[Welcome Eric Patashnik, Hosted by Steven Teles - bev]![]()
Reforms at Risk: What Happens After Major Policy Changes Are Enacted
It was not all that long ago that the careful study of the interaction of public policy and politics was a somewhat moribund field in political science. What little work existed was, too often, not terribly useful for those of us—citizens, activists, statesmen—interested in improving the quality of governance.
The last twenty years has, by contrast, witnessed an explosion of work examining how “policy makes politics”—how the design of policies influences their subsequent development, and even how they influence larger political dynamics. Doug Arnold’s The Logic of Congressional Action and Kent Weaver’s Automatic Government traced out the way that different public policies work with or against politicians’ desire to claim credit and (especially important in an era of relative austerity) avoid blame. Paul Pierson’s Dismantling the Welfare State? demonstrated that there are substantial limitations on the capacity of conservatives to retrench the welfare state inherent, in particular the high “transition costs” of change and the need for politicians to avoid blame for the consequences of change. Jacob Hacker showed in The Divided Welfare State that the central role of private providers and employers in the early development of the American welfare state made it difficult to switch to another, more state-dominated system later on. The work of Andrea Campbell, Joe Soss and Suzanne Mettler has investigated the ways that policy design shapes the degree and intensity of political participation—encouraging it in the case of Social Security and the GI Bill, discouraging it in the case of welfare policy and higher education finance.
Activists need to study works like these because they need to make choices. Because all politics is a series of games—rather than a single shot or a Battle of Armageddon—activists need to ask, “When we play this game again in a few years, which policies put in place today are most likely to make our side stronger and our opponents weaker?” All of the works mentioned above and many more I have not mentioned provide the intellectual foundation for activists to answer these sorts of questions—to be shrewd as well as idealistic.
In my judgment, there is no single book that is more instructive about the way that policy design influences the long-term development of policies than Eric Patashnik’s recently published Reforms at Risk: What Happens After Major Policy Changes are Enacted? Unlike most of the works noted above, Patashnik is less concerned with redistributive policies than with what he calls “general interest reforms”—policies designed to enhance the overall efficiency of the economy by uprooting areas of government captured by special interest—what Baumgartner and Jones astutely called “policy monopolies.” Baumgartner and Jones showed in their work that, in contrast to what has been traditionally believed, almost all of these policy monopolies are actually vulnerable—they survive only because the political system only has enough “parallel processing capacity” to draw peoples’ attention to a few issues at a time. Once a special interest’s number has been called, once policy entrepreneurs have focused the public’s attention (often through generating scandal and embarrassment), however, they often find it very hard to protect their interests. The most popular stories of the victory of the public interest over special interests—airline deregulation, tax reform, acid rain cleanup, cutting agricultural subsidies—all fit more or less into the structure Baumgartner and Jones provided.
The question Patashnik asks is (in the words of a previous version of his argument), what happens “after the public interest prevails?” Does the reform stick, or can the bruised and battered special interests recover their lost power, in some cases by completely scrapping the reform? The nature of the problem is clear from the structure Baumgartner and Jones provided—if special interests lose because the public suddenly attends to them and notices how embarrassing the special favors and protection they are receiving are, what happens when the public’s attention shifts elsewhere? Once the outrage dies down, do we just revert back to the status quo ante?
I won’t go into all of Eric’s cases—I’ll leave that for our discussion later. But let me present just one that, I believe, is immensely useful for the actual conduct of politics. As some of the old timers on FDL might remember, as recently as the 1970s airline travel was relatively luxurious but immensely expensive. Airlines’ routes and prices were tightly regulated by the Civilian Aeronautics Board, an agency that had been captured by the airlines themselves and used to prevent price competition and to limit the entry of new airlines into the business. Unable to compete on prices or routes, airlines fought over the only margin left to them—service. Wealthy fliers might fondly remember the era of glamorous air travel, including perks such as on-board piano players. The cost of such plush service were high prices that limited air travel to businessmen and the very occasional holiday trip by the middle-class.
The exception to this regulatory regime were intra-state flights, which were under the control of state authorities. California and Texas, for example, did not regulate routes and prices in the way that the CAB did, and the consequence was that prices on flights inside those states were dramatically lower than comparable flights between states. Getting the price of flights nationally down to the price of those within CA and TX would open up the skies to millions of Americans who could not afford to under the CAB’s regulated system. The airlines, by contrast, were perfectly comfortable with the regulatory status quo, which guaranteed them rich profits in a comfortable, gentlemanly market, rather than the red in tooth and claw markets that deregulation promised. I won’t go into all the details, but—due partly to the remarkable political entrepreneurship of Alfred Kahn and his allies Ted Kennedy and his young staffer Steven Breyer—the airlines lost and the reformers won.
