Here's a question that appeared on the midterm exam from my graduate Policy Fundamentals class:
There’s an old saying: “He who controls the agenda controls the outcome.” To what extent does this seem accurate? Explain the importance of problem identification and agenda setting in the policy process.
My response:
He who controls the agenda controls the outcome...Were that even close to true, Hillary Rodham Clinton would quite possibly be President of the United States and the healthcare system employed here would look vastly different than it does today.
The rest is after the fold.
In 1992, Bill Clinton won the presidency with healthcare reform as a major component of his domestic platform. At the same time, Democrats gained control of both the House and the Senate – the first one-party trifecta since the late 1970s. Five days after being sworn in, President Clinton announced the formation of the President's Task Force on National Health Care Reform and named Hillary as its chair. She was no rube; the Wellesley- and Yale-educated First Lady had served on or chaired healthcare-related boards and task forces while Bill was Governor of Arkansas, so her appointment, while unprecedented for such a high-stakes initiative, wasn't outré on its face. In his original announcement, the President put his finger firmly on the core issue: "It's time to bring costs under control so that...a medical emergency or a long illness will not mean bankruptcy. And it's time to bring quality coverage to every American – to cut back on the paperwork and the excuses and make healthcare a right, not a privilege."
One would expect that the Clinton healthcare agenda would find the wickets to adoption unguarded, wide, and closely spaced. But the Task Force had badly misread its charge; what emerged was a Byzantine bill (the Health Security Act) whose centerpiece was a mandate for employers to provide medical insurance to all its employees via an array of competing HMOs. The Act didn't seek to re-engineer the entire system by, for instance, completely decoupling healthcare access and affordability from employment and thereby plugging corporations' easy walkaround of engaging "independent contractors" instead of employees or gaming the distinction between what is or is not a full-time employee. Instead, the Task Force doubled down on the status quo, overlaying atop it an interlocking grid of new and existing actors including a new "National Health Board." The bill was assailed in both the House and Senate in 1994 and the high-profile flameout of the entire initiative contributed to the Democrats' loss of control of Congress in the subsequent mid-term elections.
This demonstrates that one can have an iron grip on the agenda – with the President, the First Lady, both houses of Congress, the media, and the national discourse all spun up – and have it fly into pieces so spectacularly that the issue remained highly radioactive when Barack Obama took it up in 2009, even though Obama's approach differed substantively from Hillary Clinton's.
Except perhaps for the debatable "right vs. privilege" argument, Bill Clinton's first-approximation identification of the problem in his original Task Force announcement appeared dead-on, but the Task Force went blind at the next analysis layer down, where one would begin examining how the existing pieces of the process fit together and determining how the process fails the citizenry. The lesson to be learned here is that a totally top-down overhaul can aim well wide of a policy target if the problem identification is faulty.
President Clinton's presumably friendly Congress and receptive public should have been the ideal opportunity to enact sweeping social legislation of import similar to that of the Civil Rights Act of 1964, but he miscalculated. His selection of Hillary to head the Task Force (would Bill have done that if she weren't already so strongly inclined?) was likely meant to show commitment but was interpreted rightly or wrongly as a move toward Hillary as "co-president" – a claim that is reinforced by the fact that the President already had at his disposal a Secretary of Health and Human Services, a Surgeon General, and a popular former Surgeon General, C. Everett Koop. Instead, Hillary's involvement poisoned the agenda-setting for many parties, suggesting that if one has a good agenda message, having it come from the wrong mouth can render it worthless.
I haven't seen a grade on my midterm yet, so I don't know what the professor's take is...what's yours?
Wed Mar 28, 2012 at 6:20 PM PT: The professor liked this one the least among the three responses, giving it an 85 vs. 90 and 93 for the other two! I was the proudest of this one, though. He didn't mark up the Hillarycare response at all, which I found odd; I have no quarrel with the grade but I'd be interested to know what his issues were.