The policy process in health care.(Initiating Change: Theory and Practice)

Members of the United States Congress may be adept at recognizing the political landscape they confront. Some may even successfully promulgate new interpretations of prevailing political circumstances that alter the nature of policy debate. Few of them, however, even those serving in the baronial Senate, actually transform the politics of policy making by the very fact of their individual presence and actions. Through a combination of fortuitous circumstances and personal determination, Senator Harris Wofford joined this select group of political earthmovers when, in November 1991, campaigning for economic change and national health care reform, he came from 45 points behind the former Pennsylvania governor and U.S. Attorney General Richard Thornburgh to win by a comfortable 55% to 45% margin in his initial bid to maintain the seat in the U.S. Senate to which he had earlier been appointed.

Senator Wofford's 1991 special election may not be remembered as the most important event of the 1990s' health care reform debate, but it will surely be a primary marker in every future chronology of our recent visitation with the issue of comprehensive reform. As Wofford notes in his commentary, he was characterized as the "first bird of spring." The University of Chicago alumni magazine tagged him the "Crocus candidate." Perhaps even more poignantly, Wofford's staff described him as the "poster child" of health care reform. Each of these monikers reflects the manner in which Wofford's electoral victory at the time energized the previously lethargic politics of change in general, and health care reform in particular. Before Wofford's victory there was noteworthy activity in Washington, DC, on the health policy front, generating one proposal after another for revising health care financing and delivery, but the political system seemed to be stuck in an all too familiar and frustrating stasis. These plans were all dressed up, but with nowhere to go. Wofford's election administered a kick to the system, what some have called the "Big Bang" in the development of health care reform (see Cook, 1991; Donovan, 1991; Hacker, in press; Peterson, 1992b). Having served at the time as a Senate legislative aide working on health policy, I can personally attest to the palpable, qualitative shift in the atmosphere among health care advocates and policymakers.(1) President George Bush, long hesitant to enter the health care reform fray but sensing the heat, introduced what he entitled "The President's Comprehensive Health Reform Program" (President's Program, 1992) 3 months after the Wofford-Thornburgh race. The stage was also set for a 1992 presidential contest in which health care would be one of the decisive issues of the campaign. I recall the 11th-grade chemistry experiment assigned to me and my lab partner in which the much-anticipated rapid heat-generating chemical reaction did not occur - until the teacher abruptly slapped the top of the lab counter with his hand. Wofford's stunning win, and the way it was achieved, slapped the health care reform debate into a measurably higher level of intensity (on the general issue of "punctuated equilibria," see Baumgartner & Jones, 1993; see also Kingdon, 1984; Polsby, 1984). In addition, it gave the new senator an immediate public platform as well as a hardy welcome into the Senate's inner circle of health policy entrepreneurs. Time would show that the forceful thwarting of comprehensive health care reform, and Senator Wofford's own defeat, could come with equal suddenness. The 1994 congressional elections, granting a majority of seats in both Houses of Congress to a conservative Republican majority for the first time in two generations, set the stage for dramatic policy change in precisely the opposite direction.

Senator Wofford's insider account of momentum toward health care reform, therefore, is offered by a particularly credible witness. His Wherrett Lecture, delivered from a practitioner's vantage point, also furnishes the analysts among us with useful insights and propositions for understanding policy change in the health care realm, as well as the persistent threats to change. My objectives for the remainder of this article are, first, to identify the essential features of Wofford's assessment of the bases for policy change, and, second, to test them, if you will, by considering them within a broader theoretical framework for assessing the prospects of health care reform.

A PRACTITIONER'S VIEW OF INITIATING CHANGE

Two guiding principles and the core questions they generate, as well as a series of supporting analytic propositions, are embedded in Senator Wofford's commentary on the status of health care reform in America. The first principle pertains to the nexus between the constitutional design of our governing institutions and the development of our political system. Together, U.S. government and politics in recent years seem to have merged into a particularly pernicious case of gridlock. The separation of powers - Edward Corwin's (1957) "invitation to struggle" - and divergent electoral constituencies for the executive and legislature always assure the potential of partisanly divided government, but in recent decades it has become more the norm than an anomaly (Fiorina, 1992). Senator Wofford emphasizes that the 1992 presidential and congressional elections returned both branches of government into the hands of a single political party for the first time in 12 years, affording an opportunity - albeit a rather temporary one - to move beyond modern gridlock. But for health care and any other policy domain, the central question remains: Would there be enough change in politics and institutions to end policy gridlock? We know from recent social science that, historically, divided government alone has not thwarted the enactment of major legislation nor has unified government guaranteed comity between the executive and legislative branches of government (see Fiorina, 1992; Mayhew, 1991; Peterson, 1990). What other changes, therefore, other than the partisan alignment of institutions, are necessary to lift the siege of gridlock?

The second principle one can derive from Senator Wofford's commentary goes to the heart of politics - …