Peterson slides.2.20.09

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Peterson slides.2.20.09

  1. 1. Is This the Era of Health Care Reform?Is This the Era of Health Care Reform? Why This Time is Different from AllWhy This Time is Different from All Other TimesOther Times Mark A. Peterson, Ph.D. Professor of Public Policy and Political Science Department of Public Policy UCLA School of Public Affairs Leonard Davis Institute of Health Economics Health Policy Seminar Series University of Pennsylvania February 20, 2009
  2. 2. The easy out: This time is not different But not so fast…is there a reason to anticipate that this time is different?
  3. 3. The Policy Window and Possible Triggers (Based on John W. Kingdon, Agendas, Alternatives, and Public Policies) PolicyPolicy Politics Politics Problem s Problem s PolicyPolicy WindowWindow Major Crisis? (health care system/ economic system?) Change in Administration (2008) Change in Congress (2006, 2008) Viable Policy Options (but no consensus) Systematic Signs of Decline or Missed Opportunities Swing in the National Mood Social Movement? Policy Image? Power of Ideas? Rearrangement of Interest Group Alliances?
  4. 4. “Google” the term “health care crisis”: Over 500,000500,000 hits
  5. 5. Costs Coverage Consequence Int’l Mea- sures HC Infla- tion Gov’t Spend Bus. Spend Indiv’l Spend Un- insured Under- insured Dispar- ities Quality/ Outcomes Int’l Rank Pop Health 1912 0 0 0 0 - 0 0 0 0 0 - FDR 0 0 0 0 -- -/0 0 0 0 0 0 Truman 0 0 0 0 -+? -+ -+ 0 0 0 0 Nixon/ Ford 0 - - -? -+ -(+) - 0 0 0 0 Carter 0? -- --? -? -+ -(+) - 0 0 0 0 Clinton -- -- -- -- -- -- - -- - - 0 Now -- -- -- -- -- -- -- -- -- -- - 0 = No evidence or limited perception of problem - = widely recognized evidence of problem -- = evidence of problem and getting worse -+ = evidence of problem but getting better Rational Responses to Health Care System Problems? © Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,” book manuscript.
  6. 6. Institutional-Political-Economic-Policy Contexts • The Institutional Context • The Political Context • The Economic Context • The Policy Context • Presidential/Administration Leadership From: Mark A. Peterson, Legislating Together: The White House and Capitol Hill from Eisenhower to Reagan (Harvard University Press, 1990).
  7. 7. Institutional-Political-Economic-Policy Contexts • The Institutional Context – Congress Mark A. Peterson, Legislating Together: The White House and Capitol Hill from Eisenhower to Reagan (Harvard University Press, 1990).
  8. 8. Types of Legislative Structure - Policy Effects Policy Effects Centralized Decentralized Fragmented Promotes Policy Change Threatens Policy Change Legislative Majority Favors Change Legislative Majority Opposes Change Supportive Chairs and Committees as Protocoalitions Antagonistic Chairs Exercise Baronial Veto Multiple Coalition Strategies Issue Complexity Reinforces Fragmentation © Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,” book manuscript.
  9. 9. Structure of the House of Representatives During Four Periods of Reform Debates Decentralization Centralization Fragmentation Fragmentation Centralization Decentralization Fragmentation Centralization Decentralization Centralization Decentralization Fragmentation 1940s (Truman) 1970s (Nixon/Ford/Carter) 1993-94 (Clinton) Now (Obama) The Senate? © Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,” book manuscript.
  10. 10. Institutional-Political-Economic-Policy Contexts • The Institutional Context – Congress – Interest Groups Mark A. Peterson, Legislating Together: The White House and Capitol Hill from Eisenhower to Reagan (Harvard University Press, 1990).
  11. 11. Changing Interest Group Communities Policy Monopoly (1940s) Polarized (1970s) Fragmented (Open to multiple coalition strategies) (1990s, Now?) “The Challengers” Poorly Mobilized Well Mobilized “TheExis Allied Split © Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,” book manuscript.
  12. 12. Interest Group Positions on Clinton’s Health Security Act 0 10 20 30 40 50 60 70Endorsed Favored Mixed Opposed Fought Percent GOP Target Groups Neither Dem Target Groups © Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,” book manuscript.
  13. 13. Institutional-Political-Economic-Policy Contexts • The Institutional Context – Congress – Interest Groups • The Political Context – Presidential Election Returns Mark A. Peterson, Legislating Together: The White House and Capitol Hill from Eisenhower to Reagan (Harvard University Press, 1990).
  14. 14. Election Results Supporting the President
  15. 15. First Election of the President—Popular Vote Percentage 0 10 20 30 40 50 60 70 % Popular Vote Percent FDR 1932 Eisenhower 1952 Obama 2008 Clinton 1992
  16. 16. Institutional-Political-Economic-Policy Contexts • The Institutional Context – Congress – Interest Groups • The Political Context – Presidential Election Returns – Congressional Election Returns Mark A. Peterson, Legislating Together: The White House and Capitol Hill from Eisenhower to Reagan (Harvard University Press, 1990).
