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. What would you like to do?
How does the policy making process work?
Identify-> Formulate->Legitimate-> Implement->Evaluate
- Problem recognition/definition
- *What is a social problem
- *what is the nature of the social problem (issue)?
- *What is the magnitude of the condition?
What are sources of agenda setting?
o Inside Government
o Events and Crises
o Executive Branch
o Campaign Promises
- *what are the policy alternatives?
- *difficult to reach a decision that has strong support if alternatives favored by an influenctial interest group are excluded.
- *who are the stakeholders?
- policy adoption
- political proecess, requires majority
- budget must support policy adopted
- policy implementation
- role of public agency
- what is done to enforce or apply a policy?
- success against others? GAO
- validity of diagnostic tests
- what is the role of gov in health care?
- should gov legislate mortality?
- moral issue or medical problem?
- public or private responsibility?
- issue of private wealth or helath?
What other variables interact with gender? and access to and control over these enables what?
- Family resources
- Economic and social resources
- political resources
- information and & educ
- time resources
Access to and control over these variables gives one power and decision-making.
- Health challenges that arise for different age strcutures, cultures
- Social construction of health
- Social distribution of disease
- Health and illness are socially produced, esp by structural features of power & stratification
Gender inequities in health care are concentrated in 3 types of imbalance
Health risks <-> opportunities to enjoy health
Health needs <-> access to health resources
- Responsibility in the health sector <->
- power in the health sector
Sex vs gender
- Sex: biological (e.g. menstruation)
- Gender: social construction (self-trait, psychological traits)
Gender disparities and health in men
- health most vulnerable to stressful life events
- key mental and physical health: work roles
- Unemployment, job insecurity, and even early retirement can bring disease and premature death to men
- Marriage and parenthood provide anchors for men emotionally
- health advantages from having access to more resources than women
Gender disparities and health in women
- may be protected from a number of diseases by their reproductive physiology and certain X-linked genes
- Estrogen protects women from heart disease and early death
- Women’s greater longevity
- Women benefit in terms of improved life expectancy from marriage as compared to their unmarried counterparts
- Social factors play a major role
- Communication b/w patients and doctors
- Tensions b/w modern medicine and cultural beliefs
- Specificity vs sensitivity in diagnosis
Look at risks. General statements.
- Life involves risks such, some of which like cancer, heart disease, unemployment, poverty, disability, and premature death are unpredictable and do not affect everyone.
- Other risks, such as old age, chronic illness, and functional decline are much more predictable and affect everyone to some degree
Who is responsible for these risks?
- state (government, collectively)
Yet market is not well suited to deal with certain risk profiles, nor can it provide all of the services needed at a marketable price. State serves as insurer of last-resort. Increasingly, and to varying degrees, the state assumes the role of the family in dealing with those risks that the market can’t absorb.
comparing health systems
Nations differ in thedegree to which their welfare policies emphasize the family, the market, or the state. Labor-based political parties tend to favor state guaranteed entitlements, while conservative parties tend to favor the market. Christian-democratic parties and the religious right in this country wish to deemphasize both the market and the state and reinforce the family.
Liberal minimal welfare model
• Minimizing the State’s role
- • Seek to individualize risks, and promote market
• Therefore, they do not favor citizen entitlements
• Social welfare programs are focused on “bad risks”
• A fairly narrow definition of who is eligible
• Means-testing is common
- • Emerge where Christian Democratic or Socialist
- movements are weak
US australia, new zealand, canada
(Scandanavian) Welfare States
• Comprehensive risk coverage
• Generous benefit levels/Income maintenance
• Egalitarianism (including gender)
- • Fusion of welfare and work: Full employment
- • Minimizes the family (state assumes responsibility
- for social services)
• Emerge from a strong Social Democratic tradition
- • Growing tax burden, but social policies favor
- the young over the old
Denmark Norway Sweden
Conservative Welfare States
(Social Insurance Model)
- • Status segmentation and corporatism (distinct social
- • Defends the family and traditional social
- • Women discouraged from working/Malebreadwinner
• Little concern with egalitarianism
• Emerge in countries with strong Christian Democratic or conservative coalitions (sometimes with a fascist interregnum)
- • Evolved from a tradition of monarchical “etatism” or
- state socialism
Germany, Austria, France, and Italy
How do welfare states respond to the new postindustrial reality?
