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Toward adoption of long term care policy for the elderly: Political features of long term care policy proposals influential to adoption, national legislation
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TOWARD ADOPTION OF LONG TERM CARE POLICY FOR THE ELDERLY;
POLITICAL FEATURES OF LONG TERM CARE POLICY PROPOSALS
INFLUENTIAL TO ADOPTING NATIONAL LEGISLATION
by
Joan F. Van Nostrand
A Dissertation Presented to the
FACULTY OF THE SCHOOL OF PUBLIC ADMINISTRATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF PUBLIC ADMINISTRATION
August 1994
Copyright 1994 Joan F. Van Nostrand
UMI Number; DP31378
All rights reserved
INFORMATION TO ALL USERS
The quality of this reproduction is dependent upon the quality of the copy submitted.
In the unlikely event that the author did not send a complete manuscript
and there are missing pages, these will be noted. Also, if material had to be removed,
a note will indicate the deletion.
Oissffirtaîiorï PfeblisMng
UMI DP31378
Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author
Microform Edition © ProQuest LLC.
All rights reserved. This work is protected against
unauthorized copying under Title 17, United States Code
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UNIVERSITY OF SOUTHERN CALIFORNIA
SCHOOL OF PUBLIC ADMINISTRATION
UNIVERSITY PARK
LOS ANGELES, CALIFORNIA 90089
Tfc c B s s e r t a t io r ij written B y
Joan Fedell Van Nostrand
under the direction of ft..(Dissertation
Com m itteej and approved B y ad its m em -
B e r s j h a s B e e n presented to and a c c e p te d B y
the (facufy of the S c h o o C of (P u B f ic
Pidministration, in partiaf fuffidment of
requ ire m e nts of the d e g r e e of
DOCTOR OF
PUBLIC ADM INISTRATION
( Dean
(Date * XyAff
DISSERTATION COMMITTEE
chai rperson
TABLE OF CONTENTS
LIST OF TABLES vii
LIST OF FIGURES ix
EXECUTIVE SUMMARY .......................................... xi
Chapter
I. THE ISSUE OF LONG TERM CARE (LTC) AND PROPOSED
RESEARCH ........................................ 1
Introduction .................................. 1
The Issue of L T C .............................. 2
What is LTC and Who Needs It? ............. 2
LTC As a Current and Future Policy
Problem .................................. 3
The Family As the Biggest Provider of LTC . 5
LTC Costs and Insurance ................... 6
National LTC Policies ..................... 8
Institutional Bias and Preference for
Non-Institutional Care ................. 11
Who Benefits? .............................. 12
Quality of L T C .............................. 13
V Perverse Incentives and Unintended
Consequences of LTC Policy . i ........ 16
Roles of Different Levels of Government . . 21
Fiscal Impact of L T C ....................... 22
Significant LTC Policy Proposals ........... 24
Congressional Reaction to LTC Policy
Proposals................................ 40
Objectives of the Research................... 40
Research Questions and Hypotheses ............. 45
II. THEORETICAL FRAMEWORK ............................ 47
Introduction .................................. 47
The Public Policy Process..................... 48
Introduction ................................ 48
Models of the Policy Process and the
Adoption Stage ......................... 49
Sequential Stages Model ................. 49
Cyclical Model ......................... 50
Model of Functional Environments .... 53
Continuous, Open-ended Model ........... 55
Comparison of Models of the Policy
Process .............................. 56
The Agenda Setting Process ................. 58
Introduction ........................... 58
Problems, Policies, and Politics .... 59
Political Leadership, Interest Groups,
and Key Events....................... 62
Perceptions, Conceptualization, and
Tentative Resolutions ............... 63
Agenda Setting by the President ........ 64
a . a .
Policy Context .............................. 55
Introduction ............................ 65
Culture.............................. 66
Conflict in the Policy A r e n a ....... 67
Political and Other Approaches to Policy
Analysis................................ 71
Introduction ................................ 71
Political Approach to Policy Analysis . . . 73
Features of the Approach ............... 73
Critique ................................ 74
Rational Approach to Policy Analysis .... 75
Features of the Approach ............... 75
Critique ................................ 77
Dialectic Approach to Policy Analysis . . . 78
Features of the Approach ............... 78
Critique ................................ 79
Interpretive Approach to Policy Analysis . . 79
Features of the Approach........... 79
Critique.............. 81
Critical Approach to Policy Analysis .... 81
Features of the Approach ............... 81
Critique ................................ 82
Comparison of the Five Approaches To
Policy Analysis ......................... 82
Building Coalitions ............................ 85
Introduction................................ 85
Historical Background ..................... 86
Coalitions and Policy Adoption ............. 87
Factors Important to Building Coalitions . . 89
Coalitions and Policy Goals ............... 92
Preference for Policies Which Limit the Extent
of Change .................................. 94
Introduction ................................ 94
Approaches to Policy Analysis Which Support
the Status Q u o ..................... 94
Introduction ............................ 94
Disjointed Incrementalism Approach . . . 95
Rational Analysis Approach ............. 96
Implications of Recent Changes in the
Public Policy Process ................... 97
Introduction ............................ 97
Changes in Preferred Policy Strategy . . 98
Changes in the Social Policy
Environment ......................... 99
Risks Inherent in Adopting Policy ......... 101
Other Features That Limit Change in
Public Policy ............................ 102
Public Mood.......................... 102
Deciding Not to D e c i d e ............. 103
Congressional Milieu ................... 104
Interaction Between Advocates and Congressional
Staff Members .............................. 104
Introduction . ............................ 104
Roles ...................................... 105
Client-Advocate Relationship ............... 107
Skills, Activities, and Interactions .... 109
Other Factors Influencing Interaction . . . 113
iii
Summary of the Theoretical Framework ........ 114
Introduction ................................ 114
Theories About the Policy Process ......... 115
Theories About Approaches to Policy
Analysis ................................ 117
Theories About Building Coalitions ........ 118
Theories About Limiting the Extent of
Policy Change ............................ 120
Interaction Between Advocates and
Congressional Staff Members ............. 122
III. RESEARCH DESIGN AND METHODOLOGY ................. 12 6
Case Study Method and Overview of Analytic
Strategy.................................... 126
Selection of Informants ....................... 129
Introduction ................................ 129
Congressional Staff ....................... 132
Advocates of LTC Policy Proposals ........ 137
Field Procedures.............................. 139
Interview .................................. 139
Protocol . . . . . . . . . . . . . . . . . . 141
Reliability and Validity of Research Design
and Collection......................... 144
Introduction............ 144
Reliability of Research Design and
Collection Phases ................... 145
Validity of Research Design and
Collection Phases ................... 145
Analytic Plan.................................. 147
Analytic Strategy ......................... 147
Pattern Matching ............................ 148
Validity of the Analysis................... 151
Introduction ............................ 151
Analytic Strategy for Validity ........ 151
Internal Validity of the Analysis .... 152
External Validity of the Analysis .... 153
IV. FIELD EXPERIENCE .................................. 155
Introduction .................................. 155
Field Experience.............................. 155
Real-Life Context of Adopting National LTC
Legislation ......................... 159
Introduction ................................ 159
Health Care Reform................... 159
Repeal of the Medicare Catastrophic
Coverage A c t ............................ 161
V. RESEARCH RESULTS .................................. 164
Introduction .................................. 164
Research Results for Hypothesis 1: Political
Approach to Analysis ....................... 165
Introduction . ....................... 165
Importance of Political and Other
Approaches to Analysis ................. 167
Political Approach to Analysis ............. 169
rv
Rational Approach to Analysis ............. 172
Combination of Techniques and Other
Approaches to Policy Analysis ........... 175
Pattern Matching ............................ 176
Research Results for Hypothesis 2; Creating
Coalitions.................................. 179
Introduction ................................ 179
Importance of Building Coalitions ......... 180
Building Coalitions and LTC Policy
Adopt ron #######.#.###### 182
Coalitions of Interest Groups ........... 182
Coalitions of Members of Congress .... 185
Coalitions and Policy Goals ............... 187
Pattern Matching ............................ 188
Research Results for Hypothesis 3: Limiting
Policy Change .............................. 189
Introduction ................................ 189
Importance of Limiting the Extent of
Policy Change ............................ 190
The Strategy of Incremental Policy
Changes.................................. 192
Risks Inherent in Policy Adoption ........ 195
Pattern Matching.......... 198
Research Results for Hypothesis 4: Skillful
Interaction of Advocates With Congressional
Staff.................................... 200
Introduction ................................ 200
The Roles of Advocates in Their Interaction
With Congressional Staff ............... 201
The Impact of Skillful Interaction on
Adoption of LTC Legislation............. 204
Relationships Between Advocates and
Congressional Staff Members ............. 206
Pattern Matching ............................ 209
Research Results for Research Question 2:
Similar Judgements By Congressional Staff
and Advocates .............................. 211
Introduction ................................ 211
Research Results ............................ 213
Other Political Features Important To LTC
Policy Adoption ............................ 222
Most Important Political Feature To LTC
Policy Adoption ....................... 226
Introduction ................................ 226
Features Selected As Most Important .... 227
The One Feature Selected As Most
Important................................ 227
Combinations of Features Selected As
Most Important .......................... 229
Applicability of Judgements To All LTC
Issues and To Other Social Policy ........ 233
Summary of Results............................ 236
Introduction............ 236
Summary of Findings for Research
Question 1 236
Summary of Findings for Research
Question 2 238
other Important Features and Most
Important Feature ....................... 240
Applicability .............................. 242
VI. OVERVIEW OF THE RESEARCH AND CONCLUSIONS......... 243
Introduction .................................. 243
Objectives.............................. 243
Conclusions About Support For the
Hypotheses........................... 245
Other Important Features ..................... 253
Most Important Feature ....................... 254
Applicability .................................. 257
Implications of the Results............. 2 59
Introduction............................. .. 259
Implications for Advocates ................. 260
Implications for Congressional Staff .... 263
Implications for the Field of Public
Administration ......................... 264
Other Knowledge Provided By the Research . . . 266
Introduction ................................ 266
Repeal of the Medicare Catastrophic
Coverage Act ............................ 266
Impact of the Congressional Budget Office . 267
LTC As a Women's Issue............... 268
The Researcher's Application of Results .... 270
Future Research ................................ 272
SELECTED BIBLIOGRAPHY ...................................... 277
APPENDIXES
A. Interview Protocol .................................. 285
B. Letter To Create An LTC Coalition in the Senate . . . 295
VI
LIST OF TABLES
1. Medicare and Medicaid Expenditures For LTC, 1991 . . 10
2. Significant LTC Policy Proposals By Type of
Organization Responsible For Their
Development ...................................... 25
3. Summary of the LTC Policy Proposal of Rivlin and
Wiener of The Brookings Institution ............. 30
4. Summary of the Pepper Commission's LTC Policy
Proposal.......................................... 32
5. Summary of the Health Insurance Association of
America's LTC Policy Proposal ................... 34
6. Summary of the American Association of Retired
Persons' LTC Policy Proposal ..................... 36
7. Summary of the Administration's LTC Policy Proposal
(Subtitle B of Title II of the Health Security
Act, H.R. 3600, S. 1757)......................... 38
8. Comparison of Models of the Policy Process ......... 57
9. Comparison of Five Approaches To Policy Analysis . . 83
10. U.S. Congressional Committees and Subcommittee
With Responsibility For LTC Legislation ........ 133
11. Organizations That Have Significant LTC Policy
Proposals and That Are Included in the
Case Study........................................ 138
12. Sources of Information in the Interview Protocol To
Address Research Questions and Hypotheses .... 143
13. Which Approach To Policy Analysis Is Important To
Formulate Influential LTC Proposals? ............. 168
14. How Important the Selected Analytic Approach Is To
Formulate Influential LTC Proposals ............. 169
15. Political Features Selected As Most Important To
Influential LTC Policy Proposals ................. 228
16. Summary of Findings For Research Question 1 237
17. Summary of Findings For Research Question 2 239
vir
18. Findings of Other Important Features and Most
Important Feature ................................ 241
19. Support for Hypotheses of Research Question 1 .... 246
20. Similarity of Judgements of Congressional Staff and
Advocates ........................................ 250
21. Comparison of Support For Research Questions 1
and 2 252
Vili
LIST OF FIGURES
1. Example of Empirical Pattern On Importance of
Political Approach To Analysis ................... 150
2. Example of Predicted Pattern on Importance of
Political Approach to Analysis ................... 150
3. Political Approach To Analysis: Hypothesized
Pattern of Importance To Influential LTC
Proposals ........................................ 178
4. Political Approach To Analysis: Empirical
Pattern of Importance To Influential LTC
Proposals ........................................ 178
5. Rational Approach To Analysis: Empirical
Pattern of Importance To Influential LTC
Proposals .................................... 179
6. Building Coalitions: Hypothesized Pattern of
Importance to Influential LTC Proposals ......... 189
7. Building Coalitions: Empirical Pattern of
Importance To Influential LTC Proposals ......... 189
8. Limiting the Extent of Policy Change: Hypothesized
Pattern of Importance To Influential LTC
Proposals... ........................................ 199
9. Limiting the Extent of Policy Change: Empirical
Pattern of Importance To Influential LTC
Proposals... ........................................ 199
10. Advocates Skillful in Interaction With Congressional
Staff: Hypothesized Pattern of Importance To
Influential LTC Proposals ........................ 210
11. Advocates Skillful in Interaction With Congressional
Staff: Empirical Pattern of Importance To
Influential LTC Proposals ........................ 210
12. Political Approach To Analysis: Congressional Staff
Members Judgement About the Importance To
Influential LTC Proposals ........................ 215
13. Political Approach To Analysis: Advocates Judgement
About the Importance To Influential LTC
Proposals ........................................ 215
iX
14. Rational Approach To Analysis: Congressional Staff
Members Judgement About the Importance To
Influential LTC Proposals ....................... 215
15. Rational Approach to Analysis: Advocates Judgement
About the Importance To Influential LTC
Proposals ........................................ 216
16. Building Coalitions: Congressional Staff Members
Judgement About the Importance To Influential
LTC Proposals .................................... 217
17. Building Coalitions: Advocates Judgement About the
Importance To Influential LTC Proposals .......... 217
18. Limiting the Extent of Policy Change: Congressional
Staff Members Judgement About the Importance
To Influential LTC Proposals..................... 219
19. Limiting the Extent of Policy Change: Advocates
Judgement About the Importance To Influential
LTC Proposals .................................... 219
20. Advocates Who Are Skillful in Interacting With
Congressional Staff: Congressional Staff
Members Judgement About the Importance To
Influential LTC Proposals ....................... 220
21. Advocates Who Are Skillful in Interacting With
Congressional Staff: Advocates Judgement About
the Importance To Influential LTC Proposals . . . 220
22. Combination Patterns of Political Features
Selected As Most Important To Influential LTC
Policy Proposals .................................. 230
23. Combination of Political Features Most Important
To Influential LTC Policy Proposals ........ .. . 256
EXECUTIVE SUMMARY
The objective of this research was to determine which
political features of long term care (LTC) policy proposals result
in serious consideration being given to them in the process of
adopting national LTC legislation. Knowledge about the critical
political features of LTC policy proposals could be useful to both
policy analysts and policy makers in developing better strategies
for success in adopting national LTC legislation. However,
theories which present a synthesis about political features of
policy proposals that are influential in the process of adopting
national legislation are not available.
In a review of the literature, some political features of
policy proposals emerged as relevant for further study. They
included; a political approach to analysis, ability to build
coalitions, limiting change so policy is acceptable to
constituents, and lobbying skills of the advocates of the
proposals. These were the political features of LTC policy
proposals examined in this research. Because an intent of the
research was to identify influential political features of
proposals to improve the success of policy analysts and policy
makers in adopting national LTC legislation, the research
addressed the extent of agreement about influential political
features between representatives of these groups.
LTC was selected for examining the process of adopting
national legislation for two reasons. One reason was to provide a
frame of reference to anchor informants as they consider the
XI
political features of policy proposals influential in the process
of adopting national legislation. The other reason was the future
impact of LTC. Over the next 50 years as the baby boom generation
reaches retirement and older ages, demands for LTC are expected to
increase dramatically. Because national LTC legislation will need
to evolve to meet increasing demands, it will be an enduring issue
on the public policy agenda well into the next century. Knowledge
about what political feature can result in a LTC policy proposal
being influential in the process of adopting national LTC
legislation will continue to be relevant and useful.
The research was a case study of the congressional
committees and subcommittees with jurisdiction over LTC programs
and their financing because of their central role in adopting
national LTC legislation. The case study approach is useful
especially when the boundaries between the phenomenon and its
context are difficult to draw, as they are in the process of
adopting national LTC legislation. A major strength of the case
study approach is its ability to provide insights to answer
questions about both process and explanation of a phenomenon.
Informants were key actors in the LTC policy arena who play
central, behind-the-scenes roles in the process of adopting
national LTC legislation. They included: the staff of
congressional committees and subcommittees with jurisdiction over
LTC programs and their financing and the advocates from a variety
of organizations, including the Administration, with LTC policy
proposals significant to the policy arena. However, the
perspective of other key actors, most notably those who are more
visible in the process of adopting legislation, were beyond the
scope of this case study. They include members of Congress,
congressional staff from committees other than those included in
this case study, advocates from interest groups with LTC concerns,
and political appointees and career bureaucrats with
responsibilities for LTC.
The approach to case study analysis is the method of
analytic generalization in which existing theory is used as a
reference point with which to compare the empirical results (Yin,
1989). A close match of patterns between the hypothesized
relationship and the empirical results provides further evidence
to support the hypotheses. The results from the analytic
generalization to existing theories and the pattern matching
confirmed the following relationships from the perspectives of
congressional staff and advocates who are some central, behind-
the-scenes participants in the process of adopting national LTC
legislation. LTC policy proposals are influential in the process
of adopting national LTC legislation when:
• They create or strengthen coalitions.
• They limit the extent of change from existing policy.
• Advocates of the proposals are skillful in interacting
with congressional staff.
Building coalitions was judged as very important, and the other
two features were seen as important, but less so than building
coalitions. Furthermore, the match of empirical patterns between
congressional staff members and advocates confirmed that they
agreed about the importance of these political features to
influential LTC policy proposals. The agreement was the closest
for limiting the extent of policy change.
The importance of formulating a policy proposal by a
political approach to analysis was not confirmed as important for
a proposal to be influential in the process of adopting national
LTC legislation. No advocates judged it as important. It was
chosen as important mostly by staff for the minority side. A
rival hypothesis, that a rational approach to analysis was
important, was examined because it was selected as important by
more informants (nearly half) that any other analytic approach.
Results from the analytic generalization and pattern matching
suggest that the rational approach may be important to formulating
influential LTC proposals. It was chosen as important mostly by
advocates and staff for the majority side. However, additional
research is necessary for a thorough examination of this rival
hypothesis.
In order to conduct a comprehensive study of the important
political features of influential LTC policy proposals, informants
were asked to identify features other than those already discussed
that were important and to select the most important feature.
Other features most frequently mentioned were; grass roots
support, constrained financial approach (does not add to the
deficit, is not re-distributive, and is not labeled as a tax), and
a horse or member of Congress deeply committed to enactment of the
policy. While a constrained financial approach can be a challenge
to prepare, it is achievable. However, the other two features are
less amenable to development and control. Horses emerge more from
personal views and experience. Efforts to mobilize grass roots
support can be difficult, as well as expensive. The outcome can
be uncertain.
When asked to select the most important political feature
for proposals to be influential in the process of adopting
national LTC legislation, about half of the informants named a
combination of features. The patterns are useful in understanding
the phenomenon of the influence of a combination of political
XIV
features. The most common pattern included grass roots support,
coalition building, constrained financing approach, and analysis,
regardless of the approach used. It may be that while each
political feature is necessary to an influential LTC proposal, it
only becomes sufficient in combination with other features.
Incremental policy change and interaction between advocates and
congressional staff members, though judged as important when
considered individually, appeared less often in these
combinations. This may reflect the fact that hypotheses
concerning these features were supported, but with reservations.
The finding of the importance of a combination of political
features disproves the notion that one overriding political
feature can result in influential LTC policy proposals. This
finding highlights the complexity of the process of adopting
national LTC legislation. It also highlights the difficulty that
participants in the policy adoption process have in influencing
the process. This difficulty occurs for both hidden participants,
like congressional staff and advocates, and visible participants,
like members of Congress and political appointees.
The results of this research can assist advocates of LTC
policy proposals and congressional staff working on LTC issues,
but for different reasons. Advocates can use the research results
to develop a strategy to target their resources to those political
features which are influential in strengthening the influence of
their LTC policy proposals. Advocates can design a strategy for
formulating LTC policy proposals that build coalitions and limit
the extent of policy change. As part of the strategy, they can
employ analysts who are skilled in interaction and give high
priority to their interaction with congressional staff. They also
XV
can devote resources to strengthening communication and
negotiation skills of their analysts. They could also refine
their strategies by targeting the biggest share of their resources
to building coalitions and the smallest share to advocates skilled
in interaction with congressional staff because of the
reservations in the support of this feature. Preliminary evidence
about the importance of a combination of political features
suggests that advocates should consider a strategy in which grass
roots support, building coalitions, constrained financing, and
analysis are all included when formulating a LTC policy proposal.
While congressional staff have an intuitive sense of what
constitutes an influential proposal, an articulated set of
guidelines about political features can be helpful in providing a
systematic approach to selection. Guidelines can be used to
systematically review proposals to identify those that can be the
most influential in shaping proposed legislation. Research
results support the use of LTC proposals which build coalitions
and limit the extent of policy change as the basis for developing
proposals for adopting LTC legislation. Preliminary evidence
about the most important political feature suggests that a good
strategy may be to select proposals that combine political
features of grass roots support, building coalitions, constrained
financing, and analysis. When proposals include some, but not
all, of this combination of political features, these research
findings can be used to pinpoint the areas where the proposal
needs strengthening. They can also be used to develop a strategy
for preparing proposed legislation. One strategy could be to
modify a proposal to increase its influence by limiting the extent
of policy change and constraining the financing. Another could be
to synthesize several proposals with some of these important
political features into one comprehensive LTC bill with all the
important political features and work to build a coalition among
the supporters of the individual proposals.
