter 8.
Operating Continuing to follow the diagram presented in the implementation phase of Exhibit 3.1, implementation eventually requires those responsible to actually operationalize policies. If a policy in the form of a public law or an amend- ment to one is intended to protect people from exposure to toxic substances in their environments, for example, its operation entails the activities involved in actually providing such protection. Such activities would include measur- ing and assessing dangers from substances in the environment and imposing sanctions, such as against polluters. If the intent of legislation is to expand Medicaid enrollment, as is the case with the ACA, successful operation of this policy requires enrolling new people in the program.
The essence of the implementation phase of policymaking is that one or more organizations or agencies undertake the operation of enacted legisla- tion in accord with the design of how to do so and the rules established to guide operating the policy. As will be discussed more fully in Chapter 8, the operation of policies is affected by a number of variables, including the fit between implementing organizations and a policy’s objectives as well as the capabilities of the managers in the implementing organizations.
Evaluating The fourth core activity in implementing policy is evaluating (again, see Exhibit 3.1). This activity brings the other elements of implementation full circle and can lead to new rounds of designing, rulemaking, and operating policy. Evaluating, and using the results of evaluation, is an important activity in effective policy implementation.
Fundamentally, evaluating something means determining “its merit, worth, value, or significance” (Patton 2012, 2). Managers of implementing organizations approach this determination by asking questions such as: How effective is the policy, or some component of it? Were the policy’s objectives achieved? Do the benefits of the policy justify its costs?
Policy evaluation is defined as systematically collecting, analyzing, and using information to answer basic questions about a policy. There are numerous types of evaluations, including process and outcome evaluations, formative and summative evaluations, and cost–benefit and cost-effectiveness evaluations. Each of these types of evaluations has specific characteristics and uses, which are described more fully in Chapter 8.
The legislative and executive branches of government are involved in policy evaluation and other forms of analysis because they are interested
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H e a l t h P o l i c y m a k i n g i n t h e U n i t e d S t a t e s94
in the performance of the policies they enact and implement. A number of agencies support the evaluation activity at the federal level, including the Agency for Healthcare Research and Quality, which is currently involved in evaluating the ACA’s coverage expansions, and the Center for Medicare and Medicaid Innovation, which was established by the ACA to test innovative payment and service delivery models for Medicare, Medicaid, and the Chil- dren’s Health Insurance Program.
Modification Phase
As we have noted, policymaking is an intricate process. It is not a perfect process. Mistakes of omission and commission are routinely made in the formulation and implementation phases. The policymaking process model presented in Exhibit 3.1 is brought full circle by the third phase of the process, modification. This phase is necessary because perfection eludes policymakers in the formulation and implementation phases. Even policy decisions that are correct when they are made must adjust to accommodate changing circumstances.
In a hypothetical policymaking process without a modification phase, policies would be formulated in their original version and then implemented, and that would be the end of the process—except, of course, for the policies’ consequences. In practice, however, policymaking does not work this way. The consequences of policies—including consequences for those who formulate and implement the policies and for the individuals, organizations, and inter- est groups outside the process but affected by policies—cause people to seek modification. They do so continually throughout the life of many policies.
At a minimum, individuals, organizations, or interest groups that ben- efit from a particular policy may seek modifications that increase or maintain these benefits over time. Similarly, those who are negatively affected by a policy will seek to modify it to minimize the negative consequences. In addi- tion, when the policymakers who formulate and implement a public policy observe it in operation, they will evaluate it against their objectives for that policy. When preferences and reality do not match, efforts to modify the policy typically ensue.
Policies have histories. An initial version is formulated and then evolves as it is implemented, either through amendments to the original legislation or through new or revised rules and other implementation decisions. Some policies eventually die—they are repealed by the legislative branch—but most have long and dynamic lives during which they are continually modified in various ways. Chapter 9 addresses the policy modification phase of public policymaking in more detail.
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Key Features of the Policymaking Process
Having brought the policymaking process full circle, we can now turn our attention to several key features of the policymaking process that are espe- cially helpful in understanding this complicated process. The first of these features is the fact that policymaking does not take place in a vacuum. It occurs in the context of a dynamic external environment with which the pro- cess interacts in many ways. We will explore this feature, along with several others, in the following sections.
Policymaking Occurs in the Context of a Dynamic External Environment An important feature of the public policymaking process is the impact of fac- tors external to the process on policymaking and, in turn, the impact of the process on the larger environment. The impact of external factors is depicted in Exhibit 3.1 by the large double-headed arrows connecting each phase of the process to the external environment. The impact of external factors means the policymaking process is an open system, one in which the process interacts with—affects and is affected by—factors in its external environment.