- Most welfare regimes were until recently based on a male-breadwinner model.
- The great rural/urban migration of the 19th and 20th centuries consisted of families in which the wife did not enter the labor force full-time.
- Today, most women have entered the work force
welfare systems models
- Entitlement vs. means-tested programs
- Visible vs. invisible taxes
- The crisis of the Welfare State? Cost, market rigidities, the jobs/equality tradeoff.
- The problem of inequality has been particularly serious for the liberal welfare states
- Almost impossible to adopt another model due to vested interests of profitting from laissez faire american system; economically centralized; corporitization of hospitals
Agenda setting: how do problems gain attention of gov?
- President and advisors maintain a list of issues they will pay attention to. The list may focus on defense, the environment, health care, transportation, education or other major areas of governmental control.
- Defining a problem automatically limits the range of solutions, but provides a focus. (example of AIDS: initial definition, meager attempts that did not identify with general public, redefined as public health concern).
- A policy entrepreneur can be used to keep the issue from fading. This is a person with a known reputation who invests time, money, and expertise in an issue such as a legislator, an agency head, a lobbyist, an academic, or a celebrity, such as Michael J. Fox, who lobbies for funding for Parkinson’s Disease
Garbage can theories
- Rejects conventional 'policy cycle' models which envisage policy development processes as rational and underpinned by the logic of problem solving.
- For Kingdon, policy making is chaotic, random and frequently irrational.
- There is a loose relationship between problems and the policy solutions offered by national governments.
- Kingdon attempts to find the origins to initiatives in government agenda setting and alternative proposals, but finds that looking at a concentration of origins is not good.
- Ideas can come from anywhere
- Tracing origins will typically lead to an infinite regress: FUTILE. DIFF TO FIND ORIGIN
- Nobody leads anybody else
Finding origins to initiatives: 3 common approaches
- Rational decision making
- (first 2 are inadequate) Incrementalism: reluctant to take big steps, conservative step-by-step process, build on what exists.
- Decision-making is a process of small, incremental, marginal adjustments in the current behavior. No large overhaul of ideas or policies.
- Describes many political and government processes.
- May explain the generation of alternatives (not necessarily agenda setting, though)
- Conservative process of political decision making using existing policies, programs, and expenditures as a base.
rational choice model
- Document Existing Conditions
- Define goals and objectives
- Generate Alternatives
- Identify Key Interest Groups
- Policy Adoption- Decide
- Evaluate Alternatives
- Implement and Monitor
- crisis/prom event
- change in respected indicator
- political process
- accumulation of knowledge
Who affects alternatives?
- Invisible participants
- academics, researchers, consultants
- election-related participants
- public opinion
Grows out of coupling of problems, policy proposals, and politics
- Ideas float in this stream like noodles in a primeval policy soup
- Includes policy entrepreneurs and policy analysts
- Accumulation of knowledge sharpens perspectives
- Refine & Fine ideas w/ knowledge
- getting policy community to be receptive to new ideas takes a long time
- serve to redress inequities & fairness
- Health problems of poor against “socialized medicine”
- balance of organized political forces
- election campaigns
- national mood
- shifts in admin
- Government control
- Professional Self-regulation
- Contract (detailed agreements)
**a problem might float by to which they can attach their solutions
Fed gov and garbage cans
- Problematic preferences – conflicting vague preferences
- Unclear technology - members do not understand the processes
- Fluid participation – people drift in and out of decision-making
- However, these organizations manage to function and survive
Main Streams running thru org
- Problem is recognized
- Solutions (not tied directly to the problems) is available and technically feasible
- Participants (political climate makes it right time for change)
- Choice Opportunities (analogy: garbage can)
- Each one is independent and exogenous of the other, but they combine/intersect at some point to present a choice opportunity (a garbage can)
- **constraints don't prohibit change
why do problems fade?
