How and why do agendas change?*

Health care – Clinton (1993-4) Health care – Obama (2009-10) Focusing events/national mood – recession; polls suggested

most people were reluctant to see wholesale policy change. Clinton relied on small, in-house expert group to craft proposal – led to charges of exclusivity.

Group dynamics – Health Insurance Association of America & hospital and pharmaceutical industries were uniformly opposed to policy change – used symbolic politics to mobilize against it. (“Harriet and Louise” ads).

Perceived costs – no single plan garnered a winning coalition; competition between single-payer plans, mandatory employer plans, insurance pool plans to bring down costs led to gridlock and made inaction least costly choice.

Jurisdictionality - an intense ideological debate erupted over whether the federal government had the responsibility to mandate universal insurance coverage.

*Jacob Hacker, 2010

Focusing events/national mood – deeper, more serious recession; polls suggested people wanted change. Media focused greater attention on health care interest groups & power – Obama set out general goals, let Senate/House craft details – messy, but inclusive.

Group dynamics – health care industry was divided; HIAA and pharmaceutical industry embraced affordability and coverage issues. AMA endorsed Senate plan so long as steep reductions in Medicare payments would not occur.

Perceived costs – Congressional Democrats felt political costs of inaction as too high – “window of opportunity” might not open again. Patient Protection and Affordable Health Care Act was a modest change from status quo.

Jurisdictionality - opponents conceded a federal role in coverage, differed on means. As courts deal with new law, one question that has arisen is – can federal government compel people to buy insurance?

New York Times - January 31, 2011

Federal Judge Rules That Health Law Violates ConstitutionBy By KEVIN SACK

A second federal judge ruled on Monday that it was unconstitutional for Congress to enact a health care law that required Americans to obtain commercial insurance, evening the score at 2 to 2 in the lower courts as conflicting opinions begin their path to the Supreme Court.

But unlike a Virginia judge in December, Judge Roger Vinson of Federal District Court in Pensacola, Fla., concluded that the insurance requirement was so “inextricably bound” to other provisions of the Affordable Care Act that its unconstitutionality required the invalidation of the entire law.

“The act, like a defectively designed watch, needs to be redesigned and reconstructed by the watchmaker,” Judge Vinson wrote.

The insurance mandate does not take effect until 2014. But many new regulations are already operating, like requirements that insurers cover children with pre-existing health conditions and eliminate lifetime caps on benefits. States are also preparing for a major expansion of Medicaid eligibility and the introduction of health insurance exchanges in 2014. . . . White House officials declared that the opinion should not deter the continuing rollout of the law. “Implementation would continue apace,” a senior administration official said. “This is not the last word by any means.”

On Capitol Hill, Republicans sent out a stream of e-mails praising the ruling, while Senator Richard J. Durbin, Democrat of Illinois, said he would convene a Judiciary Committee hearing on Wednesday to examine the constitutionality of the law.

Changing the rules may not change the game!

Since the “progressive era,” reformers have tried to thwart power of interest groups, and sub-governments, by encouraging direct legislation. In theory:

Can take advantage of shifts in public mood not reflected in legislatures due to election cycles, “safe” districts, policy inertia – a new means of agenda-setting.

Can encourage voter interest, restore trust in government, regain citizen efficacy in government, and provide greater transparency in decision-making.

In practice: Can only be done by states (federal constitution does not permit direct legislation – except through

special constitutional conventions); rarely attempted and often fails (e.g., Equal Rights Amendment).

Does not reduce power of interest groups; only shifts playing field from legislature to voters. In California, most ballot initiatives are funded by interest groups; often out-of-state, that employ advertising and symbolic names as means of influence.

New initiatives are often disconnected from older ones, reducing accountability & producing contradictory policies – new programs may not have designated revenue sources, but must be supported at prescribed level (e.g., community colleges).

Information and expertise as policy driver

Knowledge is source of power – we must know certain things to create & change policies: e.g.,

Can we clearly define problem? (e.g., children at risk of disease; environmental hazards posing a risk to species; families without health insurance).

Can we determine which solutions are most effective? (e.g., what tools and approaches help us identify the cheapest, most publically acceptable, least burdensome remedy?)

Can we measure whether the policy solution is working? (e.g., policy evaluation)

What constitutes relevant knowledge for policy depends on:

What do decision-makers and policy advocates want to use information for? Who (what institution/entity) produces/controls information?

Information and expertise are commodities

The policy analyst (a knowledge-broker who generates, uses, and applies policy-relevant information – Radin, 2000) is critical – s/he serves political ends:

NOT knowledge for knowledge’s sake, but responding to agenda-driven needs. A political advisor, not just an expert. A paradox – must be neutral to be credible, but must be sensitive to possibilities to be useful:

an ethical as well as practical dilemma.

Analysts help policy-makers make choices based on economic, political, and technical factors, including: Costs Benefits Risks Societal preferences

Expertise as a commodity – what policy analysts do?

Analysts specialize in providing different kinds of information for different policy audiences. Chief among these are:

The economic impacts of a policy – determined by benefit/cost assessment, other methodologies – e.g., Congressional Research Service, state legislative research depts.

The health or environmental consequences associated with a policy – measured by risk analysis, environmental impact assessment – e.g., US EPA, Cal EQA, National Academies of Science.

The public acceptability & feasibility of a policy – tools include survey research, willingness-to-pay studies – Brookings Institution, Center on Budget & Policy Priorities.

