In Kingdon Chapter 10, the author discusses three policy case studies to highlight the importance of the policy streams which we discussed at the beginning of class. Talk about t

Agendas, Alternatives, and Public Policies John W. Kingdon Second Edition

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Table of Contents

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From Chapter 1 of Agendas, Alternatives, and Public Policies, Update Edition, with an Epilogue on Health Care, Second Edition. John W. Kingdon. Copyright © 2011 by Pearson Education, Inc. All rights reserved.

CHAPTER 1

How Does an Idea's Time Come?

Greater than the tread of mighty armies is an idea whose time has come.

-Victor Hugo

The phrase "an idea whose time has come" captures a fundamental reality about an irresistible movement that sweeps over our politics and our society, pushing aside everything that might stand in its path. We feel that such an event can be recognized by signs like sustained and marked changes in public opinion, repeated mobilization of people with intensely held preferences, and bandwagons onto which politicians of all persuasions climb. Members of Congress are fond of trotting out the phrase whenever they are advocating a piece of landmark legislation. And policy activists of all kinds often attempt to account for the emergence of an issue to the forefront of attention with such comments as, "I don't know-it was an idea whose time had come, 1 guess."

But what makes an idea's time come? That question is actually part of a larger puzzle: What makes people in and around government attend, at any given time, to some subjects and not to others? Political scientists have learned a fair amount about final enactment of legislation, and more broadly about au- thoritative decisions made at various locations in government. But predecision processes remain relatively uncharted territory. We know more about how is- sues are disposed of than we know about how they came to be issues on the governmental agenda in the first place, how the alternatives from which deci- sion makers chose were generated, and why some potential issues and some likely alternatives never came to be the focus of serious attention.

If academics find these subjects rather murky, practitioners of the art of gov- ernment scarcely have a clearer understanding of them. They are able to de-

2 How Does an Idea's Time Come?

scribe the subjects occupying their attention with some precision, and, in spe- cific instances, can set forth a convincing account of the reasons for their focus on those subjects. But with some exceptions, they are neither inclined nor obliged to develop a more general understanding of the forces that move policy formation processes in one direction or another. As I was reminded by respon- dents in the study reported in this book, "You're the political scientist, not me" and, "It's your job to put this thing together, so that's not my worry." Yet the subject remains an absolutely critical puzzle for them. As one well-informed individual high in the federal executive branch put it:

It's a fascinating question that you're dealing with. Why do decision makers pay attention to one thing rather than another? I've seen situations in which the Secretary has been dealing with absolute junk when he should be working on some really significant issue. I've always wondered why.

This book attempts to answer that question. In these pages, we will consider not how issues are authoritatively decided by the president, Congress, or other decision makers, but rather how they came to be issues in the first place. We will try to understand why important people pay attention to one subject rather than another, how their agendas change from one time to another, and how they narrow their choices from a large set of alternatives to a very few. This intro- ductory chapter outlines the research on which this book is based; discusses the definitions, ideas, hypotheses, and theories with which the study began; pre- sents an overview of several findings and case studies; and outlines the intel- lectual journey upon which we embark through the rest of the book.

Let no reader begin with the illusion that the journey is easy. In contrast to many areas of study in the social sciences, this one is particularly untidy. Subjects drift onto the agenda and drift off, and it is difficult even to define agenda status. When a subject gets hot for a time, it is not always easy even in retrospect to discern why. The researcher thinks one case study illuminates the process beautifully, only to discover another case study that behaves very dif- ferently. Conceptual difficulties often rise up to ensnare the traveler.

But the journey is also rewarding because the phenomena involved are so central to our comprehension of public policy outcomes and governmental processes, yet they are so incompletely understood. The patterns of public pol- icy, after all, are determined not only by such final decisions as votes in legis- latures, or initiatives and vetoes by presidents, but also by the fact that some subjects and proposals emerge in the first place and others are never seriously considered. l This book tries to contribute to a more complete understanding of these predecision public policy processes.