Given the enormous losses that deregulation threatened to impose on the airlines, why were they not able to reverse deregulation once everyone’s attention shifted elsewhere? Patashnik shrewdly notes a few of the factors that caused airline deregulation to stick. First, the airline deregulation bill eliminated the CAB, meaning that the opponents of deregulation would—literally—have to rebuild an agency to achieve their ends. Second, airlines were faced with a very tricky strategic choice after deregulation—they could either adapt to the new regulatory structure by totally redesigning their route and price system, or they could stick with the status quo and hope to reverse deregulation. In classic prisoner’s dilemma fashion, every airline “defected”—even though they would have rather stuck with the old system, they had no choice but to shift to a more competitive approach, out of fear for what their fellow airlines would do. Changing their route structure meant huge fixed costs, especially those involved in creating “hubs” in particular cities. Once these had been built, the airlines now had a concentrated investment in the new system.
Most critically, however, the policy of airline deregulation killed off its most fervent political opponents. Those who most feared deregulation were the financially weakest airlines, and it was they who fought the hardest to keep it from happening. Almost as soon as deregulation happened, these weaker airlines quickly were ushered into Chapter 11. Being out of business also meant that they were out of politics—dead men don’t lobby. Airline deregulation stuck in part because the design of the policy ensured that the political game in the future would be played with a new cast of characters.
I think there is a critical lesson here for health care reform. Those of us who care about getting to universal health care often pay a great deal of attention to how the new system will work and whether care will be improved in quality and cost. Equally important to these questions is whether the reforms we put in place now will survive, and whether they will reshape the political environment in a way that will make further reforms more likely? The best way to reshape that political environment is, as airline deregulation showed, to use policy to destroy your most fervent opponents.
So, as a first question, I’d like to ask Eric what his important book has to tell us about the debates that are going on even as we speak about the shape of health care reform. What are the features of the bills currently under discussion that have the most potential to reshape the contours of health care politics in the future? And what does your book tell us are likely to be the reforms that will have the greatest difficulty sticking in the future?



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Eric, Welcome to the Lake.
Steven, Thank you for Hosting today’s Book Salon.
Thank you very much, Steve. And thank you to Firedoglake for this opportunity to chat about my book.
Steve’s question is a nice way to begin our conversation. Everyone recognizes how massive the stakes are in the health reform debate. The health reform decisions that Congress makes this year will obviously affect the lives of millions of Americans and help determine the fate of the Obama presidency. At the same time, today’s decisions will shape the political terrain on which progressives and conservatives will do battle in the future.
Consider the heated debate over whether the reform should include a public insurance option. At first blush, this would appear to be narrow, technical issue. After all, the U.S. already has a mixed public-private health care system. Most Americans obtain private health insurance through their employers. Most people would continue to have private insurance even after the reform bill passes. Obama has promised that Americans who like their existing plans can keep them. Many other Americans, of course, are already in a public health insurance pool like Medicare, Medicaid, or the VA. Why should creating one more public plan be such a big deal? Why is it sparking so much resistance?
The reason, of course, is that actors are thinking not only about what will happen the moment after health reform is enacted. They are also thinking about what might happen years in the future. Actors are thinking about the sustainability and long-term effects of the public option, and how it might alter interests, ideas, and coalitional alignments.
If a robust public option is implemented, it might create competitive pressure on private insurers, weeding out the least efficient and profitable ones, as Steve points out. The constellation of interests in the health care arena would change.
At the same time, the public plan could gain political legitimacy. It could build a powerful constituency. People would make economic and personal decisions based on the expectation that the public plan would be there for them in the future. These transformations would not necessarily eliminate ideological conflict over the government’s role in the health care sector. But they would change the political status quo, and increase the probability that the U.S. would move toward a single payer system over time.
That’s why many progressives insist it is vital for health reform to include a public option: to reconfigure the political dynamic.
Happy to be here. As I think I made clear in my introductory essay, this is a book of the first order of importance, and a relatively rare case of a scholarly work with significant lessons for political activists.
You mention the public plan, which gets at the issue of “reliance”–policies are durable to the degree that significant numbers of citizens depend upon them. This also will tend to generate organization–it’s not hard to imagine the creation of groups of public plan users who would be likely to protect the plan and even help expand it.
