Policy Analysis Models

and Healthcare Issues

Interdisciplinary Studies:
Social Science,
Understanding Society,
And Policy Making
 How Models Are Helpful
• Order and simplify reality
• Help identify what is significant
• Congruent with reality, i.e., apply to and in the real world
• Provide meaningful communication about the world
• Help direct inquiry and research into problems, issues, and
world as it is or can be known
• Suggest explanations for what is observed
• Suggest alternative solutions for issues, problems, etc.

All models from Thomas Dye, Understanding Public Policy, 7th edition, unless otherwise indicated.
 Socio-Political Forces and Society
Economy--production & Culture--artifacts, symbols,
distribution of resources as Nations & International values, norms, expectations,
well as class status. Organization assignment of social status

Community

Secondary Groups
and Associations

Primary Groups

INDIVIDUAL

Family, Kinship Groups,

Tribal Groups
Schools, Employers, Npfs,
Voluntary Groups, Businesses,
etc.

Neighborhoods, Towns, Cities,

Villages--Connected Places
State--Collective authority,
right to make binding Nation of Citizenship
decisions and apply World Nations, UN, etc. From Norbert Wiley, Ph.D., 1977.
legitimate power and force. Dept. of Sociology, University of Illinois C-U.
 The Wiley Model of Society
• Three forces impact all levels of human life and society--
culture, economy, and the state or political system.
• What is valued, emphasized, and important in each is
critical in its impact on all we do, including how we view
and pursue what we call science.
• Of the three forces, the most dominant in American society
is probably the economy, i.e., the capitalist approach to
the production and distribution of goods, services, and
economic value.
• Cultural values include many values and beliefs that conflict
with those of science.
• The state role is to use authority to decide these conflicts.
 “Wicked” Problems and Healthcare Issues
Complex choices about and also involving the interaction of
state/culture/economy create “wicked” problems:
1. Intractable and very difficult
2. Never simple or singular but multiple issues nested
or interlocked with other equally complex issues.
3. Definition of the problem and also of solutions vary
from stakeholder to stakeholder.
4. Rarely are solutions value-free, totally objective, or
fully rational in nature.
5. Yet, they are important and have serious consequences.
6. Costs are differential and often paid by others.
7. Require community-building & consensus.
8. Open-ended and hard to know when fully studied or
finally, if ever, solved.
From Cunningham & Cunningham (2006). Principles of Environmental Science. See p. 355.
 Remembering Wicked Problems
• Healthcare problems tend to be intractable because
they are nested within sets of interlocking issues--
some involving access to healthcare resources or
the health systems, others scientific, cultural,
economic, and/or political in basis.
• Often poor match between bearers of costs and
bearers of benefits--the Navajo example,
East St. Louis example, RMI example, etc.
• No value-free objective answers exist.
• Best approach is often consensus building which
may be hard or impossible to do.
 Exercise: Applying Wiley
1. Name one wicked healthcare problem.

2. Name one characteristic of our economy or our

economic behavior that contributes to that problem?
Diminishes that problem?

3. Name one characteristic of our culture or cultural

behavior that contributes to that problem?
Diminishes that problem?

4. Name one way that government helps solve the problem?

Make it worse?
A Wicked Example--SW Power
The Flip Side of the Solution
 Two Views of Equality

Substantive
Equality/
Fairness

Procedural Equality/Fairness
People can be treated “fairly” but in a manner that fair procedures deny fairness in outcomes.
 Choosing Means of Acting
• We can choose to act individually or collec-
tively to solve problems.
• We can use primary groups like the family.
• We can use voluntary groups or nonprofit
organizations as allies or problem solvers.
• We can use private businesses to supply
and from which to buy solutions.
• We can call on government to define public
interest, solve problems, and take action.
Why Government Gets Involved
• When a primary level solution doesn’t work
• When voluntary or nonprofit solution doesn’t
work or is too limited
• When a private sector solution doesn’t work, is
too expensive, or distributes benefits and costs too
inequitably
• When consensus must be built across institutions
and levels of society
• When authoritative, binding decisions are needed
and applicable across all of society and citizens
 Governments by “Democratic” Typology

LOW

Procedural/ Pure
Processes/ Democratic democracies
Sructural oligarchies
outcomes

