Action Items In addition to the reading assignments for this module, conduct research for the topics listed below. You must use at le
Action Items
- In addition to the reading assignments for this module, conduct research for the topics listed below. You must use at least two relevant, scholarly sources in addition to your textbook. Begin your research at the Franklin University Library (Links to an external site.).
- Kingdon's Three Streams
- The Window of Opportunity
- Conduct research regarding a health policy issue. It is recommended that you visit the following websites to begin your research. Alternatively, you may locate other sources from which to identify a health policy issue:
- Write a 3- to 4-page paper in which you address the items (listed below) related to the issue that you chose. Write your paper in terms of the three streams and the window of opportunity.
- Discuss the specifics of the problem.
- Discuss the possible solutions.
- Describe the current political circumstances.
- Forecast potential strategies and actions that you would take to move the issue into the policy formulation phase; in other words, what would it take to get this issue on the right "table" in front of the right people to begin formulating a policy?
- Prepare your assignment for submission:
- You must incorporate research into your paper from at least two relevant, scholarly resources in addition to your textbook.
- Follow all applicable APA Guidelines (Links to an external site.) regarding in-text citations, the list of cited references, and document formatting for this paper. Failure to properly cite and reference sources constitutes plagiarism.
- The title page and reference list are not included in the page count for this paper.
- Proofread your assignment carefully. Improper English grammar, sentence structure, punctuation, or spelling will result in significant point deductions.
- Submit your assignment. Your work will automatically be checked by Turnitin.
CHAPTER
135
POLICY FORMULATION: AGENDA SETTING
Learning Objectives
After reading this chapter, you should be able to
• define agenda setting; • understand Kingdon’s conceptualization of the confluence of problems,
possible solutions, and political circumstances in opening a window of opportunity in agenda setting;
• describe how problems emerge for consideration in policymaking; • appreciate the role of research in selecting among possible solutions to
problems; • describe the role of political circumstances in agenda setting; • understand the role of interest groups in agenda setting; • describe the tactics used by interest groups in influencing the policy
agenda; • understand the role of chief executives in agenda setting; and • describe and explain the nature of the health policy agenda.
T his chapter and the four that follow examine in greater detail the three distinct phases of the health policymaking process described and mod- eled in Chapter 3. This chapter focuses on the agenda setting that
occurs in the policy formulation phase. Chapter 6 focuses on the develop- ment of legislation that also occurs in that phase. Chapter 7 describes policy implementation and implementing organizations, whereas Chapter 8 describes the policy implementation activities of designing, rulemaking, operating, and evaluating. Chapter 9 discusses the policy modification phase. These chapters apply the model to health policymaking almost exclusively at the national level of government. However, as is true of previous chapters, much of what is said here about the process of public policymaking also applies at the state and local levels. The contexts, participants, and specific mechanisms and pro- cedures obviously differ among the three levels, but the core process is similar.
5
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Remember from the discussion in Chapter 3 that the formulation phase of health policymaking is made up of two distinct and sequential parts: agenda setting and legislation development (see the darkly shaded portion of Exhibit 5.1). Each part involves a complex set of activities in which policy- makers and those who would influence their decisions and actions engage, but policy formulation begins with agenda setting.
Agenda Setting
As noted in Chapter 3, agenda setting is deciding what to make decisions about in the policy formulation phase of policymaking. It is the crucial ini- tial step in the process. Kingdon (2010) describes agenda setting in public policymaking as a function of the confluence of three streams of activity: problems, possible solutions to the problems, and political circumstances. According to Kingdon’s conceptualization, when problems, possible solu- tions, and political circumstances flow together in a favorable alignment, a “policy window” or “window of opportunity” opens. When a policy window opens, a problem–potential solution combination that might lead to a new public law or an amendment to an existing one emerges from the set of competing problem–possible solution combinations and moves forward in the policymaking process (see Exhibit 5.2).
Current health policies in the form of public laws—such as those per- taining to environmental protection, licensure of health-related practitioners and organizations, expansion of the Medicaid program, cost containment of the Medicare program, funding for acquired immunodeficiency syndrome (AIDS) research or women’s health, and regulation of pharmaceuticals— exist because problems or issues emerged from agenda setting and triggered changes in policy. However, the existence of these problems alone was not sufficient to trigger the development of legislation intended to address them.
The existence of health-related problems, even serious ones such as inadequate health insurance coverage for millions of people or the continuing widespread use of tobacco products, does not always lead to policies intended to solve or ameliorate them. There also must be potential solutions to the problems and the political will to enact specific legislation to implement those solutions. Agenda setting is best understood in the context of its three key variables: problems, possible solutions, and political circumstances.
Problems The breadth of problems that can initiate agenda setting is reflected in the broad range of health policies. Chapter 1 discussed how health is affected by several determinants: the physical environments in which people live and
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C h a p t e r 5 : P o l i c y F o r m u l a t i o n : A g e n d a S e t t i n g 137
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work; their behaviors and biology; social factors; and the type, quality, and timing of health services they receive.
