Nearly three weeks have elapsed since President Clinton outlined his Administration's health care reform proposals in his Sept. 22 address before a joint session of Congress. During this time, a diverse collection of players has been jockeying for position - lawmakers, consumer groups, medical industry representatives, unions, small and large businesses, doctors - all of them with interests at stake in the debate. Affected parties who sense that their interests are threatened have been voicing a steady stream of reservations about various aspects of the Clinton plan.
Let us view this tableau of discontent and protest from the perspective of the policy analyst. It is clear that we are already seeing glimpses of what might happen to the Clinton plan if it reaches the stage of actually being carried out, its directives translated into action and results - in other words, the implementation phase of the policy process.
The policy process does not end when legislation is voted on and passed. In fact, building a consensus to ensure passage of laws is only half the struggle. The remaining half of the process is the policy implementation phase. It is here that the ultimate effects of any given legislation are shaped and determined. Legislators can not simply conjure policy into being - in order to implement the laws they make, agencies and bureaucracies must be created, staffers and administrators hired, information made available to the public, monies and resources dispersed, etc. Without proper implementation of policy, true in spirit to the legislative intent which created it, no policy can succeed in its ultimate goals - making a difference, changing lives and circumstances, altering the status quo.
As outlined by Bullock and Lamb, there are several variables that analysts and social scientists have agreed are crucial to the ultimate success or failure of a given policy's implementation. These variables include policy clarity, specificity of standards used to evaluate the policy, presence of an enforcement agency, enforcer commitment, attitudes of those who benefit from the policy, monitoring, commitment of the enforcement agency's superiors, administrative coordination, costs and benefits, and direct federal involvement. We will explore how each of these variables has implications for the ultimate fate of Clinton's reform proposals. Briefly, we will also look at how health care reform might be affected by some of the implementation "games" as conceived by Bardach, i.e., problems that can arise when actors connected with the implementation phase decide to throw wrenches into the works.
The need for policy clarity means that the actors responsible for implementing policy (i.e., agencies or bureaucracies) must have clearly defined policy goals to work with.
The central problem with any discussion of Clinton's proposed health care reforms is that even at this point, the Administration's plan is still up in the air. In order to better deal with the initial flurry of opposition to some of the plan's elements and vague funding mechanisms, hasty finetuning is now underway and consequently, the plan has still not been presented in final legislative form to Congress. In order to weather the long months of political struggle ahead, the President and Mrs. Clinton have both repeatedly served notice that "the only (inviolable) parts of the proposal are the overarching principles, which call for security, responsibility, simplicity, choice, savings, and quality." (NYT, 9/28/93, p A10) These terms may only be soundbites designed to ensure that whatever compromises are eventually made, none that deviate too far from the President's plan will be considered politically feasible. However, by signalling that everything is still on the table, the emphasis on these six principles conveys a sense of vagueness that does not bode well for policy clarity.
The fifty state governments will ultimately be responsible for implementing President Clinton's reforms. His plan saddles them with a "mind-boggling array of new duties" (NYT, 9/23/93, p A1), everything from establishing new regional health care alliances to buy insurance for their residents, to paying subsidies to help poor people and small businesses buy their insurance (using state and federal money), to collecting the huge amounts of data needed to measure and compare the quality of care within their borders. In many areas, Clinton's plan does not give states clear instructions on how to accomplish these goals, such as how to "make sure that 'all eligible individuals,' including homeless people, drug addicts, and residents of remote areas, enroll in a regional alliance." (NYT, 9/23/93, p A12)
Specificity of standards means there must be reliable standards by which to measure the effects of a newly implemented policy. One of the most important standards by which the success of health care reform will be measured is how good a job it does in slowing the increase of health care costs, which have been spiraling out of control. In this regard, at least, the plan has built in specificity of standards. Since Clinton's proposed regional health alliances will all offer consumers a standard set of health benefits packages, cost comparison among plans and alliances will be relatively easy.
A similar specificity of standards exists in the plan's main funding mechanisms. There are four of them: savings to be realized through decreased Medicaid and Medicare expenditures (1), estimated revenues from taxes on tobacco products (2) and taxes on companies who opt to continue insuring their own employees instead of joining regional health alliances (3), and estimated increased tax revenues from economic expansion made possible by lower health care costs to businesses (4). Any deviation from these funding estimates once the plan is operational (for example, if people buy less tobacco products because of the level of tax, therefore generating less actual tax revenues) would likely be detected immediately.
Unless voluntary compliance with a policy's directives can be guaranteed, there is a need for enforcement agencies to be set up, charged with enforcing compliance. This need is particularly great in complex policy situations like health care reform, a reform process that will touch millions of people, thousands of institutions, and require them all to change long-established ways of doing things. On this count, which usually involves the creating of new bureaucracies, there is little doubt that the Clinton plan will fail to deliver.