But the other part of the health care plan that seems relevant to me are the “exchanges” and the regulations that will be attached to them. Won’t these, if the rules are very tight, tend to kill off large numbers of the more bottom-feeding insurance companies? In that sense, doesn’t health care reform mirror the story I told from your book above, on airline deregulation?
Put another way, will health care reform kill off reform’s opponents, thereby making even further changes more likely in the future?
That’s right. The key point of my book — which I hope is relevant to the work of political activists — is to think dynamically. As hard as it is to pass a reform, it is even harder to sustain it over the long haul. Reformers have to create a self sustaining dynamic that will protect their hard-won legislative victories.
Right. What will change if health reform is adopted? Well, the big question is whether old interest groups will be destroyed, and new interests created.
That’s how we have made reforms last in the past.
Welcome to FDL this afternoon Steve and Eric.
Eric, I have not had an opportunity to read your book but based on Steve’s intro, I do have a question.
How would you go about assuring that the Policy change of Health Care reforms become institutionalized? Or can they be?
It seems that the results of the airline de-regulation is not all that pertinent in a world where health care is un-affordable for many. And it is a totally different un-affordability than pre-deregulation flying was.
So we’ve established two mechanisms for durability–”reliance” (the public plan) and the capacity of reform to cripple one’s opponents. If there is a zero-sum choice between these two–if Henry Waxman is sitting in conference and had to compromise one to get the other, is there anything in the history of reforms that suggests which he ought to prefer, and which, if he must, he should compromise on?
There is a fundamental tension in democracy: politicians and voters are highly responsive to short-term pressures-—but big problems like controlling health care costs and covering the uninsured require long-term solutions. The danger is that politicians who vote for reforms can change their minds and even if they don’t, their successors may have different priorities.
The moral for reformers is not to despair but to understand the political strategies and tactics that increase the odds of success.
For activists – is there an approach to looking at needed reforms, what to look for, a systematic approach? How do you get momentum started, then maintain the progress?
Welll, I would challenge the premise that this is a zero-sum choice. The most durable reforms have both destoryed the old subsystem AND created a new one.
That said, in a way, you are really asking whether it makes sense to pursue a bipartisan or partisan strategy for reform. Let’s talk about that for a minute.
For activists, I would recommend the following:
1) Identify the actors who oppose your reform, and figure out how to defang them. That is NOT the same as buying off the opposition.
As a technical note, there is a “Reply” button in the lower right hand corner of each comment.
If you click on the “Reply” when you are responding to a specific comment, it allows everyone to follow along the conversation.
Let me elaborate. In the 1990s, Presidnet clinton and Congres tried to retrench farm subsidies. These subidies benefited wealthy agri businesses and were absurdly expensive.
So, reformers gave farmers extra “market transition” payments to buy out their opposition. But the problem was the bargain didn’t stay stuck. Nothing had changed. If you are going to give opponents a bribe to go away, you have to change the rules of the game to make sure they really disappear.
In the health care reform case, we need to make sure that if we bribe provider interests to go along with the reform, that we change institutions and rules so that the goverment has the capacity to protect the reform against inevitable attacks from groups who might complain the public plan reimbrusement rates aren’t generous enough.
So many fresh hells lately. You are saying, too, maybe reformers need to divide up and conquer, some watchdogging one area, others watchdogging others over long term. And as Pete Seeger used to say, think globally but act locally.
It seems so no-win. How can we possibly compete with legalized bribery?
So frustrating that single payer did not make it to the table. It would have been PORTABLE and would save a lot of overhead during job migrations and layoffs. But corporation has stranglehold on OUR (not) reps!
And homeless are not in the equation, the invisible nation, now that insurance won’t cover everyone.
One thing to remember is that reforms can build over time. Remember, when Social Security was passed in 1935, its benefits and coverage were meager. But the program was remarked to increase its growth potential.
What would that look like? What changes who give reform sufficient insulation? The Medicare commission that has been thrown in the last week or so? That would seem like a real “institutional reform”–that changes the rules of the politics that will go on from now on, at least where Medicare is concerned.
Yes, one idea that I like is to create a strong independnet agency that would make recommendaitons for improving the efficiency and quality of the health care system, and then force Congress to vote up or down on the policies. Of course, many members of Congress are reluctant to reduce their power and ability to serve powerful health care interests. The public needs to counterpressure them.
A strong independent agency – such as Elizabeth Warren is trying to do for oversight in the banking / The Fed? Do you think she will succeed in getting this started?
