Peterson slides.2.20.09

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Is This the Era of Health Is This the Era of Health Care Reform? Care Reform? Why This Time is Different Why This Time is Different from All Other Times from All Other 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

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Transcript of Peterson slides.2.20.09

Page 1: Peterson slides.2.20.09

Is This the Era of Health Care Reform?Is This the Era of Health Care Reform?Why This Time is Different from All Why This Time is Different from All

Other TimesOther Times

Mark A. Peterson, Ph.D.Professor of Public Policy and Political Science

Department of Public PolicyUCLA School of Public Affairs

Leonard Davis Institute of Health Economics Health Policy Seminar Series

University of PennsylvaniaFebruary 20, 2009

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The easy out: This time is not different

But not so fast…is there a reason to anticipate that this time is different?

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The Policy Window and Possible Triggers(Based on John W. Kingdon, Agendas, Alternatives, and Public Policies)

Po

licyP

olicy

Politics

Politics Problems

Problems

Policy Policy 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?

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“Google” the term “health care crisis”:

Over 500,000500,000 hits

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Costs Coverage Consequence

Int’lMea-sures

HCInfla-tion

Gov’tSpend

Bus.Spend

Indiv’lSpend

Un-insured

Under-insured

Dispar-ities

Quality/Outcomes

Int’lRank

PopHealth

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.

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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).

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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).

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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.

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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?The Senate?© Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,” book manuscript.

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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).

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Changing Interest Group Communities

PolicyMonopoly(1940s)

Polarized(1970s)

Fragmented(Open to multiple

coalition strategies)

(1990s, Now?)

“The Challengers”

Poorly Mobilized Well Mobilized

“Th

e E

xis

tin

g S

tak

eho

lde

rs”

Allied

Split

© Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,” book manuscript.

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Interest Group Positions on Clinton’s Health Security Act

0

10

20

30

40

50

60

70

Perc

ent

GOP Target Groups

Neither

Dem Target Groups

© Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,” book manuscript.

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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).

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Election Results Supporting the President

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First Election of the President—Popular Vote Percentage

0

10

20

30

40

50

60

70

% Popular Vote

Perc

ent

FDR 1932Eisenhower 1952Obama 2008Clinton 1992

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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).

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Democratic and Republican Seats in the U.S. House

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Democratic and Republican Seats in the U.S. Senate

Cloture (1917-74)

Cloture (1975 - )

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Party Unity U.S. House and SenateFrom Nolan McCarty, Keith T. Poole, and Howard Rosenthal, Polarized America: The Dance of

Ideology and Unequal Riches (MIT 2006) [http://polarizedamerica.com/]

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Comparison of Three Democratic Presidents and “Solid Votes” (Majority = 218)

President First Year Democratic SeatsDemocratic 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.

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Net Change in Number of Democratic Congressional Seats

-10

0

10

20

30

40

50

60

Net Change House Seats Net Change Senate Seats

Nu

mb

er o

f S

eats

1990+1992 2006+2008

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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).

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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)

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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 inCourse of Work Life

Rising Cost of HealthCare

Decline of LargeManufacturers

Fewer EmployersProvide 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

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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

Per

cent

Defeat of Clinton’s HSA

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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 OurOwn

2 3 4 We're in thisTogether

Perc

en

t

11%

Source: Blue Sky module, UCLA Team, 2006 Cooperative Congressional Election Survey, N=1,000

The truly Rugged

Individualists

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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 Servicesfor All

Provided as aRight

Don't Know

Perc

en

t

Source: Blue Sky module, UCLA Team, 2006 Cooperative Congressional Election Survey, N=1,000

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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).

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Resources and the Politics of Policy Change

Growing Economy/Rising Revenues

Economic CrisisStagnant Economy/ Budget Deficits

Pro

spec

ts f

or

Maj

or

Po

licy

Ch

ang

e

LBJ

Nixon,Carter,Clinton

(1993-94)

FDR,[Reagan],

Obama

© Mark A. Peterson

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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 LeadershipMark A. Peterson, Legislating Together: The White House and Capitol Hill from Eisenhower to Reagan (Harvard University Press, 1990).

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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)

Num

ber

of R

epre

sent

ativ

es

RepublicansDemocrats

Source: Gary Jacobson, “Public Opinion and the Impeachment of Bill Clinton,” 1999.

About 1/3 could be either Dem or GOP

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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)

Num

ber

of R

epre

sent

ativ

es

RepublicansDemocrats

4 of the 5 defeated in 2008

15 of the 26 defeated/departedIn 2008

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Political Hurdle #2:The Fear Arc

Time

© Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,” book manuscript.

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IssueVisible “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”

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IssueVisible “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”

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The Individual Cognitive Process

• Duality of Individuals’ Information ProcessingBased on Drew Westen, The Political Brain (PublicAffairs, 2007)

– “Rational”

But also…

– “Emotional”• Kahneman and Tversky: “Prospect Theory”

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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

Th

is D

irec

tio

n D

oes

No

t W

ork

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Retooling Obama's campaign machine for the long haulThe 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 haulThe 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

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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?]

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http://www.blueskyhealthinitiative.org/

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