Authoritarian Authoritarian
oligarchies democracies

HIGH
Distributive/substantive/egalitarian outcomes
 Categories of State Authority
• Government or the state exist along a continuum
from mostly democratic/participatory/open to
mostly authoritarian/elitist/closed.
• In the first people can influence what is done,
including in areas like healthcare access.
• In the latter, one or at most a few elites have the
power to decide what is done in society--and in
healthcare.
• The U.S. is a republican form of democracy--
citizens select representatives to decide action.
 Continuum of Authority Types
POPULAR ELITIST

HIGH LEGITIMACY LOW

Mass Pluralist Mixture Oligarchy/ Totalitarian/

democracy Democracy Dictatorship Dictator

PARTICIPATORY/OPEN ELITIST/CLOSED
 Principles of Democracy
• Right to popular participation in decision that impact

• Government by majority rule with minority rights (free

speech, free assembly, free press, petition, dissent,
formation of opposition, run for public office, etc

• Commitment to individual dignity and liberal values of

life, liberty, and property

• Commitment to equal opportunity and development of

individual capacity (possibly equality of substance)

• Right to revolt against illegitimate authority

 Key Framing Values of U.S.
Governance & Authority

1. Freedom---for whom, in what situations/conditions, how

much
2. Order---how to maintain, in what situations/conditions,
with how much sacrifice of freedom and why
3. Equality---how much and for whom, substantive or
procedural in nature
4. Rule by the few or the many--majoritarian democracy,
pluralist democracy, or more purely elitist authority

Examples: Private versus public healthcare, single payer or

mutli-payer healthcare, etc.
 Key Features of Government
• Possesses authority---decisions are binding
• Must maintain maximum legitimacy with citizens
• Can use sanctions to enforce laws & policies
• Legitimate authority can include right to use
imprisonment, force and violence as means to
enforce policies and laws
• Government also can legally take private property,
take human life, and in general use force--even
again state-sanctioned violence--to further enforce
laws, policies, the “public will,” etc.
 Added Features of U.S.
Government
• Constitutional
• Federal---division of power to levels
• Separation of powers
• Checks and balances
• Republican or representative democracy
• Bicameral legislative branch
• Supremacy of law and judiciary
• Pluralist in nature--democratic elitism/groups
Institutional Complexity of Policy Making in the U.S. System
 Institutional Complexity
• Founders trusted neither the people or the elites to
rule, preserve liberty, and make best policy.
• Framers split authority between many different
institutions within government.
• Designed to prevent tyranny of oligarchs or
tyranny of the masses.
• Makes solving wicked problems more difficult.
• Takes more time and is more incremental.
• Often requires crisis before action will be taken.
The Systems Model and Influencing Public Policy Making
Features of the American System
• Representative--people select others to make policy,
including environmental kinds.
• Representatives are to respond to citizen inputs--demands
and support primarily via elections and electoral parts of
system.
• Legitimacy of policy depends on citizens playing this part
and expressing desires.

Examples: Individual student activities in support of

healthcare policy? Name any?
The “Middle Bias” in American Two-Party System
 Public Choice in the U.S.
• Choice can be seen along a conservative to liberal
continuum.
• Because of nature of the system, including the two-party
electoral input process, representatives gravitate toward
middle where most of citizen voters are (excluding non-
voters, disenfranchised, satisfied, anomic, etc.)
• Healthcare policy, like most public policy, tends toward
same middle ground.

Example: Current attempts to limit healthcare costs, improve

healthcare access for children, reduce impact of
preventable illnesses, etc.
The Elite Dominance in Most Public Policy Making
 Elitist Slant to Public Policy
• Most citizens are relatively uninformed and “too
busy” to pay attention to most issues.
• Healthcare access, healthcare provision, and
access to healthcare resources falls down the list
of what interests many existing and also possible
voters/citizens--satisficing phenomenon.
• Because healthcare issues are “wicked problems,”
citizens prefer smarter elites to suggest,
implement, and manage policy.
Question: What “issues” or problems are of most
interest to students today?
The Power of Group Influence in a Pluralist, “Free” Society
 Group Influences on Policy