Congressional staff, especially those working for the
minority party, need to communicate better with advocates about
the importance of the political approach to policy analysis. They
need to give examples of the utility of the approach and emphasize
their preference for its use when formulating policy proposals.
Convincing advocates to use a political approach to analysis,
either alone or with a rational approach, may result in stronger
LTC proposals for use as the basis of proposed legislation.
Results of this study suggest several recommendations for
future research. One recommendation concerns the lack of support
for the hypothesis about the importance of formulating a policy
proposal by a political approach to analysis. A rival hypothesis,
that a rational approach to analysis was important, was examined
because it was selected as important by more informants (nearly
half) that any other analytic approach. Results suggest that the
rational approach may be important. However, additional research
is recommended for a thorough examination of this rival
hypothesis. Because some of the informants identified both
political and rational approaches as important, additional
research should examine the importance of combination approaches
to analysis to formulate influential LTC policy proposals.
The second recommendation is to expand the applicability of
findings to other social policy. Confirmation by informants that
their conclusions were applicable to other social policy issues
suggests building on and expanding the results of the preceding
XVli
research about LTC legislation. Additional research could examine
the importance of these political features in adopting national
legislation about a spectrum of social policies.
A final recommendation for future research concerns the
finding that about half of the informants identified a combination
of political features as the most important to an influential LTC
proposal: grass roots support, coalition building, constrained
financing approach, and analysis. The dynamics of the phenomenon
of a combination of important political features suggest Kingdon's
model (1984) of the agenda setting process. In Kingdon's model,
agenda setting is the result of the coupling of three streams:
problems, policies, and political receptivity. None of the
streams is sufficient to place an issue on the policy agenda. But
when a precipitating event, like a crisis, occurs and the streams
are coupled, the issue is placed on the policy agenda. Each
stream has it own processes, patterns, and constraints. Kingdon's
model can provide a framework for conceptualizing additional
research about the combination of political features which has the
greatest impact on developing influential LTC policy proposals.
Future research to understand the phenomenon of multiple political
features can suggest a nascent theory about the impact of a
combination of political features on the adoption of national LTC
legislation.
If findings of this recommended research support a nascent
theory concerning LTC legislation, additional research should
attempt to generalize the theory to other social policy areas.
Such a general theory can provide guidelines for policy analysts
to strengthen their proposals so they are more likely to be
influential in the legislative process. It also can provide
x v m
guidelines for policy makers to identify proposals and modify
them, if necessary, so they are more likely to be enacted. If a
general theory could be developed, it could make an important
contribution to our understanding of the process of adopting
national legislation and our ability to impact on it.
xrx
CHAPTER I
THE ISSUE OF LONG TERM CARE AND PROPOSED RESEARCH
Introduction
The objective of this research is to determine which
political features of long term care (LTC) policy proposals result
in serious consideration being given to them in the process of
adopting national LTC legislation. Knowledge about the critical
political features of LTC policy proposals could be useful to both
policy analysts and policy makers in developing better strategies
for success in adopting national LTC legislation. LTC was
selected for examining the process of adopting national
legislation for two reasons. One reason is to provide a frame of
reference to anchor informants as they consider the political
features of policy proposals influential in the process of
adopting national legislation. The other reason is the future
impact of LTC. Over the next 50 years as the baby boom generation
reaches retirement and older ages, demands for LTC are expected to
increase dramatically. Because national LTC legislation will need
to evolve to meet increasing demands, it will be an enduring issue
on the public policy agenda well into the next century. Knowledge
about what political feature can result in a LTC policy proposal
being influential in the process of adopting national LTC
legislation will continue to be relevant and useful.
This chapter presents the issue of LTC which is the frame
of reference for the research. It then presents the proposed
research, including the objectives, research questions, and
hypotheses. Chapter 2 presents the theoretical framework for the
research. Chapter 3 describes the research design and
methodology.
The Issue of LTC
What is LTC and Who Needs It?
LTC is assistance needed by the disabled to live as
independently as possible. More technically, LTC is "health,
personal care, and social services delivered over a sustained
period of time to persons who have lost or never acquired some
degree of functional capability" (Kane & Kane, 1987, p. 4).
People who need LTC are so disabled by physical or mental
conditions that they do not have the capacity for self care.
Disability, regardless of the age at onset, is so severe that they
need the help or supervision of another person in performing
activities of daily living (ADL's). ADL's include bathing,
dressing, eating, using the toilet, and transferring from bed to
chair. Many of the persons who need LTC are elderly. The oldest
of the old, those aged 85 and older, are at the highest risk
(Estes & Swan, 1993).
The major providers of formal LTC for the elderly are
nursing homes (where most LTC is provided) and home health
agencies, which provide nursing and housekeeping services in the
disabled person's own home. LTC covers a broad range of services,
including homemaker services, adult day care, congregate and home
delivered meals, transportation and escort services, and legal
protective services and counseling (Kane & Kane, 1987). The major
public program which funds LTC is Medicaid. It has a bias toward
the funding of institutional LTC, although it covers some home
health and community-based care. In 1991, Medicaid spent six
times as much on nursing home care ($28.9 billion) as on home
health and community-based care ($4.8 billion) (Buck & Klemm,
1993). These figures include both federal and state expenditures.
Wiener, Hanley, Clark, and Van Nostrand (1990) estimate
that the elderly population who need LTC because they require the
help of another person with at least one ADL was about 2.3 million
persons in 1987. A higher estimate using an ADL criterion of
greater disability was developed by the Pepper Commission (1990)
based on a micro-simulation model developed by the staff of The
Brookings Institution and ICF, Incorporated (Rivlin & Wiener,
1988). In 1990 about 3.3 million elderly needed LTC because they
required the help of another with three of five ADL's or required
substantial supervision due to cognitive impairments or disruptive
behavior (Pepper Commission, 1990, p. 91). These severely
disabled elderly account for about 11 percent of all older
persons.
LTC As a Current and Future Policy Problem
The current need for LTC for 11 percent of older persons
is viewed as a problem not only by experts in the field of LTC,
but also by the elderly themselves. Some experts characterize the
gaps between the need for LTC and the availability of services as
reaching crisis proportions. To Estes and Swan (1993), there is
"a widening gap between [community-based] services that are
available and services that are appropriate to the care needs of
the elderly" (p. xi). They characterize this situation as "elders
trapped in a no-care zone". To other experts, LTC is a
fundamental issue of how our society cares for its most frail
meitvbers (Kane & Kane, 1987). "It ultimately concerns how and
where people with disabilities will live and die." They see LTC
as a dilemma for policy-makers because it is ". . . caught between
the unassailable good of health and the stigma of welfare" (Kane &
Kane, 1987, pp. 3-4). Still other experts see the current
problems of service gaps, poor quality, and high costs as
intensifying in the future as the population ages and the need for
LTC increases. "Experience so far raises serious questions about
the adequacy of current LTC mechanisms to respond to greater need"
(Pepper Commission, 1990, p.108). With the current emphasis on
health care reform, the elderly themselves are becoming
politically galvanized about their considerable risk of needing
LTC and its often catastrophic costs. A staff member of the
American Association of Retired Persons who spoke to the elderly
in six states about health care reform reported that their message
is: "any proposal that has LTC, we're ready to support by writing
letters and making phone calls" (Priest, 1994).
There is considerable controversy over whether the demand
for LTC will increase dramatically in the future because of
increases in life expectancy. The group aged 65 and older, which
numbered 31 million in 1990, will grow from 13 to 20 percent of
the total population in the next 50 years (Day, 1992). Of the
people who turned 65 in 1990, about 43 percent are projected to
enter a nursing home sometime before they die (Kemper & Murtaugh,
1991). Even more important is the fact that more people are
living into their nineties than ever before (National Center for
Health Statistics, 1993). Some argue that this has critical
implications for the need for LTC because the greatest users of
LTC are persons aged 85 and older (Kane & Kane, 1987; Rivlin &
Wiener, 1988; Pepper Commission, 1990). This age group will
double in size by 2020 and quadruple by 2040 (Day, 1992). As a
consequence, many members of the policy arena believe that LTC
policy for the elderly will be an enduring issue for the nation
for the next 50 years.
As people live longer, some argue that they will do so
with more disability (Rice & LaPlante, 1988), especially from
dementia and cognitive impairments (Kramer, 1980). This
disability is the result not so much of the impact of "killer"
conditions like stroke and heart disease, but of non-lethal
diseases like arthritis which cause severe disability (Verbrugge,
1984). Others argue that there will be a compression of morbidity
in that the onset of disability will occur shortly before death
(Fries, 1980). A recent analysis of longitudinal data from 1982
to 1989 showed a decline in the prevalence of ADL disability for
the elderly (Manton, Corder & Stallard, 1993). A modest decline
in the incidence of disability for the elderly (that is, in the
rate of new cases of disability) has also been identified
(Freedman & Soldo). Favorable as these research findings are,
they have not resulted as yet in a consensus among the members of
the policy arena that the reductions in disability will result in
significant decreases in the future need for LTC.
The Familv As the Biggest Provider of LTC
Currently, the bulk of LTC is provided informally by
spouse, usually the wife, and family, usually daughters and
daughters-in-law (Stone, Cafferata & Sangl, 1987). This pool of
available and willing caregivers is being reduced. More and more
women have joined the labor force with full-time jobs and are not
at home to provide LTC to family members. This situation creates
a serious problem for those elderly, especially the demented, who
need 24-hour care or supervision (Mace & Rabins, 1981). In search
of a solution, disabled elderly and their families are turning
more and more to the formal LTC system. Many women are caught in
the middle of providing care not only to their children, but also
to their disabled elderly parents (Brody, 1985). Others must
balance the demands of working with those of providing care (Brody
& Schoonover, 1986). It is generally when a catastrophe occurs,
like a broken hip, or care is needed on a 24-hour basis that
families consider nursing home care for their elderly members
(Shanas & Van Nostrand, 1988).
LTC Costs and Insurance
For some elderly, the cost of LTC can be catastrophic,
wiping out life-time savings when constant care is needed. The
average monthly cost of nursing home care is expensive, about
$2,500 in 1990 (Pepper Commission, 1990). Stays can be long.
About 37 percent of all nursing home discharges in 1985 had stays
of six months or more (Sekscenski, 1990).
About sixty percent of nursing home residents on January
1, 1987 relied on Medicaid as their primary source of payment.
Nearly all the rest relied on their own personal resources. As of
that same date, about eleven percent of residents met eligibility
requirements for Medicaid because they had "spent-down" their
assets during their stay (Short, Kemper, Cornelius & Walden,
1992). Some argue that the figure of eleven percent of the
elderly who become impoverished by catastrophic costs of nursing
home care is an under-estimate. This is because the figure on
asset spend-down is based on survey data which does not collect
information about all previous nursing home stays of the resident.
Thus, residents impoverished by a previous nursing home stay would
not be classified as spending-down assets to become eligible for
Medicaid (Adams, Meiners & Burwell, 1993). Federal and state
government costs for nursing home care are difficult to control
because of the Medicaid entitlement. Because nearly half of the
national cost of nursing home care is paid by Medicaid (Health
Care Financing Administration, 1992), the increasing demand for
LTC as the number of elderly grows will lead to greater strain on
state budgets.
Although the insurance industry offers insurance coverage
for acute care for the elderly (called medigap insurance) it only
began covering LTC in 1987. Insurers were hesitant because of the
high risk of estimating the future cost of LTC since most
insurance purchasers would not use it for 20 years. Of the few
LTC policies that exist, the monthly premium costs are high. In
some policies, benefits are not indexed and, hence, do not keep up
with the rapidly rising cost of care. Between 1987 and 1991,
about 2.4 million LTC policies were purchased (Health Insurance
Association of America, 1993). Most policies are purchased
through employers or as additions to life insurance policies.
Some see LTC insurance as economically feasible only for middle
and upper income elderly because of the cost (Rivlin & Wiener,
1988). Older persons need to be educated about their risks of
needing LTC, its catastrophic costs, and the general lack of
funding from Medicare or their own medigap policies to cover
costs. Otherwise, the elderly will incorrectly assume that they
have LTC coverage and will not purchase LTC insurance (Rivlin &
Wiener, 1988; Health insurance Association of America, 1990,
1991).
National LTC Policies
The unprecedented growth of the elderly population and
their high risk of needing LTC has served as an impetus for
adopting legislation to create an overarching LTC policy for the
nation. Over 80 programs established by national legislation
provide for some aspect of LTC, either by provision of services,
cash-assistance, or in-kind transfers (U.S. House of
Representatives, Committee on Ways and Means, 1990). The
legislation which comprises the core of national LTC policies for
the elderly includes:
• Medicaid, Title XIX of the Social Security Act,
• Medicare, Title XVIII of the Social Security Act,
• Social Services Block Grant (SSBG), Title XX of the
Social Security Act, and
• Older Americans Act (QAA), Title III.
To characterize these national policies in a global way.
Medicare concentrates on skilled care, Medicaid on both skilled
and personal care, and the SSBG and the QAA on social services.
Although the intent of the legislation is to establish a national
LTC policy which provides for a continuum of care, in reality
services which do exist are fragmented among programs with
different eligibility criteria and benefits (Kane & Kane, 1987).
The concept of a continuum of care is central because LTC
emphasizes the importance of a range of services to fit the
diverse needs of the disabled elderly. The continuum ranges from
intensive health and rehabilitation services at one end to social
services at the other. Some elderly require the care of a
registered or licensed nurse to provide skilled care. Others
require less-skilled, less-costly social services, such as help
with buying groceries, household chores, and getting around in the
community (Kane & Kane, 1987).
It is not surprising that legislation was adopted for
Medicaid, Medicare, and OAA during the "Great Society" era in
which the overarching approach to national policy was that
government programs were solutions to the problems of poverty,
disability, and other social ills (Reischauer, 1990; Schick,
1975). The one exception is the SSBG legislation. It was adopted
as a categorical program in 1975. It was amended subsequently by
Congress in 1981 into a block grant to control its escalating
costs (U.S. House of Representatives, Committee on Ways and Means,
1990) .
Medicare focuses on LTC very narrowly, its services
generally are limited to those elderly needing post-operative,
acute medical care (Estes & Swan, 1993). Medicare covered LTC
services include a maximum of 100 days of skilled nursing home
care, home health care, and hospice. Table 1 presents Medicare
and Medicaid expenditures for LTC for 1991. (Comparable data for
OAA and SSBG are not available.) In 1991, Medicare spent more on
home health care ($4.4 billion) than on nursing home care ($2.7
billion) (Health Care Financing Administration, 1992). Medicaid
has a broader focus ; it addresses the LTC problems of poor elderly
who are disabled. Medicaid covered LTC services include skilled
and intermediate levels of nursing home care, home health, and
adult day care. In 1991, Medicaid spent six times as much on
nursing home care ($28.9 billion) as on home health care ($4.8
billion) (Buck & Klemm, 1993). The 1991 expenditures for home
health care were similar for Medicare and Medicaid at between $4
to $5 billion. In contrast, the expenditures for nursing home
TABLE 1
MEDICARE AND MEDICAID EXPENDITURES FOR LTC, 1991
LTC Policy
Nursing Home
Care
Expenditures
Home Health
and Community-
Based Care
Expenditures
Ratio of
Nursing Home
to Home
Health and
Community
Care
Expenditures
Medicare $2.7 billion $4.4 billion 0.6
Medicaid $28.9 billion $4.8 billion 6.0
Note; Expenditures for Medicaid are for the fiscal year.
care differed dramatically. Medicaid spent nearly 11 times more
on nursing home care than did Medicare.
The SSBG provides a variety of social services to persons
of all ages at state option. Services can include home maker,
home health aide, personal care, home delivered meals, and adult
day care. The OAA also provides a variety of social services, but
gives priority to in-home LTC. Other LTC services provided
include case management, adult day care, and protective services.
In its overview of LTC entitlement programs, the Committee on Ways
and Means concluded that the roles of the SSBG and the OAA in LTC
are limited. Because available funding for these programs is
limited, they have limited ability to address the growing need for
and problem of financing community-based LTC (U.S. House of
Representatives, Committee on Ways and Means, 1993, pp. 260-261).
10
Institutional Bias and Preference for
Non-Institutional Care
Medicaid policy has a strong bias toward funding for
institutional care (Rivlin & Wiener, 1988). When Medicaid was
enacted in 1965, its LTC benefit was care in a skilled nursing
facility. In late 1971, Medicaid was amended to cover care in an
intermediate care facility, which provides a lower skill level and
is less costly than the skilled nursing facility (Congressional
Research Service, 1993). It was not until 1981 that Congress
made some effort to move Medicaid away from its institutional bias
by providing a benefit for home and community-based care. Thus,
for the initial sixteen years of Medicaid policy, institutional
care was the available LTC benefit. In the 1981 Omnibus Budget
Reconciliation Act (OBRA), section 2176 established waivers which
gave states the flexibility of substituting state-funded home
health care in place of nursing home care. However, federal
government approval of waiver requests have been limited to
contain Medicaid costs (Kane & Kane, 1987). In the 1987 OBRA,
states were given waiver authority to provide home and community
based care to persons at risk of a nursing home admission on a
budget neutral basis. States were limited to an annual overall
maximum seven percent growth rate of all LTC services (U.S. House
of Representatives, Committee on Ways and Means, 1990). Up to
now, these efforts have had limited impact on the institutional
bias of Medicaid policies as Table 1 indicates. In 1991, total
Medicaid expenditures for nursing home care were six times higher
than for home health and community-based care (Buck & Klemm,
1993).
Although Medicaid has a bias toward institutional LTC, the
preferences of the elderly and their families are for maintaining
11
independence by receiving LTC in the home or the community. About
95 percent of elderly who needed LTC and lived in the community in
1982 indicated that they would like to stay out a of nursing home
as long as possible (Rivlin & Wiener, 1988). In a national poll
in 1988, nearly 90 percent of respondents supported public policy
for care at home for those needing LTC (Louis Harris and
Associates, 1988). The public felt so strongly on this issue that
they indicated, in another survey, their willingness to support
LTC even if it meant higher costs to them (R. L. Associates,
1987).
Who Benefits?
Although these LTC policies benefit the disabled elderly
with a special focus on those who are poor, different definitions
of these criteria result in different beneficiary groups. The
elderly are defined as age 65 and older in Medicare and Medicaid
policy and as age 60 and over in the OAA. Persons eligible for
the SSBG are not only the elderly, but also families and children.
The disabled are narrowly defined in Medicare policy as
those persons with needs for specific nursing and rehabilitation
services. The disabled are defined more broadly in Medicaid
policy as those persons needing skilled or intermediate nursing
home care, or persons who would benefit from home care because
they are at risk of admission to a nursing home.
Poverty in Medicaid policy is defined by a standard
established by the federal government. Medicaid also has several
provisions to allow states to provide LTC to other groups of
elderly (Congressional Research Service, 1993). One optional
provision allows states to cover the medically needy, who are
persons who meet the non-financial standards for Medicaid but who
12
exceed its income or resource requirements. Each state
establishes its standard for defining the medically needy, so that
standards differ from state to state. Some elderly may also
deplete their resources on medical bills, "spend-down" to the
state-established standard for the medically needy, and become
eligible for Medicaid. Another group eligible for Medicaid is
older persons receiving LTC in nursing homes, at home, or in the
community. States can choose to establish a maximum income for
eligibility for Medicaid not to exceed 300 percent of the basic
Supplemental Security Income program benefit which was $1,266 per
month in 1992. These elderly are considered eligible for Medicaid
under the "300 percent" rule (Congressional Research Service,
1993, p. 12).
For the SSBG policy, poverty is defined by each state.
Some states set their levels considerably below the federal
standard established for Medicaid in order to control costs. One
consequence of the differences in criteria and definitions is that
a low-income, older person may be eligible for Medicaid and SSBG
services in one state, but not in another. An important factor
for any proposed LTC policy which mandates standard income
criteria for eligibility is that the percent of cost increases
will vary by state. This situation suggests that congressional
representatives of states with large cost increases would be
unlikely to support adoption of such a policy.
Qualitv of LTC
Quality is a special concern in LTC for the elderly
because it is difficult to define and assess (Kane & Kane, 1987;
Estes & Swan, 1993). "Quality has been inadequately defined with
too much emphasis on structure, credentials, and written policies
13
and too little on the quality of life. ..." (Kane & Kane, 1987,
p. 85). One difficulty with defining quality stems from the
problem of identifying appropriate service outcomes for
chronically ill persons who have no hope of a "cure" as they would
have with an acute illness. Measurement of the quality of care
becomes even more problematic when norms for desired outcomes are
not available. In addition, many elderly have memory or cognitive
problems that make it difficult to impossible to depend on their
personal reports about the receipt and quality of the services.
Nursing home care has had a history of serious quality
problems, including inadequate care resulting in bedsores, overuse
of physical restraints, inadequate diagnosis and treatment of
acute illnesses, and insufficient rehabilitation and mental health
services (Kane & Kane, 1987; Institute of Medicine, 1986; U.S.
Senate, Special Committee on Aging, 1974). In the mid-1980s the
Institute of Medicine began a study of government regulation of
nursing homes to recommend changes in regulatory policy to improve
the quality of care (Institute of Medicine, 1986).