  17. 17. Democratic and Republican Seats in the U.S. House
  18. 18. Democratic and Republican Seats in the U.S. Senate Cloture (1917-74) Cloture (1975 - )
  19. 19. Party Unity U.S. House and Senate From Nolan McCarty, Keith T. Poole, and Howard Rosenthal, Polarized America: The Dance of Ideology and Unequal Riches (MIT 2006) [http://polarizedamerica.com/]
  20. 20. Comparison of Three Democratic Presidents and “Solid Votes” (Majority = 218) President First Year Democratic Seats Democratic Party Unity “Solid Votes” Carter 1977 292 X .67 195 Clinton 1993 258 X .85 219 Obama 2009 257 X .96 (110th Congress) 247 Economic Stimulus: 246 © Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,” book manuscript.
  21. 21. Net Change in Number of Democratic Congressional Seats -10 0 10 20 30 40 50 60 Net Change House Seats Net Change Senate Seats NumberofSeats 1990+1992 2006+2008
  22. 22. Institutional-Political-Economic-Policy Contexts • The Institutional Context – Congress – Interest Groups • The Political Context – Presidential Election Returns – Congressional Election Returns – Public opinion Mark A. Peterson, Legislating Together: The White House and Capitol Hill from Eisenhower to Reagan (Harvard University Press, 1990).
  23. 23. Timing—Dynamism of Domestic Policy Mood Updated from James A. Stimson, Public Opinion in America: Moods, Cycles, and Swings, 2nd Ed. Boulder: Westview 1999 (updated data set—Mood5204.xls—at www.unc.edu/~jstimson)
  24. 24. Most individuals in the United States currently get health insurance coverage through their employer or through a family member’s employer. Some people believe that employer-based health insurance is an effective way to provide health coverage and will remain so in the future. Other people believe that the employer-based approach will not continue to work in the future because of changes in our economy. When thinking about the future of employer-based insurance, for each of the following statements do you think the issue is--Not a problem for employer-based insurance; A potential threat to employer-based insurance; Certain to lead to the failure of employer-based insurance; or Don’t know? (Pre-Election Survey) 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100 % Multiple Employers in Course of Work Life Rising Cost of Health Care Decline of Large Manufacturers Fewer Employers Provide Coverage Not a Problem Potential Threat Certain Failure Don't Know Source: Blue Sky module, UCLA Team, 2006 Cooperative Congressional Election Survey, N=1,000
  25. 25. Public Support for Major Health Care System Change 0 10 20 30 40 50 60 70 80 90 100 1982 1984 1988 1990 1993 1994 (9/94) 1998 2000 2006 Percent Defeat of Clinton’s HSA
  26. 26. People have different views about what affects their own health and the health of their families. Some people believe that health is an individual matter, determined by their own preferences, decisions, and actions (“we’re on our own”). Let’s say that they are 1 on a five-point scale. Other people believe that health is a community matter, with their own health affected by the health and well-being of others (“we’re in this together”). Let’s say that they are 5 on the five-point scale. On the scale below, please indicate where you would place yourself. (Pre-Election Survey) 0 5 10 15 20 25 30 35 40 We're on Our Own 2 3 4 We're in this Together Percent 11% Source: Blue Sky module, UCLA Team, 2006 Cooperative Congressional Election Survey, N=1,000 The truly Rugged Individualists
  27. 27. When you consider the best way to think about health care services (provided by doctors, nurses, other health professionals, clinics, hospitals, etc.), which one of the following three statements comes closest to your own opinion? Health care services are “private goods” that people should buy somewhat like cars and televisions, and based on what they can afford; Basic health care services that should be available to everyone, like public education, but people who can afford to should be able to buy more or better care, similar to paying for private schools; or All effective health care services should be universally available, provided to everyone as a right of citizenship and based on the services they need. (Pre-Election Survey) 11 34 50 5 0 10 20 30 40 50 60 Private Goods Basic Services for All Provided as a Right Don't Know Percent Source: Blue Sky module, UCLA Team, 2006 Cooperative Congressional Election Survey, N=1,000
  28. 28. Institutional-Political-Economic-Policy Contexts • The Institutional Context – Congress – Interest Groups • The Political Context – Presidential Election Returns – Congressional Election Returns – Public opinion • The Economic Context – Growing Resources vs. 0-sum constraint vs. Crisis Mark A. Peterson, Legislating Together: The White House and Capitol Hill from Eisenhower to Reagan (Harvard University Press, 1990).
  29. 29. Resources and the Politics of Policy Change Growing Economy/ Rising Revenues Economic CrisisStagnant Economy/ Budget Deficits ProspectsforMajorPolicyChange LBJ Nixon, Carter, Clinton (1993-94) FDR, [Reagan], Obama © Mark A. Peterson
  30. 30. Institutional-Political-Economic-Policy Contexts • The Institutional Context – Congress – Interest Groups • The Political Context – Presidential Election Returns – Congressional Election Returns – Public opinion • The Economic Context – Growing Resources vs. 0-sum constraint vs. Crisis • The Policy Context -- Regulatory & Redistributive: high conflict • Presidential Leadership Mark A. Peterson, Legislating Together: The White House and Capitol Hill from Eisenhower to Reagan (Harvard University Press, 1990).