"In (some) ways Mr. Clinton would make the system even more complicated. He would create new agencies and a complex new apparatus to buy insurance. There would be regional health alliances, health plans, a powerful National Health Board, a new Federal advisory committee to assess the reasonableness of new drug prices and a new Government agency to decide the number of young doctors entering each medical specialty." (NYT, 9/24/93, p A10)
On paper at least, these enforcement agencies will be charged with the responsibility of overseeing compliance with reform. The crucial question, however, is just how will compliance be achieved? If cost savings are less than projected in certain areas of the plan, what happens? "The government could withdraw subsidies to small businesses and low-income households. Or it could take over the operation of health alliances that failed to meet targets for saving, thus acknowledging failure of the plan's fundamental structure. As with nuclear weapons, it is hard to imagine use of such penalties. Determined efforts to reach the saving targets are likely to provoke a backlash from providers and patients." (NYT, 9/22/93, p A21)
There are several dimensions to enforcer commitment, or the willingness of those who actually staff enforcement agencies to carry out the enforcement of policy. Policy must be a priority for either the enforcement agency as a whole or individual staffers. There is also the question of agency co-optation, or the "capture" of an agency by the very forces it is supposed to be regulating. This can come in the form of representatives of the regulated being chosen to lead or serve in regulatory agencies, or interest groups exercising undue influence over the agencies that regulate them through their allies in legislatures.
There is a very real danger of such co-optation befalling the regional health alliances or other new regulatory agencies created by the plan, simply due to the complexity of the health care delivery system itself and the technical knowledge that will be demanded of people overseeing and dealing with the consequences of reform. However, the Administration insists:
"Consumers will be safeguarded by the requirement that the alliances' boards include equal numbers of representatives of employers, consumers, the self-employed and other covered groups. They would not include people associated with health care providers, law firms involved with health care, pharmaceutical companies or suppliers of medical equipment or services." (NYT, 9/25/93, p 8)
Attitudes of intended policy beneficiaries are crucial; their support, opposition or disinterest translates into varying degrees of pressure on legislators to act on a given policy when results of implementation are reviewed, and often means the difference between policy life or death. The reactions of key intended beneficiaries of health care reform such as doctors, older Americans, business owners, underinsured Americans, etc., will be the determining factor in the plan's eventual success. Of course, if the plan works well, it stands to reason that public reaction to it will be favorable. Currently, however, although Clinton's plan has the support of a majority of the public (with 61% saying they were willing to pay higher taxes so that all Americans would have guaranteed health insurance, even before Clinton's Sept 22. televised health care address) (NYT, 9/22/93, p A1), reaction from some intended beneficiaries is decidedly mixed. Doctors, for example, are split in their opinions of the plan roughly along lines of those who are still privately employed (hesitant about reform) and those who already draw salaries working for clinics, hospitals, group practices and HMO's (welcome the proposed changes). (NYT, 9/24/93, p A11)
The remaining five variables crucial to policy implementation are monitoring of policy compliance, commitment of the enforcement agency's superiors, administrative coordination, policy costs and benefits, and direct federal involvement. These are all relatively less central to the implementation of health care policy than the first five, for various reasons. Monitoring of policy compliance will be subsumed in the duties of policy enforcement as carried out by the regional health alliances and new health regulatory agencies created by the plan.
Commitment of the enforcement agency's superiors means, in the case of health care reform, the extent to which the Clinton Administration has committed itself to the enterprise, which is to say totally. This commitment is borne out of a widespread sentiment in the country at large that the health care delivery system does need reforming. It is a public mood that could shift, of course, and turn against health care reform, if during the process of implementing the Clinton plan things go awry.
Administrative coordination is important as it relates to the extent that agencies in the government with overlapping jurisdictions are able to cooperate on policy implementation. It will be important in areas where HEW has to work with the proposed National Health Board, other new regulatory agencies, and the regional health alliance boards.
"Mr. Clinton's proposal would open a new chapter in the history of Federal-state relations, placing huge new obligations on the states to run a social welfare program that would dwarf Social Security in terms of money." (NYT, 9/23/93, p A12)
Interesting problems could arise in matters involving coordination between state governments and the regional health alliances, because the health alliances will themselves be handling more money than most state governments!
Policy costs and benefits generally refer to the consequences of compliance or non-compliance with a given policy. The Clinton plan imposes increased tax costs on businesses who opt out of the regional health alliances, costs on individuals who choose more generous packages of health benefits than the norm, and various other measures intended to induce businesses and consumers to comply with the plan's reforms.
Finally, direct federal involvement refers to the extent which the federal government itself will be actually implementing policy.
"The Federal Government will have to issue dozens of new regulations translating any new law into terms that can be applied to doctors, hospitals, clinics, and insurance companies. But every state will need to pass legislation filling in details of the Federal framework." (NYT, 9/23/93, p A12)
Actions by the new National Health Board and other new health regulatory agencies notwithstanding, the bulk of Clinton's reforms will be implemented at the state level, by state governments and the new regional health alliances.