The inability of nursing homes to recruit and retain
registered nurses was identified as a major problem in providing
quality care. Policies which held wages of nurses low in
comparison to occupations with similar education and
responsibility were seen as a major factor in recruitment and
retention problems of registered nurses in both nursing homes
(Institute of Medicine, 1986) and hospitals (Friss, 1981). The
problem in nursing homes was exacerbated by their history of poor
working conditions and heavy work loads (U.S. Senate, Special
Committee on Aging, 1974; Vladeck, 1980). As a consequence, the
Institute of Medicine recommended that nursing homes place their
14
highest priority on the recruitment, retention, and support of
adequate numbers of professional nurses (p. 103).
Based on the recommendations of the Institute of Medicine,
Congress passed legislation in OBRA of 1987 to strengthen the
approach of Medicaid in providing quality nursing home care (U.S.
House of Representatives, 1990). Requirements for the
certification and inspection of Medicaid-approved nursing homes
were upgraded by consolidating them with Medicare requirements.
Other important features of the legislation intended to improve
the quality of nursing home care were an initial assessment of the
resident, a care plan which is updated periodically, and an
inspection which examines the care plan and the outcome of care.
Implementation of the reforms began in 1990. The legislative
changes are such that the quality of care is expected to improve
over time (Estes & Swan, 1993).
The quality of home health care has been characterized by
some as a "black box" because most attention is given to whether
the home health agency meets written requirements and little
attention is given to actual patient outcomes (U. S. House of
Representatives, Select Committee on Aging, 1985). Problems in
the quality of home health care which are frequently identified
include; workers who perform their duties inadequately or
incorrectly, workers who are tardy or who miss their visits
altogether, and theft and other financial exploitation (U. S.
House of Representatives, Select Committee on Aging, 1986; U. S.
Senate, Special Committee on Aging, 1986; U. S. General Accounting
Office, 1987). Some consider the quality of home health care as
higher for agencies certified by Medicare than those licensed by
the state, or unlicensed (Estes & Swan, 1993). They view the
15
greater regulation and higher standards for education and training
of staff as indicators of quality. However, a case study in
California of certified or licensed home health agencies versus
unlicensed agencies found similar problems in the quality of
services regardless of licensing status (Grant & Harrington,
1989). Others have expressed concern that the lack of systematic
monitoring of the quality of unlicensed home health agencies will
exacerbate the problem of quality home health care. Quality
problems will intensify because unlicensed providers outnumber
certified agencies by at least 2 to 1, and their number is
increasing (Estes & Swan, 1993).
The quality of social services— as provided by the SSBG,
the OAA, and other sources— is also difficult to assess because it
is subject to local area standards (Estes & Swan, 1993).
Generally, the state or service area contracts with a local agency
to provide social services in the home. Because each local agency
has its own quality standards and approaches to measuring them,
the quality of in-home social services varies according to local
area.
Perverse Incentives and Unintended
Consequences of LTC Policv
Certain aspects of these LTC policies result in perverse
incentives and unintended consequences. This section highlights
some of the major problems. The Medicare requirement that the
beneficiary of home health services be homebound results in a
perverse incentive of continuing disability. In order to maintain
their eligibility for Medicare payments for home health care,
disabled elderly make little effort to improve their functioning.
They remain homebound in order to maintain eligibility. An
16
unintended consequence in Medicare is the result of the
requirement for a three-day hospital stay before the older person
is eligible for nursing home care. A doctor who determines that a
patient needs nursing home care may be inclined (and may be
pressured by the patient's family) to admit the patient to the
hospital because the admission is mandatory to establish
eligibility for LTC under Medicare. The consequence is
unnecessary hospital utilization and costs for Medicare.
There is little agreement in the policy arena as to
whether Medicare's prospective payment policies for hospital care
have resulted in increased admission to nursing homes of elderly
with health problems too acute for a nursing home to address
adequately. Between 1977 and 1985, there was a small increase in
nursing home admissions from hospitals. However, nursing home
residents admitted from hospitals had a significant increase from
4.0 to 4.5 in the average number of ADL's for which help was
required (Hing, 1989). Given that the decline continues in the
prevalence of ADL disabilities for the elderly population overall
(Manton, Corder & Stallard, 1993), this increase in disability in
nursing homes suggests that residents admitted from hospitals have
greater needs for care.
Because Medicaid provides the most funds for LTC, its
unintended consequences and perverse incentives have the most
serious impact on the disabled elderly. Some of the unintended
consequences of Medicaid policy are the result of the welfare
aspects of the program. The expense of nursing home care ($2,500
per month in 1990) results in some older persons spending their
savings and assets on LTC and then qualifying for Medicaid. Many
disabled elderly are surprised to discover that Medicare generally
17
does not provide for LTC benefits and are horrified that they must
"go on welfare" because they cannot cover the high cost of a long
nursing home stay. This stigma of welfare associated with LTC has
resulted in the strong support from the elderly and their
advocates for LTC policy with a non-welfare approach (American
Association of Retired Persons, 1992).
Medicaid allows the elderly receiving nursing home
benefits to maintain some of their resources, but the amounts are
low. The personal needs allowance ranged from $30-$75 per month
for 1991, depending on the state (Congressional Research Service,
1993). Except for the personal needs allowance, all the available
social security and retirement benefits of the elderly resident go
to pay for nursing home care. Medicaid pays the remaining amount.
The community dwelling spouse of the nursing home resident has
protected resources, both for income and assets. This protection
is known as Medicaid's "spousal impoverishment" rules
(Congressional Research Service, 1993). The monthly protected
income for the community dwelling spouse varies by state. In
1991, it was about $900 for about 60 percent of the states and
$1600 for the other 40 percent. The minimum protected assets for
the community dwelling spouse (after a home) was about $13,300 for
60 percent of the states and $66,000 in the remaining states
(Rowland, Feder, Lyons & Salganicoff, 1992). One unintended
consequence of this policy on protected income and assets is that
the older person without a spouse may only have enough money to
maintain a private household for the first few months of a nursing
home stay. Lack of a private household can result in a decision
to maintain the resident in the nursing home until the resident
dies. In spite of the monthly protected income and protected
18
assets for the spouse living in the community, many of them live
near poverty and fear losing their homes, especially as property
taxes rise.
There is a controversy in the policy arena concerning
targeting Medicaid LTC services to the poor. Some members of the
policy arena believe that the elderly feel stigmatized by its
welfare nature, and view Medicaid as a last resort to pay for LTC.
Others believe that the elderly see it as a way to preserve an
inheritance for their adult children. Some argue that although
Medicaid is intended as a health program for the poor, it is
becoming a LTC program for the middle class. There is little
agreement in the policy arena about the extent of use of
Medicaid's LTC benefits by the middle class. It is possible for
elderly persons with incomes well above the poverty level to
divest themselves of their assets legally and become eligible for
Medicaid. The divestiture is usually made to adult children.
Divestiture is accomplished within the legal standards which
specify the amount of assets which can be maintained and the
minimum length of time required after divestiture of asserts
before the person can become eligible for Medicaid. In order to
target Medicaid to the poor. Congress has required states since
mid-1988 to determine if assets were divested at less than fair
market value during a 30-month period beginning with date of
admission to a nursing home (U. S. House of Representatives,
Committee on Ways and Means, 1990). If so, the person is
ineligible for Medicaid for 30 months beginning with the date of
the divestiture.
Other unintended consequences of Medicaid policy result
from the set-rate payment approach used by most states to pay for
19
nursing home care (Rowland, Feder, Lyons & Salganicoff, 1992).
The Medicaid payments are set well below the actual cost of
providing care. As a result, cost shifting and access problems
occur. Nursing homes make every attempt to admit private-pay
patients over Medicaid patients. These private-pay patients are
charged higher amounts (Hing, Sekscenski & Strahan, 1989) to
compensate for the low-paying Medicaid patients. For private pay
patients with long lengths of stay, the high cost reaches a
catastrophic level. Their savings and assets are "spent-down" to
the amount that makes them eligible for Medicaid. Nursing homes
make special efforts not to admit Medicaid patients who have heavy
care needs. Because they require substantial time from highly
trained nurses, the cost of providing them with care greatly
exceeds the low Medicaid payments.
The unintended consequences of the SSBG and the OAA
policies have a limited impact on the elderly in comparison to the
impact of Medicaid and Medicare. For the SSBG, the competing
needs of the eligible groups of elderly, families, and children
result in gaps in service among localities. Localities in which
the majority of the population is below the poverty line may
provide most of their services to children and families even
though the elderly living there may have greater needs than in
another location with a richer package of services available to
the elderly. The OAA has a "catch 22" situation which results in
a bias of providing services to the younger, healthier elderly.
Because the locus of the program is the local senior center, the
elderly usually learn about availability of LTC services by a
visit to the center. However, those disabled elderly most likely
to need LTC services do not apply for LTC because they have great
20
difficulty in traveling to the senior center where they could
learn about service availability. The OAA is establishing
outreach programs to address this problem, but the extent of their
success is not known.
Roles of Different Levels of Government
The four national LTC policies have major implications for
different levels of government. Crucial responsibilities are
assigned to particular levels of government not only to administer
the programs but also to fund them. The major responsibility for
program operation is at the federal level for Medicare, at the
state level for Medicaid and the SSBG, and at the local level for
OAA. In addition, the federal government has an important role in
the state-operated Medicaid program. It is responsible for
providing matching funds to the states. Overall, the federal
government provides 50 percent of the funds, although the amount
differs by state (Rowland, Feder, Lyons & Salganicoff, 1992). The
federal government also establishes which services are mandatory
and which are optional. In LTC, skilled nursing home care and
home health care are mandatory.
For the SSBG, the state may delegate the responsibility of
operating the program to the local level of government. The
responsibility usually is delegated to the social services agency
or the welfare agency. These agencies have the option of
providing the services directly, of contracting with organized
service providers (e.g., a visiting nurse association), or hiring
specific individuals (e.g., a list of home health aides hired by
the agency as needed).
The OAA is operated at the local government level by an
Area Agency on Aging (AAA). There are about 700 AAA's throughout
21
the country. There are also 200 Indian Tribal Organizations (ITO)
that receive OAA funding. The AAA's and ITO's can either provide
social services directly or under contract with providers or
individuals as is done by local areas responsible for the
operation of the SSBG. The state government has a limited
operational role. It disperses money according to a formula based
on the proportion of elderly in the local area and acts as liaison
between the local and federal governments.
Fiscal Impact of LTC
With the exception of Medicare which is federally funded,
all these LTC policies have placed severe fiscal stress on both
the federal and state budgets. This is because the elderly have
been the fastest growing segment of the population. These
stresses will intensify in the future as even greater increases
are forecast when the baby boom generation reaches retirement
(Day, 1992).
For Medicaid, the fiscal pressures fall at both the
federal and state government levels. This situation exists
because Medicaid is a jointly funded federal-state program. The
federal share is determined annually by a formula designed
specifically to provide a higher federal match to states with
lower per capita incomes. The minimum federal match rate is 50
percent, and the maximum is 83 percent. In fiscal year 1992,
eleven states received the minimum match rate. While no state
received the maximum rate, the 80 percent rate for Mississippi was
the highest (Congressional Research Service, 1993, p. 25). States
are responsible for the non-federal share of their Medicaid costs.
Some require local governments to cover part of the costs. In
addition, most states are under additional pressure to provide
22
services that are optional and expand the beneficiary population
to encompass more of the medically needy, i.e., persons who are
otherwise eligible for Medicaid, but whose incomes are slightly
above the limit for basic eligibility.
For Medicare, increased fiscal pressure is placed at the
federal government level on the social security trust fund.
Medicare LTC expenditures are not the only pressure placed on the
social security trust fund. The future reduction in the ratio of
working population to retirees (Day, 1992) is focusing more
attention on the viability of social security. At issue is the
negative impact on young families of the intergenerational
transfer of funds.
For the SSBG, the fiscal impact is at the federal level
because grant funds are from the federal budget. In an effort to
contain costs. Congress placed ceilings on the federal SSBG
expenditures. However, there is some potential for impact at the
state or local government levels if they provide matching funds.
(For example, Massachusetts is one state that does so.) Although
many states provide matching funds for SSBG, it is not a
legislative requirement. It is a holdover from the 1975-1980
period before the SSBG became a block grant program (U.S. House of
Representatives, Committee on Ways and Means, 1993).
The OAA places fiscal stress on both the federal and state
governments and, in some cases, on the local government. Although
the federal government provides the majority of funds, each state
is required to provide funds which amount to at least a 15 percent
match. One-quarter of the state matching funds must come from
state or local public funds, and the rest can come from a mix of
public and private funds. States and local areas which are under
23
the most fiscal pressure for the OAA are those from the Sunbelt.
Because of their warmer climates, these states have experienced
the migration of many retirees whose needs for LTC increase as
they age.
Key informants at the state level characterized the LTC
fiscal situation as critical and bleak (Estes & Swan, 1993). The
informants from state government and from LTC providers were
interviewed in 1987 and 1991 about the issues confronting the LTC
system in their state. They represented five states with over 30
percent of the nation's elderly population. About 20 percent of
the key informants reported that, when compared to 1987, the 1991
fiscal conditions were very unfavorable for health and social
services for the elderly. LTC programs were not able to keep pace
with growing demand between 1987 and 1991 (p. 239). These fiscal
problems will intensify as the elderly population grows over the
next 50 years and needs for LTC increase.
Significant LTC Policv Proposals
The preceding discussion about LTC provides a perspective
on the historical development and current status of national LTC
policy. This section examines five recent LTC policy proposals to
illuminate the thinking in the policy arena about which LTC policy
problems to address and how to solve them. The LTC policy
proposals of five organizations were selected for examination
because of their significance to the LTC policy arena. The
proposals are listed in Table 2 by the type of organization
responsible for their development. The list is ordered by time;
the proposals at the beginning were the earliest ones developed.
24
TABLE 2
SIGNIFICANT LTC POLICY PROPOSALS BY TYPE OF ORGANIZATION
RESPONSIBLE FOR THEIR DEVELOPMENT
Research and Public Policv Organization
The Brookings Institution
Bipartisan Congressional Committee
The Pepper Commission
Industrv Representative
Health Insurance Association of America
Advocacv Group for the Elderlv
American Association of Retired Persons
Administration Proposal
Health Security Act, Title II, Subtitle B, 1993, H.R. 3600,
S. 1757
These proposals were selected as significant for several
reasons. One, LTC policy is such a concern to them that they
devoted substantial resources to prepare comprehensive LTC policy
proposals. Two, their LTC policy proposals were so important they
were discussed at length in the policy arena and influenced the
views of the members. Three, their advocates are respected by the
members of the LTC policy arena for their knowledge and judgment.
Finally, they provide a comprehensive view of the LTC policy arena
because they represent a variety of organizational perspectives
25
and interests. The Brookings Institution is a non-partisan
research and public policy organization. Publication of research
by the Brookings Institution indicates that it ". . . is deemed a
competent treatment worthy of public consideration, but does not
imply endorsement of conclusions or recommendations" (Rivlin &
Wiener, 1988, p. v). The Pepper Commission is a bipartisan
congressional committee. The Health Insurance Association of
America (HIAA) is one component of the LTC industry, and the
American Association of Retired Persons (AARP) is an advocacy
group for the elderly. The Administration developed the LTC
Subtitle of the Health Security Act.
The LTC policy proposal of Rivlin and Wiener (1988) of the
Brookings Institution was the first of this group of significant
proposals to be developed. It was developed in a professional
forum of economists, who created a dynamic, micro-simulation model
(The Brookings/ICF, Incorporated, model) based on a monte carlo
approach in order to examine various LTC benefit packages and
their costs. In this approach, the simulation represents a
complex, real-world system described through time (White, Clayton,
Myrtle, Siegel & Rose, 1985). Probable events related to LTC,
such as the risks of disability, a nursing home stay, and
depletion of savings and assets to pay LTC bills, are included in
the simulation. In the Rivlin and Wiener proposal, large
quantities of information were used and many options were
evaluated. Because the model simulated the use and financing of
LTC for a national sample of elderly from 1986 to 2020, it
required extensive information about demographics, economics,
assets, pensions, savings, and disability. The model was used to
examine the use and cost for a variety of LTC options. Options in
26
the private sector included LTC insurance, retirement communities,
individual medical accounts, and home equity conversions. Options
in the public sector included block grants, family responsibility,
support of unpaid caregivers, liberalized Medicaid. Options which
did not protect a large proportion of the elderly from
catastrophic LTC cost were eliminated as not feasible.
The policy proposal of the bipartisan congressional
committee (Pepper Commission, 1990) was developed in an open forum
based on hearings and a modification of the micro-simulation model
previously developed by Brookings/ICF, Incorporated. The Pepper
Commission proposal examined three options: private LTC insurance,
public LTC insurance, and public nursing home care insurance. The
analysis examined the percent of elderly and younger disabled
protected by the options. Although the same simulation model was
used by the Pepper Commission and by Rivlin and Wiener, the Pepper
Commission used different assumptions and more recent data. The
results from the Pepper Commission were consistent, but not
identical, to those of Rivlin and Wiener.
The policy proposal of the HIAA (HIAA, 1990, 1991)
concentrates on insurance issues, including what should be
included in a LTC insurance package to protect consumers. The
proposal was developed in a professional forum of insurance
executives, used a analytical model to estimate cost, and was
approved by their Board of Directors. In 1991, the HIAA
represented about 300 insurance companies providing health
insurance to about 95 million Americans (HIAA, 1991). Recently,
they have lost membership, especially from some large insurance
companies. This loss may be related to HIAA's negative television
advertisements about the Administration's Health Security Act.
27
The policy proposal of AARP (AARP, 1992, 1993) was
developed in an open forum by policy staff and revised based on a
review by their Board of Directors and members. Extensive input
was obtained from members in meetings held throughout the country.
AARP has 33 million members, about half are aged 65 and older.
As of February 1994, AARP had spent $20 million educating its
members about the issues of health care reform. It plans to spend
another $10 million on such education this year (Priest, 1994a),
The Administration's LTC proposal is part of the national
health care reform legislation introduced in Congress in November,
1993 (Health Security Act, Title II, Subtitle B, 1993, H.R. 3600,
S. 1757). Title II on new benefits includes subtitle B on LTC
which was developed in a large, professional forum of LTC experts,
many of whom were health economists. Input from interest groups
was obtained as the proposal was developed.
Tables 3-7 summarize the LTC policy proposals of the
organizations selected according to some basic issues. While this
summary examines the proposals globally, their individual
provisions on a specific issue can be quite different and require
separate attention. It may be that it is the similarities among
the proposals that merit the most attention in the policy adoption
process because they are the basis for building coalitions (Radin
& Hawley, 1988; Stone, 1988). While the Administration's LTC
proposal is part of their health care reform strategy, all other
LTC proposals stand alone. All proposals, except for that of
Rivlin and Wiener of The Brookings institution, call for benefits
for all disabled regardless of age. All proposals establish a
more liberal definition of poverty so that more elderly can
quality for LTC payments under Medicaid. The Medicaid beneficiary
28
can retain a higher level of assets, the beneficiary's spouse
living in the community can retain a higher level of income, and
the nursing home resident can retain a higher personal needs
allowance than is currently the case. All the proposals call for
a clarification of the tax code to treat LTC insurance as health
insurance. Private LTC insurance is seen as a viable option
although the Rivlin and Wiener proposal and the AARP proposal see
its impact as limited. Proposals from HIAA and the Administration
call for specific consumer protection for the purchase of LTC
insurance. Delivery of home and community-based services is
emphasized. With the exception of the Administration's proposal,
all the others call for shifting LTC services from Medicaid to
either Medicare or to a newly established program. Generally the
federal government role is establishing guidelines, while the
state role is administering the program within the guidelines.
States have a more critical role in the Administration's proposal.
They establish what services, beyond the required help with ADL's,
go to groups of disabled beneficiaries and how the program would
mesh with existing LTC programs, especially Medicaid. Proposals
all include co-payments for care on a sliding scale. Except for
the detail in the Administration's proposal, financing of the
other proposals generally is left vague. A variety of options,
most of them taxes, are proposed.
29
TABLE 3
SUMMARY OF THE LTC POLICY PROPOSAL OF RIVLIN AND WEINER
OF THE BROOKINGS INSTITUTION
OVERVIEW
Proposal provides coverage for elderly aged 65 and older for
home and community based LTC and nursing home care through a
public insurance program and liberalizes the definition of
impoverishment to quality for LTC payments under Medicaid.
ROLE OF THE PUBLIC SECTOR
Cover LTC for the elderly under Medicare rather than under the
welfare program of Medicaid. All persons 65 and older are
entitled to benefits, with substantial cost sharing.
One option is to develop public LTC insurance to provide
everyone with a basic level of services and financial
protection against the risk of LTC. Private insurance would
wrap around the public benefits to cover additional services
and provide for additional financial protection beyond public
insurance. Another option is for the public sector to cover
the catastrophic cost of LTC beginning coverage 1-2 years after
the admission to LTC. Private LTC insurance would cover the
cost of the initial 1-2 years of LTC.
Liberalizes the definition of impoverishment to quality for
nursing home care under Medicaid by increasing the amount of
protected assets, increasing the amount of income retained by
spouse living in the community, and raising the personal needs
allowance of the nursing home resident.
ROLE OF THE PRIVATE SECTOR
Make available private LTC insurance and other private sector
approaches to cover a greater share of LTC financing. Of all
private sector approaches (continuing care retirement
communities, social/health maintenance organizations, home
equity conversions), private LTC insurance has best chance of
becoming a major supporter of LTC.
Work with government to change the tax code to treat LTC
insurance as health insurance and to establish policies to
encourage purchase of LTC insurance through public education
about the risk of needing LTC and the limited public funding
available for it.
30
TABLE 3 (continued)
FEDERAL-STATE ROLES
The roles of federal and state governments were not addressed
in this policy proposal. See above for the roles of the public
sector as an indication of the major role for government in
LTC.