The example of agricultural subsidies is interesting. One of the points you make in the book is that if you get reform only by bribing opponents (giving them “side payments”) rather than by rolling over them, the lesson they take from it is that they didn’t really get beaten. So they take the bribe initially and as soon as the reform is passed, immediately start trying to reverse the negative (from their point of view) changes that they swallowed. Whereas if they really get beaten, if reformers refuse to give side payments, then it signals that they really did lose and have to adapt to the new status quo.
Eric, I haven’t had a chance to read the book yet, but do you get into the role of agency regulators in ensuring that major policies that have been adopted are continued?
Two negative examples are the Bush administration anti-trust regulators, who often gave approval to mergers that never would have passed scrutiny under prior administrations (under the theory that efficiency is more important than regulating monopolistic practices). Another example was the willingness of many financial regulators to look the other way rather than push for more oversight in the financial industry (Can you say “AIG”? Sure you can . . .)
But that presumes that there is enough political power to really roll over one’s opponents–isn’t that the risk that health care reformers are taking by pushing for comprehensive reform this year, that they aren’t really in such a powerful position vis a vis the existing health care industry? In that sense, one might say that reform this year was premature and Obama would have been better off with something more incremental, rather than getting out ahead of where his actual power position was (hence the need to buy off rather than crush opposition).
Yes. It is very hard, often, for Congress to pass reofrms without side payments. The trick is to find ways to ensure that the groups who receive the side payments lose their ability to come back for more. That didn’t happen in the farm subsidy reform case. But side payements worked better when Congress created the emissions trading program to control acid rain, because the payments were in the form of emissions permits that were harder for Congress to dole out.
Peter raises a good point. I try to distinguish in my book between actions by elected officals (who may try to undo a reform they don’t like) and actions by administrators (who may drag their feet and not implement it). Both problems can arise.
One thing, in general, that I’ve been concerned about is that the Obama Administration is taking on so many reform causes — education reform, health reform, financial sector reform. All are necessary and vital. But we need to do the hard follow up work to make sure that reforms, once passed, aren’t watered down. The media’s attention is crutical to getting the reforms passed. But the meida is fickle. After enactment, they move onto to other sexier issues. So it is critical for activists to keep a close eye on what’s really happening in the committee chambers, the courts, and the bureaucracy.
In most of the cases I looked at, the reforms that died were never formally repealed. They were just killed or watered down when no one was watching.
There’s a parallel here, I think, to the 1986 tax reform (I’ll explain why in a second). I think that is one of the most important cases in the book, because for a while people thought this was the best example of a “public interest reform,” and yet within a decade it was coming unwound. Could you explain briefly why tax reform didn’t stick?
Also, when you get a chance, I’d be interested if you could expand on this point. We’re all interested in the blogosophere here, something that didn’t exist during the time that almost all of your cases were working their way out. Does the involvement of so many people on blogs like this change the nature of the “attentive public” in a way that devalues the ability of interest groups to maintain constant attention after reforms, while that of the broader public tends to diminish? Should we expect reforms to be more likely to stick, in a world in which a large, decentralized group of bloggers can pay close attention to the details of policymaking and regulation?
The reasons were the tax reform’s failure were multiple and reinforcing.
First, the main problem with tax policy is that members of Congress use the federal tax code as a political resource. They extra campaign funds from lobbyists, and they claim credit for opening up special tax breaks.
The tax reform act closed a whole bunch of loopholes that benefited powerful lobbies like the oil industry, realtors, etc. No one thought the reform could pass.
But after the reform, tax policymaking dynamics regressed to their old ways. There was no changes in institutions or rules to make it harder for members of congress to do what they had always done. Some people, at the time, said that we need a Federal Reserve to control the details of the tax code. I think Alan Blinder made that suggestion. But it went no where.
In addition, the political process continued. Ronald Reagan signed the tax reform law but of course he was replaced by George H W Bush who never believed in the reform. When he became presidnet, he immediately tried to recreate the capital gains loophole and other special tax breaks, and he did. The reform failed to bind future politicians.
This is speculation, of course, but I suspect that the new media environment will change the dynamic somewhat with the current reform efforts when compared with those of the past.
For instance, with the internet there are a lot more eyes looking into those committee chambers, courtrooms, and bureaucratic offices. Even if the traditional media move on to the next sexy issue, those activists who are committed to a particular cause can and will keep watch on those who are supposed to oversee its implementation and protect it from repeal.
Any speculation on your end as to how the internet changes the game of post-reform oversight?
