Chapter 4: The Overview of Health Policymaking
Conceptual Frameworks and Theories of Policymaking
Policymaking is a complex, context-dependent decision-making process across federal, state, and local levels; frameworks and theories help explain parts of the process but no single theory fully explains it.
Key frameworks and theories:
Stages heuristic (Lasswell, 1956): policymaking viewed as four stages—agenda setting, formulation, implementation, evaluation. Useful but oversimplified.
Policy triangle (Walt & Gilson, 1994): actors, context, and processes interact to produce policy.
Networks and policy communities: rising networks of actors around policy issues; tightly knit networks influence outcomes.
Multiple-streams theory (Kingdon, 2010) and punctuated-equilibrium theory (Baumgartner & Jones, 1993):
Multiple-streams theory emphasizes separate streams of problems, solutions, and politics; a confluence creates a window of opportunity for policy action.
Punctuated-equilibrium theory posits incremental policymaking punctuated by bursts of rapid change.
In practice, multiple theories apply concurrently; no single theory captures all dynamics of policymaking.
Core takeaway: health policymaking is a dynamic, political, and multi-theoretical process shaped by time, context, and actors.
A Core Model of the Public Policymaking Process
Exhibit 4.1 (Longest) presents the public policymaking process as three interrelated, cyclical phases: formulation, implementation, and modification.
External Environment interacts with all phases; the process is open and influenced by external variables.
Bridge between formulation and implementation: enactment of legislation (formal passage of laws).
Key features:
Three phases are interconnected and cyclical, not strictly linear.
Each phase contains sub-activities that feed into subsequent phases.
The external environment shapes and is shaped by policy decisions.
Phase interactions and sequence can be revised through modification.
Window of Opportunity: a favorable confluence of problems, possible solutions, and political circumstances opens a path for progression through formulation, enactment, implementation, and modification.
External Environment
The policymaking process is influenced by a dynamic external environment and is itself an open system.
Important external variables include:
Situations and preferences of individuals, organizations, and groups
Biological, biomedical, cultural, demographic, ecological factors
Economic, ethical, legal, psychological, scientific, social, technological factors
Technology as an example: public funding for tech influences policy funding priorities; technologies must be integrated into public programs like Medicare/Medicaid.
Legal variables: legal decisions and the broader legal system shape and are shaped by policy decisions; decisions can be reversed if unconstitutional.
The Phases of the Policymaking Process Are Interactive and Interdependent
Exhibit 4.4 illustrates the interactive relationships among the formulation, implementation, and modification phases, emphasizing bidirectional influences.
Within each phase, activities are also interactive and interdependent (designing, rulemaking, operating, evaluating feed back into policy design and modification).
The policymaking model emphasizes that policy is a continuous cycle rather than a one-time event.
Formulation Phase
The formulation phase consists of two sequential parts:
Agenda setting
Development of legislation
Outcomes of formulation: new public laws or amendments to existing laws; later stages produce rules, regulations, or implementation decisions; judicial decisions can emerge at any phase.
Agenda setting:
Arises from interactions among health problems, possible solutions, and political circumstances.
Decisions about prioritizing problems and potential policy demands.
Examples: Medicare, Medicaid, and the Affordable Care Act (ACA) illustrating problem-solution conjunctions and political context.
Agenda setting is a crucial initial step; discussed in depth in Chapter 5.
Development of Legislation:
When problems reach actionable priority, specific legislation (bills) are proposed as solutions.
Policymakers propose legislation; proposals may become new laws or amendments to existing laws.
Kingdon describes convergence of problems, solutions, and political conditions as a window of opportunity.
Presidential approaches can differ: Johnson era proposed a specific piece of legislation for Medicare; Obama era communicated broad principles to Congress, which drafted legislation.
Four basic types of legislation: bills, joint resolutions, concurrent resolutions, simple resolutions.
The Legislative Process (US Congress) involves 13 steps to enact legislation (see below for steps).
The Legislative Process (US Congress)
Step 1: Referral to Committee — Bills/resolutions are referred to standing committees according to rules.
Step 2: Committee Action — Committee on the bill on its calendar; may refer to subcommittee; committee action determines passage chances; inaction equals death of the bill.
Step 3: Subcommittee Review — Hearings held to gather executive, expert, and public views; testimony may be oral or written.
Step 4: Mark Up — Subcommittee may amend the bill before reporting to full committee; no report equals bill death.