  31. 31. Political Hurdle #1: Ideological Positions on House Roll Call Votes, 93rd Congress (1973-74) 0 10 20 30 40 50 60 70 -1 -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8 1 DW-Nominate Scores (1st Dimension) NumberofRepresentatives Republicans Democrats Source: Gary Jacobson, “Public Opinion and the Impeachment of Bill Clinton,” 1999. About 1/3 could be either Dem or GOP
  32. 32. Political Hurdle #1: Ideological Positions on House Roll Call Votes, 110th Congress (2007-08) (Source: Poole and Rosenthal, http://voteview.uh.edu/dwnomin.htm) 0 10 20 30 40 50 60 70 -1 -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8 1 DW-Nominate Scores (1st Dimension) NumberofRepresentatives Republicans Democrats 4 of the 5 defeated in 2008 15 of the 26 defeated/ departed In 2008
  33. 33. Political Hurdle #2: The Fear Arc Time © Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,” book manuscript.
  34. 34. Issue Visible “Polled” Attitude Model CModel C Implication 9 Implication 7 Implication 8 Model BModel B Implication 6Implication 6 Implication 4Implication 4 Implication 5Implication 5 Model AModel A (current dominant)(current dominant) Implication 3Implication 3 Implication 1Implication 1 Implication 2Implication 2 © 2006 Frameworks Institute—Susan Bales and Frank Gilliam Strategy: Without Framing and Reframing—People Default to the Dominant “Pictures in their heads”
  35. 35. Issue Visible “Polled” Attitude PreventionPrevention Healthy others mean healthier me Stay healthy Self financing Inter- dependent Current system inefficient and unreliable Every one is in this togetherEvery one is in this together Need an infrastructureNeed an infrastructure ConsumerConsumer Reform: “Do me no harm”Reform: “Do me no harm” Private goodPrivate good Personal cost issuePersonal cost issue © 2006 Frameworks Institute—Susan Bales and Frank Gilliam (amended) Strategy: Without Framing and Reframing—People Default to the Dominant “Pictures in their heads”
  36. 36. The Individual Cognitive Process • Duality of Individuals’ Information Processing Based on Drew Westen, The Political Brain (PublicAffairs, 2007) – “Rational” But also… – “Emotional” • Kahneman and Tversky: “Prospect Theory”
  37. 37. People Need Values Cues (Based on George Lakoff)  Level One: Big ideas (and Emotional Connectons), like freedom, individual rights/responsibilities, justice, prevention, family, equality, security, and opportunity  Level Two: Issue-types, like women’s rights, the environment, children’s issues, work, health care  Level Three: Specific proposals, like the earned income tax credit, day care, minimum wage, individual health insurance mandate © 2006 Frameworks Institute—Susan Bales and Frank Gilliam ThisDirectionDoesNotWork
  38. 38. Retooling Obama's campaign machine for the long haul The vast network that helped elect Obama will be tapped to lobby lawmakers on behalf of the president, with an eye toward reelection. A service organization as a nonprofit arm is also considered. By Peter Wallsten January 14, 2009 Reporting from Washington — As Barack Obama builds his administration and prepares to take office next week, his political team is quietly planning for a nationwide hiring binge that would marshal an army of full-time organizers to press the new president's agenda and lay the foundation for his reelection. The organization, known internally as "Barack Obama 2.0," is being designed to sustain a grass-roots network of millions that was mobilized last year to elect Obama and now is widely considered the country's most potent political machine. Organizers and even Republicans say the scope of this permanent campaign structure is unprecedented for a president. People familiar with the plan say Obama's team would use the network in part to pressure lawmakers -- particularly wavering Democrats -- to help him pass complex legislation on the economy, healthcare and energy. Retooling Obama's campaign machine for the long haul The vast network that helped elect Obama will be tapped to lobby lawmakers on behalf of the president, with an eye toward reelection. A service organization as a nonprofit arm is also considered. By Peter Wallsten January 14, 2009 Reporting from Washington — As Barack Obama builds his administration and prepares to take office next week, his political team is quietly planning for a nationwide hiring binge that would marshal an army of full-time organizers to press the new president's agenda and lay the foundation for his reelection. The organization, known internally as "Barack Obama 2.0," is being designed to sustain a grass-roots network of millions that was mobilized last year to elect Obama and now is widely considered the country's most potent political machine. Organizers and even Republicans say the scope of this permanent campaign structure is unprecedented for a president. People familiar with the plan say Obama's team would use the network in part to pressure lawmakers -- particularly wavering Democrats -- to help him pass complex legislation on the economy, healthcare and energy. © Los Angeles Times
  39. 39. Presidents in Political Time (Stephen Skowronek, The Politics Presidents Make: Leadership from John Adams to Bill Clinton) • Reconstruction of the political order – FDR – [Reagan] – Obama? • Articulation of the political order – LBJ • Preemption of the political order – Nixon – Clinton • Disjunction of the political order – Hoover – Carter – [Bush II?]
  40. 40. http://www.blueskyhealthinitiative.org/

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