Again, from the point of view of learning from your cases for contemporary politics, do you think that the current health care proposals really change the actual processes of decision-making sufficiently to make reforms stick, as well as to make them “generative” (that is, to lead to future changes). If one were in a positive frame of mind, one might think of the IMAC idea (the strengthened Medicare commission, which is a little like the base closing commission) and the exchanges as actual institutional changes–they create new governing capacity and change the processes by which decisions will be made. Or are these not really “game changers” in terms of the decision-making process of health care?
You make an excellent point. I think the Internet has the potential to make a big difference. The question is whether it can enhance democratic accountability, because politicians know that their moves are being monitored.
What makes me a tad nervous though is the new information technology can also be used to spread misinformation. In the repeal of the Medicare catastrophic coverage act, for example, a lot of working class seniors were mobilized against the reform because they were duped into believing (falsely) that the law wouldn’t help them. So, remember ,there are counter-organizations that can also use mass information to try and accomplish their goals.
Let me raise a related aspect of the health reform question: Should Obama go for a bipartisan health bill to increase its political sustainability? Many pundits say he should. I’m curious what people think, but I’m happy to share my own insights.
The point about Medicare CC is suggestive here, isn’t it? You had these new taxes being imposed, but the benefits were going to take a while to come into place. Sound like anything? Doesn’t the structure of the plans under discussion now suggest that, a la Medicare CC, that there’s a really significant chance that the pain is going to be felt before the (hopefully compensating) pleasure starts to work its way through the system? Is there a real chance we could be seeing a replay of Medicare CC?
Does this view of policy and change correspond to current conditions? Obama has raised the issue of reform on numerous issues but his follow-through doesn’t look like reform at all. On top of this, there are critical issues that can’t wait or be finessed. Obama’s economic plan simply doesn’t address what is wrong with the economy. In 2011, if not before, things are going to go splat. Yet Geithner’s regulatory proposals don’t mention Glass-Steagal, leave in place TBTF banks, as well as all the toxic financial instruments up to and including naked CDSs.
We can see the same thing on the global warming legislation. Most of it doesn’t take effect until 2020 and later long after we will have reached and passed tipping points on the severity of global warming effects. Maybe if we had known more about global warming in the past and had enacted cap and trade 20 years ago, we might be OK but as it is we are seeing too little too late.
As for healthcare this is the second go round, yet single payer couldn’t even make it to the table. So we have a system with out of control costs delivering unequal care and we get pretty much a giveaway to insurance companies, BigPharma, and the medical industry, and either a weak or no public option.
I think the rules have changed. We are looking at complete regulatory capture here. Reform will not come outside of a catastrophe, and possibly not even then.
I think this is a big danger. It worries me a lot that many Americans apparently can’t grasp (or are confused about) what the health reform bill offers to them. Some of the benfits Obama is talking about are long term benefits, such as higher future salaries that people will get once health costs come down. But those are distant, and it is key to build an immediate constituency to protect the reform when problems arise (as they do under any complex reform measure).
In response to that–what is the evidence, from your book and other sources, that having a bipartisan coalition makes reforms more likely to stick? And does the form of bipartisanship matter? The Bush tax cuts, of course, were “bipartisan” if we count having a wholly unified party plus a smattering of people from the other party. That’s very different from something like the Clean Air Act amendments, which had pretty significant support within both caucuses. Then again, Tax Reform had very significant support in both parties and came unwound. So can we say anything useful about this?
A big problem is the fear of spending public money (to build new interst groups) due to (understandable) concern about the deficit. When we have durably changed politics, and created a new expecation of social provision, net public outlay has expanded. Think of Social Security’s massive growth in the 1950s, or Medicare in the 1960s.
Obama is operating in a very tough context, and balancing responsible fiscal policy with smart politics is not easy.
No.
Even if we get a semi-decent health care reform bill out of all this discussion, the insurance industry is still going to be too powerful. As soon as a reform bill is passed, I think the insurance industry is going to be working overtime with a compliant Republican ‘caucus’ that is frothing to see Obama fail and also see Health care is that failure happen.
The more restrictions and such they can place on a public plan, the easier it will be to gut it later.
This is not a one time deal. This is going to be re-visited over and over for decades.
Obama has gone the bipartisan route several times. This has led him to big initial concessions followed by more concessions to Blue Dogs and end products that Republicans voted against anyway even though they had become essentially conservative bills.