CONCEPTS AND DEFINITIONS

Though a drastic oversimplification, public policy making can be considered to be a set of processes, including at least (1) the setting of the agenda, (2) the

lSchattschneider's oft-quoted statement, "The definition of the alternatives is the supreme instru- ment of power," aptly states the case. See E. E. Schattschneider. The Semi-Sovereign People (New York: Holt, Rinehart, and Winston, 1960), p. 68.

Concepts and Definitions 3

specification of alternatives from which a choice is to be made, (3) an authori- tative choice among those specified alternatives, as in a legislative vote or a presidential decision, and (4) the implementation of the decision. 2 Success in one process does not necessarily imply success in others. An item can be prominently on the agenda, for instance, without subsequent passage of legisla- tion; passage does not necessarily guarantee implementation according to leg- islative intent. This study concentrates on the first two processes. We seek to understand why some subjects become prominent on the policy agenda and oth- ers do not, and why some alternatives for choice are seriously considered while others are neglected.

The word "agenda" has many uses, even in the context of governmental pol- icy. We sometimes use the word to refer to an announced subject for a meeting, as in the sentence, "The agenda before the committee today is H.R. 1728 and proposed amendments thereto." At other times, we might mean the kind of plan an organizer wants participants to adopt, as in the phrase, "a hidden agenda." And sometimes the word "agenda" refers to a coherent set of proposals, each related to the others and forming a series of enactments its proponents would prefer, as in "an agenda for the 1980s." It is thus important to define with some precision how the word will be used in this book.

The agenda, as I conceive of it, is the list of subjects or problems to which governmental officials, and people outside of government closely associated with those officials, are paying some serious attention at any given time. Within the general domain of transportation, for instance, the Secretary of Transportation and the members of the congressional committees of jurisdic- tion could be considering, at any given time, a range of problems like the cost of mass transit construction, the deterioration of highway surfaces, the ineffi- ciencies produced by economic regulation of the airlines, and tanker spills in the ports of the country. Out of the set of all conceivable subjects or problems to which officials could be paying attention, they do in fact seriously attend to some rather than others. So the agenda-setting process narrows this set of con- ceivable subjects to the set that actually becomes the focus of attention. We want to understand not only why the agenda is composed as it is at anyone point in time, but how and why it changes from one time to another.

We have been speaking of a governmental agenda, the list of subjects to which governmental officials and those around them are paying serious atten- tion. Of course, this list varies from one part of the government to another. The president and his closest advisers, for instance, have as their agenda the "biggest" items, things like international crises, major legislative initiatives, the state of the economy, and major budgetary decisions. Then there are more specialized agendas, including agendas for health officials or transportation of- ficials. Even within an area like health, there are still more specialized agendas,

2When discussing decision-making models, Simon distinguishes between directing attention, dis- covering or designing possible courses of action, and selecting a particular course of action. These cate- gories roughly correspond to agendas, alternatives and choice. See Herbert Simon, "Political Research: The Decision-Making Framework," in David Easton, ed., Varieties of Political Theory (Englewood Cliffs: Prentice-Hall, 1966), p. 19. For another use of similar distinctions, see John W. Kingdon, Con- gressmen's Voting Decisions, 3rd ed. (Ann Arbor: University of Michigan Press, 1989), Chapter 12.

4 How Does an Idea's Time Come?

lists of subjects that dominate the attention of people in areas like biomedical research or direct delivery of medical services. We should also distinguish be- tween the governmental agenda, the list of subjects that are getting attention, and the decision agenda, or the list of subjects within the governmental agenda that are up for an active decision. As we will see later in this book, governmen- tal and decision agendas are affected by somewhat different processes.

Apart from the set of subjects or problems that are on the agenda, a set of al- ternatives for governmental action is seriously considered by governmental officials and those closely associated with them. If the cost of medical care is a prominent agenda item, for instance, officials could seriously consider a number of alternatives related to that problem, including directly regulating hospital costs, introducing incentives into the system to encourage market reg- ulation, paying consumers' costs through comprehensive national health insur- ance, enacting such partial insurance plans as catastrophic insurance, national- izing the system in a scheme of socialized medicine, or doing nothing. Out of the set of all conceivable alternatives, officials actually consider some more se- riously than others. So the process of specifying alternatives narrows the set of conceivable alternatives to the set that is seriously considered.