- ppl in gov feel they have solved a prob perhaps by passing leg
- idea no longer novel, now boring
- too much time, effort, mobilization, expend of political resources required
need to be ready. streams could be unpredictable.
dynamic ever changing process of achieving helath in each dimension
- • Social
- • Emotional
- • Mental
- • Spiritual
- • Environmental
How does social inequality bring about differences in health?
- Social, environmental, medical
- Psychological & behavioral
- Outcome=Health and illness
Other determinants of health
- Non-medical determinants of health
- Stress (subjective)
- Stress ->coping -> disease (physicial or mental breakdown)
- New moribidity: road roage
- Individual and institutional racism
individuals who have organized themselves around some common goal or purpose and who seek to influence public policy
involved in advocacy or lobbying
- They have evolved from cohesive alliances to
- their current position as diverse, large, and powerful players in federal and state policy making. They also establish coalitions that allow them to devote their efforts to deflect broad policy changes
play role in problem framing, drawing attention to health problems, construction of (breast cancer) knowledge
interest groups provide community-action research that enhances the knowledge and skills of community health leaders
Groups that require members to possess certain professional or occupational credentials
1. Mass membership, 2. Professional Associations, 3. Public-interest organizations
concerned with who speaks for women's health in the electronic age" given the large number of various women's health organizations and the way the average consumer looks for such information using search engines like Yahoo and DHHS Healthfinders.
What information is needed to support better quality care
- Patients need evidence-based information to make specific health care decisions
- Advocates need information about how well the health care system works
- Are doctors recommending care based on evidence?
- Are patients being informed of all their treatment options?
- Are they being told the strength of evidence in support of those options?
- Being offered participation in a clinical trial?
- Getting an accurate diagnosis?
- Being treated with respect?
- Getting the information and support they need to make informed decisions?
- Having a fair way to fix problems?
legislative influences on health policy making
- state vs federal
- Federalist papers-fundamental ideas
- Republicanism- power is delegated to a small number of citizenswho are elected by the rest
- Federalism-power divided between federal and state governments.
- Separation of Powers- among three branches of government
- Free Government- to protect the security, liberty, and the property of individuals
- "social primary goods" vs. "natural primary goods"
- Good health is categorized as a natural primary good, but an argument could also be made for its inclusion in the list of "social primary goods
- rational model simply does not explain behavior of politicians
- a political and social-constructionist perspective on policy
- antithetical to rational analysis
- policy-making is a constant struggle over criteria for classification, boundaries of categories and definition of ideals; policy is always conflicting values, not tidy and quanitifiable
Part 1: Society
- market vs polis
- self interest vs collective interest
Part 2: Goals
- Equity: cake example
- Security: based on need, the minimum requirements for biological survival
- Liberty: self-protection interfering with liberty (increase security actually creates true liberty, enabling an indiv to make free choices)
- Security and liberty are paradoxical: security seems to be necessary for liberty and yet undermines it
Part 3: Defining problems and demonstrating them in politics
- Symbols: stories, synecdoche, metaphor, and ambiguity
- Numbers: providing methods of measurement; per stone, counting is political (requires categorization in/exclude, can be ambiguous, can be used to tell stories, etc)
- Interests: concept of taking sides based on interests
- Decisions: debunking rational model (depends on cost benefit/risk/decision analysis)
Part 4: Solutions
- Inducements: system of altering the consequences of individual actions so that what is good for the community is also good for the individual
- Rules: essential form of social organization; prescribe actions to be taken in various contexts; can include/exclude, unite/divide (rules need to be flexible! can benefit and harm)
- Facts: can change ppl's mind. subject to interpretation. means of manipulation. not neutral.
- Rights: Normative rights are those rights that you SHOULD have, while positive rights are those rights that you DO have. If someone kills you, the language of positive rights would say that you lost your right to life, but the language of normative rights would say that your right to live was violated
Policy actions as multiplier effects: people’s beliefs/actions are shaped by structures and rules w/o cont’d. reinforcement and effects transcend into rules and structures governing their own goals
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