Written by Christopher Plein, Ph.D. West Virginia University and MFLN Military Caregiving Team Member
Changes in Health Policy
In my last blog, I talked about the influence of history on shaping change in the political and policy arena. You may recall that we talked about Alexander Hamilton and how he and other influential leaders were constrained by choices made in the past in their design of the U.S. Constitution. In turn, the choices made 230 years ago influence our political and policy environment today.
Another force that shapes change is compromise. Even the strong-willed Alexander Hamilton realized this as he cooperated – sometimes grudgingly — with other leaders during the early constitutional era. Without compromise and negotiation, it is difficult to enact effective public policy and to achieve positive results.
The Affordable Care Act offers a case in point for the need to compromise. The legitimacy of the ACA has been questioned from day one because of the perception that there was little room for compromise when the law was passed in 2010. Members of the then minority party, the Republicans, felt largely shut out of the proceedings. Today, members of the minority party, the Democrats, complain of being left out of the process as “repeal and replace” is considered. At the highest political and partisan levels, the ACA is distinctive because the basic premises and provisions of the act have remained unresolved and unsettled by a lack of compromise and acceptance.
The big takeaway here is that sparking and managing change requires a willingness to compromise. Without this, decisions for change may lack the benefit of broad-based input and may not be accepted by those who are affected by proposed changes.
Compromise means that the hopes of those advocating for change may not be fully realized, but it also means that the fears of those opposed to change may be allayed. Fortunately, this process of compromise – as rough and tumble as it may be – is still present in policy making and implementation. Indeed, some of the brighter spots in the ACA implementation experience have been a product of lower level compromises somewhat removed from the din and clamor of national politics. These involve policy management actions that have or are being worked out between the states and the federal government in Medicaid programming and insurance regulation.
In this and my last blog on “What History Can Teach Us”, we have explored how the past can shape our options and choices for change and we have explored how compromise plays a role in catalyzing and managing change. Political scientists and other scholars spend a lot of time trying to explain change and how it is constrained by context and behavior. Two helpful terms to take away from such discussions are path dependency and incrementalism.
Path dependency refers to how the past shapes current and present choices. In a must read for those interested in health care that I mentioned in a previous blog, Atul Gawande, a writer for the New Yorker, explains how basic historical and institutional forces have shaped health systems in the United States and elsewhere.
Incrementalism, a term used by many political scientists and popularized many years ago by Charles Lindblom, recognizes the importance of the past in constraining options for change but also helps us clearly understand how compromises and negotiation shapes change – both in decision making and in its implementation. Lindblom reminds us that we tend to “muddle through” on the path to change as we encounter unexpected problems and challenges, as we adjust along the way, and as we compromise on our expectations and methods of achieving change.
In my last blog, I offered the old adage that “the only thing that is constant is change.” I will leave you with one more common saying – change is in the air. For those of you who are part of our MFLN network, you will begin to see that the topic of change will be front and center in some of our upcoming programming. Along with our colleagues in other MFLN concentration areas, those of us in the Caregiving Concentration are helping to organize a Virtual Conference to be held online on September 26-29, 2017. The overarching theme of this Virtual Conference will be on the topic of “Learning Through Change”– be it at the policy level, in the lives of those that we service, within culture and society, or in our own professional roles. We are gathering experts from across the country and from various fields to help us better understand and manage change in its many different contexts.
This MFLN-Military Caregiving concentration blog post was published on August 11, 2017.