IMPLEMENTATION
Reduce the bias toward nursing home care by liberalizing home
care under Medicaid, relaxing restrictions on Medicaid waiver
programs for home and community based care, and increasing the
funding for the Social Services Block Grant.
Support unpaid caregivers, not by a tax because of substantial
loses in federal revenue, but by carefully controlled, direct
payments.
COSTS AND FINANCING
Costs are about $56 billion per year in 1987 dollars. The
projected increase in costs over the next 30 years is about 7
percent per year.
Require cost-sharing. Encourage a variety of service
mechanisms, such as case management and social/health
maintenance organizations, which limit service use and costs to
appropriate amounts.
Financing a public insurance program through 2020 would require
a 3.0 percent payroll tax. Other potential sources of
financing are premiums paid by the elderly, state financial
participation, estate, excise, and income taxes.
31
TABLE 4
SUMMARY OF THE PEPPER COMMISSION'S LTC POLICY PROPOSAL
OVERVIEW
Proposal provides coverage for all Americans regardless of age
for home and community-based LTC and protection against
impoverishment due to lengthy nursing home stays through a
public insurance program.
ROLE OF THE PUBLIC SECTOR
Covers home and community-based care for severely disabled
persons of all ages. Persons who are severely disabled are
those who need help with at least 3 of 5 ADL's or constant
supervision due to cognitive, mental, or behavior problems.
Requires a 20 percent co-payment.
Public insurance covers the cost of nursing home care for the
first 3 months with a co-payment of 20 percent.
Establish a Nursing Home Program to provide financial
protection so that no one faces impoverishment for stays longer
than 3 months. Liberalizes the definition of impoverishment to
quality for LTC payments under Medicaid by raising floor of
financial protection for assets and for spouse residing in the
community and by increasing the personal needs allowance of
nursing home residents.
Clarify the tax code so that private LTC insurance is treated
as health insurance.
ROLE OF THE PRIVATE SECTOR
Structure private LTC insurance to fill service gaps, pay co
payments, and provide greater asset protection than provided by
public insurance.
32
TABLE 4 (continued)
FEDERAL-STATE ROLES
The federal government finances home and community-based LTC
and the first 3 months of a nursing home stay. It also sets
provider payment rates.
The federal and state governments share financial
responsibility for the Nursing Home Program which provides
financial protection to persons with stays longer than 3
months. At the onset, states would contribute the amount they
spend on LTC for Medicaid. Annual increases would be jointly
financed.
The federal government establishes guidelines for cost
containment, quality, and consumer protection. The state
governments administer the program according to these
guidelines.
IMPLEMENTATION
Benefits will be phased in over four years for fiscal and
administrative reasons. Phase I of implementation concentrates
on home and community care benefits, and Phase II on nursing
home benefits, including increasing the rates of reimbursement.
Phase III expands coverage of home and community based care,
and Phase IV further increases nursing home reimbursement
rates.
COSTS AND FINANCING
Costs for the completely phased-in proposal are $42.8 billion
in 1990 dollars. They are projected to increase by 8-9 percent
per year.
While the Commission did not recommend a particular funding
source, it developed six options which meet criteria of a
progressive tax, contributions by persons of all ages, and a
source which grows to meet the 8-9 percent yearly increase in
program costs. These options are combinations of several types
of taxes : personal and corporate income; payroll, excise,
estate, and value-added taxes; and Medicare premium.
33
TABLE 5
SUMMARY OF THE HEALTH INSURANCE ASSOCIATION OF AMERICA'S
LTC POLICY PROPOSAL
OVERVIEW
Proposal provides for approaches for public and private sector
financing of LTC so that persons of all ages are encouraged to
pay for their own LTC by purchasing LTC insurance. Shift LTC
from the Medicaid program into a new LTC Security Program and
increase the extent of estate recovery to fund it. Liberalizes
the definition of impoverishment to qualify for LTC under
Medicaid.
ROLE OF THE PUBLIC SECTOR
Clarify the tax code for LTC insurance to help stimulate the
private market. LTC insurance should be treated the same as
health insurance. Assist the private sector in educating the
public about the risk of needing LTC and the limited government
financing for it. Support programs for counseling older
persons on the best LTC insurance package to meet their
specific needs.
Give today's elderly a $100 credit toward purchase of LTC
insurance because they face the greatest problems in affording
insurance since insurance premiums are higher for this group.
Shift LTC from the Medicaid program into a new LTC Security
Program to cover persons with low income. Liberalize
requirements for asset protection and personal needs allowance
of nursing home residents. Encourage the use of home and
community based care over nursing home care and ensure quality.
ROLE OF THE PRIVATE SECTOR
Provide private insurance packages to cover needs for LTC for
persons of all ages. Include coverage of nursing home care and
custodial care. Cover persons with Alzheimer's Disease.
Policies should prohibit prior care requirements before LTC is
covered as specified in the model act on LTC insurance
developed by the National Association of Insurance
Commissioners. This includes: the prior use of hospital care
before LTC is covered, the prior use of a high level of nursing
home care before a lower level of such care is covered, the
prior use of nursing home care before home health care is
covered.
Except as above, support use of other gate keeping mechanisms,
such as case management, assessment, eligibility based on ADL
needs.
34
TABLE 5 (continued)
ROLE OF THE PRIVATE SECTOR (continued)
Protect the consumer by supporting insurance that guarantees
renewability, continuation, and conversion of LTC policies.
Protect insurers by permitting standard actuarial tools to help
them define and control their risks, such as deductibles,
ceilings on daily benefit levels, maximums, and policy
limitations.
FEDERAL-STATE ROLES
Remove LTC from the Medicaid program into a new LTC Security
Program and establish uniform financial and functional criteria
for benefits. The amount paid by the government for LTC would
be a loan to be repaid by the person's estate. The lien
against assets would not be activated until surviving spouse
dies. If estate is valued at less than loan, balance is
written off.
States administer the LTC Security Program, share in its
financing, and implement estate recovery.
IMPLEMENTATION
Clarification of the tax status of private LTC insurance is the
most critical activity required for implementation. Most
principles and objectives for the LTC Insurance Model Act of
the National Association of Insurance Commissioners should be
included in all private LTC insurance plans.
COSTS AND FINANCING
Costs range from $8.4 to $51 billion depending on which options
of the proposal are implemented. (No mention is made in the
report about constant dollars. Because the report was
published in 1990, 1990 dollars are assumed.) The $8.4 billion
cost per year of the recommended core program includes: the
costs for educating the public about LTC and liberalizing
Medicaid asset tests, costs for counseling the elderly on the
best LTC insurance package to meet their specific needs, the
$100 insurance premium subsidy for the elderly, and costs for
estate recovery and write-off of loans. The cost for
liberalizing nursing home and home health care benefits in the
new LTC Security Program is $8.2 billion per year over current
publie expenditures.
Options for financing sources for the $8.4 billion core program
include : revenues from Medicaid's estate recovery program after
surviving spouse dies and tightening Medicaid's rules for
transfer of assets so that fewer persons are eligible for LTC
under Medicaid. Financing for the $8.2 billion new LTC
Security Program beyond the current funding levels of federal
and state dollars would be covered by the federal government.
35
TABLE 6
SUMMARY OF THE AMERICAN ASSOCIATION OF RETIRED PERSONS'
LTC POLICY PROPOSAL
OVERVIEW
Proposal provides for a New Medicare Program for all Americans
regardless of age for nursing home care covered under Part A
and home and community-based LTC covered under Part B.
Includes co-payments and protection against impoverishment due
to lengthy nursing home stays.
ROLE OF THE PUBLIC SECTOR
Create a New Medicare program which covers nursing home care
under Part A with a 35 percent co-payment and home and
community based care under Part B with a 20 percent co-payment.
Premium cost for Part B remains at 25 percent of program costs.
LTC services also include homemaker, transportation, and home
repair.
Eligibility for persons of all ages is determined by the State
Care Coordinating Agency which uses a uniform assessment tool.
Requirements are the need for active assistance for 2 or more
ADL's or for cognitive, mental, or behavioral problems.
Beneficiaries can choose the care settings based on the plan
prepared by the Coordinating Agency.
Provides for a cap on out-of-pocket expenses. Also provides
increased financial protection for nursing home residents
receiving Medicaid. This includes protection of assets,
protection against impoverishment of the community-dwelling
spouse, and an increase in the monthly personal needs
allowance.
ROLE OF THE PRIVATE SECTOR
Role for private LTC insurance is similar to role of medigap
insurance for acute care. LTC insurance would be a wrap-around
of the New Medicare Program LTC benefits.
36
TABLE 6 (continued)
FEDERAL-STATE ROLES
Federal government sets spending targets for each state,
reimbursement methods and rates, specifications for uniform
assessment for eligibility, and guidelines for licensure,
certification, and quality.
State government administers program within these Federal
guidelines, including the Care Coordinating Agency and the care
management system of uniform assessment and care planning.
IMPLEMENTATION
Begin implementation with the home and community based care
benefit as Part B of New Medicare Program and gradually shift
nursing home care from Medicaid to Part A of the New Medicare
Program. Reduce the role of Medicaid in LTC to the coverage of
out-of-pocket expenses of low income persons.
Target services first to persons most in need by focusing on
(1) home and community based care and (2) the severely impaired
who require active assistance with 3 or more ADL's. By the
year 2000, cover the disabled with 2 or more ADL's. Begin with
persons eligible for Medicaid and others whose incomes are
below the poverty level.
For Part B, home and community based care, begin with 60
percent co-payment and gradually reduce it to 20 percent.
COSTS AND FINANCING
When the program is completely phased in by year 2005, the cost
in 1994 dollars for nursing home care (Part A) is $99 billion
and for home and community based care (Part B) is $42 billion.
Financing options include; a three percent income tax, a five
percent value-added tax, sin taxes, estate taxes. Establish a
separate LTC account in the Medicare trust fund to administer
the program and monitor the program's ability to cover its
costs.
37
TABLE 7
SUMMARY OF THE ADMINISTRATION'S LTC POLICY PROPOSAL
(SUBTITLE B OF TITLE II OF THE HEALTH SECURITY ACT,
H.R. 3600, S. 1757)
OVERVIEW
Creates a federal-state program to expand home and community
based care for four groups of the disabled, regardless of age.
Prograun is separate from the health alliances in the Health
Security Act. Federal match covers form 78 to 95 percent of
program costs. Assistance with ADL's is a required service,
all others, such as home health, rehabilitation, and respite
care, are optional. Not an individual entitlement. Includes
improved Medicaid coverage for nursing home care. Services are
allocated on the basis of severity of disability and not on the
basis of income. Federal budget is capped, but increases
yearly. Co-payment of up to 25 percent required. Liberalizes
the definition of impoverishment to quality for LTC payments
under Medicaid. Includes tax incentives and consumer
protection for private LTC insurance, tax incentives for
younger disabled to work, and demonstrations of the integration
of acute care and LTC.
ROLE OF THE PUBLIC SECTOR
Provide home and community based care to disabled persons of
all ages. Develop protocols to determine eligibility of four
different groups of disabled persons and to establish care
plans. Integrate program with Medicaid and other public
programs for LTC and for the disabled. Identify which types of
LTC services are available to each of the four different groups
of disabled. Develop reimbursement rates, methodologies for
reimbursement, and quality assurance mechanisms.
ROLE OF THE PRIVATE SECTOR
Provide LTC insurance within the consumer protection
regulations for coverage, sales practices, and policy renewal
issued by the federal government.
FEDERAL-STATE ROLES
The role of the federal government is to: (1) approve state
plans and provide allotments to states for program funds based
on established methodology, (2) issue regulations for consumer
protection for private LTC insurance, (3) develop protocols for
screening and assessment to determine eligibility and establish
a care plan, (4) develop criteria to define four groups of
disabled beneficiaries: need help with three or more ADL's,
severely cognitively impaired, mentally retarded, severely
disabled children.
38
TABLE 7 (continued)
FEDERAL-STATE ROLES (continued)
The role of the state government is to (1) develop overall
state plans within federal guidelines and manage program. Plan
must provide screening for possible eligibility, continue state
Medicaid program, specify methods of quality assurance, and
allocate services among the four groups of disabled, (2)
specify the LTC services available and their limits for each of
the four groups of disabled, (3) develop plan to include
"consumer directed" services from providers selected, trained,
and managed
by the disabled beneficiary, (4) develop criteria to set
reimbursement rates and the methodologies for reimbursement,
including cash payments and vouchers.
IMPLEMENTATION
A seven year phase-in period begins in 1996.
State designates how plan is integrated with other public
programs for the disabled and for LTC. The LTC programs
include: Medicaid, Title XX of the Social Security Act (i.e.,
the Social Services Block Grant), and the Older Americans Act.
Consultation required by federal and state government with
advisory groups in which the majority of members are the
disabled or their representatives.
COSTS AND FINANCING
Total federal budget for program is capped and begins at $4.5
billion for fiscal year 1996 and increases steadily to $38.3
billion by fiscal year 2003. Increases after that time are
tied to an adjustment of the Consumer Price Index.
Formula for state allocation of federal funds includes
adjustment for the number of disabled and for low income
individuals.
Federal government reviews state costs and plans and increases
federal budget for state plans by amount that federal
expenditures for LTC services under Medicaid is reduced.
Payment to providers limited to those who agree to accept
established rate and co-payment amount as full payment.
Cost sharing requires a nominal payment for services from those
150 percent below the poverty level up to a 25 percent payment
from those at or above 250 percent of the poverty level.
39
Congressional Reaction to LTC Policy Proposals
These streams of increasing demand, increasing cost, and
decreasing family support merge to form a sobering prediction for
the future; it is likely that more elderly will need LTC from the
costly formal care system. It also is likely that they may become
impoverished because of the long, costly episodes of LTC.
LTC policy has been placed on the congressional agenda
because it is included in the Administration's proposal for health
care reform. Advocates consider this a major step forward since
LTC policy was not on the congressional agenda in the 1980s in any
significant way (Kingdon, 1984). Interviews with key members and
staff of Congress (Rich, 1993) highlight congressional skepticism
over costs of LTC. Conservatives fear that costs will increase
rapidly because of the "woodwork" phenomenon. This is the
situation in which many more beneficiaries than expected emerge
"out of the woodwork" to claim benefits and the costs of the
program substantially exceed the estimates. The lack of a
societal consensus as to whether LTC is a family or a government
responsibility (Kane & Kane, 1982) is reflected in Congress. Many
conservatives are critical of the proposed LTC legislation because
they see it as just the beginning of a LTC policy with heavy
government involvement and high public expenses.
Objective of the Research
Considerable attention has been given to development of
comprehensive theories about the public policy process and its
individual stages (Nakamura & Smallwood, 1980; Brewer & deLeon,
1983; Radin & Hawley, 1988; Stone, 1988; Anderson, 1990). The
theories address the policy process overall and make no
distinctions about the process of making policy by issue or by
40
environmental context. The theories apply equally to economic,
defense, transportation, health, social, and other issues and to
policy environments that are stable or turbulent. The policy
adoption stage is addressed as one component of these theories on
the policy process.
Theories of the overall policy process that concentrate on
a political perspective (Radin & Hawley, 1988; Stone, 1988)
recognize that the influence of a policy proposal in the adoption
of national policy goes beyond the proposal's technical merit.
Proposals that have technical merit often fail to influence the
adoption of national legislation. Limited theoretical attention
has been given to a synthesis of the political features of policy
proposals that make them influential in the process of adopting
national legislation. Information about the influence of
political factors of policy proposals on policy adoption appears
in some of the comprehensive theories of the policy process. In a
review of these theories (see chapter 2 for details), some
political features of policy proposals emerged as relevant for
further study. They include; a political approach to analysis,
ability to build coalitions, limiting change so policy is
acceptable to constituents, and lobbying skills of the advocates
of the proposals. However, theories which present a synthesis
about political features of policy proposals that are influential
in the process of adopting national legislation are not available.
Knowledge about the critical political features of policy
proposals could be useful to both policy analysts and policy
makers in developing better strategies for success in adopting
national legislation.
41
The objective of this research was to determine which
political features of LTC policy proposals result in serious
consideration being given to them in the process of adopting
national LTC legislation. Knowledge about the critical political
features of LTC policy proposals could provide policy analysts
with guidelines to strengthen proposals so that they are more
influential in the process of adopting national LTC legislation.
Such knowledge could provide policy makers with criteria to
identify those LTC proposals which could assist them in
successfully adopting national LTC legislation.
The research concentrated on the following political
features of LTC policy proposals;
• The development of the policy proposals by a political
approach to analysis,
• The ability of the policy proposals to create or
strengthen coalitions,
• The ability of the policy proposals to limit the extent
of change from existing policies, and
• The skill of the advocates of the policy proposals in
interacting with congressional staff.
Because an intent of the research was to identify influential
political features of LTC policy proposals to assist both policy
analysts and policy makers in the process of adopting national LTC
legislation, the research addressed the extent of agreement about
influential political features between representatives of these
groups.
LTC was selected for examining the process of adopting
national legislation for two reasons. One reason was to provide a
frame of reference to anchor informants as they consider the
42
political features of policy proposals influential in the process
of adopting national legislation. The other reason was the future
impact of LTC. Over the next 50 years as the baby boom generation
reaches retirement and older ages, demands for LTC are expected to
increase dramatically. Because national LTC legislation will need
to evolve to meet increasing demands, it will be an enduring issue
on the public policy agenda well into the next century. Knowledge
about what political feature can result in a LTC policy proposal
being influential in the process of adopting national LTC
legislation will continue to be relevant and useful.
The research was a case study of the congressional
committees and subcommittees with jurisdiction over LTC programs
and their financing because of their central role in adopting
national legislation. The case study approach provides an
understanding of the dynamics in a particular setting. It is
useful especially when the boundaries between the phenomenon and
its context are difficult to draw. A major strength of the case
study approach is its ability to provide insights to answer
questions about process (how) and explanation (why) of a
phenomenon (Yin, 1989; Eisenhardt, 1989; Agranoff & Radin, 1991).
Informants were key actors in the LTC policy arena who play
central roles in the process of adopting national LTC legislation.
They fell into two general classes: the staff of congressional
committees and subcommittees with jurisdiction over LTC programs
and their financing and the advocates from a variety of
organizations, including the Administration, with LTC policy
proposals significant to the policy arena. Kingdon (1984) labels
these actors as some of the hidden participants in the policy
process. They work mainly behind-the-scenes to recombine and
43
refine policy options for consideration by the members of
Congress.
Results of the research were compared to theories on the
policy process to identify areas where existing theories were
confirmed or were questioned. (See chapter 2 for a presentation
of the theories.) Each hypothesis was compared to relevant
theories. If hypotheses are supported, results may suggest areas
where existing theory could be extended. This approach to case
study analysis is the method of analytic generalization in which
"... previously developed theory is used as a template with
which to compare the empirical results of the case study (Yin,
1989, p. 38).
Informants were asked to use LTC as their frame of
reference in considering the political features of policy
proposals as they influence adopting national LTC legislation.
They also were asked to consider if their comments applied equally
to all LTC policy issues or were more applicable to some and less
to others. This information can indicate how applicable the
results of the research were to the spectrum of LTC policy issues.
Informants also were asked to consider the applicability of their
responses to other social policy issues. In so far as informants
reported their conclusions as applicable to other social policy
issues, confirmation of hypotheses in this research on LTC can
suggest future research toward developing a nascent theory
(Eisenhardt, 1989) about important political features of policy
proposals that influence the process of adopting social
legislation.
The results of this research should be helpful to
advocates of LTC policy proposals and to congressional staff
44
working on LTC issues, but for quite different reasons. For
advocates of LTC policy proposals, the results can provide
guidelines on developing LTC policy proposals which will be more
influential in the process of adopting national LTC legislation.
Advocates could use the research results to develop a strategy to
target their resources to the political features which are
influential in strengthening the influence of their LTC policy
proposals. For example, if research confirms the importance of
building coalitions and disconfirms the importance of the skill of
lobbyists, advocates could design a strategy to devote more
resources to building coalitions to support the policy proposal
and less to selecting and supporting analysts who are skillful in
interacting with congressional staff. For congressional staff
members working on LTC issues, the results of the research can
provide criteria for selecting and using LTC policy proposals most
likely to lead to success in the process of adopting national LTC
legislation.
Research Questions and Hypotheses
Research Question 1; What are the important political
features of LTC policy proposals that result in serious
consideration being given to them in the process of adopting
national LTC legislation?
Hypothesis 1; Key actors in the LTC policy arena judge
that LTC policy proposals are given serious consideration in the
process of adopting national LTC legislation when they were
formulated by a political approach to analysis.
Hypothesis 2: Key actors in the LTC policy arena judge
that LTC policy proposals are given serious consideration in the
45
process of adopting national LTC legislation when they create or
strengthen coalitions.
Hypothesis 3; Key actors in the LTC policy arena judge
that LTC policy proposals are given serious consideration in the
process of adopting national LTC legislation when they limit the
extent of change from existing policies.
Hypothesis 4; Key actors in the LTC policy arena judge
that LTC policy proposals are given serious consideration in the
process of adopting national LTC legislation when the advocates of
the proposals are skillful in interacting with congressional
staff.
Research Question 2; Do judgments about the important
political features of LTC policy proposals that result in serious
consideration being given to them in the process of adopting
national LTC legislation differ by whether the actors are staff
members of the U. S. Congress or advocates of policy proposals?
Hypothesis 1; Judgments about the important political
features of LTC policy proposals that result in serious
consideration being given to them in the process of adopting
national LTC legislation are the same for congressional staff
members and advocates of policy proposals.
