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Policy Analysis Models
and Healthcare Issues
Interdisciplinary Studies:
Social Science,
Understanding Society,
And Policy Making
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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 meanin ful communication about the world
Help direct inquiry and research into problems, issues, andworld 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.
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Primary Groups
Secondary Groups
and Associations
Community
Nations & International
Organization
Economy--production &distribution of resources as
well as class status.
Culture--artifacts, symbols,
values, norms, expectations,
assignment of social status
Socio-Political Forces and Society
INDIVIDUAL
Family, Kinship Groups,
Tribal Groups
Schools, Employers, Npfs,
Voluntary Groups, Businesses,
etc.
Neighborhoods, Towns, Cities,
Villages--Connected Places
Nation of Citizenship
World Nations, UN, etc.
State--Collective authority,
right to make binding
decisions and applylegitimate power and force.From Norbert Wiley, Ph.D., 1977.Dept. of Sociology, University of Illinois C-U.
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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
v
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.
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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.
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Remembering Wicked Problems Healthcare problems tend to be intractable because
they are nested within sets of interlocking issues--some involving access to healthcare resources orthe health systems, others scientific, cultural,economic, and/or political in basis.
Often poor match between bearers of costs andbearers 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.
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Exercise: Applying Wiley
1. Name one wicked healthcare problem.
2. Name one characteristic of our economy or our
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?
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A Wicked Example--SW Power
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The Flip Side of the Solution
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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.
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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 nonprofitorganizations as allies or problem solvers.
We can use private businesses to supplyand from which to buy solutions.
We can call on government to define publicinterest, solve problems, and take action.
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Why Government Gets Involved
When a primary level solution doesnt work When voluntary or nonprofit solution doesnt
work or is too limited
en a pr vate sector so ut on oesn t wor , stoo expensive, or distributes benefits and costs tooinequitably
When consensus must be built across institutionsand levels of society
When authoritative, binding decisions are neededand applicable across all of society and citizens
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Governments by Democratic Typology
Procedural/Processes/
Sructural
LOW
PuredemocraciesDemocratic
oligarchies
Distributive/substantive/egalitarian outcomes
HIGH
Authoritarian
oligarchiesAuthoritarian
democracies
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Categories of State Authority
Government or the state exist along a continuumfrom mostly democratic/participatory/open tomostly authoritarian/elitist/closed.
,including in areas like healthcare access.
In the latter, one or at most a few elites have thepower 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.
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Continuum of Authority Types
HIGH LEGITIMACY LOW
POPULAR ELITIST
Totalitarian/
DictatorOligarchy/
Dictatorship
Mass
democracy
Pluralist
Democracy
PARTICIPATORY/OPEN ELITIST/CLOSED
Mixture
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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,
, ,
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
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Key Framing Values of U.S.Governance & Authority
1. Freedom---for whom, in what situations/conditions, how
much
---. , ,
with how much sacrifice of freedom and why3. 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.
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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 useimprisonment, 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--evenagain state-sanctioned violence--to further enforcelaws, policies, the public will, etc.
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Institutional Complexity of Policy Making in the U.S. System
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Institutional Complexity
Founders trusted neither the people or the elites torule, 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.
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The Systems Model and Influencing Public Policy Making
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Features of the American System
Representative--people select others to make policy,including environmental kinds.
Representatives are to respond to citizen inputs--demands
system.
Legitimacy of policy depends on citizens playing this part
and expressing desires.
Examples: Individual student activities in support of
healthcare policy? Name any?
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The Middle Bias in American Two-Party System
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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-partyelectoral input process, representatives gravitate towardmiddle where most of citizen voters are (excluding non-
, , , , .
Healthcare policy, like most public policy, tends towardsame middle ground.
Example: Current attempts to limit healthcare costs, improvehealthcare access for children, reduce impact ofpreventable illnesses, etc.
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The Elite Dominance in Most Public Policy Making
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Elitist Slant to Public Policy Most citizens are relatively uninformed and too
busy to pay attention to most issues.
Healthcare access, healthcare provision, andaccess to healthcare resources falls down the list
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?
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The Power of Group Influence in a Pluralist, Free Society
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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 acombination of elite and group dynamics.
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It Makes a Difference--Who Makes, Implements, Influences Policy
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Healthcare Group Action Healthcare nonprofit, nongovernmental,
professional, educational, and other engagedorganizations often run by well educated, highlymotivated, and often elite leadership.
and managed from above in many importantinstances.
Organizations try to mobilize interested citizens
who aid in influencing rest of the masses and inimpacting policy making elites.
Often is a very top-down process.
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Fighting for Influence The group process is like a teeter-totter.
Each group or interest tries to sway the mass ofcitizens, the elected, representatives, and othergovernment officials to its point of view.
ea t care groups compete w t a ot er groupsfor influence, including economic/business oneswith different views of how to best use resources,how, why, etc.
Influence often goes to groups with mostresources--political, economic, human, systemic,etc.
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Balancing Costs, Benefits, Social Value and Social Costs
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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 mostpeoples minds and lives will be more valued than
investment in universal healthcare, immediate creature
comforts more than taking care of ones health, etc.
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The Scientific or Rational Model of Public Policy Making
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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 solvingcomplex, wicked problems.
The scientific methods also encourages doubt.
Because people and policy makers in society are influenced by many otherthings besides logic and critical reasoning, scientific reasoning as a basis formakin olic is often at a serious disadvanta e and takes back seat to otherfactors.
It is also true that, while all benefit from the advances science makepossible, many are inherently suspicious of and hostile to scientists andscience in general.
Example: Determining the extent of, the cause of, and a solution for lack of
health insurance for 50 million Americans.
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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
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When Elitism Breaks Down
Sometimes the masses are able to elect to politicaloffice elites who do not share the values ofscientific elites and science itself.
-
scientific biases and values of the leastknowledgeable and most hostile of the masses.
Sometimes nonscientific elites just dont believe
the science. Often other elites, especially economic ones,
benefit economically by ignoring the science.
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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
ro ec poss e expec e cos s, ene s, an ou comes
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.
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Environmental Policy
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The Policy Cycle
Actors work to continually define and refine thepublic agenda.
One big obstacle to overcome is getting a problem-
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?
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ROLE OF INDIVIDUAL ACTION
Become informed about what you care about andwhat you should care about!
Get involved in the political system (model).
o n or at east gat er n ormat on rom pert nentenvironmental organizations.
Influence policy elites through voice oforganizations, by voting and supporting health-
based astute political elites, write, call, givemoney, lobby/educate, be an engaged, activecitizen in our representative democracy.
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Why We Care--The Primary Level We are all members of and
are dependent upon the
healthcare system. The health of each of us is
dependent upon the
One family
of consumers/
citizensimpacted by
public policy
and impacting
resources and
ava a ty o an access
to healthcare resourceswithin society.
Our reasons for caring,including as faculty, begin
at Wileys primary level ofsociety--with our ownfamilies acrossgenerations.
Four generations
from that single
family--Frances, 93,
and Jonah, 3 months,linked by past and
present resources
consumption