• It is very difficult for the isolated and atomized

individual citizen to have influence.
• Best way to have policy influence is through collective
or group organization and voice.
• Interest groups/lobbies are plural in number and views.
• Groups add more input to the policy making process and
compete for elite/representative interest.
• Healthcare policy is almost always driven by a
combination of elite and group dynamics.
It Makes a Difference--Who Makes, Implements, Influences Policy
 Healthcare Group Action
• Healthcare nonprofit, nongovernmental,
professional, educational, and other engaged
organizations often run by well educated, highly
motivated, and often elite leadership.
• Healthcare organizations and policy is organized
and managed from above in many important
instances.
• Organizations try to mobilize interested citizens
who aid in influencing rest of the masses and in
impacting policy making elites.
• Often is a very top-down process.
 Fighting for Influence
• The group process is like a teeter-totter.
• Each group or interest tries to sway the mass of
citizens, the elected, representatives, and other
government officials to its point of view.
• Healthcare groups compete with all other groups
for influence, including economic/business ones
with different views of how to best use resources,
how, why, etc.
• Influence often goes to groups with most
resources--political, economic, human, systemic,
etc.
Balancing Costs, Benefits, Social Value and Social Costs
 Defining Maximum Gain
As the previous slide shows, what often happens is that
groups fight and compete with each other to define what
will deliver the most “maximum social gain” with the
minimum level of loss to key groups, society as a whole,
and to especially important interests.

Most times---not all---economic benefits will trump other

“values,” including those prevalent in environmental and
natural resources conflicts. Jobs, for instance, in most
people’s minds and lives will be more valued than
investment in universal healthcare, immediate creature
comforts more than taking care of one’s health, etc.
The Scientific or Rational Model of Public Policy Making
The Problem with “Rational” Science
• The major problem with science as a model for policymaking, as depicted in
the previous slide, is that science is a rational model and process.
• It depends on complex data and factual input--often difficult when “solving”
complex, wicked problems.
• The scientific methods also encourages doubt.
• Because people and policy makers in society are influenced by many other
things besides logic and critical reasoning, scientific reasoning as a basis for
making policy is often at a serious disadvantage and takes back seat to other
factors.
• It is also true that, while all benefit from the advances science make
possible, many are inherently suspicious of and hostile to “scientists” and
science in general.
Example: Determining the extent of, the cause of, and a solution for lack of
health insurance for 50 million Americans.
 Irony of American Democracy
• The few or elite possess power
• Masses possess influence over multiple
elites (Pluralism--Group Model)
• Upward mobility into elite is slow,
controlled, selective
• Elite share consensus on values and this
preserves democracy
• Public policy usually elite, not mass based
 When Elitism Breaks Down
• Sometimes the masses are able to elect to political
office elites who do not share the values of
scientific elites and science itself.
• Sometimes political elites pander to the anti-
scientific biases and values of the least
knowledgeable and most hostile of the masses.
• Sometimes nonscientific elites just don’t believe
the “science.”
• Often other elites, especially economic ones,
benefit economically by ignoring the science.
 Steps in Ideal Environmental Policy Analysis
Choice, and Decision Making
• Define the problem
• Assemble appropriate information and evidence
• Identify & construct alternative policy options
• Define and select decision making criteria
• Project possible & expected costs, benefits, and outcomes
• Confront and balance appropriates trade-offs
• Influence key power and authority centers to decide
• Tell your story
From Eugene Bardach, A Practical Guide for Policy Analysis, 2000.
Environmental Policy
 The Policy Cycle
• Actors work to continually define and refine the
public agenda.
• One big obstacle to overcome is getting a problem
noticed in the age of ever-increasing volume and
tenor of shocking news.
• Does radical rhetoric help or harm?
• How radical do you have to become as an
individual? As a group?
• How critical the crisis before anyone cares or acts?
Among masses? Among elites?
 ROLE OF INDIVIDUAL ACTION
• Become informed about what you care about and
what you should care about!
• Get involved in the political system (model).
• Join or at least gather information from pertinent
environmental organizations.
• Influence policy elites through voice of
organizations, by voting and supporting health-
based astute political elites, write, call, give
money, lobby/educate, be an engaged, active
citizen in our representative democracy.
Why We Care--The Primary Level
• We are all members of and One family
are dependent upon the of consumers/
citizens
healthcare system. impacted by
public policy
• The health of each of us is and impacting
dependent upon the resources and
other citizens
availability of and access
to healthcare resources
within society.
Four generations
• Our reasons for caring, from that single
including as faculty, begin family--Frances, 93,
and Jonah, 3 months,
at Wiley’s primary level of linked by past and
society--with our own present resources
consumption
families across
generations.