46
CHAPTER II
THEORETICAL FRAMEWORK
Introduction
This chapter presents the theoretical framework for the
research. It begins with a section that presents an overview of
theories about the policy process. Then, the theories associated
with the hypotheses are presented in separate sections as follows:
• Political and other approaches to policy analysis—
Hypothesis 1 of research question 1 on the importance
of using a political approach to policy analysis for
formulating policy proposals that are considered
seriously in the process of adopting national LTC
legislation.
• Building coalitions— Hypothesis 2 of research question
1 on the importance of creating or strengthening
coalitions for policy proposals to be considered
seriously.
• reference for policies which limit the extent of
change— Hypothesis 3 of research question 1 on the
importance of limiting the extent of change from
existing policies for policy proposals to be considered
seriously.
• Interactions between advocates and congressional staff
members— Hypothesis 4 of research question 1 on the
importance of advocates of proposals being skillful in
interacting with congressional staff for policy
47
proposals to be considered seriously. This section
also addresses hypothesis 1 of research question 2 that
judgments about important features of policy proposals
are the same for congressional staff and for advocates
of proposals.
The Public Policy Process
Introduction
This section presents an overview of theories about the
policy process overall and its segments. The models of the policy
process described here provide a variety of theoretical
perspectives: sequential, cyclical, functional environments, and
continuous. In this description, special attention is given to
the theory about policy adoption and how adoption relates to the
other segments of the policy process. Next, theories of agenda
setting are reviewed because of the impact agenda setting has on
the decision agenda in the policy adoption stage. Because context
is an important factor in the policy process, theories concerning
policy context are examined here also. In examining policy
context, theories about conflict in the policy arena are given
special attention because conflict is high in the LTC policy
arena.
Central to a case study about the features of a policy
proposal that can influence it being taken seriously in the
process of policy adoption is an examination of the theories of
the policy process. These theories provide differing perspectives
for understanding and explaining characteristics which influence
policy adoption. Allison (1971) highlights the importance of
examining situations from alternative paradigms in order to arrive
at a thorough explanation and understanding of complex events. He
48
concludes that "... different conceptual lenses lead analysts to
different judgments about what is relevant and important"
(p. 251).
Models of the Policy Process and the Adoption Stage
Sequential Stages Model
The policy process. In Brewer and deLeon's (1983) theory,
the policy process consists of six sequential stages which they
call phases. They are : initiation, estimation, selection,
implementation, evaluation, and termination. Each stage is linked
conceptually and in time to preceding and succeeding stages. The
policy process is a complicated stream of events following this
sequence of stages. It is political in nature and includes many
individuals in the process.
A description of each stage highlights the linkages among
them. The initiation stage concerns recognition of the problem
and tentative explorations of solutions which are ill-defined and
often inappropriate. The estimation stage (what most theorists
call analysis) concerns determining the risks, costs, and benefits
of specific options. Some of the options analyzed originated in
the initiation stage. Others emerge during the estimation stage
as a consequence of the analysis. The selection stage (what most
theorists call adoption) entails a decision by a policy maker
about which option is best to address the problem. The policy
maker is "anyone authorized or able to alter the flow of pertinent
events" (p. 18). The implementation stage concerns the execution
of the selected option, and the evaluation stage concerns the
comparison between the expected and actual performance. The final
stage is termination. It is either the adjustment of policies
49
that are not working well or that have worked so well that they
have solved the problem and are unnecessary.
Adopting policv. The debates, bargains, and compromises
which occur in the adoption stage culminate in a choice of a
preferred policy by a policy maker. The choice is usually from
among the options developed in the analysis stage (p. 179). Of
the six stages of the policy process, the adoption stage is the
most political. The need for a consensus means that the option
finally chosen addresses many interests such that no one group
will conclude that the policy is exactly what was desired.
Furthermore, the need for a consensus among multiple interests
often leads to policy goals which are obscure and conflicting
(Nakamura & Smallwood, 1980).
To Brewer and deLeon, policy is developed by a complex
resolution of "ideology, ethics, politics, economics, and other
considerations. ..." (p. 182). They see the integration of
values into the policy process as an important feature of the
adoption stage and as essential for a democracy to function.
However, the integration of values creates a tension between the
analysis and adoption stages. It is not unusual for disagreements
to arise in the adoption stage over the political and social
meaning of the analysis (p. 181).
Cyclical Model
The policv process. Anderson (1990) conceptualizes policy
as ". . . a purposive course of action followed by an actor or set
of actors in dealing with a problem or matter of concern" (p. 5).
In his theory of the cyclical model, the policy process is ". . .
an inherently political process involving conflict and struggle
among people (public officials and private citizens) with
50
conflicting interests, values, and desires on policy issues"
(p. 24). This policy process is ". . . cyclical, rather than
linear, and continuous rather than finite in duration" (p. 253).
When he describes the process as continuous, Anderson does not
mean that the process has no beginning or end. Rather, it is
within these markers that the process is continuous. The policy
process includes the following activities: a problem is defined
and placed on the government agenda, alternatives are developed
and one is adopted, implementation begins, and evaluation and
feedback follow (p. 253). The implementation, evaluation, and
feedback steps may lead to adjustments in the policy which
generates implementation of the revised policy, its evaluation,
and feedback. While this cycle can continue, changes in it do
occur. In a few cases, the policy is terminated. In other
situations, policy becomes settled and routine administrative
processes for minor policy modifications take over. More
frequently, the environment changes, the problem is re-defined,
and the policy is changed in significant ways.
The policy process is complex and untidy. It has
uncertain boundaries due to fragmentation of authority and power.
The policy process is pluralistic because a variety of actors from
within and outside the government play a role in shaping policy.
These features make policy making difficult to understand,
explain, and predict. Policy making in the United States
emphasizes an adversarial clash of views and interests rather than
a cooperative or objective approach to problem solving. Anderson
views this adversarial approach as ". . . more congruent with
American culture and self-assertive values" (p. 265).
51
While some see public policies as being generated by
society at large (Brewer & deLeon, 1983, p. 6), Anderson is more
specific. Public policies ". . . emerge in response to policy
demands, or those claims for action or inaction on some public
issue made by actors— private citizens, group representatives, or
other public officials— upon government officials and agencies"
(p. 6). Policy demands can differ, either calling for something
to be done or specifying the particular action desired. Not all
policy demands are met, of course.
Anderson offers the following theories from the political
science perspective from which to choose, in whole or in part, to
explain the policy process. One theory is the political systems
model in which public policy is seen as the response of the
political system to demands arising from its social and economic
environment. Another is the group theory model in which public
policy is the result of a struggle between groups with differing
interests. A third theory is that public policy is the result of
values and preferences of a governing elite who hold the power. A
fourth theory is the institutional model. Public policy is the
result of processes, rules, formal structure, and behavior of
participants in key institutions, such as the Congress. The final
explanation is the rational choice theory. Public policy is the
result of choices by rational decision makers (i.e., policy makers
and voters) in pursuit of their self-interests.
Adopting policv. There are certain features of the
adoption stage that are of consequence when the policy setting is
the Congress. In this setting ". . . logrolling, alliance
building, negotiations and bargaining, and compromise" are common
(Anderson, 1990, p. 264). Selection of a policy alternative is
52
not from among a variety of indepth options. Instead, it is
". . . action on a preferred policy alternative for which the
proponents of action think they can win approval, even though it
does not provide all that they might like" (p. 110). Formal
authority for national policy adoption rests with a variety of
public officials, including legislators, presidents, judges,
executives and administrators. However, authority and legitimacy
is most closely associated with the legislature.
Model of Functional Environments
The policv process. Nakamura and Smallwood (1980)
describe the policy process in terms of three functional
environments which are interrelated. These environments are
policy formation, implementation, and evaluation. Each
environment has several arenas in which actors interact with each
other. The term "environment" is used to indicate certain aspects
of the policy process. One aspect is that the process is always
in flux. The same actors attempt to influence the policy process
by appearing in all three environments in different roles with
different amounts of power. Another aspect is that the
environments are not mutually exclusive. Actors in one
environment can influence those in other environments in
significant ways. A third aspect is the flow of the process. It
is neither hierarchial nor unidirectional. It does not proceed
from top to bottom nor from one stage to the next. The flow is
circular and the three environments are connected by
communications and compliance linkages among the different actors
(p. 27). The policy process is an open system. Policies can
originate from outside the system or from within the system in any
of the three environments.
53
Adopting policv. In Nakamura and Smallwood's theory, the
process of adopting public policy occurs in the policy formulation
environment, which they label as environment I. Environment I
concentrates on "... legally prescribed policy making
mechanisms" (p. 22). At the national level, this includes laws
passed by Congress or executive orders issued by the President.
Major actors are elected policy makers, such as Congress and the
President. Others are interest groups and powerful constituents.
Environment I is the most formal and structured of the three
environments. When policies originate in this environment, they
are often in response to government actors, crises, or general
concerns of the public. Policy formation is completed when a
policy is legitimized by the legally prescribed policy making
mechanisms.
Other aspects of the model. In the policy implementation
environment, or environment II, the actors are guided
theoretically by the policies legitimized in policy formation
environment I. However, Nakamura and Smallwood note that the
actors can also be influenced by their own perspectives and by the
perspectives of actors who participate in one way or another in
the implementation. Implementation ends when the formal policy
makers from environment I terminate the policy, either because of
success, failure, or loss of interest.
Policy evaluation, or environment III, attempts to
determine if the policy was successful and what could be done to
improve it. Actors from environments I and II usually are
involved in environment III. Actors from the implementation
environment II are involved in evaluation because they provide
much of the information used to examine if the program was
54
successful. Actors from formation environment I can be involved
because they provide information on the objectives and priorities
of the policy as a framework for the evaluation.
Continuous, Open-ended Model
The policv process. The policy process has been described
as a sequence of stages by some theorists (Anderson, 1990; Brewer
& deLeon, 1983). Radin and Hawley (1988) built on the work of
these theorists by comparing the model to what actually occurred
in the late 1970s when Congress adopted legislation to create the
Department of Education. Instead of a sequential process moving
from one discrete stage to another, they describe a policy process
that is open-ended and continuous, as well as fragmented and
pluralistic. The stages are sequential, but they overlap so that
a new stage began before the previous stage ended. Fragmentation
occurs because new actors, opportunities, and constraints emerged
at each stage of the process. Issues that were resolved and
decisions that were made in the previous stage were examined,
defined, and deliberated anew. A major reason for this recycling
of issues is that new actors appear at each stage. They raise new
questions and provide additional perspectives about the issues.
Another complexity of the process is that the power and the
legitimacy of the actors are not stable, but shift from stage to
stage.
Radin and Hawley comment that "[t]his case study indicates
the difficulty of finding an actor or set of actors who
consistently influence the development of an issue over time"
(p. 3). They note the critical role of interest groups in
providing communication linkages between the stages in their
attempts to influence development of the issue. Radin and Hawley
55
also note the need for the president to play the role of what
Bardach (1977) conceptualizes as a "fixer" in the development of
the policy during its movement through the various decision
arenas. Recent experience of the Clinton Administration suggests
that the president should focus the role of "fixer" on the issues,
rather than on making deals. In discussing the Clinton
Administration's strategy for passing health reform legislation,
one Administration source noted that:
The president will be listening and
persuading, but not deal-making. . . . The big
lesson we learned [from the 1993 legislative
experience] is that to the extent the
president in the midst of a legislative
campaign becomes the negotiator-in-chief
instead of commander-in-chief, we tend to lose
control of the debate (Priest & Marcus, 1994,
p. A13).
Adopting policv. The focus of the adoption stage was on
the actors' efforts to establish a consensus to pass the bill.
Creating coalitions, through negotiations and bargaining, was
their major activity. Issues that seemed settled were re-examined
and the proposed legislation changed whenever the actors believed
that a change would help to build a coalition to support the
legislation. As a result, the proposed policy is in a continuing
state of flux throughout the adoption stage. Actors cannot assume
that once an issue was resolved to their satisfaction it would
remain settled. They must continue to be vigilant and involved
throughout the entire process until legislation is adopted.
Comparison of Models of the Policy Process
Table 8 presents a comparison of major features of the
four models of the policy process. The six stages of the
sequential and cyclical models are similar, although they have
different labels. The main difference between the six-stage
56
TABLE 8
COMPARISON OF MODELS OF THE POLICY PROCESS
Feature
Sequential Cyclical Functional
Environment s
Continuous
Stages initiation,
estimation,
selection,
implemen
tation,
evaluation,
termination
problem
defined,
alterna
tives
selected,
adoption,
implemen
tation,
evaluation,
feedback
policy
formation,
implemen
tation,
evaluation
identifi
cation,
formula
tion,
legitima
tion,
applica
tion,
evaluation
Process political,
pluralistic
complex,
untidy,
pluralistic
overlap of
environ
ments
new actors,
opportu
nities, and
constraints
emerge at
each stage
Flow sequence of
stages,
stages are
linked
cyclical
and
continuous
open, in
flux,
circular,
policy
originates
in any of
the envi
ronments
stages
overlap,
open-
ended,
continuous
Adopt
Policy
most
political,
integrates
values
action on a
preferred
option,
alliances,
negotiation
formulation
is most
formal and
most
structured
environment
fragmented,
policy in
flux,
coalitions,
negotiation
sequential and cyclical models and the five-stage continuous model
is that the six stage models make feedback a stage separate from
evaluation, while the five-stage model covers these activities in
the evaluation stage. In the functional environment model of the
policy process, the three environments correspond to adoption,
implementation, and evaluation stages of the other models. A
major difference between this and other models is that problem
57
definition and alternative selection can occur in any one of the
three environments.
The policy process is seen as continuous in the cyclical,
functional environment, and continuous models. The stages overlap
in the continuous model, with one stage beginning before the
previous stage is completed. In contrast, the stages in the
sequential model are linked but they are not conceptualized as
overlapping. The policy adoption stage of the cyclical and
continuous models is conceptualized as action on a preferred
option, rather than selection from several options. Negotiations
and coalition building are major activities in these two models.
All models view policy adoption as the most political of all the
stages of the policy process and, when adoption takes place in the
U. S. Congress, as a formal process in which rules must be
followed to legitimize the policy choice.
The Agenda Setting Process
Introduction
Theories of agenda setting are reviewed here because of
the impact agenda setting has on the decision agenda in the
process of adopting national legislation. These theories explain
the agenda setting process as it is influenced by:
• Problems, policies, and politics;
• Political leadership, interest groups, and key events;
and
• Perceptions, conceptualization, and tentative
resolutions.
Agenda setting by the president is also addressed because of the
importance of the administration's LTC proposal to the process of
adopting national policy on LTC.
58
Problems, Policies, and Politics
Kingdon (1984) defines a governmental agenda as . . the
list of subjects or problems to which government officials, and
people outside of government closely associated with these
officials, are paying some serious attention, at any given time"
(p. 3). He distinguishes between the list of subjects of the
governmental agenda and a decision agenda. A decision agenda
includes only those subjects moving into position for some sort of
authoritative decision, such as legislation (p. 4). Participants
in the process of agenda setting are both visible and hidden.
Visible participants are the President, high level political
appointees. Congress, members of the media, and other elected
officials. Hidden participants are congressional staff,
bureaucrats, researchers, and academics.
There are three streams of processes central to agenda
setting: problems, policies, and politics. Each stream has a
distinct set of dynamics, patterns, and internal processes which
is independent from the others. In Kingdon's theory, the
probability of an item rising on a decision agenda is dramatically
increased if all three elements— problems, policy proposals, and
political receptivity— are linked in a single package. Partial
linkages of only two of the three elements are ". . . less likely
to rise on decision agendas" (p. 211).
Kingdon distinguishes between agendas, or lists of
subjects, and alternate specifications. Alternate specifications
are ". . . a set of alternatives for government action [that] is
seriously considered by governmental officials and those closely
associated with them" (p. 4). The process of narrowing all
conceivable alternatives to a set that is seriously considered is
59
similar to Darwin's process of natural selection. Kingdon labels
this process of narrowing the alternatives as the policy primeval
soup: "... many ideas float around, bumping into one another,
encountering new ideas, and forming combinations and
recombinations" (p. 209). The recombinations are more important
that invention and can result in significant change and
innovations. The process of alternate specifications occurs in
policy communities which consist of persons inside and outside of
government who are concerned with a particular policy problem and
interact frequently with each other (p. 123). They try out ideas
on one another. In a process of selection, some ideas survive,
and others are rejected. A "softening-up" process occurs in which
entrepreneurs of a proposal attempt to gain support for their
ideas by getting the policy community accustomed to the ideas and
concepts. They create a climate for change to their preferred
alternative. Ideas which survive to be placed on the short list
of alternatives for serious consideration are those that are
technically feasible, compatible with values of the policy
community, and can deal with the constraints created by budgetary,
public, and political factors. Kingdon characterizes these as
". . . a set of a few prominent alternatives [which] has risen to
the top of the policy primeval soup, ready for policy makers to
consider" (p. 147).
Advocates with either a problem they want solved or a
favored solution they want used act when a policy window opens.
They combine problems, policies, and politics to place an item on
the agenda. "These policy windows, the opportunities for action
on a given initiative, present themselves and stay open for only
short periods" (p. 174). Policy windows open for two different
60
reasons. The problem window opens when a new problem appears,
either through a crisis, or by a change in a key indicator, such
as the unemployment rate. A political window opens when a
political event occurs such as a new administration or a change in
national mood. Windows can open predictably, such as when an
election occurs, or unexpectedly, such as when a national disaster
occurs. In either case, the opening of policy windows is scarce
and limited to a short period of time. Some participants serve as
policy entrepreneurs by investing their resources in linking the
problems, policy solutions, and politics into a package at the
propitious moment when a policy window opens.
Kingdon does not see the agenda setting process as a
linear one in which a problem occurs and then a solution is
identified. Advocating a solution often occurs before a problem
is identified, and the policy entrepreneur then looks for a
relevant problem the preferred solution can address. Agenda items
can either begin in the public arena and be transferred to the
government agenda or vice versa. The agenda setting process has
". . . considerable doses of messiness, accidents, fortuitous
coupling, and dumb luck" (p. 216). While it has some
unpredictability, it is not random. Instead, patterns, processes,
and constraints on each stream in the system are evident. For
example, not all situations are seen as serious problems, and not
all proposals are seen as viable alternatives to problems.
Proposals must be technically, politically, and economically
feasible. The national mood, the preferences of specialized
publics, and the various procedural rules also set constraints on
the coupling of the streams of problem, policies, and politics.
61
Political Leadership, Interest Groups,
and Key Events
To Anderson (1990), "those demands that policy makers
choose or feel compelled to act on at a given time, or at least
appear to be acting on, constitute the policy agenda. . . ."
(p. 82). A public problem is converted into an issue when
government action is demanded, but the public disagrees over the
best solution. Those problems which legislators and other public
officials give serious attention to are the governmental agenda
(p. 83). It is specific, concrete, and designed as an action
agenda, not merely one for discussion. Anderson makes the same
distinction as Kingdon (1984) between the governmental agenda and
the decision agenda. A decision agenda is a list of items up for
an active decision, not just legislative attention.
Anderson sees the congressional agenda as not very
structured and as sometimes difficult to pinpoint. Some
indicators of its content are presidential messages, legislation
identified as important by party leaders, and issues addressed by
the media (p. 84). Problems and issues compete for a slot on the
agenda, and several factors influence the selection process. One
factor is interest group pressure on government to address certain
problems. Another factor is political leadership. The President,
members of Congress, and other political leaders place problems
and proposed solutions on the agenda for several reasons:
political advantage, public interest, and political reputation.
The President has the most prominent role, whatever legislation he
proposes generally is placed on the agenda. Presidents are
motivated to select some problems and issues and not others by
needs to maintain an electoral coalition (especially during his
first term), desires for accomplishments to give him a place in
62
history, ideological concerns, and personal commitments. Key
events are another way an item can be placed on the agenda.
Congress may be influenced by crises, national disasters, protest
demonstrations, attention by the media, shifts in public mood, or
results of political elections.
Perceptions, Conceptualization, and
Tentative Resolutions
Brewer and deLeon (1983) use the term "initiation" to
describe agenda setting. Agenda setting begins when a political
problem is first sensed, recognized, or identified. Then possible
approaches to resolve the problem are explored in a quick,
tentative way. The thorough, systematic review of options is
conducted later, in the analysis stage. Agenda setting is the
most creative stage of the policy process. It emphasizes
conceptualizing (and, perhaps, redefining) the problem and
determining if it is important enough to merit further attention.
Other activities included in agenda setting are collecting
information to develop a range of responses and beginning to
specify possible policy choices within this range (p. 18). Brewer
and deLeon note that the agenda setting stage ". . . is one of the
most complex and difficult to conceptualize and therefore one of
the least studied" (p. 31). It involves a variety of activities
from perception and pattern recognition of the problem, to
communication through existing organizational networks,
creativity, and innovation.
Agenda setting impacts on the subsequent stages of the
policy process. If the problem is defined incorrectly, it may
take much time to correct at the analysis stage, or it may lead to
policy that would exacerbate rather than solve the problem. If
63
normative goals, values, and policy objectives are not made
explicit during agenda setting, the resulting policy could be
antithetical to existing values, beliefs, and goals. Brewer and
deLeon see the agenda setting stage as so crucial in the policy
process that failure here can result in being unaware of or
ignoring a problem until it reaches such proportions that it
cannot be resolved very well with the available policy tools
(p. 32). They offer as examples of such a situation the stock
market crash in 1929, the civil rights demonstrations of the
1960s, and the energy crisis of the early 1970s.
Agenda setting originates in perception of the problem and
the subsequent action that starts the policy process. It has four
components: recognition of the problem, identification of the
problem context, determination of goals and objectives, and
generation of alternatives (p. 33). As part of the policy
context, the analyst prepares a political definition of objectives
and goals. This is a list and rank of the objectives and goals of
relevant actors. It describes how the actors are affected and the
magnitude of the resources they could mobilize in the policy
debate (p. 52). This political definition of objectives and goals
serves to assist the decision maker in considering as many
relevant factors as possible when making a choice.