The external environment in Exhibit 3.1 is shown to contain a number of important variables, including the situations and preferences of individuals, organizations, and groups, as well as biological, biomedical, cultural, demo- graphic, ecological, economic, ethical, legal, psychological, science, social, and technological variables. These environmental variables affect the poli- cymaking process and are affected by the policies produced by the process. Technology provides an example of an environmental variable that illustrates the two-way relationship between policymaking and the processes’ external environment.
The United States is the world’s major producer and consumer of health-related technology. As Exhibit 3.1 shows, technology variables flow into and out of the policymaking process. Technology is produced in part through public funding, and the policies that determine funding levels and priorities, and once in place various technologies must be factored into public and private insurance programs including Medicare and Medicaid. Medical technologies can be cost-increasing, neutral, or cost-saving but must be taken into account in establishing funding for publicly financed health services (Congressional Budget Office 2014; Sorenson, Drummond, and Bhuiyan Khan 2013).
Legal variables provide another example of the two-way relationship between policymaking and its external environment. As we discussed briefly in Chapter 1 and will discuss more fully in Chapter 4, authoritative decisions made within judicial branches of governments are themselves policies. In addition, however, decisions made within the legal system influence other
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decisions made within the larger policymaking process. Legal variables may help shape all other policy decisions, including by reversing them when they are unconstitutional.
The Phases of the Policymaking Process Are Interactive and Interdependent While the policymaking model shown in Exhibit 3.1 emphasizes the phases of the policymaking process, it also shows that they are highly interactive and interdependent. Exhibit 3.4 illustrates the interactive and interdependent nature of the three phases of policymaking in a different way.
Furthermore, within the phases, much of the activity is also interactive and interdependent. Designing for implementation—planning, organizing, staffing, directing (motivating, leading, and communicating), control- ling, and decision making—leads to rulemaking, which in turn guides the operation of policies, which can be evaluated and may lead to new rounds of designing, rulemaking, and operating.
The public policymaking process modeled in Exhibit 3.1 includes the following three interconnected phases:
1. Policy formulation, which incorporates activities associated with setting the policy agenda and, subsequently, with the development of legislation
2. Policy implementation, which incorporates activities associated with designing for implementation, rulemaking that helps guide the
Policy Formulation
Policy
Im plem
entation
Po lic
y
M od
ifi ca
tio n
EXHIBIT 3.4 The Interactive
and Inter- dependent
Relationships Among
the Policy Formulation,
Implemen- tation, and
Modification Phases of
Policymaking
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97C h a p t e r 3 : T h e P r o c e s s o f H e a l t h P o l i c y m a k i n g
implementation of policies, the actual operationalization of policies, and evaluation, which may lead to subsequent rounds of these activities
3. Policy modification, which allows for all prior decisions made within the process to be revisited and perhaps changed
Once enacted as laws, policies remain to be implemented. The formu- lation phase (making the decisions that lead to or amend public laws) and the implementation phase (taking actions and making additional decisions necessary to implement public laws) are bridged by the formal enactment of legislation, which shifts the cycle from the formulation to the implementa- tion phase.
Implementation responsibility rests mostly with the executive branch, which includes the Department of Health and Human Services (www.hhs.gov) and the Department of Justice (www.usdoj.gov), and independent federal agencies such as the Environmental Protection Agency (EPA; www.epa.gov) and the Consumer Product Safety Commission (www.cpsc.gov). These and many other departments and agencies in the executive branch exist primarily to implement the policies formulated in the legislative branch. This relation- ship between policy formulation and implementation is illustrated by the list of major federal laws that the EPA is responsible for implementing (see Appendix 9).
Authoritative decisions made in the course of policy implementation become policies themselves. Rules and regulations promulgated to imple- ment a law and operational protocols and procedures developed to support a law’s implementation are policies as surely as is the law itself. Similarly, judicial decisions regarding the applicability of laws to specific situations or regarding the appropriateness of the actions of implementing organizations are public policies. Policies are routinely established within the formulation and the implementation phases of the overall process.
The policy modification phase exists because perfection cannot be achieved in the other phases and because policies are established and exist in a dynamic world. Suitable policies made today may become inadequate with future biological, biomedical, cultural, demographic, ecological, economic, ethical, legal, psychological, science, social, and technological changes. Pres- sure to change established policies may come from new priorities or the perceived needs of individuals, organizations, and interest groups affected by the policies.
Policy modification, which is shown as two-direction arrows in Exhibit 3.1, may entail only minor adjustments in the implementation phase or mod- est amendments to existing public laws. In some instances, however, the con- sequences of implementing certain policies can feed all the way back to the
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agenda-setting stage. For example, formulating policies to contain the costs of providing health services—a continuing challenge facing policymakers today—is to a large extent an outgrowth of previous policies that expanded access and increased the supply of human resources and advanced technolo- gies to be used in providing health services.