Step 5: Committee Action to Report a Bill — Full committee may report the bill with amendments and recommendations.
Step 6: Publication of a Written Report — Committee provides a written report detailing intent, scope, impacts, executive branch position, and dissenting views.
Step 7: Scheduling Floor Action — Bill placed on calendar; scheduling depends on chamber rules; House vs Senate calendars vary.
Step 8: Debate — Floor debate follows rules governing debate duration and conditions.
Step 9: Voting — Bill passed or defeated by members’ vote.
Step 10: Referral to Other Chamber — Bill moves to the other chamber where it may follow a similar route; may approve, reject, ignore, or amend.
Step 11: Conference Committee Action — If chambers differ, a conference committee reconciles differences; report requires approval by both chambers.
Step 12: Final Actions — If both chambers pass identical form, it goes to the President for signature; or veto; or pocket veto if Congress adjourns.
Step 13: Overriding a Veto — If vetoed, Congress may override with a two-thirds vote (roll call) in each chamber.
Note on enactment patterns: Presidents Johnson and Obama used different strategies—Johnson pushed a specific Medicare bill; Obama guided Congress to draft ACA legislation through broad principles.
Legislative activity (selected Congresses, approximate figures):
111th (2009–2011): introduced 11{,}192 pieces; 385 signed; 2.8 ext{ ext{%}} enacted.
112th (2011–2013): introduced 10{,}865; signed about 284; 2.8 ext{ ext{%}} enacted.
113th (2013–2015): introduced 9{,}184; signed 296; 2.8 ext{ ext{%}} enacted.
114th (2015–2017): introduced 10{,}334; signed 329; 2.7 ext{ ext{%}} enacted.
115th (2017–2019): introduced 11{,}474; signed 443; 3.3 ext{ ext{%}} enacted.
Source: GovTrack.us (2019). These figures illustrate that only a small fraction of health-related problems reach enacted legislation.
Implementation Phase
Transition from formulation to implementation occurs upon enactment; the boundary is porous.
Implementation involves managing human, financial, and other resources to achieve enacted policy goals; primarily a management function (public administration).
Responsibility rests mainly with the executive branch (federal and state), including departments and agencies; collaboration with the legislative branch for ongoing modification.
Examples: ACA implementation involved complex IT systems for health insurance exchanges; varied state participation created a mix of federally operated, state-operated, and hybrid exchanges; states leveraged administrative capacity and policy expertise to influence implementation.
Key agencies and roles:
US Department of Health and Human Services (HHS) involved in Medicaid expansion and waivers.
Internal Revenue Service (IRS) involved in shared responsibility payments.
CMS Innovation Center established by ACA to test new payment and delivery models.
Other agencies like FTC and DOJ assess new structures (e.g., ACOs) and their implications.
The implementation phase comprises four interrelated activities:
Designing: setting working agenda for implementing organization, planning, organizing the agency.
Rulemaking: developing regulations to implement laws; rules are policies; involves publishing proposed rules and final rules in the Federal Register; opportunity for public participation.
Operating: actual enactment of policy into practice; e.g., enrolling Medicaid beneficiaries, monitoring environmental protections, or enforcing safety standards.
Evaluating: systematically collecting, analyzing, and using information to assess policy merit, effectiveness, and costs; types include process vs outcome, formative vs summative, cost-benefit, and cost-effectiveness evaluations; agencies like AHRQ and CMS Innovation Center support evaluation for ACA.
The management functions underpinning designing and operating include planning, organizing, staffing, directing, controlling, and decision-making (as summarized in Exhibit 4.3).
Rules and regulatory processes are themselves policies and subject to revision as experience dictates.
The implementation phase may be affected by intergovernmental bargaining, state administrative capacity, and policy expertise.
Rulemaking
Rules (regulations) are detailed directives developed by implementing agencies to guide the operation of laws.
Rules are policies in their own right; regulatory decisions can be revised as experience dictates.
Rulemaking follows statutory guidelines and includes publishing proposed rules to solicit public comment; final rules follow after consideration of input, and both are published in the Federal Register.
The process is dynamic; new administrations can reverse or modify prior policies through rule changes or new administrative approaches.
Operating
Operating means putting enacted laws into productive use through administrative agencies.
Examples include environmental protections, safety standards, and ACA implementation to expand Medicaid enrollment.
Effectiveness depends on the fit between implementing agencies and policy objectives, agency capabilities, and management quality.