Beyond these determinants, as shown in the external environment component of Exhibit 5.1, the situations and preferences of individuals, orga- nizations, and groups as well as biological, biomedical, cultural, demographic, ecological, economic, ethical, legal, psychological, science, social, and techno- logical variables affect policymaking throughout the process. These inputs join with the results and consequences of the policies produced through the ongo- ing policymaking process to continuously supply agenda setters with a massive pool of contenders for a place on that agenda. From among the contenders, certain problems find a place on the agenda while others do not.
Problems That Drive Policy Formulation The problems that eventually lead to the development of legislation are generally those that policymakers broadly identify as important and urgent. Problems that do not meet these criteria languish at the bottom of the list or never find a place on the agenda. Price (1978), in a classic article, argues that whether a problem receives aggressive congressional intervention in the form of policymaking depends on its public salience and the degree of group conflict surrounding it. He defines a publicly salient problem or issue as one with a high actual or potential level of public interest. Conflictive problems or issues are those that stimulate intense disagreements among interest groups or those that pit the interests of groups against the larger public interest. Price contends that the incentives for legislators to intervene in problems or issues are greatest when salience is high and conflict is low. Conversely, incentives are least when salience is low and conflict is high. Appendix 12, which pertains to the legalization of recreational marijuana, illustrates the difficulty of legislative intervention when the conflict sur- rounding a problem is high.
Problems that lead to attempts at policy solutions find their place on the agenda along one of several paths. Some problems emerge because trends
EXHIBIT 5.2 Agenda
Setting as the Confluence
of Problems, Possible
Solutions, and Political
Circumstances
A Place on the Policy Agenda
Problems
Possible Solutions
Political Circumstances
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in certain variables eventually reach unacceptable levels—at least, levels unac- ceptable to some policymakers. Growth in the number of uninsured and cost escalation in the Medicare program are examples of trends that eventually reached levels at which policymakers felt compelled to address the underlying problems through legislation. Both problems are addressed in the Affordable Care Act (ACA).
Problems also can be spotlighted by their widespread applicability (e.g., the high cost of prescription medications to millions of Americans) or by their sharply focused impact on a small but powerful group whose members are directly affected (e.g., the high cost of medical education). Another example of a widespread problem that led to specific legislation was that a large number of people felt locked into their jobs because they feared that preexisting health conditions might prevent them from obtain- ing health insurance if they changed jobs. In response to this problem, the Health Insurance Portability and Accountability Act of 1996 (P.L. 104-191) significantly enhanced the portability of health insurance coverage when people change jobs. Other provisions in this law guarantee availability and renewability of health insurance coverage for certain employees and individu- als and an increase in the tax deduction for health insurance purchased by the self-employed.
Some problems gain their place on the agenda or strengthen their hold on a place because they are closely linked to other problems that already occupy secure places. Efforts by the legislative and executive branches of the federal government to address the nation’s budget deficit problem, at least in part through reduced expenditures on the Medicare program, are a recur- ring example of the link between one problem (cost increases in the Medicare program) and another (growth of the federal deficit). Linking these two problems significantly strengthens prospects for the development of legisla- tion intended to curtail Medicare program expenditures.
Some problems emerge more or less simultaneously along several paths. Typically, problems that emerge this way become prominent on the policy agenda. For example, the problem of the high cost of health services for the private and public sectors has long received attention from policymak- ers. Even though the rate of growth in health costs has slowed in the past few years, these costs remain high and problematic (Martin et al. 2014). This problem emerged along a number of mutually reinforcing paths. In part, the cost problem has been prominent because the cost trend data disturb many people. The data contribute to and reinforce a widespread acknowledg- ment of the problem of health costs in public poll after public poll and have attracted the attention of some of those who pay directly for health services through the provision of health insurance benefits, especially the politically powerful business community. Finally, the health cost problem, as it relates to
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public expenditures—for the Medicare and Medicaid programs especially— has also been linked at times to the need to control the federal budget.
The importance of these variables has been magnified greatly in the context of the global financial crisis engulfing the world beginning in 2008 (Shah 2013). The variables of healthcare costs and the escalating federal budget form a combination of interacting circumstances, which is largely why this problem remains perennially prominent in the minds of many policymak- ers. The persistence of this problem, and many others, is also related to the difficulty of finding and pursuing potential solutions.
Possible Solutions The second variable in agenda setting (see Exhibit 5.2) is the existence of possible solutions to problems. Problems themselves—even serious, fully acknowledged ones with widespread implications such as high costs, poor quality, and uneven access to needed health services—do not invariably lead to policies. Potential solutions must accompany them. The availability of pos- sible solutions depends on the generation of ideas and, usually, a period of idea testing and refinement. As Appendix 13, which pertains to the Centers for Medicare & Medicaid Services (CMS) Innovation Center’s search for new and better payment and health services delivery models, illustrates, numerous ideas might serve as solutions to problems, either in single application or in various combinations.
While the menus of alternative solutions vary in size and quality, alter- native solutions almost always exist. An excessive number of alternatives can slow the problem’s advancement through the policymaking process as the relative merits of the competing alternatives are considered. Without at least one solution believed to have the potential to solve it, however, a problem does not advance, except perhaps in some spurious effort to create the illu- sion that it is being addressed.
