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LD5655.V856 1994.M436.Pdf (10.97Mb) A CENTURY OF DEMOCRATIC DELIBERATION OVER AMERICAN AND BRITISH NATIONAL HEALTH CARE: EXTENDING THE KINGDON MODEL by Rene P. McEldowney Dissertation submitted to the Faculty of the Virginia Polytechnic Institute and State University in partial fulfillment of the requirements for the degree of DOCTOR OF PHILOSOPHY in Public Administration and Public Affairs APPROVED: Ot ab earT Hs Charles T. Goodsell, Chairman a CB Meh? Dreeye coy James R. Bohland ° Larkin Dudley December 20, 1994 Blacksburg, Virginia Dn bey RE mL 9 V$ obo | Ct ony ‘f 3G, A CENTURY OF DEMOCRATIC DELIBERATION OVER NATIONAL HEALTH CARE: EXTENDING THE KINGDON MODEL by Rene P. McEldowney Committee Chairman: Charles T. Goodsell Public Administration (ABSTRACT) The issue of national health care has actively plagued the 20th century political spectrum in both the U.S. and the United Kingdom. It has been an issue of astounding resilience and vexation, alluding almost all simple-quick answers while consuming an ever increasing amount of public resources. There have been three principal time periods when both the United States and Great Britain have actively addressed universal coverage: the 1910s; the 1940s; and the 1990s. This dissertation extends John Kingdon’s theory on policy agenda formation by examining the aforementioned debates. The conclusions that come from this study are four fold. (1) Contemporaneous interactions can occur between nations. (2) Century-long longitudinal development of a single policy area is possible and is illustrated. (3) Kingdon’s policy streams approach can be utilized to conduct a comparative analysis of the policy agenda formation process. (4) Kingdon’s conceptual model is more accurate at depicting the policy agenda formation process of the British parliamentary system than it is for the divided government structure of the US.. Lovingly dedicated to: my husband George A. McEldowney Jr. and Mrs. Louise Barr both of whom excel in all of life’s most important qualities IV ACKNOWLEDGEMENTS I would like to thank all of my many teachers and colleagues who have helped to make this dissertation possible. I reserve a special gratitude for my chairman Charles Goodsell. His personal and professional kindness are surpassed only by his extreme patience and dedication to the field. TABLE OF CONTENTS Chapter 1 _— Politics and Health . 1 Chapter 2 Early-Century Debates and Disillusion.........2...........cccsssscesees 35 Chapter3 Mid-Century: Unfinished Business 72 Chapter 4 Late-Century: Coming Full Circle........ 114 Chapter5 A Tale of Two Countries . 171 Bibliography.. sescesessccscscsecccacssecsssacessscecsccesersasasessesers 204 Vita 214 ACRONYMS AND ABBREVIATIONS American Association of Labor Legislation American Federation of Labor American Hospital Association American Medical Association British Medical Association Diagnostic Related Group General Practitioner Health Maintenance Organization 1911 National Health Insurance Act 10. National Hospital Association 11. S.S. Social Security CHAPTER ONE POLITICS AND HEALTH Greater than the tread of mighty armies is an idea whose time has come. Victor Hugo Health care has become an essential part of modern contemporary life; it has become the policy area where all the social forces converge to express themselves with great clarity and where societal norms and values are made manifest. It is a reflection of a nation’s people, its government, and its priorities. Hence, health care has become a kind of political mirror image of contemporary society. There is scarcely a country in the modern world where the subject of health care has not edged its way onto the political and social landscape. It has, for most countries, become the arena whereby the greatest of passions, expectations, and political foreplay reach their zenith. This is only quite natural, for the determination of a nation’s health care policy affects the grandest mansion and the humblest abode alike. In short, it affects every citizen in every capacity. Health care policy in the United States, as elsewhere in the world, is also no stranger to this type of political controversy. The debate over national health insurance in this country has extended over one third of our nation’s entire existence. Starting in 1912 with Teddy Roosevelt’s Bull Moose campaign, and then with varying degrees of intensity, the issue of national health insurance has held a place in U.S. politics right up to and including today. When approaching the subject of national health insurance, England’s National Health Service (NHS) is always a logical starting place. It has long served as the model for health care distribution across the globe.’ Numerous countries such as Canada and Israel have used the NHS model in establishing and developing their own respective national health insurance programs. But this is not to say that the NHS model is the Rosetta Stone of national health insurance reform. Far from it, for while the development of the British National Health Service is often depicted as having emerged upon the national agenda very rapidly, the reality has been quite different. Like the United States, the issue of national health insurance first appeared on the British political landscape in the early 1910s. And similar to the United States, its development has been an evolutionary process, a succession of problem-solving attempts rather than a single revolutionary event. While the methods of health care delivery in the United States and Great Britain have been quite different, each country has enjoyed a rising standard of health care since World War II. In both countries, most citizens have been well satisfied with their respective health care systems and have seen little need for confrontation or dramatic change. But, after decades marked by general complacency, the issue of health care reform has once again become a point of intense political focus for both nations. Faced with increasing health care demands, aging populations, and ever tightening budgets, both countries have begun to look seriously at reforming their current health care systems. The health care sector in Great Britain, as in the United States, has been growing at a remarkable pace. Both countries have experienced rapid increases in gross national expenditure rates, numbers of health professionals, and patient loads. Throughout the 1980s, both nations presided over unprecedented expansions of their health care sectors. Expensive new technology such as CAT scanners and lithotripsy units evolved from high-technology rarities to essential parts of the modern hospital setting. New types of pharmaceuticals and therapy treatments were also introduced, and the health care sector of both countries took on expanded roles as seen in the proliferation of cardiac rehabilitation centers and sports medicine clinics. In short, both the U.S. and Great Britain embarked on a road of no return. This is a road of increased services, expanded facilities, and augmented scopes of care. These new roles of medical services have started to raise some tough political issues. During the 1980s, questions as to how to control costs within an environment of ever diminishing tax dollars, aging populations, and global competition, began to surface on both sides of the Atlantic. The once back-stage issue of health care delivery suddenly became a policy star of intense focus. Both Great Britain and the United States are standing at the political crossroads of health care reform. One system has looked towards the competitive forces of a free market system to solve its health care dilemma, while the other system seems headed toward government intervention and control. And while these two nations are, seemingly, moving to the opposite sides of the ideological spectrum, both have the same goals. They want to control spiraling health care costs by reducing demand and increasing system efficiency. The bitter-sweet fruit of historical understanding teaches us that there are valuable lessons to be learned from the past. This is especially true of the untidy world of policy development. It is an arena where issues can move in and out of focus with little apparent logic or reason. The question as to why certain issues receive political attention and subsequently develop into governmental policies is as intriguing as it is difficult. It is also to be the focus of this dissertation. THIS STUDY Public policy making is a subject which is as complex as it is diverse. The concept of who decides and who gets heard has long intrigued the policy and political science community. Over the years, several theories have emerged which attempt to unravel the policy process and unearth its decision making mechanisms. One of the more celebrated schools of this line of inquiry is that of agenda formation. Policy agenda formation is concerned with what problems or issues get put on the public agenda and which ones do not. It seeks to understand why an issue becomes a national focus and what makes it fade from view. There are always more problems than a single government or administration can address. The study of policy agenda formation seeks to understand how this indeterminable list is narrowed to a definable set of addressable issues and solutions. One of the more popular works in the field of agenda formation is John Kingdon’s 1984 book Agendas, Alternatives, and Public Policies.” Kingdon explains the policy agenda formation process by using the metaphorical example of three policy streams: (1) problems; (2) politics; and (3) policies. He hypothesizes that for any Presidential or legislative action to take place on a particular problem or issue, the aforementioned policy streams must first come together, couple, and then proceed through a window of opportunity. Kingdon characterizes this process as an untidy amalgamation of values, economics, and politics. This dissertation extends Kingdon’s theory of policy agenda formation in several different ways. First, it applies the theory to a comparative study, showing that Kingdon’s theory is valid in political systems outside of the United States.
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