Agenda Setting by the President
The case study of the creation of the U.S. Department of
Education provides an example of presidential agenda setting
(Radin & Hawley, 1988). The agenda to create the department was
established by Carter during his presidential campaign. Education
policy was a major issue for Carter when he was governor of
Georgia. He was successful in achieving his major policy goals in
64
education toward the end of his term. The issue of reorganization
of government was also of great interest to Carter as governor,
and he spent considerable time and energy on it. These interests
and experiences as governor influenced Carter's view that
reorganization was a relevant approach to improve national
education policy.
Carter's campaign promise to make creation of a Department
of Education a major agenda item if elected president gained him
the support of the National Education Association (NEA). The NEA
was interested in furthering its policy interests by entering into
presidential politics. It had financing and an organized, grass
roots structure of educated, politically active members to provide
strong support for a candidate (p. 220). The NEA was crucial to
Carter's election. "There was no doubt that Carter and his
closest associates felt they owed a debt to the NEA" (Radin &
Hawley, 1988, p. 42). The campaign promise gave momentum for
creating the department. In spite of a paper arguing not to
create a separate department prepared by a member of the
transition team, most members of the transition team took the
campaign promise seriously in their planning. Radin and Hawley
note that the agenda setting stage was very political and included
a wide variety of actors: the president's campaign team, the
transition team, administration officials, interested members of
Congress, and interest groups.
Policv Context
Introduction
Theories concerning policy context are presented here
because context is an important factor in focusing and
constraining the decisions of policy makers. Two aspects of
65
policy context are presented. One is culture and its overall
influence in the policy process. The second aspect is conflict in
the policy arena. Theories on conflict are important background
for this research because conflict is high in the LTC policy
arena.
Culture
Political culture. According to Anderson (1990), the
policy process cannot be analyzed adequately apart from the
context in which it occurs (p. 43). The context serves both to
limit and to direct the actions of policy makers. He
conceptualized context broadly, at a national level. Context
encompasses such factors as: geography, demographics, national
resources, economic system, political culture, and social
structure. Of these factors, he sees political culture and
socioeconomic characteristics as most influential. They work to
shape, direct, and constrain policy. The political culture
consists of ". . . widely held values, beliefs, and attitudes
concerning what governments should try to do and how they should
operate, and the relationship between the citizen and the
government" (p. 44). These values, beliefs, and attitudes are
internalized by the individual through a socialization process
that begins with parents and continues through education, work,
and social experiences (Berger & Luchmann, 1966). Anderson sees
distinctive political subcultures in the United States: young and
old. North and South, minority and non-minority. Socioeconomic
factors influence public policy because various socioeconomic
groups have different interests and views of government
responsibility. Weaker and poorer groups often turn to the
government and its public policy process to improve their
66
situation (p. 47). In addition, the economic resources available
to the government limit its ability to provide services to its
citizens. The budget deficit has become a major factor in the
making of public policy at the national level.
The framing of political preferences. Wildavsky (1987)
theorizes that culture is a major influence in framing political
preferences of nations, groups, and individuals (pp. 16-17).
Because culture is critical in determining what citizens want from
their government, it has a major impact on the public policy
process. Wildavsky's model of four cultures, each with a
different political preference, is based on the interaction of two
variables. They are the strength of group boundaries that make
decisions binding on the individual (weak versus strong) and the
number and variety of prescriptions of the culture that constrain
the individual (few, similar prescriptions versus many, varied
prescriptions). When boundaries are weak, if prescriptions are
few, political and policy preferences emphasize individualism. If
prescriptions are many, political and policy preferences emphasize
fatalism. When boundaries are strong, if prescriptions are few,
preferences emphasize egalitarianism. If prescriptions are many,
preferences emphasize collectivism.
Conflict in the Policy Arena
Conflict of beliefs, issues, settings. Jenkins-Smith
(1990) synthesizes the work of other theorists to define the
policy arena. He defines the policy arena as an issue network
(Heclo, 1979) that coalesces around interests and concerns over a
particular policy problem (Kingdon, 1984). Members of the policy
arena include ". . . actors in legislative committees, interest
groups, executive agencies, academia, the press, and
67
elsewhere. ..." (Jenkins-Smith, 1990, p. 88). In his theory of
a policy analysis paradigm, Jenkins-Smith (1990) describes several
contextual factors of the policy arena which interact to produce
conflict in policy analysis and adoption stages of the process.
The first factor is the belief systems which exist in the policy
arena. Members of the policy arena rely on their belief systems,
". . . key values, interests, and sets of causal
assumptions. ..." (p. 89) to evaluate proposed policy options.
The core of a belief system consists of values and assumptions
which are fundamental and extremely résistent to change. The
periphery of the belief system consists of secondary values and
assumptions which are tentative and subject to revisions.
Conflict in the policy arena occurs when little consensus on the
core values of the belief system exist among the different
coalitions in the policy arena. Members of any one coalition
share common core beliefs, but core beliefs among the coalitions
differ and are often in conflict. Such conflict among the
coalitions plays a major role in the policy adoption. When
conflict is high because core belief systems of one coalition are
criticized or questioned by another, coalitions are likely to
defend their policy position vigorously. They use policy analysis
as a political tool to support their position and to influence
policy adoption (p. 95). When conflict is moderate, coalitions
use results of analysis to influence policy adoption.
The second contextual factor which can lead to conflict in
the policy arena and influence the adoption of policy is the
tractability of the policy issue. An issue is tractable when
there is general agreement in the policy arena on data, concepts,
and theories about the issue. This agreement in the policy arena
68
constrains the level of conflict and increases support for the
preferred policy option. When there are wide-ranging
disagreements on data, concepts, theories, and conclusions of the
policy analysis; the policy issue is intractable. An intractable
issue can result in a broad array of policy positions, likely
increases in conflict, and greater difficulty in creating a
coalition needed to adopt legislation (Jenkins-Smith, 1990,
p. 99).
The final contextual factor is the nature of the analytic
forum. The analytic forum is defined as the number and kinds of
people who participate in the policy analysis process (p. 99).
An open forum is one in which all interested persons can
participate in the debate. Jenkins-Smith considers Congress an
open forum. A closed forum is one in which admission is
restricted to persons specifically screened by political elites,
such as a group of White House staff created to develop options
about a particular issue. The professional forum consists of
persons with a common professional background, such as the
professional staff of the Brookings Institution. The type of
forum has implications for the level of conflict in analysis and
adoption stages of the policy process. In comparison to an open
forum, professional and closed fora have lower levels of conflict
because their members are screened. Screening creates a group of
persons with similar belief systems and common education who share
underlying agreements on values, assumptions, concepts, and
methods to verify causality. These factors act to minimize
conflict in the policy arena. Kahn (1970) notes the important
influence of education on scientists; their acceptance of
69
plausible explanations for scientific phenomena is based on the
models and processes they learned as students.
Jenkins-Smith theorizes that conflict in Congress is
likely because it is an open forum where many belief systems
exist. Hearings and floor debates provide opportunities for all
sides of an issue to be heard. As a consequence, policy analysis
will have little impact on creating a consensus for adoption of a
particular policy option (p. 100). Shifts from either a
professional forum or a closed forum at the analysis stage to an
open forum at the adoption stage have implications for conflict.
Because the shift is from a forum of shared beliefs to a forum of
conflicting beliefs, conflict is intensified at the adoption
stage.
Conflict of ideology, interests and information. Weiss
(1983) theorizes that the interaction of ideology, interests, and
information impacts on policy adoption because it influences the
views of the policy maker. Weiss defines ideology as philosophy,
values, and ethics of the policy maker (p. 224). Ideology is
fundamental to the individual, and it changes very slowly. Weiss
defines interests as self-interests for power, reputation, and
financial reward (p. 224). Interests can change rapidly as
personal perspectives and group affiliations shift. Information
consists of a sense of the current state of affairs, the gravity
of the policy problem, and possible solutions to the problem
(p. 225). Sources of information are varied, including
professional education, training, media, and social science
research (p. 227). When the ideologies and interests of policy
makers are in conflict, new information has the greatest impact on
the preferred position and decisions of the policy maker. Such
70
conflict between ideologies and interests is not unusual in
Congress. This is because there are frequent shifts in interests.
This is especially the case for members of the House of
Representatives. The demands of a two-year election cycle can lead
to shifts in self-interests as constituency concerns change.
Political and Other Approaches to Policv Analysis
Introduction
This section presents the theoretical framework for
hypothesis 1 of research question 1 on the importance of using a
political approach to policy analysis for formulating policy
proposals that are considered seriously in the process of adopting
national LTC legislation. Approaches to policy analysis are
concerned with methods for making decisions. These approaches
deal with selecting a preferred option from among a variety of
alternatives to achieve a policy goal. Such decision making is the
outcome of the analysis phase of the policy process. The approach
to policy analysis used can have a profound effect on the
alternatives. Allison (1971) has illustrated how public problems
often are approached in predictable ways based on the perspective
of the analyst and the paradigm employed.
In some approaches, policy analysis is a technique, in
others it is a craft. Wildavsky (1979) characterizes policy
analysis as a craft of "speaking truth to power." In his view,
"craft is distinguished from technique by the use of constraints
to direct rather than deflect inquiry, to liberate rather than
imprison analysis within the confines of custom" (p. 396). Policy
preferences, as part of our culture and social process, are
important to the craft of policy analysis and to its future
development. "When it becomes clear that people (re) make their
71
social structure much like they (re) make their policies, the next
stage in the study of public policy analysis as a social process
will have begun" (p. 405).
In most models of the policy process, the analysis stage
is the prelude to the adoption stage. Thus, the approach used in
the analysis stage can influence the views and impact on the
choices of the actors in the adoption stage. Policy analysis
approaches are described here by concentrating on theories of
major proponents. The description begins with the political
approach to policy analysis. This is because it is the focus of
hypothesis 1 of research question 1 on the importance of policy
proposals formulated by a political approach to analysis. Other
approaches to policy analysis are presented also because they are
alternatives, or rivals, to hypothesis 1. As Yin (1989) notes,
causal support for a confirmed hypothesis can be even stronger if
rival hypotheses can be disconfirmed as well. This analytic
approach of disconfirming rival hypotheses is discussed indepth in
the Analytic Plan section in Chapter 3. Other approaches to
policy analysis include: rational, dialectic, interpretive, and
critical methods. The disjointed incrementalism approach is
presented in a subsequent section of this chapter on Preferences
for Policies Which Limit the Extent of Change. It is presented
there because it is central to the theoretical framework for
hypothesis 3 of research question 1 on the importance of limiting
the extent of policy change, but it is relevant also as an
alternative to hypothesis 1.
72
Political Approach to Policv Analysis
Features of the Approach
The political approach to policy analysis focuses on the
community and its shared interests, rather than on the individual
and self-interest (Stone, 1988). This theory is the basis for
hypothesis 1 of research question 1 on the importance of policy
proposals formulated by a political approach to analysis. Stone
labels the political approach to policy analysis as the polis, or
political society. Community groups and organizations are the
building blocks for public policy. They concentrate their
attention on the public interest and on achieving a consensus on
what that interest entails. The community is convinced by a
political analysis when it perceives that appropriate treatment
goes to similar cases but not to dissimilar ones.
In the political approach to policy analysis, most of the
significant policy problems are those in which the interests of
the community conflict with the interests of individuals. This
conflict is resolved in favor of community interests because of
three factors: influence, cooperation, and loyalty. Through
education and other modes of transmitting cultural values, society
influences the perceptions, thinking, and actions of its members.
Societal influence works to structure views of reality, fairness,
and appropriate behavior (Berger & Luckmann, 1966). The polis
debates and seeks consensus over preferred policies to achieve
abstract, highly valued public goals. Cooperation— through
coalitions, alliances, interest groups— is a standard approach for
competing with other groups which have different conceptions of
the public interest. Stone sees power as the force that
73
subordinates individual interest to the interests of the
community.
Decision making in the political analysis approach is a
forced choice between only two options. These options are
strategically structured as a choice between a favored-unfavored
dichotomy, and the choice is an obvious one. Options are
ambiguous and dynamic so that they appeal to many groups and
provide the basis for building coalitions. As the community
struggles with ideas, beliefs and values are essential factors.
To Stone, "policy analysis is political argument, and vice versa"
(p. 306).
Radin and Hawley (1988) note the dominance of the
political approach to analysis in policy adoption by the U.S.
Congress. Arguments are built not so much by logic and rational
thinking but by strategically selecting information to support the
preferred option and neutralize the opposition. In the adoption
stage, little effort is devoted to analyzing all possible policy
options. Instead, negotiating agreement among the key actors in
Congress and in relevant interest groups is the major activity.
Critique
A major advantage of the political approach to policy
analysis is that it emphasizes democratic participation by
citizens in the policy making process. Such citizen participation
is a critical concern in a democracy (Brewer & deLeon, 1983;
Byrne, 1987; Hawkesworth, 1988; Jenkins-Smith, 1990). In the
political approach, policy analysis is the result of public input
and discussion, rather than the result of decision making by a
credentialed elite. A disadvantage of the political approach is
that policies may represent the dominant interest of large, well-
74
organized groups and not the interest of small, less-powerful
groups and persons who are not group members (Stone, 1988).
Rational Approach to Policv Analysis
Features of the Approach
This approach to policy analysis is presented as a rival
to hypothesis 1 of research question 1 on the importance of a
political approach to policy analysis. The rational approach is a
systematic procedure of examining all options on an issue in order
to make an informed choice. It uses a variety of analytic
techniques and multiple fields of knowledge. The steps in the
systematic procedure include: identifying the problem, specifying
the goals, identifying available policy options, estimating the
effects of the options, imputing benefits in a standard metric to
the effects, and choosing the "best" alternative by applying an
explicit decision rule (Jenkins-Smith, 1990, p. 11). The
analytic techniques cover such fields as economics, statistics,
and operations research and the fields of knowledge cover such
topics as sociology, economics, and policy science. This approach
is based on a positivist epistemology which "seeks to explain and
predict what happens in the social world by searching for
regularities and causal relationships . . . based on traditional
approaches which dominate the natural sciences" (Burrell & Morgan,
1979, p. 5). It excludes consideration of values such as equity,
freedom, and responsibility. It is often characterized as a
scientific, value-free approach (Byrne, 1987; Hawkesworth, 1988).
In Jenning's view (1987), the rational approach to policy
analysis (i.e., science in search of "truth") is dominant in the
field. It is the basis of the curriculum of many professional
schools of public affairs and of some leading textbooks in policy
75
analysis (Stokey & Zeckhauser, 1978; Weimer & Vining, 1989). An
understanding of the rational analysis approach is necessary
background for understanding other approaches. Many of them were
conceptualized and developed to address the shortcomings of the
rational approach and to reject the logical positivist
epistemology upon which it is based (Burrell & Morgan, 1979;
Morgan, 1983). Even though Braybrooke and Lindblom (1963) argue
that it is not cognitively possible to consider all options as the
rational approach specifies, the rational approach is frequently
applied in practice (whether in a pure application of the approach
or with some variations).
Jenkins-Smith (1990) sees the development by economists of
utility theory (basically stated as the pursuit of pleasure and
the avoidance of pain) as the "logical and normative core" of the
rational approach (p. 15). Given this economic core, it is not
surprising that benefit-cost analysis is a common analytic
technique of rational analysis (Rivlin, 1971; Stokey & Zeckhauser,
1978; Weimer & Vining, 1989).
Lindblom (1959) characterizes the rational approach as a
comprehensive method in that all important and relevant options
are to be considered and values are distinct from the analysis of
options. Radin and Hawley's (1988) conceptualization of the
culture of analysis characterizes the rational approach.
Information is pursued in order to adequately review all possible
options. The emphasis is on using the information to identify
cause-effect relationships (p. 226). Establishing causality is
important in the rational approach to ensure that the options will
achieve the desired policy goals (Cook & Campbell, 1979). The
notion of solving a problem by identifying a cause-effeet
76
relationship is a common one in our scientifically oriented
culture (Kaplan, 1963), whether by showing that the hypothesis is
"true" or that it has not as yet been proven to be "false"
(Popper, 1959). The scientist's laboratory is the symbol of the
culture of analysis. In the laboratory extraneous variables can
be controlled, the relationship between variables identified, and
laws about the relationship discovered.
Jenkins-Smith (1990) theorizes that the rational approach
has an impact on the policy debate onlv when certain conditions
exist in the policy-issue context. These conditions include;
conflict over values in the issue network is neither high nor low,
the issue is not intractable, and a forum exists in which debate
is limited to those with a similar professional background. These
conditions are crucial because persons who are open to changing
values, agree on data and theories about the issue, and share a
common training are more likely to agree on an assessment and
solution to a policy problem. In situations where value conflict
is high, the issue is intractable, and the forum is open, the role
of rational analysis in shaping the debate is reduced.
Critique
A major advantage of the rational approach is its
examination of a range of options in a systematic manner. Major
disadvantages are that it places the decision making process in
the hands of a technically trained elite, is not able to address
values adequately, and limits the democratic participation of
citizens in pubic decision making (Byrne, 1987; Hawkesworth, 1988;
Jenkins-Smith, 1990). Democratic participation of citizens in
public decision making is of such significance and the rational
approach is so weak in this regard that democratic participation
77
is a major characteristic of several other approaches to policy
analysis.
Dialectic Approach to Policv Analvsis
Features of the Approach
This approach to policy analysis is presented as another
rival to hypothesis 1 of research question 1 on the importance of
a political approach to policy analysis. In Majone's theory
(1989) of a dialectic approach to policy analysis, experts openly
advocate their policy positions in a structured setting. They
react to the arguments of other advocates, highlighting unstated
assumptions as well as gaps in knowledge and evidence. Thus,
multiple advocacy creates a "competition of ideas and viewpoints
. . . to expose the policy maker systematically to competing
arguments . . . to insure that all interested parties are
represented in genuinely adversarial roles and that debate is
structured and balanced" (p. 40). In this dialectic process,
arguments about the importance of values like freedom, equity,
wealth, and efficacy are as critical as the technical aspects of
the policy options. In Majone's view, institutions which permit
this critical debate about policy preferences are needed at all
levels of policy making.
Arguments and persuasion are essential components of the
process (Foster, 1980). Arguments are a blend of facts,
interpretations, opinions, and evaluations. Persuasion is
important for two reasons. One, it permits decision makers to
change their minds about the preferred policy option. Persuasion
motivates them to re-evaluate their views and their rankings of
the importance of different values. The second reason persuasion
78
is important is that it makes the advice acceptable and, thereby,
increases the willingness of the decision maker to act.
Jenkins-Smith (1990) describes situations in which even
the most objective of policy analysts are induced to engage in
advocacy. Such a situation occurs in a joint bureaucratic
analysis where uncertainty about data and cause-effeet
relationships is high. When other analysts are "shading" their
analyses toward their favored options, providing neutral advice is
"to give away the game . . . the inclination will be to counter
bias with bias" (p. 108). If a variety of analyses exist with
opposing biases, the result can be a composite analysis to inform
the decision maker.
Critique
An advantage of the dialectic approach to policy analysis
is that values are an essential part the process. A major
disadvantage is that the decision making setting may not be
structured to give a hearing to all the differing views of the
issue so that decision makers may have a biased view of the issues
(Majone, 1989).
Interpretive Approach to Policv Analvsis
Features of the Approach
This approach to policy analysis is presented as a third
rival to hypothesis 1 of research question 1 on the importance of
a political approach to policy analysis. In Jenning's theory
(1987), interpretive policy analysis is the practice of giving
political counsel. Such counsel aims to understand the meaning of
contemporary problems as they are experienced by the community, to
clarify the meaning so that solutions can be developed, and to
79
guide selection of options in relation to the good of the
community (p. 129). Policy analysis as counsel provides a
broader, more public, and more objective perspective than that
provided by advocacy. That is because the preferred options of
advocates are based on self-interest, while those of counselors
are based on an understanding of problems from the perspective of
the community. Interpretive social science concentrates on making
sense of individual actions in relation to their intentions as
defined by conventions, rules and norms of the culture. Thus, it
treats both facts and values in its analysis. The interpretative
approach is useful, in particular, for analyzing policy failures
and developing new options for action. Policy failures are a
consequence of significant actors not behaving as the policy
assumed. The interpretive analysis identifies why these
unexpected actions occurred. It then provides policy options
based on a more realistic understanding of the behavior of
significant actors. Its focus on actors and their intentions also
provides a greater understanding of the impact of governmental
actions on citizens.
Jennings sees interpret ive policy analysis as a rhetorical
and persuasive medium in which literary, figurative, and stylistic
considerations and skills are important. Each interpret ive policy
analysis is a perspective on needs and interests of the public,
rather than of specific groups (p. 146). Hence, interpret ive
policy analysis is more in keeping with democratic participation
of citizens than is analysis based on self-interest of advocates.
Jennings also view interpret ive policy analysis as providing
policy makers with better understanding of the impact of policies
on community life, empowerment, and volunteerism. Use of
80
interpretive policy analysis could refocus the style of government
toward greater citizen participation and strengthen the democratic
foundations of decision making.
Critique
An advantage of this approach is that it can result in
greater citizen involvement in the policy making process. A
disadvantage is that it is difficult, in general, to determine the
intentions of individual actors in a standard way. Because
determination of intentions is central to interpret ive policy
analysis, this problem limits the practicality of this approach
(Paris & Reynolds, 1983).