When alternative solutions do exist, policymakers must decide whether the potential solutions are worth developing into legislative proposals. Frequently, multiple solutions to a particular problem will be considered worthy of such action, resulting in the simultaneous development of several competing legislative proposals. Competing proposals tend to make agenda setting rather chaotic, although rigorous research and analysis can sometimes provide more clarity.
The Role of Research and Analysis in Defining Problems and Assessing Alternatives Health services research is “the multidisciplinary field of scientific investiga- tion that studies how social factors, financing systems, organizational struc- tures and processes, health technologies, and personal behaviors affect access
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to healthcare, the quality and cost of healthcare, and ultimately our health and well-being. Its research domains are individuals, families, organizations, institutions, communities, and populations” (AcademyHealth 2014). It has been defined more succinctly as “scientific inquiry into the ways in which health services are delivered to various constituents” (Forrest et al. 2008). Health services researchers seek to understand how people obtain access to healthcare services, the costs of the services, and the results for patients of using this care. The main goals of this type of research include identifying the most effective ways to organize, manage, finance, and deliver high- quality care and services and, more recently, how to reduce medical errors and improve patient safety. Health services research, along with much bio- medical research, contributes to problem identification and specification and the development of possible solutions. Thus, research can help establish the health policy agenda by clarifying problems and potential solutions. Well- conducted health services research provides policymakers with facts that might affect their decisions.
Policymakers value the input of the research community sufficiently to fund much of its work through the National Institutes of Health (NIH), the Agency for Healthcare Research and Quality (AHRQ), and other agencies. AHRQ, the health services research arm of the US Department of Health and Human Services (HHS), complements the biomedical research mission of its sister agency, NIH. AHRQ is the federal government’s focal point for research to enhance the quality, appropriateness, and effectiveness of health services and access to those services.
In addition to these traditional research and analysis agencies, the ACA significantly improved the government’s ability to use analysis and research in guiding agenda setting. For example, the ACA created the Center for Medicare and Medicaid Innovation (CMI) within CMS, and appropriated $10 billion for the FY2011 to FY2019 period—along with $10 billion for each subsequent ten-year period. The purpose of CMI is to test and imple- ment innovative payment and service delivery models. These models are intended to reduce program expenditures under Medicare, Medicaid, and the Children’s Health Insurance Program while preserving or enhancing the quality of care furnished under these programs (Redhead 2014).
The ACA also established and funded an Independent Payment Advi- sory Board (IPAB) to make recommendations to Congress for achieving specific Medicare spending reductions if costs exceed a target growth rate. IPAB’s recommendations are to take effect unless Congress overrides them, in which case Congress would be responsible for achieving the same level of savings.
Further supporting the research and analysis basis for policymaking, the ACA established a trust fund to finance the Patient-Centered Outcomes
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Research Institute (PCORI). The main purpose of PCORI (2014) is to support the conduct of comparative clinical effectiveness research. Appro- priations to this trust fund were $10 million for FY2010, $50 million for FY2011, and $150 million for each of FY2012 through FY2019, for a total of $1.26 billion over that ten-year period. For each year of FY2013 through FY2019, the trust fund is to receive additional appropriations equal to the net revenues from a new health insurance policy or plan fee, as well as Medicare trust fund transfers. Each fiscal year, 20 percent of the funds in the trust are to be transferred to the secretary of HHS, with 80 percent of the transferred funds provided to AHRQ.
Research and analysis play two especially important roles in agenda setting. First, an important documentation role is played through the gather- ing, cataloging, and correlating of facts related to health problems and issues. For example, researchers documented the dangers of tobacco smoke; the presence of human immunodeficiency virus (HIV); the numbers of people living with AIDS, a variety of cancers, heart disease, and other diseases; the effect of poverty on health; the number of people who lack health insurance coverage; the existence of health disparities among population segments; and the dangers imposed by exposure to various toxins in people’s physical environments. Quantification and documentation of health-related problems give the problems a better chance of finding a place on the policy agenda.
The second way research informs, and thus influences, the health policy agenda is through analyses to determine which policy solutions may work or to compare alternative solutions. Health services research provides valuable information to policymakers as they propose, consider, and prioritize alternative solutions to problems. Often taking the form of demonstration projects intended to provide a basis for determining the feasibility, efficacy, or basic workability of a possible policy intervention, research-based recommen- dations to policymakers can play an important role in policy agenda setting. Potential solutions that might lead to public policies—even if the policies themselves are formulated mainly on political grounds—must stand the test of plausibility. Research that supports a particular course of action or attests to its likelihood of success—or at least to the probability that the course of action will not embarrass proponents—can make a significant contribution to policymaking by helping shape the policy agenda.
What research cannot do for policymakers, however, is make decisions for them. Every difficult decision regarding the health policy agenda ulti- mately rests with policymakers.
Making Decisions About Alternative Possible Solutions Problems that require decisions and alternative possible solutions to them are two prerequisites for using the classical, rational model of decision making
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