We lack a definitive political science study to resolve the question of whether bipartisanship promotes sustainability. We do know that policies that are passed under unified party government are less likely to be amended subsequently.
What my book does show is that bipartisan enactment absolutely does not guarantee political sustainability A large bipartisan majority can vote for a reform at one moment, and vote to undo it later. That happened in the Medicare catastrpohic case and several others.
So, I’m pretty skeptical about the importance of process per se. I think it is more important to get the substance of the reforms right. By that, I mean design a reform in a way that delivers tangible, visible benefits to people and create the institutions and rules to support it. I think a policy that has those features is more likely to stick, even if passed somewhat narrowly, than a policy that passes by bigger margins but has a flacid design.
Dakine01 writes, “This is not a one time deal. This is going to be re-visited over and over for decades.”
EXACTLY. That’s why it is so important to ask: if we pass a health reform with this feature, what kinds of decisions will future policymakers face?
Now, remember, it is easy to be mistaken. A lot of activists though the passage of Medicare/ Medicaid in 65 would leave to a universal health system–and it didn’t happen. In part, because those policies left uncovered weak clientele groups. So it is important to ask who is left out, and what incentive there will be to expand coverage in the future.
A good example of this has been the legislative treatment of abortion/choice post-Roe v Wade.
The policy question may have been (and continue to be) fought in the courts, but the details have been ongoing fights for Congress, the executive branch, and the states to wrestle with: government funding for abortions, restrictions on money sent to family planning groups overseas, the whole “partial-birth” (yes, that’s a misnomer) fight, etc.
Steve earlier raised the issue of institutional change. It is important to note that institutions CAN change to protect reforms.
Sometimes, this involves destroying old institutions that merely serve to protect narrow interests. For example ,the Civilian Aeronautics Board was terminated because it merely protected the airlines under the pre 1978 system.
Sometimes, new institutions are created, for example, an emissions banking system, administered by the EPA, which gave credibility to acid rain provisions of the 1990 Clean Air Act.
Often, needed institutions are not created, though. In Clinton’s “reinventeing government” effort, for instance, he was never able to strengthen the bureacuracy to really implement his reforms with maximum effect.
In the health reform debate, again, there has been talk about changing institutions too –but it is too soon to know whether the structures will have the requisite capacities.
I can’t say that I have seen either from Obama. If you look past the TARP which I think was largely a distraction to the Treasury’s backstopping money markets, the FDIC’s credit line, and the Fed’s expansion of its balance sheet and movement away from Treasuries, there has been a profligate and unquestioning spending of trillions on the financial sector, the least productive portion of the economy. At the same time, programs like the stimulus or aid to homeowners or even the GM and Chrysler bankruptcies get nickle and dimed to death. We could run much larger stimuli for years and not equal what has already been sunk into the financial industry in less than a year.
When you are facing the worst economic downturn since the Great Depression, deficits even very large ones are OK. It’s Keynesian. Unproductive bank bailouts, attempts to reflate housing and speculative bubbles, and tax and spending cuts aren’t.
In talking about Obama’s reforms, and trying to reconfigure the political dynamic, it is important to remember that conservatives play this game too. Arguably, President Bush’s Social Security privatization plan was less about fixing Social Security than trying to create a new politics, and change the relationship between citizens, the market, and the state. But I’m glad that one failed.
In respect to destroying institutions, what is your take on the creation of the Homeland Security and destroying the existing Treasury and Justice agencies?
Interesting point–a more severe, market-oriented response to the financial crisis could have led to a durable shift in the politics of financial regulation. If even more of the large banks had failed, that would have limited the coalition against further reforms. Of course, it might have led to the implosion of the world economy. But that gets to a larger question–all market-oriented reforms, of the kind Eric talks about in his book, create losers. Eric–is it reasonable to say that the losers are only really durably hurt when their interests have been, for some reason, “stigmatized?” When reformers have been able to convince the public that the losers deserve to lose, because they are, for some reason, illegitimate? Maybe airline deregulation is an exception to that, but usually the losers get massively compensated and then come back to fight another day (farmers, coal miners) because their interests are seen to be morally worthy of protection.
I’m not an expert in this area, but my former UCLA colleague Amy Zegart has written some fine books about the national security bureaucracy, and her main conclusion is that the system is stil an organizational mess. What we often do in American politics is not actually destroy dysfunctional agencies, but rather layer more agencies atop the old ones, making it impossible for any of them to work well or be held democratically accountable.
This problem of layering — of grafting new reforms and new policies and new agencies onto a bad system– is just a very severe one. It is often easier to create something new than to eliminate something old, but as long as the old structure is in place, it is hard to chart a new direction in govenrment.