Evaluating
Evaluating means systematically collecting, analyzing, and using information to judge policy merit and outcomes.
Key questions include: How effective is the policy? Were objectives achieved? Do benefits justify costs?
Types of evaluations include: process vs outcome, formative vs summative, cost-benefit, and cost-effectiveness analyses.
Evaluation support exists at federal level via agencies like AHRQ and the CMS Innovation Center.
Modification Phase
Policymaking is not perfect; modification is necessary as circumstances change.
Modifications can be minor adjustments or substantial amendments, and can even involve revisiting the agenda.
Example: Part D of Medicare created prescription drug coverage later expanded; 2006 amendments addressed drug costs for seniors.
The ACA era shows that policy effects can generate new demands for modification, which may include changes to enforcement mechanisms (e.g., repeal or modification of the shared responsibility payment in 2017).
Policy histories: initial versions are revised through amendments, new rules, or new implementation decisions; many policies persist long or evolve over time.
Chapter 9 covers policy modification in more detail.
Key Features of the Policymaking Process
Policymaking occurs within a dynamic external environment and is an open system; external factors both shape and are shaped by policy.
External variables include technology, legal systems, economic conditions, social norms, ecological and demographic changes, etc.
Technology example: public funding for tech influences policy funding; technologies must be integrated into health programs (e.g., Medicare/Medicaid).
Legal variables: laws, court decisions, and regulatory actions influence all phases and can reinterpret or reverse previous policies.
The Phases Are Interactive and Interdependent (Exhibit 4.4)
Relationships among policy formulation, implementation, and modification are bidirectional and dynamic; changes in one phase affect others.
Policy design in the formulation phase shapes rulemaking and operation in implementation; evaluation feeds back into new rounds of design and rulemaking.
Policymaking Is a Cyclical Process
The policymaking cycle is continuous: formulation -> enactment -> implementation (designing, rulemaking, operating, evaluating) -> modification -> possible revisiting of agenda items.
At any time, multiple policies may be in different phases across all levels of government.
The cycle provides ongoing opportunities to adjust policies to improve outcomes.
Policymaking Is a Highly Political Process
The policymaking process involves human actors with varying degrees of altruism and self-interest; ethics influence problem framing and policy design.
It is not purely rational; political bargaining, interest group influence, ideological biases, and vote trading shape outcomes.
Policymakers must balance public-interest goals with self-interest and industry interests; the ACA experience shows shifts in priorities and political support over time.
The ACA has reduced some disparities in access to care; evidence suggests narrowing gaps in uninsured rates for Black and Hispanic populations and reducing some socioeconomic disparities, though disparities remain.
Public policy in health is complex, cyclical, external-environment driven, and highly interactive across phases; it requires informed decision-making and prudent judgment.
Summary (Key Takeaways)
Health policies are formed in policy markets where demanders and suppliers interact; federal, state, and local levels share similar decision-making processes with variations.
Public policymaking in health is a human process with ethical, political, and practical implications; informed decision-making is essential.
The policymaking process is composed of three interconnected, cyclical phases—formulation, implementation, and modification—with an external environment that both influences and is influenced by policy.
Each phase contains essential activities (agenda setting, development of legislation; designing, rulemaking, operating, evaluating; modification) that can lead to new rounds of policy design and implementation.
The process is highly political and open to modification over time in response to changing circumstances, political dynamics, and external variables.
Review Questions
Draw a schematic model of the three phases of the public policymaking process.
Describe the general features of the model drawn above.
Discuss the formulation phase of policymaking.
Discuss the implementation phase of policymaking.
Discuss the modification phase of policymaking.
Discuss how the phases of policymaking interact with one another.
How does passage of the ACA illustrate both multiple-streams and punctuated-equilibrium theories of public policymaking?
References (Selected)
Abramson, M. A., and P. Lawrence. 2014. What Government Does: How Political Executives Manage.
Baumgartner, F. R., and B. D. Jones. 1993. Agendas and Instability in American Politics.
Kingdon, J. W. 2010. Agendas, Alternatives, and Public Policies.
Sabatier, P. A., and C. Weible (eds.). 2014. Theories of the Policy Process.
Weissert, C. S., and W. G. Weissert. 2012. Governing Health: The Politics of Health Policy.
See also Congress.org (2019) for the legislative process; GovTrack.us (2019) for statutory activity and trend data.