This distinction between agenda and alternatives will turn out to be quite useful analytically. In much of the current literature, "agenda setting" refers to both of them at once, and the distinction between agenda and alternatives is not very sharply drawn. One scholar will argue that professionals, experts, and technicians dominate "the agenda," for example, while another will argue that highly visible crises and the public positions of presidents and key Senators dominate "the agenda." Perhaps agenda setting and alternative specification are governed by quite different processes. Experts might then be more important in generating alternatives, and presidents might be more important in setting the agenda. Presidents can dominate the congressional agenda, for example, but they have much less control over the alternatives members of Congress con- sider. We will return to this distinction between agenda and alternatives repeat- edly.

A BRIEF ACCOUNT OF THE RESEARCH

The research on which this book is based was designed to follow the develop- ment of public policy over time, concentrating on the areas of health and trans- portation in the federal government of the United States. I gathered two kinds of information for the study. The first consisted of four waves of interviews, in 1976,1977,1978, and 1979, with people close to decision making in health and transportation. Over the four years, I conducted 247 lengthy and detailed inter- views, 133 in health and 114 in transportation. One-fifth of thef!! were with congressional staff, either committee staff or people located in support agen- cies. About a third were in the executive branch, including upper-level civil servants, political appointees in departments and bureaus, and presidential staff. The remaining interviews were with people outside of government, in- cluding lobbyists, journalists, consultants, academics, researchers, and other

The Lay of the Land 5

"important" people in health and transportation. Many respondents carried over from one year to the next; others were replacements. My aim was to tap into entire policy communities, not just parts like Congress, the presidency, the bu- reaucracy, or lobbies.

I asked these respondents many questions, but among the central ones were the following: "What major problems are you and others in the health (trans- portation) area most occupied with these days? Why? What proposals are on the front burner? Why?" I also asked about some problems and proposals that were not prominent, and why they were not. I then could compare one year to the next. If a previously prominent item fell by the wayside, or if a new item came to the fore during the year, I asked why. We can thus trace the rise and fall of items on policy agendas, and discover why items get hot or fade.

In addition to these interviews, research assistants and I developed a series of case studies of policy initiation and non initiation, drawing from my inter- views and from such publicly available sources as government documents, pop- ular and specialized accounts, and academic writings. We identified for de- tailed analysis twenty-three case studies, covering many policy changes in health and transportation over the last three decades. Finally, we also gathered information on subjects that were currently prominent, from such sources as congressional hearings and committee reports, presidential State of the Union addresses and other messages, party platforms, press coverage, and public opinion data.

The appendix to this book discusses the study's methods in more detail.

THE LAY OF THE LAND

What do the agendas in health and transportation look like? To give a view of the events we seek to understand, let us examine four brief case studies. Each will describe the events and pose some questions that represent the sorts of questions we want to answer. We will then return to these and other case stud- ies throughout the book.

Health Maintenance Organizations In the early 1970s, people in the Nixon administration were concerned about the dramatically rising cost of medical care, and particularly of Medicare and Medicaid. 3 Rapidly rising cost was a problem not only in absolute dollar terms; it also created a tremendous budgetary pressure on other programs in the Department of Health, Education, and Welfare (HEW). In addition, administra- tion officials saw Senator Edward Kennedy as at least one of the prominent po- tential presidential challengers in 1972. Since Kennedy was quite visible in the health area, administration officials felt that they too should be known for

lFor fuller treatments of the HMO case, see Lawrence D. Brown, Politics and Health Care Organi- zation: HMOs As Federal Policy (Washington, D.C.: The Brookings Institution, 1983); Joseph L. Falk- son, HMOs and the Politics of Health System Reform (Bowie, MD: Robert J. Brady, 1980); and Patricia Bauman, "The Formulation and Evolution of the Health Maintenance Organization Policy," SOCial Sci- ence and Medicine 10 (March-April 1976): 129-142.