Yes, American politicians have a very hard time imposing losses on a discrete group unless the group can be case as somehow morally underserving. That is a big reason we can’t reform farm subsidies, even though it is a scandal. Agribusinesses hide beyhind the symbol of the “family farmer” and efforts to get people to wake up to the fact that this is largely a lie just don’t get traction.
In the airline dereg case, not that the reform didnt’ impose losses directly, it just changed the rules of the game and said, OK, compete. To the extent there were expected losers ,like rural commmunites expected to lose air service, they were compensated in the bill and in fact are still being compensated 30 years later!
Doesn’t that suggest something important for health care? By pulling all these health care interests into the process–giving them a “seat at the table”–aren’t we sending a signal that their interests are legitimate, that they have a right to be protected from the impact of reform? Would Obama have been more successful in the short term, and more likely to have his reforms stick and expand in the future, if he had opened up both barrels on the health care industry, in the way that opponents of the tobacco industry did?
If you want to look at another example of where regulation failed, look at McCain-Feingold. This was supposed to put the brakes on out of control campaign financing but its effects were largely cosmetic. Money simply moved around it and the end result was essentially a bought political system. But once done politicians treated campaign finance reform as a dead issue.
Eric, if you had to pick a half dozen people/offices/committees that would be central to protecting whatever health care reform is passed, who/what would they be?
Head of HHS?
Chair of Senate Health, Education, Labor, and Pensions committee?
House Committee on Oversight and Government Reform?
Every reform has its enablers and guardians — where would you see them in the case of health care?
That’s what I think. We are letting the people who screwed things up in a violent struggle for their own short term gains decide the limits of change. We did the same thing in the energy field, and more recently in the financial area.
It is great question. In some ways, I think the Administration is trying not to repeat the mistakes of the Clinton Administration, which of course stimulated a huge backlash from the health insurance industry. But it may be that the Administration has gone too far in the other direction.
I’m beginning a new project (with Alan Gerber, Yale) that looks at the whole issue of evidence-based medicine. One of the biggest problems we face (which the Obama Administration to its great credit is out on front on) is that we simply lack good evidence on what treatments are most effective for what patients. But one reasons we are in this situation is that doctors often don’t demand objective information about treatments’ effects, relying instead on what they hear from drug companies or even on their own hunches. So doctors and certainly Pharma are part of the problem. But doctors and probably the health sector in general still enjoy a higher degree of trust among many Americans than does government. So it is hard in this area to target political enemies as a way of promoting big policy change. After all, these people (with the possible exception of insurance companies) look like they are helping us.
Of course, tax reform had its supposed “guardians”–Rostenkowski in the House, Packwood in the Senate. They both had their reputations on the line in making tax reform stick. That suggests that just having important members of Congress behind the reform is no guarantee that it will stay in place (in part because those guardians don’t always stay in place). I think the important lesson of Eric’s book is that people are less important than policies, rules and institutions.
Yup. Once a government program is created, it provides an easy platform for fresh change.
In my former life, back in the 1980s and early 1990s, I was a congressional staffer and worked on 2 bills — campaign finance reform and the motor voter bill. I concluded that there was simply no way we could durabaly repair our campaign finance system, given constitutional constraints and political realities. Sad but true. So I tried to focus most of my energy on making it easier for people to vote, which one hopes serves as a counterweight to the narrow intersts.
This is why getting evidence about what procedures work and don’t work is so important. Phil Longman has a great piece in the current Washington Monthly arguing that the provisions in the stimulus to get docs to switch over to electronic records (which if done right could provide a lot of data along these lines) are badly designed (in large part because they don’t use open-source software of the kind used at the VA). FDL readers should check the piece out at: http://www.washingtonmonthly.c…..ngman.html
Lots of names come to mind–Jacob Hacker, Judy Feder, to name two political scientists who are also experts on health policy. You need people who understand both the policy details and the larger poltical strategies.
Banksters are about the least sympathetic group imaginable. Yet not only did they not lose or face sanction or penalty, they were hugely rewarded left unreformed and in place.
What I have been trying to get at in my comments is that I see a discontinuity where previous approaches to policy and change don’t cut it anymore. We have a systemic problem where special interests will push for their gain to the exclusion of all else even if it means crashing the rest of the system. And we are at a point where system crash is possible, even likely.