Policymaking Is a Cyclical Process As Exhibit 3.1 illustrates, the policymaking process is a continuous cycle in which all decisions are subject to modification. Public policymaking is a pro- cess in which numerous decisions are reached and then revisited as circum- stances change. The continuously cyclical nature of health policymaking can be seen in the pattern of Medicare policy presented in Appendix 10, in which Medicare policy is revisited and modified on a regular basis.
Policymaking occurs in each of the three phases of interconnected activity. In reality, of course, all three phases are active simultaneously. At any point in time, in all levels of governments it is possible to find multiple poli- cies in the form of authoritative decisions being made in each of the three phases. The essence of the flow of these decisions, however, is cyclical: Policy in the form of laws and amendments is formulated, then implemented— which involves more policymaking in the form of designing, rulemaking, operating, and evaluating decisions, and finally, all decisions made in the for- mulation and implementation phases can be revisited and possibly modified. It helps all involved in the process or affected by the decisions resulting from policymaking to know of the cyclical nature of the process. There is comfort to be taken from the fact that the decisions made in the policymaking process are not final. There is always at least the potential to change unsatisfactory policies.
Policymaking Is a Highly Political Process One feature of the public policymaking process that the model presented in Exhibit 3.1 cannot adequately represent—but one that is crucial to under- standing the policymaking process—is the political nature of the process in operation (Weissert and Weissert 2012). In this process, all decisions are made by humans. Thus, various mixes of altruism and egoism influence what takes place. Human control of the public policymaking process means that its operation, outcomes, and consequences are directly affected by the eth- ics of those who participate in the process. Ethical considerations help shape and guide the development of new policies by contributing to definitions of problems and the structure of policy solutions.
While many people believe—and still others naively hope—that public policymaking is a predominantly rational decision-making process, this is not
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99C h a p t e r 3 : T h e P r o c e s s o f H e a l t h P o l i c y m a k i n g
the case. The process would no doubt be simpler and better if it were driven exclusively by fully informed consideration of the best ways for policy to sup- port the nation’s pursuit of health, by open and comprehensive debate about potential policies, and by rational selection from among policy choices strictly on the basis of ability to contribute to the pursuit of health, and all done by ethical decision makers.
Those who are familiar with the policymaking process, however, know that a wide range of other factors and considerations influence the process. The preferences and influence of interest groups, political bargaining and vote trading, and ideological biases are among the most important of these factors. This is not to say that rationality plays no part in health policymak- ing. However, it is, at best, only one of many considerations involved in the complex decision making that leads to policy.
The political nature of the policymaking process in the United States accounts for competing theories about how this process plays out. At the opposite ends of a continuum sit strictly public-interest and strictly self- interest theories of how policymakers behave. Policies made entirely in the public interest would be the result of all participants acting according to what they believe to be the public’s interest. Alternatively, policies made entirely through a process driven by self-interests would reflect the interplay of the various self-interests of the diverse participants. Policies resulting from these two hypothetical extremes would indeed be different.
In reality, however, health policies always reflect a mix of public-inter- est and self-interest influences. The balance between public- and self-inter- ests being served is important to the ultimate shape of health policies. For example, the present coexistence of the extremes of excess (the exorbitant incomes of some physicians and health plan managers, esoteric technologies, and various overcapacities in the healthcare system) and deprivation (lack of insurance for millions of people and inadequate access to basic health ser- vices for millions more) resulting from or permitted by some of the nation’s existing health policies suggests that the balance has been tipped too often toward the service of self-interests. As the ACA is more fully implemented, some of the disparities and gaps in access may be diminished. However, that is unlikely to take place on a large scale for years to come.
Public- and self-interest influences aside, public policymaking in the US health domain is a remarkably complex process, although clearly an imperfect one. The intricacies of the process are explored more thoroughly in subsequent chapters. In general, policymaking is a highly political process, it is continual and cyclical in its operation, it is heavily influenced by factors external to the process, and the component phases and the activities within the phases of the process are highly interactive and interdependent.
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H e a l t h P o l i c y m a k i n g i n t h e U n i t e d S t a t e s100
Summary
Health policies, like those in other domains, are made in the context of policy markets, where demanders for and suppliers of policies interact, as was described in Chapter 2. The federal, state, and to a lesser extent local govern- ments have important health policy roles, and their policymaking processes are similar.
Public policymaking in the health domain is a human process, a fact with great significance for the outcomes and consequences of the process and one that argues for ethical behavior and good judgment by all involved in the process.
The policymaking process itself, as depicted in Exhibit 3.1, is a highly complex, interactive, and cyclical process that incorporates formulation, implementation, and modification phases. These phases are outlined in this chapter and discussed in greater detail in subsequent chapters.
Review Questions
1. Draw a schematic model of the three phases of the public policymaking process.
2. Describe the general features of the model drawn in question 1. 3. Discuss the formulation phase of policymaking. 4. Discuss the implementation phase of policymaking. 5. Discuss the modification phase of policymaking.
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