6 How Does an Idea's Time Come?

health initiatives. Both the cost problem and the political considerations pro- duced a receptivity to ideas for health initiatives. As the political appointees in the Nixon administration cast about for ideas, they ran into some difficulty finding possible initiatives that would meet their requirements, including low cost and compatibility with their values of less regulation and smaller govern- ment.

Enter Paul Ellwood, the head of a Minneapolis-based policy group called InterStudy. Ellwood was a firm believer in the virtues of prepaid group prac- tice, an arrangement that has been operating successfully in a number of loca- tions for many years. Instead of paying a provider a fee for services rendered at every encounter, patients and their employers pay a yearly fee, in return for which the organization furnishes care as needed. Ellwood was well-known in the community of health policy specialists. He was known, among others, to Thomas Joe, then a top assistant to HEW Undersecretary John Veneman. In the words of one of my respondents:

The story goes that Ellwood was in town, and when he left, he happened to sit on the plane next to Tom Joe. They got into a conversation, and Joe started bitching about how they have this problem and nobody has any ideas. So Ellwood says, "I've got an idea," and laid it out for him.

Ellwood proposed federal assistance for what he called Health Maintenance Organizations (HMOs). But instead of presenting it as a liberal do-gooder idea, Ellwood rather cleverly packaged it as a way of introducing marketplace com- petition into the medical care system. Different kinds of HMOs could compete both with each other and with traditional fee-for-service and insurance systems, and the resultant competition in the marketplace would regulate expenditures. Thus the administration could propose the desired initiative while avoiding a major new dose of government regulation. This twist on the idea made the pro- posal congruent with the ideology of the Nixon administration. Joe arranged for Ellwood to meet with Veneman and several other top-level HEW officials. They were sold on the idea. The proposal grew from a conversation to a memo, then from a very thick document to the status of a major presidential health ini- tiative, all in a matter of a few weeks.

This story poses a number of intriguing questions. Given that prepaid prac- tice had been established and well-known for years, why did the HMO idea suddenly take off as a federal government initiative at this particular time? Did events really turn on a chance airplane meeting? How important was the pro- posal's packaging? What underlying forces drove the events? This book tries to provide answers to questions like these.

National Health Insurance During the Carter Administration National health insurance proposals are hardy perennials.4 Public discussion of the idea in the United States stretches back at least to Teddy Roosevelt. It re- ceived some consideration during the New Deal period. Harry Truman pro-

4Most of the infonnation about this case study is drawn from my interviews and from contemporary press accounts.

The Lay of the Land 7

posed national health insurance in the late 1940s and early 1950s. Medicare and Medicaid, health insurance targeted toward the elderly and the poor, were passed in the mid 1960s. The idea of a more general national health insurance received considerable attention once again in the 1970s. There was a serious flurry of activity in 1973 and 1974, when Senator Edward Kennedy sponsored a scaled-down proposal together with Wilbur Mills, the chairman of the House Ways and Means Committee.

Interest rose once again during the Carter administration. Jimmy Carter was publicly committed to some version of national health insurance during the 1976 campaign. The United Automobile Workers (UA W) had been ardent pro- ponents of comprehensive national health insurance for years. When Carter was elected with UA W support and with a hefty Democratic majority in both houses of Congress, many advocates thought that the time had come for an- other push.

National health insurance proposals are famous for their diversity. Even when it was clear that the subject would be on the agenda in 1977 through 1979, dramatically different proposals were put forward by their advocates. Some called for a plan that would be financed and administered entirely by the government; others provided for substantial doses of mandated private insur- ance. Some plans provided for comprehensive benefits, so that virtually all medical expenses would be covered; others were more selective in the benefits they would provide. Some provided for universal coverage of the entire popula- tion; others targeted subsets of the population. Some had the insurance foot the entire bill; others provided for patients to pay for a portion, either a portion of each year's expenses or a portion of each encounter with a medical care provider. Aside from the disputes, the complexities of the various proposals were staggering. Even among the advocates of national health insurance, there was considerable dispute over very fundamental features of their desired plans.