The legal/constitutional implications of a policy – legal briefs, compliance assessments; Heritage Foundation, CATO institute.

The long term, unintended implications of an issue – Office of Technology Assessment (abolished 1994), Congressional Research Service, Twentieth Century Fund.

Assessing economic impacts – challenges

Distributional issues not always assessed – on whom do costs fall; which groups benefit the most? (Compensatory issues): arise in debates over infrastructure and distributive policies, e.g., Transportation & housing. Employment and regulatory policies.

Long-term benefits and costs are often inexactly captured: Affected by "discount rate" (anticipated cost of money) e.g., water projects, other public works.

Some benefits and costs not easily quantifiable; estimated based on “replacement values” or “eco-system service values” (e.g., endangered species; deaths from airplane crashes, loss of jobs via disasters – Robert Costanza, et. al., 1997).

Pecuniary effects: some benefits aren’t really "new," but merely re-allocate gains that would accrue somewhere, by focusing them elsewhere (e.g., California re-development agencies according to PPIC, 1998).

Assessing environmental and health consequences – challenges

Environmental and health consequences are often described in the language of risk – i.e., the probability of a hazard occurring, and the consequences if it does.

Technical challenges: accurately prioritizing hazards impeded by: lack of information on estimates of magnitude; likelihood that risks can be controlled/mitigated, uncertainty: Missing or incomplete data. Late or latent effects.

Social challenges: hazards important to public differ from those considered most serious by experts (NAS, EPA Science Advisory Board) – raises concerns about public trust /confidence: Tradeoff problems: e.g., is the use of air bags, while likely to save lives in vehicle accidents,

likely to put small children and infants at special risk? Actual vs. perceived risk – how people view control, trust, and relevance of information.

Actual vs. perceived risks –how analysts and politicians differ

Some social and cultural factors “amplify” (according to social psychologists) how policy-makers and public view risks. Examples?

Dread: When we think about something awful, we try to predict what will happen, often pessimistically. We then have feelings of dread as we imagine terrible outcomes (e.g., war, terrorism – analysts can look dispassionately at questions of WMD, politicians cannot).

Control: We often perceive that we have more control that we actually have over some risks – thus, voluntary risks more acceptable than involuntary ones (e.g., smoking, drinking, riding motorcycles without a helmet – analysts say “all are dangerous,” politicians must decide what’s feasible to regulate).

Children: Given how we are socialized, if a hazard affects children to a greater extent than adults (e.g., toxics, pollutants, food, water) we rank it higher in importance, even if the probability of harm is low (e.g., public insistence on maximum protectiveness in child safety, health and nutrition).

Personal impact: If I am the subject of risk, then I am likely to assess the risk as being higher than if I am a bystander. (e.g., certain types of surgery). Also explains why perceptions vary with proximity to a hazard (e.g., “Not-in-my-Backyard”).

Trust: Where the risk involves actions of others, how we assess risk is affected by the extent to which we trust or have confidence in institutions (e.g., why some technologies are challenging to manage - nuclear power, airline travel).

Assessing public acceptability - challenges

Polls and surveys can be problematical and biased:

Often assume high-level of knowledge and interest – what do people really know? How choices are worded can be problematical – and sometimes invalid (e.g., ‘either we create more jobs or

impose higher environmental costs on business.’) Protagonists can often manipulate public sentiments – by drawing attention to one issue at expense of others.

Longitudinal opinion studies provide little guidance into which priorities are consistently important – subject to national mood.

Willingness-to-pay studies – have assorted challenges: People may say one thing but actually do another. Intrinsic values may be and harder to gauge than instrumental ones (e.g., how much someone is willing to

spend to see an endangered animal, or to purchase “eco-friendly” coffee may depend on perceived benefits, and income/education levels.

Information as a source of power – analysis and democracy Information is not equally available to all policy protagonists:

Decision-makers often have greater access to information, can afford to acquire it, can better influence its application than the publics affected by it – an “asymmetry” of information-power.

Principal-agent theory – contends that while decision-makers (principals) have more information, the public and policy activists (agents) often have better ideas about the actual problem and how to solve it (but lack information to make their plans credible– e.g., parents and school systems, community activists and public health/nutrition).

Information used for policy decisions is often incomprehensible to lay audiences: Information must be “translated” to decision-makers as well as the public (e.g., climate

forecast data, epidemiological models, learning outcome scores in public schools).

In some policy areas, there are established means of translation – but not in all! (e.g., Cooperative Extension Services for agriculture and resource management: land-grant universities provide networks of stakeholder interactions with farmers, county officials.

Some information important to public policy is restricted: Analysis can improve citizens’ ability to make choices to improve their health and well-being,

reduce risks to their lives and property, and hold institutions more accountable (e.g., EPA’s Toxics Release Inventory on criteria pollutants; nutritional labeling of foods and food products, better dissemination about pharmaceutical products.

Some information is shielded from the public and even policy-makers due to proprietary concerns or national security/homeland security concerns.

Disclosure is a policy remedy that aims to “establish levels of acceptable risk by means of public pressure” (Brookings Institution, 2003).

Many public policies have been designed to disclose and “make more affordable” important policy information: e.g., the Pure Food and Drug Act, Securities and Exchange Commission, many environmental laws).

Problems continue to arise that enter policy debates in Congress and the courts, e.g., lack of standardized means of disclosure; how protect proprietary and national security information?

Analysis and democracy (con.)