A final look at some of the implementation "games" as conceived by Bardach, and how they relate to implementation of health care reform. These games describe problems that can arise when actors connected with the implementation phase of the policy process decide, for various reasons, to derail or hinder successful policy implementation. Three games are of particular interest to us: Easy Money, Up For Grabs, and Piling On. Easy Money describes what happens when private sector elements find they can take undue advantage of the government trough via involvement in some public program, and by ripping the program off manage to circumvent or subvert any goals policymakers may have had of getting a good job done cheap. There is already concern that some businesses may begin to play a variety of Easy Money called the "subsidy game" once Clinton's health reforms pass. Since the Clinton plan would subsidize the purchase of health insurance for businesses with less than fifty employees, the fear is that some medium-size businesses will re-organize into smaller firms, in order to take advantage of the subsidies.
Up For Grabs is a predicament similar to the situation that confronts a regulatory agency in danger of being co-opted by the interests it is supposedly regulating. It happens when a policy mandate is formulated that "may have been the result of strong pressures on government to do something about what is generally perceived to be an urgent social problem, even though no one quite knows what ought to or could be done." (Bardach, p 90) Sounds almost like health care reform, doesn't it. As previously stated, regardless of the Administration's assurances that consumers will be given equal or greater representation than medical insurance and pharmaceutical industry representatives on regional health alliance boards, the whole spectrum of new agencies and deliberative bodies responsible for overseeing reform will be very much Up For Grabs. The five giants of the medical insurance industry - Prudential, Cigna, Aetna, Travelers, and Metropolitan Life - as well as the more than 70 Blue Cross and Blue Shield plans and dozens of already established HMO's have already staked out enormous victories in terms of the plan's general outlines, which assign them all central, very profitable roles.
Finally, there is a game called Piling On. This describes what happens when onlookers see a new program gathering speed, and attempt to use it for the advancement of their own political objectives. The obvious way in which this game is now being played with respect to health care reform is on the issue of abortion. The federal government has blocked abortion subsidies to poor women since 1981, through a series of anti-abortion amendments sponsored by Rep. Henry Hyde, (R-IL). The most recent attempt to defeat the Hyde amendment by passing a national pro-choice bill went nowhere. Pro-choice advocates are now attempting an end run around their most recent legislative defeat by insisting that abortion be covered under the Clinton health care reform package, regardless of whether or not doing so would jettison the bill's chances of final passage. This development presages a trend which will undoubtedly intensify during implementation of reform. Interest groups will likely mobilize to have benefits added to the plan's standard coverage package which are not currently covered, i.e., dental and eye care for adults, hearing aids, in-vitro fertilization, etc. With the addition of every added benefit, the plan's costs will increase, growing heavier and heavier under its burdens and edging ever closer back to the state of spiraling health costs which occasioned reform in the first place.
In closing, I'm sure glad I'm not the one responsible for eventual implementation of Clinton's health care reforms. I hope they work, and they look somewhat more promising when analyzed in terms of variables important for successful implementation, but there are too many games that could be played, too many pitfalls - I guess the whole thing is still too much of a Rube Goldberg contraption for me.
Attitudes of (intended) program beneficiaries: a short case study
"'One of my main reasons for being a doctor was I wanted to run my own clinic', said David Williams, 24, who is from a suburb of Salt Lake City and is interested in rural medicine. 'I wanted to do it on my own, and it sounds like he's trying to force all doctors into larger health care organizations instead of allowing any kind of entrepreneurial spirit in doctors.'" (NYT, 9/24/93, p A11)
"The uneasiness elsewhere in the nation over the proposal dates to a bygone idea of health care, Dr. Crosson (a doctor employed by Kaiser Permanente, the nation's largest HMO) said. 'Most people have grown up with a clear vision of what medicine is about,' he said. 'It's one physician...practicing by themselves in a small office with a nurse.' But with technological advance, Dr. Crosson said, 'the black bag could not hold all the tools of the trade, the small office could not contain all the tests and interventions a patient could need.' Thus group practices became more common and 'the new challenge became how to deliver that complicated care in a way that's still personal.'" (NYT, 9/24/93, p A11)
"A giant national health care system, many (medical students) feared, would only aggravate a trend toward having to practice medicine by bureaucratic decree, whether from the government or a private insurer." (NYT, 9/24/93, p A11)
"Other (insurance company) employees were skeptical that a vast new Government bureaucracy could streamline anything, let alone medical care paperwork. They said the most up-to-date HMO's already had more ambitious goals, like getting rid of all paperwork." (NYT, 9/24/93, p A11)
"While poor people worry that their needs may be neglected, state officials, for their part, fear that the Clinton plan may duplicate a fundamental problem of Medicaid: the proliferation of Federal mandates without enough Federal money to pay for them." (NYT, 9/23/93, p A12)