It isn’t like we haven’t tried to solve this problem before. Back in the mid 1990s, a fedearl agency published a careful study concluding that most back operations are not necessary and that most people would be better off with rest and exercise. Well, of course, back surgeons screamed to Congress, and the agency was virtually eliminated. This was around the time that the Office of Technology Assessment was killed. We badly need an agency like that now.
Eric–we’re coming near the end. If you had to sum up the basic lessons from your book about what explains why some reforms stick, and some fail, what would they be? What’s the “bottom line” of Reforms at Risk?
First, thanks to Steve and Bev and all the people who asked great questions. This has been a fun conversation!
In terms of concluding thoughts, I would say this:
First, reform must be seen as a dynamic process, rather than a one-shot static affair. Sustaining reforms may be even tougher than winning adoption in the first place. The losers from reform may not disappear, may come back to fight another day. And the winners may not be well organized enough to protect their collective interests.
The moral for reformers is not to despair but to understand the political strategies and tactics that increase the odds of success.
The outcomes of reforms vary in systematic ways, but political institutions and policy feedbacks are crucial.
The old policy system must be uprooted or at least seriously contained—and a new policy system must be constructed
While reform outcomes are never completely settled, a reform CAN become so deeply embedded in institutions, governance and the adaptations of social actors that its subsequent reversal becomes almost unthinkable.
This happened with Social Security. It happened with Medicare. It can happen again.
As we come to the end of this very good Book Salon,
Eric, Thank you for stopping by the Lake and spending the afternoon with us discussing your new book and the current reforms.
Steven, Thank you very much for Hosting this Book Salon.
Everyone, if you haven’t bought Eric’s book yet, here is a link.
Thanks all.
Evidence based medicine depends a lot on studies which as you point out are often industry funded. Those that don’t often take years to track and analyze results. In the interim new drugs and approaches can come on line making conclusions difficult. There are also a lot of off-label uses for medications that evidence based medicine might have a difficult time following. Almost all the anti-convulsants for example have important off-label uses.
At the same time, I think there needs to be more emphasis on agreeing on best practices standards. These certainly can be evidence based. But they can streamline approaches by reducing medico-legal liability.
I want to thank Eric and all the commenters for participating. And I want to reiterate that this is a genuinely great book. It’s a rare case of a book that has fascinating case studies (seriously the airline deregulation and carbon dioxide trading chapters rock, and are worth the price of the book all by themselves), a powerful theory, and real policy implications. The one final point I would make, perhaps to put a downer on the conversation, is that things that look like real reforms can sometimes come unwound. Winning a big battle is just the beginning of the process, not the end. I think this has serious consequences for organizers and activists. Once the bill passes, don’t just move on to something else. Locking a reform in, or expanding on it, is if anything a HARDER task than passing reform in the first place. To paraphrase something written over the building that Eric works in, the price of serious reform is eternal vigilance.
Sorry, I got here late, but perhaps we start lowering the age that Medicare is available. People would be able to leave their jobs (retire) and new people could come into the job market. Suggested last night on Moyers.
Jim Moss has a Seminal post, upstairs!
To Them, The Magic Of Low Prices Just Happens
The problem is that the Chinese, who are the ones financing our debt, are starting to make like they won’t be buying any more of our T-bills. So there’s a limit to what we can do.
Congressman John Fleming ( Louisiana physician) has proposed an
amendment that would require congressmen and senators to take the
same healthcare plan they force on us (under proposed legislation
they are curiously exempt). Congressman Fleming is encouraging
people to go on his Website and sign his petition (very simple -just
first, last and email). I have immediately done just that at:
http://fleming.house.gov/ .
You mean “robust” like not kicking in until 2013, and then only covering 9 million people until 2019?
Robust like MA, where the mandate forced everybody into the plan so the numbers looked great, and then compliance dropped when people figured out they were being forced to buy junk insurance?
Robust like a program that may not let people join public option, even if they don’t like their current employer-based insurance?
Robust like a program that leaves the real problem, which is health insurance for profit, in place?
Is public option even on topic, here? I thought the book was about major policy change…
Now, single payer: That would be a major policy change. Fortunately, it’s been tested and proven to work elsewhere, so there are precedents to follow and people to ask for help.
Yeah, Jacob Hacker. I’m surprised to hear him mentioned here. Hacker is the “bait” to the “progressive” switch.
Hacker’s public option would cover 130 million Medicare or VA-style.
Public option as embodied in legislation only covers 10 million, according to CBO estimates.
“Yup. Once a government program is created, it provides an easy platform for fresh change.”
Just… Wow.