Critical Approach to Policv Analvsis
Features of the Approach
This approach to policy analysis is presented as another
rival to hypothesis 1 of research question 1 on the importance of
a political approach to policy analysis. In Hawkesworth's theory
(1988), a critical scrutiny of contending policy arguments can
serve to inform the general public and decision makers. Such
systematic inquiry entails a critical examination of the political
implications of differing policy objectives. A critical inquiry
can identify errors, distortions, mistaken beliefs, and fallacious
arguments. It recognizes that fallacy is inescapable because of
the limitations of human cognition. Essentially, this approach to
policy analysis is the critical investigation of assumptions,
evidence, arguments and explanations of opposing policy proposals.
It illuminates the contentious nature of policy questions and the
political implications of different options. It permits policy
actors and citizens alike to consider "the contours of the world
81
and the character of life which would be created" if specific
policies were adopted and implemented (Hawkesworth, 1988, p. 9).
Critique
An advantage of this approach is that it makes the process
of decision making more accessible to the citizen, a critical
factor in maintaining a democracy (Brewer & deLeon, 1983;
Hawkesworth, 1988; Jenkins-Smith, 1990, Anderson, 1990). A
disadvantage is that the criticism of all the assumptions and
arguments associated with each option may provide so much
information, some of it in conflict, that the decision maker is
overwhelmed and making a decision becomes even more difficult.
Comparison of the Five Approaches To
Policv Analvsis
Table 9 presents a summary of five approaches to policy
analysis. The political approach concentrates on achieving a
consensus among community groups as to the one policy option that
is in the public interest. The rational approach, in contrast,
examines all options systematically in a standard metric. The
other approaches provide advice to the decision maker. The
dialectic approach consists of experts advocating preferred policy
in a structured setting. The interpret ive approach is political
counsel about the meaning of shared problems to the community, and
the critical approach is an investigation and assessment of the
assumptions and evidence of opposing policies. Arguments,
persuasion, and critical thinking are the dominant techniques for
the dialectic, interpretive, and critical approaches. Arguments
and persuasion are also part of the coalition building which is
dominant in the political approach. The rational approach, in
82
TABLE 9
COMPARISON OF FIVE APPROACHES TO POLICY ANALYSIS
Feature
Political Rational Dialectic Inter
pretive
Critical
General Shared
interests
of the
community
Syste
matic
exam of
all
options
in
standard
metric
Experts
advocate
preferred
policy
Polit
ical
counsel
about
meaning
of
problem
to
comm
unity
Critical
exam
of
policy's
evidence
and
assump
tions
Tech
nique
Build
coali
tions
Cost-
benefit,
statis
tics,
modeling
Argument,
persua
sion
Rhetor
ical
Critical
thinking
Values Essential
to
process
Not
consid
ered
Critical
factor
Criti
cal
factor
Critical
factor
Citizen
Invol
vement
Essential
to
process
None Audience
to
persuade
High High
Decis
ion
Making
Tech
nique
Forced
choice
between
favored-
unfavored
dichotomy
Explicit
decision
rule
applied
Competing
arguments
assessed
Choice
based
on
polit
ical
counsel
Choice
based on
critical
exam of
policy
options
Major
Advan
tage
Focuses
on
citizen
partici
pation
and
values
Examines
entire
range of
options
in
standard
way
Values
essential
part of
process
Examine
policy
failure
and
develop
new
options
Citizens
have
better
access
to
decision
making
Major
Disad
vantage
Emphasis
on
interests
of
dominant
groups
Value-
free
policy
made by
tech
nical
elite
Options
can be
focused
on self-
interest
of
advocates
Bias
toward
views
of
major
ity
Too much
criti
cism can
over
whelm
decision
maker
83
contrast, relies on statistics, modeling techniques, and cost-
benefit analysis.
Values are an important component of all the approaches
except for the rational approach in which values usually are not
considered because they cannot be quantified. Citizen involvement
is essential to the process of political analysis and is high for
dialectic, interpret ive, and critical approaches. There is no
citizen involvement in the rational approach. Instead, it relies
on technical elites to identify and assess the policy options.
Decision making techniques differ substantially among the
five policy analysis approaches. The political approach uses a
strategic technique to select the preferred option. It creates a
forced-choice between a favored versus an unfavored option and the
decision is a foregone conclusion. The rational approach applies
an explicit decision rule, often of a quantitative nature to
select the "best" option. The dialectic and interpret ive
approaches support the preferred option through arguments and
persuasion. The critical approach relies on analysis of the
evidence and arguments of options to inform the decision maker
about implications of the policy option.
A major advantage of the political and critical approaches
is that both emphasize citizen involvement in decision-making.
Another advantage of the political approaches is that it
emphasizes values. So does the dialectic approach. A major
advantage of the rational approach is that it systematically
examines the entire range of options. This is in contrast to the
political, dialectic, and interpret ive approaches which focus on a
preferred option. A major advantage of the interpret ive approach
84
is its usefulness in examining policy failure and identifying new
options based on the behavior of key actors.
A major disadvantage of the political, dialectic, and
interpretive approaches is bias toward the view of the majority.
The preferred option often reflects the views of the dominant
community groups. A major disadvantage of the rational approach
is that citizen's views and values are not considered when
developing the options. A disadvantage of the critical approach
is that so much critical information about the option is available
that decision makers can be overwhelmed and can have difficulty
choosing an option.
Building Coalitions
Introduction
This section presents the theoretical framework for
hypothesis 2 of research question 1 on the importance of creating
or strengthening coalitions for policy proposals to be taken
seriously in the process of adopting national LTC legislation. It
examines the historical background of coalitions in the United
States, their specific role in policy adoption, their creation,
and their impact on policy goals. Most theorists of the process
of policy adoption agree on the essential role of coalitions and
interest groups in passage of national legislation. Some
emphasize the positive aspects (Stone, 1988; Radin & Hawley, 1988;
Linowes, Zeigler & Bennett, 1983), and others emphasize the
negative (Nakamura & Smallwood, 1980; Brewer & deLeon, 1983). On
the positive side, bargaining and compromising permit access to
the decision making process by diverse interests. They create the
opportunity to be heard and possibly to influence public policy.
On the negative side, bargaining and compromising can be endless
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and can make the decision to adopt a policy difficult, even
impossible. The vague goals needed for building a coalition can
make implementation problematic because the adopted policy lacks
specifics on means and ends.
Historical Background
The need for coalitions when adopting national policy is a
consequence of the concerns of the framers of the Constitution.
They structured the federal government to circumscribe its power
and, especially, the power of the majority. The three branches of
government, the system of checks and balances, and bicameral
legislature serve to fragment power among many decision makers
(Anderson, 1990). These features along with the election of
congressional representatives for relatively short terms make
bargaining, compromise, and coalitions essential to passing
legislation. Anderson (1990) notes that "although coalition
building is necessary in all democratic legislative bodies, it is
especially notable in multiparty legislatures" (p. 126).
Letter number 10 in the Federalist Papers, written by
James Madison in 1787, specifically addresses the role of interest
groups and coalitions in a republican form of government. What
now is called an "interest group" was labeled by Madison as a
"faction." Madison defines a faction as a group of citizens
united by "some common impulse of passion, or interest, adversed
to the rights of other citizens, or to the permanent and aggregate
interest of the community" (p. 12). His definition was all-
inclusive; legislators are members of interest groups. Madison
not only recognized the negative and positive aspects of interest
groups and coalitions, but also saw them as essential to a
republication form of government. The regulation of various
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interests "forms the principal task of modern legislation" and
involves factions in "the necessary and ordinary operations of the
government" (p. 13). Madison feared a government run by the
tyranny of the majority and saw interest groups and coalitions as
a remedy. ". . . [Y]ou take in a greater variety of parties and
interests, you make it less probable that a majority of the whole
will have a common motive to invade the rights of other
citizens. ..." (p. 16).
Coalitions and Policv Adoption
In Stone's theory (1988) of the political community,
community interests, public interests, and coalitions are major
factors in the policy process. The motivating forces for policy
development and adoption are cooperation, loyalty, and collective
purpose of the political community (Stone, 1988, p. 7).
Coalitions develop through collective mobilization and establish
community interests. Interests are the different perspectives
about a given policy problem as represented by the proponents and
opponents of the policy. According to Stone, there is no such
thing as an interest that is apolitical (Stone, 1988, p. 183).
Stone sees coalitions as continuing, rather than temporary. This
is because cooperation creates loyalty among coalition members
and, consequently, continuing support for the coalition. The
process of organizing and using coalitions to influence public
policy is empowering to its members. Participation in a coalition
creates and engenders energy, motivation, and commitment to the
coalition and its goals (p. 25).
In their case study of the passage of legislation to
create the Department of Education, Radin and Hawley (1988)
emphasize the critical role of coalitions. "Ability to build
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coalitions as a way of resolving conflicts is more than often the
path to success" (pp. 144-145). This case study illustrates the
critical nature of negotiation, accommodation, compromise, and
deal-making during policy adoption. These activities occur not
only within Congress, but also among Congress, interest groups,
and the administration. As issues arose in the policy adoption
arena, the players relied on negotiation, accommodation, and deal-
making to build coalitions in support of or in opposition to
policy proposals. While some of these activities can be studied
easily because they occur in the open fora of Congressional
sessions, many others cannot because they occur in private
conversations and informal meetings. Further information
sometimes can be culled from memoirs and reminiscences of major
policy actors (for example, O'Neill & Novak, 1987; Koop, 1991).
However, these accounts are heavily influenced, some would say
biased, by the perspectives of the policy actors and how they wish
to be viewed by historians.
Anderson (1990) labels the process of negotiation,
accommodation, compromise, and give-and-take necessary to build a
coalition as bargaining. He defines bargaining as "a process in
which two or more persons in positions of power or authority
adjust their at least partially inconsistent goals in order to
formulate a course of action that is acceptable but not
necessarily ideal to the participants" (p. 127). Although his
definition focuses on individuals, it applies equally well to
groups.
Radin and Hawley found that interest groups, as important
building blocks of coalitions, were the major link between the
stages of the policy process. They provided information and
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consultation to the multiple policy actors. The interest groups
operated more as issue networks (Heclo, 1979) and less as a member
of the iron triangle of congressional committees, bureaucrats, and
interest groups. Relationships among interest groups were fluid;
they agreed on some issues and disagreed on others. The situation
was complex; interest group membership and the level of commitment
to issues in coalitions varied depending on the particular issue
and on how it was framed.
The interaction between legislators and interest groups
during the policy adoption process can build trust and
interdependence. Interaction is so common and so frequent that
legislators often rely on interest groups as major sources of
information on political and technical questions (Pierce &
Lovrich, 1983). Legislators and other policy makers at the state
level trusted the information provided by interest groups.
Legislators had greater trust in the information provided by
interest groups than did the general public.
The importance of coalitions in policy adoption is not
limited to the United States. In Britain and Western Europe,
interest groups have been integrated into the policy-making
process to such an extent that policy communities have been
created (Jordan & Richardson, 1983). The predominant policy style
in these countries is the bureaucratic accommodation of interest
groups. As part of the process of adopting policy, government
departments routinely consult with interest groups and coalitions
that comprise the relevant policy community.
Factors Important to Building Coalitions
Several theorists have identified characteristics and
conditions essential to building coalitions. Brewer and deLeon's
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(1983) theory of coalition building focuses on the characteristics
of the policy issue. To them, a coalition is easily built and
maintained when the number of issues is small and the importance
of the issues is high to a large number of actors in the policy
arena (p. 215). As the number of issues addressed by a coalition
increases, maintaining the coalition becomes more and more
difficult. This is because the variety of the issues may lead to
a diversity in policy views. This diversity leads, in turn, to an
inability of the coalition to develop and support policies to
satisfy the diverse views. The difficulty in building coalitions
and their critical importance to adopting legislation are forces
which have major implications for the extent of policy change.
These forces work against policy changes and strongly support the
status quo (p. 216).
In Stone's (1988) theory of the political community,
values are important factors in coalition building. Community
members create and join coalitions due to a combination of values
and other factors. One, community members are influenced by moral
and social values of significant others in their lives, such as
spouses, family, friends, co-workers, bosses. Two, they are
influenced by community norms for altruism. Finally, they are
motivated by the energy and feeling of empowerment generated
through participation in a group with a common goal. These
feelings of empowerment lead to continuing support for the
coalition even as it achieves its current goals and moves on to
new agendas.
In May's (1989) theory, there are a few policies for which
coalition-building is difficult, even impossible, because no
citizen groups are interested in the issue. He calls these
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"policies without publics." Usually, such policies involve
technological and natural hazards. Scientific and technical
communities may have some interest in such policies. However,
they have limited incentives for creating coalitions because other
issues are more relevant to them. For policies without publics.
May views the dynaunic of the policy process as apolitical. He
sees a limited potential for a latent public to be aroused after
legislation is adopted and to react strongly to the policy as
implementation occurs. He contrasts policies without publics to
those issues with established, active interest groups. "Policies
with publics," as he calls them, generally focus on social issues
such as health and welfare. For policies with publics, the
dynamics of the policy process are infused with politics. A
challenge to those responsible for adopting policy is to create
coalitions by using what May calls "political" as opposed to
"rational" logic for justifying new policies (p. 5). Political
logic consists of selectively chosen symbols, slogans and
arguments to gain acceptance of a proposed policy. Other
theorists have recognized symbolism as a powerful force not only
in coalition-building (Stone, 1988) but also in political
leadership, political settings, political language, and political
goals (Edelman, 1985).
LTC fits May's description of a policy with publics. The
issue has a variety of active, well-established interest groups.
Some appear to have concerns which are compatible and are likely
candidates for a coalition; for exaimple, the group concerned about
quality nursing home care and the group representing the views of
the elderly. Other groups have conflicting concerns that make
coalition building more difficult and symbolism more critical; for
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example, the group concerned about quality nursing home care and
the group representing proprietary-owned nursing homes.
Coalitions and Policv Goals
Nakamura and Smallwoood (1980) view vague, diverse goals
as important to coalition building. In comparison to very
specific goals, vague goals make it is easier to gain agreement
among groups. Interest groups may reach an agreement that is
tentative at the policy adoption stage because opportunities exist
at the implementation stage to shape the policy toward their
preferences. In effect, the conflict over differing perspectives
about the policy, which would occur in the adoption stage were the
policy to be precisely stated, are postponed to the implementation
stage. Otherwise, arguments at the adoption stage may preclude
the passage of legislation (P. 39). In some cases the goals are
so diverse that they are contradictory. Coalition-building is of
such priority that contradictions are set aside during policy
adoption, to be addressed in the implementation stage. Nakamura
and Smallwood note the relative ease of getting coalitions
mobilized behind a vague problem in comparison to the limited
appeal of a narrowly stated problem (p. 37). The strength of a
coalition can be measured by the number of members, its stability,
and the amount of consensus on the meaning of policy goals and
instructions.
Because of the importance of coalitions in policy
adoption, the approach of congressional actors is not the
development of clear policy that precisely specifies the goals and
means to achieve them. Instead, the approach is the development
of a coalition around an ambiguous policy. While vague, diverse
goals are important to building coalitions for policy adoption,
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Nakamura and Smallwood see this lack of specificity as a major
drawback at the policy implementation stage where specifics are
critical. The goals of the vaguely stated policy may be unclear
and priorities may be lacking. Furthermore, the means to achieve
these goals may be unstated. If means are stated, it may be
uncertain whether they can attain the goals. In all these cases
of vague policy, implementation is problematic. Hence, the very
characteristics that move a policy proposal toward adoption make
the proposal, once it is adopted, extremely difficult to
implement.
Stone's (1988) theory also supports the need for policy
goals that are vague and diverse in building coalitions. The more
vague and diverse the policy goals are, the larger the number of
supporters mobilized, and the greater the chance for the policy to
be adopted. Therefore, favored policy options are purposely
ambiguous and dynamic. As such, they appeal to many
constituencies which can be the basis for building a coalition.
Radin and Hawley (1988) concluded that coalitions can be
built either around abstract principles or around diverse, often
conflicting, goals with legislation that has something for
everyone. Building coalitions, compromising, and modifying
legislative language are the major tools used by staff and members
of Congress to achieve adoption of legislation. At the policy
adoption stage, the focus is on whatever it takes to pass
legislation, not on analysis of options. Efforts are shifted away
from analysis and are concentrated on negotiation and compromise
(p. 129).
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Preference for Policies Which Limit the Extent of Change
Introduction
This section presents the theoretical framework for
hypothesis 3 of research question 1 on the importance of limiting
the extent of change from existing policies for policy proposals
to be considered seriously in the process of adopting national LTC
legislation. It presents theories that identify factors which
influence policy makers to limit policy changes and maintain the
status quo. These factors include: approaches to policy analysis
which produce options that minimize change, recent changes in the
public policy process that have a chilling effect on adopting
policies which are sweeping changes from the status quo, and the
risks inherent to adopting public policy which influence elected
policy makers to minimize policy change. The section ends with a
description of the impact that public mood and the policy adopting
milieu of the U.S. Congress have on limiting the extent of policy
change.
Approaches to Policv Analvsis Which
Support the Status Quo
Introduction
When policy makers choose from a set of options which only
differ incrementally from each other and from existing policy,
policy adoption is restricted to marginal changes, and the status
quo is maintained. Two approaches to policy analysis result in
such limited options: disjointed incrementalism and rational
analysis. This section describes these commonly used approaches
and pinpoints the reasons why they support the status quo.
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Disjointed Incrementalism Approach
Disjointed incrementalism focuses on only those policy
options of interest which are close to the status quo. In this
analytic approach, only small modifications in existing policies
are made. Hence, the label incrementalism (Lindblom, 1959;
Braybrooke & Lindblom, 1963). Analysis is disjointed in that it
occurs in many locations with many different formulations of the
problem and alternate solutions. The approach generates policy
options where an increment of one value is desirable over an
increment of another. Therefore, policy alternatives are
restricted to a smaller variety than all possible alternatives.
In addition, a restricted number of consequences are considered
for any given policy. The disjointed incrementalism approach does
not require a scientific theory or a cause-effect relationship as
its basis. Braybrooke and Lindblom (1963) view the approach as
one in which there is a close relationship between fact and value.
This close relationship assures that both objectives and values
will be incorporated in the incremental policy changes. In the
disjointed incrementalism approach to analysis, the goals of
public policy are governed by the certainty of the means to obtain
them and by their costs. If means of obtaining policy goals are
uncertain and cost are extremely high, the option is judged
"impossible" and abandoned. Disjointed incrementalism is serial,
involving a chain of small modifications to an existing policy
over a long period of time. The approach has a remedial
orientation; it moves away from a particular problem rather than
moving toward a goal. The focus is more on reducing a problem,
rather than on achieving an objective. Because of its serial,
remedial, and reconstruct ive features, Braybrooke and Lindblom
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view disjointed incrementalism as a flexible, pragmatic approach
to policy analysis.
Proponents of disjointed incrementalism view the limited
impact of its policy options as a major advantage. If the chosen
option does not achieve the goal or has negative consequences, the
policy can be undone easily, before much damage is done (Lindblom,
1959). In addition, incremental changes in policy minimize the
impact of unintended consequences. These features serve to limit
public dissatisfaction with the policy and the policy makers who
adopted it. Disjointed incrementalism reinforces the status quo
by making only small changes in existing policy. A major drawback
is that it encourages policy makers to ignore problems that have
not yet been addressed by public policy. The next incremental
step in addressing the problem cannot be taken when an existing
policy is not available to modify slightly for the next iteration.
Critics argue that certain problems do not fit well with the
disjointed incrementalism approach (Lustick, 1980). Problems of
great complexity and size, such as national health insurance or
welfare reform, cannot be addressed adequately by this approach.
Such problems require significant, rather than slight, changes in
policy.
Rational Analysis Approach
The rational approach to policy analysis was described
indepth in the previous section on Political and Other Approaches
to Policy Analysis. The features of rational analysis which
result in support of the status quo are described here. In this
approach to policy analysis, all options on an issue are examined
systematically. The benefits of each option are compared
according to a standard metric, and the "best" solution is
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selected according to explicit decision rules (Jenkins-Smith,
1990). This approach to policy analysis is viewed as one that
produces policy options which support the status quo (Byrne, 1987;
Jenkins-Smith, 1990).
In the process of adopting policy, conflict about
appropriate values can be high and knowledge about issues can be
limited. Such conflict clouds and confuses the policy debate so
that policy makers are unwilling to adopt options which differ
significantly from current policy because their impact is
unpredictable. This is especially the case in the social policy
arena where knowledge is often not definitive. As a consequence,
it is rare for analysts to demonstrate conclusively that their
conclusion is correct. Instead, they can produce only evidence
and arguments to persuade, but not to convince (Majone, 1989).
Byrne (1987) argues that when the analytic requirement of
commensurability is not met (i.e., the cost and impact of all
options cannot be measured by the same metric), making a policy
choice cannot be justified. Therefore, the status quo is
maintained. He concludes that "... consequential problems must
be forsaken for the most manageable" (p. 87).
Implications of Recent Changes in
the Public Policv Process
Introduction
The process of public policy making in the Congress is not
static. Changes, both intended and unintended, occur continually
and have implications for the extent of change in adopted policy.
Recent changes have occurred in the policy making process overall
(Anderson, 1990), in the preferred policy strategy (Kirlin, 1984),
and in the social policy environment (Reischauer, 1990). One
97
example of a change in overall process is the shift to
subcommittees which has reduced the power of committees and their
chairs. The hiring of subcommittee staff who are experts in
specific policy areas has resulted in a greater emphasis on
technical specialization in the Congress (Anderson, 1990). Recent
changes in preferred policy strategy and social policy environment
serve to maintain existing policies. These changes, described
below, have a chilling effect on adopting policies that are
significant modifications to the status quo.
Changes in Preferred Policy Strategy
Kirlin (1984) argues that the preferred model of policy
strategy in the United States has changed in the last decade from
a synoptic to a strategic approach. In the mid-1980s, the
preferred model of policy strategy had a synoptic orientation.