Early in the tenure of the Carter administration, Kennedy and labor entered into a series of conversations with the top policy makers and political advisers in the White House over the salient features of the administration's proposal. The labor-Kennedy coalition very much wanted the proposal to be formulated and announced before the 1978 congressional elections, reasoning that if there actually were an administration plan on the table, their people in each congres- sional district could firm up commitments from legislators and future legisla- tors as a part of the campaign process. Several months into the new administra- tion, the major supporters of comprehensive national health insurance, including Kennedy and organized labor, revised their insistence on the compre- hensive plan they had held out for all these years. Here they had a president committed to national health insurance and a Democratic Congress. They rea- soned that a similar opportunity might not come around again for another decade or even another generation. So while maintaining their proposal for comprehensive benefits and universal coverage, they dropped their insistence on a totally government program, and worked up a proposal for both underwrit- ing and administration by private insurance companies. They claimed this gave Carter two features he wanted: a place for private insurers, and a way to get much of the cost off the federal budget. The critics of the new plan claimed it

8 How Does an Idea's Time CorneY

was still too costly and administratively unworkable, but compromise seemed to be in the air.

Meanwhile, a conflict developed within the administration between those (especially in HEW and in the president's Domestic Policy staff) who favored a proposal with comprehensive benefits and universal coverage, phased in over several years, and those (especially in Treasury and in the Office of Management and Budget) who favored much more limited initiatives providing for catastrophic insurance and some improved coverage for poor people, if there was to be any plan at all. The latter advisers were worried about the im- pact of a more ambitious plan on inflation and on the federal budget, particu- larly in light of what they perceived to be the more conservative national mood exemplified by such occurrences as the passage of Proposition 13 in California. Other administration figures, both in HEW and in the president's Executive Office, took the role of negotiating between the factions.

The resultant delay in announcing the administration's proposal made labor restive. Indeed, Douglas Fraser, the head of the United Auto Workers, referred in a late 1977 speech to his displeasure with the administration over this and several other issues. In a not-so-veiled reference to a potential Kennedy chal- lenge, he raised the possibility of labor seeking "new allies" in their struggle. By some time in 1978, there was a fairly pronounced break with the labor and Kennedy people, and to the extent that the administration was consulting on the Hill, they did so with such other important actors in the process as Russell Long, the chairman of the Senate Finance Committee; Dan Rostenkowski, chairman of the House Ways and Means health subcommittee; and his succes- sor, Charles Rangel.

Shortly after the 1978 elections, Senator Long made quite a dramatic move; he decided to mark up national health insurance in early 1979, before the ad- ministration's plan was announced, and proceed to actual drafting sessions. Long's move prodded administration officials into an accelerated timetable for their proposal. They had been actively working on the proposal, at President Carter's personal insistence, through 1978. After Long's action, they an- nounced a first-phase proposal that included catastrophic coverage, help for the poor and near-poor, maternal and child benefits, and several other features; all in the rubric of a government plan that appealed to some liberals more than the revised Kennedy-labor approach.

So in 1979, there were several serious proposals under consideration: Long's, the administration's, the revised Kennedy-labor plan, and some others. Figure I-I shows the degree to which my health respondents paid attention to various types of proposals. There can be little doubt that they were indeed re- ceiving a great deal of notice.

The rest of the story goes beyond the agenda-setting phase. But in brief, the whole thing fell through. National health insurance ran afoul of (1) substantial worries in the administration that the enactment of any plan would create im- posing pressures on the federal budget, (2) a national mood that seemed to pre- fer smaller government, and (3) the inability to gather a unified coalition around one proposal.

What accounts for these ebbs and flows of attention to national health insur- ance? What conditions would increase the chances for enactment? How impor-

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The Lay of the Land 9

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