Policy making was based on the assumptions of a rational,
predictable social science. Problems were assumed to be stable
and clearly defined. The capacity of institutions and
organizations for rational, problem-solving action was seen as
high. Solutions to problems were seen as permanent and were
dominated by the views of professionals. These characteristics of
the synoptic orientation resulted in a preferred policy strategy
consisting of a universal, prescriptive solution. The program to
address the problem was administered centrally by a top-down
hierarchy.
A contrasting approach of policy strategy, more relevant
to the fluid policy environment which currently exists, is the
strategic model. In the strategic model, problems are assumed to
be changeable and ill-defined. The capacity of institutions and
organizations for taking problem-solving action is seen as
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limited. The preferred policy strategy is one that facilitates,
rather than prescribes, solutions. The strategic approach results
in a solution which is temporary, reversible, and malleable.
Problem solving is dominated by an entrepreneurial, as opposed to
bureaucratic, perspective. To the extent that contemporary policy
problems are ill-defined and changing, strategic approaches that
move away from permanent, universal solutions toward temporary,
malleable solutions are more appropriate. Because of the focus on
temporary, malleable solutions, a strategic approach can result in
adopting new policies with limited, rather than sweeping, changes
from the status quo.
Changes in the Social Policy Environment
Reischauer (1990) identifies several important changes in
the policy environment over the past thirty years that have
implications for developing and adopting social policies in the
1990s. These factors can result in adopting policies which limit
the extent of change from existing policies. He characterizes the
policy environment in the early 1960s as one in which "[t]he holes
in the social safety net were so large that policy makers could be
sure that virtually any patch would do some good" (p. 213). There
was virtually no concern that the proposed policy would not patch
the hole in the safety net, with neither overlaps nor gaps with
existing policies. The state of policy analysis was rudimentary,
with limited data and methodological approaches. The nation had
the resources and the commitment to solve social problems with
straight forward solutions. Reischauer believes that the policy
process in the 1960s had "some coherence" (p. 213) because of
strong committee chairmen and a focus on executive departments.
Options were developed by the executive branch. Congress adopted
99
policy based on these options, often after consulting with the
executive branch for technical advice (p. 213).
Reischauer and others characterize the 1960s as a time of
turbulence. Citizens became disillusioned over the power and
policies of government to resolve society's problems (Schick,
1975). By the close of the decade, a paradox existed between a
nation enjoying prosperity and economic growth and one divided
over social policy issues, such as poverty, discrimination, crime,
and unemployment (Gordon, 1968). The traditional paradigm of
public administration was criticized as being value-free and
unconcerned with social equity (Marini, 1971).
Along with this turbulence and criticism of paradigm came
changes in the social policy environment which have implications
for adopting social policy in the 1990s and can lead to support
for the status quo. Greater sophistication is needed not only in
conducting analysis to design social policies, but also in making
political judgments to adopt social policy. Adopted policies must
fill only the gaps in the social safety net without adversely
affecting those who have not slipped through the net, but are
close to its edge. The constrained resource environment must be
addressed in developing financing for social policies. Proposed
policies that have no financing mechanism or are highly re
distributive are not likely to be adopted. Self-financed or pay-
as-you-go mechanisms are likely to be more viable financing
approaches. Finally, new groups of actors have emerged in the
policy process, and they play influential roles in shaping policy.
They are members of the staff of congressional subcommittees and
entrepreneur-politicians. These influential actors must be
included when a consensus is sought around proposed legislation.
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The policy making process has become even more complicated.
Relationships exist between seemingly unrelated issues and
policies. The number of actors with vested policy interests has
increased. These factors constrain policy makers in their
development and adoption of policy and serve to limit the extent
of policy change.
Risks Inherent in Adopting Policv
To Brewer and deLeon (1983), policy is developed by a
complex resolution of "ideology, ethics, politics, economics, and
other considerations. . . ." (p. 182). They see the integration
of values into the policy process as an important feature of the
adoption stage and as essential for a democracy to function.
However, the integration of values creates a tension between the
analysis and adoption stages. It is not unusual for disagreements
to arise in the adoption stage over the political and social
meaning of the analysis (p. 181). This sensitive, ambiguous area
between values and facts is where policy makers operate. They
weigh values and facts, judge consequences of choosing each policy
option, and accept responsibility for the decision in terms of
public confidence and support (p. 187). For them, the process of
adopting policy is fraught with uncertainty and a variety of
risks. One risk is in choosing the best policy option to address
the problem without creating serious unintended consequences.
Another risk is in obtaining public support for the chosen option.
A third risk is in maintaining voter support for their overall
performance as legislators. Maintaining the support of their
voting constituency is essential to elected policy makers. It is
especially critical for elected officials with short terms, such
101
as members of the U.S. House of Representatives who are elected
every two years.
Other Features That Limit Change in Public Policv
Public Mood
Kingdon (1984) provides several labels for the concept of
public mood: "the national mood, the climate in the country,
changes in public opinions, or broad social movements" (p. 153).
Common to the concept are the notions that many citizens are
thinking along similar lines and that changes in the mood impact
on policy choices and outcomes. Elected policy makers judge the
public mood from assessing the media and from interacting with
constituents and interest groups. They view shifts in public mood
as important indicators. Shifts in public mood can support the
status quo when they make some policy proposals virtually
impossible to adopt.
Brewer and deLeon (1983) view public mood and emotions as
playing significant roles in adopting policy. They theorize that
the mood of the public and the confidence and respect it has for
the governing authority strongly influence reactions to proposed
policy. These reactions, in turn, influence the choices of policy
makers. If the mood is positive, confidence strong, and respect
high; then the public is unlikely to challenge the policy
consensus. But, if the mood is negative, confidence weak, and
respect low; the public will challenge the proposed policy and
adoption becomes problematic. Major changes in policy can
generate in the voting public wariness, fear, and sometimes panic.
This can result in a negative mood of the public and their loss of
confidence in elected officials. This dynamic can lead policy
makers to choose policies that maintain the status quo or make
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only incremental changes. Policy makers are not as concerned with
adopting a policy that is rational as with one that sustains a
consensus of emotionally satisfied constituents. Furthermore,
emotions, such as blind passion, panic, hope, wariness, and fear,
can be viewed as a summary of the experiences and expectations of
each individual. These emotions provide the policy maker with
choices for action. Emotions of wariness and fear can lead to
adopting policies which reinforce the status quo (p. 183).
Deciding Not to Decide
In some situations, policy makers deliberately choose to
maintain the status quo. Although the adoption stage usually
culminates in a decision. Brewer and deLeon (1983) point out that
policy makers can avoid making a decision deliberately, thereby
supporting the status quo. There are a variety of reasons for a
non-decision. In some situations, the problem may not be seen as
important. In other situations, time may be needed to gain more
information or to achieve a consensus. In still others, the
problem may be diminishing in its intensity. And finally, the
issue may be so contentious that achieving consensus may be close
to impossible.
Anderson (1990) characterizes negative public policy as
". . . a decision by government officials to do nothing on some
matter on which government involvement was sought. . . ." (p. 7).
Such inaction can impact on a subgroup or on society as a whole.
Anderson distinguishes negative public policy from situations in
which no public issue exists. Negative public policy, which
maintains the status quo, is an active choice not to make a policy
decision.
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Congressional Milieu
The milieu of the U. S. Congress serves to limit the
extent of policy change. Radin and Hawley (1988) describe the
dominance of the political approach to analysis in the policy
adoption stage. They note that in the Congressional setting the
preference is to keep the extent of change to a minimum. Those
who want change must justify it strongly (p. 227). Furthermore,
the political advantage as well as the political costs of a
proposal receive great attention. Congressional advocates of a
proposed policy option often link ". . . arguments to their
calculations of political advantage for personal, partisan and
interest group agendas" (p. 219). Negotiating agreement among the
key actors in Congress and in relevant interest groups is the
major activity. Arguments are built not so much by logic and
rational thinking but by strategically selecting information to
support the preferred option and neutralize the opposition.
Interaction Between Advocates and
Congressional Staff Members
Introduction
This section presents the theoretical framework for
hypothesis 4 of research question 1 on the importance of advocates
of a proposal being skillful in interacting with congressional
staff for policy proposals to be taken seriously in the process of
adopting national LTC legislation. It also provides a theoretical
basis for hypothesis 1 of research question 2 that judgments about
important features of LTC policy proposals are the same for
congressional staff and for advocates. Their views were
hypothesized to be the same based on existing theories about the
mutual exchange of ideas and information and their continuing
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interaction with each other during the process of adopting policy.
Theories about the exchanges between advocates and congressional
staff members cover several topics: roles; relationships; and
skills, activities, and interactions. The literature relevant to
these topics concentrates on types of policy analysts and the
client-analyst relationship.
Roles
The common labels found in the literature for policy
analysts who most often participate in the adoption stage of the
policy process are entrepreneurs and advocates. According to
Meltsner (1976), entrepreneurs are both political and analytical.
They combine knowledge, communication, and coordination skills
with pragmatism in an attempt to influence policy. They enjoy
working in the political environment. From their view, knowledge,
as generated by analysis, is power because it can influence public
policy. They judge success not in personal terms, but as the
development of acceptable public policy which can be implemented
to aid beneficiaries.
In his analysis of how the governmental agenda is set,
Kingdon (1984) identified policy entrepreneurs as advocates who
invest their energy, reputation, and money to promote a policy
option in anticipation of future benefits (p. 188). He notes that
entrepreneurs can be, among others, lobbyists, members of
Congress, and congressional staff. Generally, entrepreneurs are
both generators of policy positions and policy brokers. As
brokers, they negotiate compromises among different proposals and
create coalitions. By linking problems, proposals, and politics
when a window of opportunity opens, entrepreneurs can place the
issue high on the governmental agenda.
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Radin and Hawley (1988) characterize the movement from the
formulation to the adoption stage of the policy process as a shift
from the culture of analysis to the culture of politics. They
note that policy analysts operating in the adoption stage
emphasize their political and negotiating skills rather than their
analytical expertise. They also note that the chief spokespersons
for policy proposals in the adoption stage were not the
technicians that developed the proposals, but political
generalists who "interpreted and gave meaning to their proposals"
(p. 112).
Jenkins-Smith (1990) defines issue advocates as analysts
actively involved in the process of influencing the content and
adoption of their preferred policies. Issue advocates are
political actors who provide persuasive arguments to gain wide
support for their policy proposals. Their arguments are
structured to influence even the most hostile of audiences to the
preferred policy position. Arguments are presented according to a
pluralistic or an adversarial model. While both models assume all
major proposals are debated, the pluralistic model emphasizes
competition among multiple advocates to influence decision makers.
The adversarial model, in contrast, emphasizes a more formal,
court-room approach of presentation of evidence by supporters and
detractors.
Foster (1980) encourages members of the field of policy
analysis to acknowledge the existing tendency to advocate policy
positions rather than pretend advocacy does not exist. The
responsibility among advocates is to provide the best possible
arguments for the preferred policy. He likens policy advocates to
lawyers who use their training and skills to advocate for their
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clients. Foster argues that the acknowledged advocacy of lawyers
is seen as appropriate behavior because the occupation has had
professional status for several hundred years. He believes that
this acknowledged advocacy role is applicable to policy advocates
and would not be detrimental to their professional status.
To Majone (1989), the distinction made between policy
analysts and policy advocates is artificial and does not reflect
what actually happens in the policy process. He notes that
"objective analysis, unassisted by advocacy and persuasion, is
seldom sufficient to achieve major policy innovations" (p. 36).
Policy advocates use convincing arguments and persuasion to
support the acceptability of preferred policy proposals.
Client-Advocate Relationship
In the fragmented, decision making milieu of the U.S.
Congress, the real client of a policy proposal is not always
obvious. As the stage shifts from policy formulation to policy
adoption the clients shift from top level bureaucrats and ranking
members of the administration to members of Congress (Meltsner,
1976: Radin & Hawley, 1988: Majone, 1989).
Meltsner (1976) notes that almost any actor involved in
the policy making process can be a client. His clues for
identifying the immediate client are: who the analyst writes for,
gets guidance from, and gives advice to. However, as the policy
process unfolds, informal clients like Congressional members and
their staff supplant the formal clients who may have requested the
policy analysis. Advocates and their clients have a mutually
dependent relationship. Because advocates are seeking
opportunities to shape policy, they expect their clients to
provide the power to adopt the preferred policy. The clients
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expect the advocate to provide policy proposals which take
political feasibility into consideration.
In Meltsner's theory, the client-analyst relationship is
"something like a marriage: compatibility is essential" (p. 227).
In the adoption phase of the policy process, mutual choice by
client and advocate is an important factor. Congressional staff
members as clients have many advisors to choose from. Advocates,
too, have opportunities to seek clients amenable to their
preferred policies. However, their choice of clients is
circumscribed by the congressional committees and subcommittees
with jurisdiction over the issue.
Majone (1989) cautions against assuming that the immediate
client is the only recipient of the policy proposal. There are
multiple actors in our complex political system that can be
influenced by a proposal and can use it for decision-making.
Sometimes the same proposal is used by decision-makers with
opposing viewpoints to support their differing views. Majone
recommends conceptualizing "client" as an "audience" of potential
or actual recipients or users of policy proposals. Arguments
should be relevant to the specific concerns of each audience.
Therefore, arguments should differ as the audience changes.
Advocates for particular policy proposals prefer clients
who are like-minded, and advocates try very hard to select such
clients. Uncommitted clients are a second choice of advocates
because advocates believe it is possible to persuade the
uncommitted to accept the preferred policy proposal (Jenkins-
Smith, 1990: Weimer 5 Vining, 1989). The advocate's proximity and
access to the client is important to their relationship. Close
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proximity and easy access permit greater feedback and increase the
chances that the advocate can influence the client
{Jenkins-Smith, 1990).
Skills, Activities, and Interactions
To Meltsner (1976), advocates (or entrepreneurs as he
labels them) must be knowledgeable and have analytic,
communication and coordination skills. Communication skills are
critical because advocates must be able to interpret complex
analyses to technically unsophisticated clients. Although he
concentrates on analysis in the bureaucracy, Meltsner notes that
any actor involved in policy making can turn out to be the client.
Hence, his theory has relevance for the advocate-congressional
staffer relationship. The primary link in this relationship is
communication. He sees the relationship as complementary; the
advocates provide proposals and arguments that the congressional
staffers can use in negotiations and the staffers provide
political constraint assessments that the advocates can use in
modifying proposals and arguments and in building alliances.
Advocates provide several things to staffers;
• Direction as to what policy decision to make,
• Dependable information and defensible arguments to
support preferred policy proposals and neutralize
opposition, and
• Protection so that the staffers do not recommend foolish
positions to their bosses, do not inadvertently
jeopardize good relationships with other members of
Congress, or with important interest groups.
Advocates must not only emphasize their expertise, but
also acknowledge the limits of their policy analysis if they want
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to build confidence with staffers. Central to building confidence
between advocates and staffers are characteristics of proximity,
mutual exchange of ideas and information, and shared general
values, such as values on the role of government and on the
responsibility of the family.
In his description of entrepreneurs, Kingdon (1984)
characterizes advocates as persons who merit a hearing from
decision makers either through expertise or because they speak for
powerful interest groups. They have strong negotiating skills and
often have good political connections. Most importantly, they are
persistent in pushing their policy proposals through their own
efforts. They write letters and papers, give speeches, and have
lunch with persons they believe can push their preferred
positions. They give special attention to Congress; they draft
legislative language, brief staff, and when they can arrange it,
testify at hearings. Because of their contacts with key actors in
the policy arena, they serve as brokers by negotiating compromises
and creating alliances around a policy proposal.
Advocates bend the problem to fit their preferred
solution, package their preferred solution to an existing
problem, and link this package to political momentum. They
constantly recombine the major elements that can lead to placing a
proposal on the decision agenda. They hook the steams of policy,
problems, and practical events together and unhook them and
repackage them in a different way. When a propitious opportunity
occurs (what Kingdon calls the opening of a policy window), they
are there with a package to advocate. Kingdon does not, however,
see the personality and efforts of advocates as the sole reason
that proposals are placed on the decision agenda. It is a joint
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process, relying on both personality and structure. The opening
of the policy window (i.e., the structure) is not within the
control of advocates. But, when it does open, advocates are there
with their packaged policy proposals (p. 192).
Kingdon characterizes the interaction between
congressional staff and advocates as exchanges between hidden
participants in the policy process. He defines the group of
hidden participants as including, among others, congressional
staff members, researchers, and analysts who work for interest
groups. They form a loosely knit community of subject-matter
specialists who are knowledgeable about the issues in a specific
policy arena. They exchange ideas and positions about policy
proposals, and refine and recombine options. Most of their
interactions are informal: phone conversations, face-to-face
meetings, lunches. Some interactions are formal: circulation of
papers, drafting legislative language, speeches, congressional
hearings. It is the responsibility of the congressional staffers
to arrange for hearings, prepare briefings and speeches for the
members, and draft and redraft legislation based on negotiations
with interested parties. As they do so, they draw upon the ideas
and options provided by advocates and interact with them to refine
the proposals.
According to Radin and Hawley (1988), an essential skill
for both congressional staffers and advocates is the ability to
build coalitions. Skill is needed to build two different types of
coalitions: those around abstract principles and those around
diverse, often conflicting, goals (p. 144). The perspective of
congressional staffers changed when the policy process shifted
from formulation to adoption. At the formulation stage, their
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interests were in analytic issues. At the adoption stage, their
interests were in gaining agreement to obtain passage of the
legislation. Expertise of both staffers and advocates is defined
by previous success in preparing proposals that influenced
legislation, not by credentials. The relationship between
advisors and decision makers is often uneasy (p. 228). Advisors
struggle to obtain specific reactions and commitments to preferred
proposals. Decision makers strive to remain non-committal about
proposals. They want to gauge the reactions of others first and
keep options open to allow themselves room for bargaining.
According to Foster (1980), policy analysts are advocates
and advisors. Majone (1989) expands this advocacy model to
address the role of advocates in the decision making process.
Advocates use persuasion to redirect attitudes, preferences, and
cognitive beliefs of decision makers. Persuasion is essential to
gain the attention of decision makers and the general public who
ignore new ideas and approaches because they are blinded by
standard patterns of thinking, beliefs, and stereotypes. The lack
of clarity in the social policy arena about problems and
definitive solutions increases the importance of persuasion in the
policy adoption process. Because there is no standard agreed-upon
way to formulate options and choose among them when problems are
complex and solutions are imperfect, persuasion is needed to
redirect thinking. Persuasion, bolstered by existing empirical
evidence, will help address complicated social problems until more
definitive solutions are developed. An essential skill of the
advocate is the ability to communicate. Advocates use style,
elegance of expression and novel modes of communication as
approaches in developing persuasive arguments. Arguments must be
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so persuasive that they can convince a "hostile and disbelieving"
audience (p. 41). Arguments are tailored for specific audiences.
As audiences change, the arguments change also.
In the interaction between advocates and staffers, Majone
theorizes that the advocates use their strongest, most persuasive
arguments to support their proposals. In addition, they criticize
rival proposals by identifying the unstated assumptions, the
differing interpretations, and the gaps in evidence and logic.
The congressional staffers role in this situation is to use the
arguments of rival advocates to assess multiple proposals and to
choose the preferred options.
According to Jenkins-Smith (1990), when the policy arena
contains multiple analysts with a variety of proposals, advocates
employ non-analytical approaches to provide support for their
preferred proposals. Political symbols, packaging, and rhetorical
tactics are used. Furthermore, advocates are predisposed to shade
the analysis toward their favorite options to counter the biases
of other advocates.
Other Factors Influencing Interaction
The open nature of the Congressional legislative process
has implications for interactions and relationships between
advocates and clients in several ways. In their case study of the
creation of the Department of Education, Radin and Hawley (1988)
noted the tangled set of relationships which existed between
advocates of interest groups and Congressional staff and committee
members. They found examples of Heclo's (1978) issue networks.
Interest groups formed alliances according to their positions on
specific issues under consideration. Congressional staff must
keep abreast of the existing issue alliances and any shifts as the
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policy debate precedes. The policy process has many points of
access and opportunities for participation in policy adoption. A
diverse set of advocates, special interest groups, and other
constituencies make their concerns and demands known to the formal
policy makers (Anderson, 1990; Radin & Hawley, 1988; Nakamara &
Smallwood, 1980).
The role of the advocate in interacting with the
congressional staff is also influenced by the model for the
process of policy adoption. In the Congress, the dominant model
is one of competing arguments, similar to the legal process
(Anderson, 1990; Majone, 1989: Foster, 1980). The advocate
provides evidence and arguments to gain support for this proposal
in the structured adversarial setting of the Congress. The debate
exposes decision makers to competing arguments and claims. Foster
(1980) notes that the pluralistic nature of our democratic system
is well served by a process of competing arguments by advocates.
It gives access at many levels and a hearing of options to
multiple participants. The process of rational decision making by
scientific experts who are searching for "truth" does not support
democratic principles of citizen input and participation.
Summary of the Theoretical Framework
Introduction
This section presents a summary of the theoretical
framework for the research. It begins with a summary of theories
about the policy process. Then, the theories associated with each
research question and related hypotheses are summarized.
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Theories About the Policy Process
Of the major models of the policy process, the sequential
(Brewer & deLeon, 1983), cyclical (Anderson, 1990), and continuous
(Radin & Hawley, 1988) have similar stages, although the labels
for them differ. The stages are: identification of the problem,
formulation of the alternative options, policy adoption,
implementation, and evaluation and modification of the policy. In
the functional environments model (Nakamura & Smallwood, 1980),
the three environments correspond to adoption, implementation, and
evaluation stages of the sequential, cyclical, and continuous
models. Problem identification and policy adoption can occur in
any of these environments. While the cyclical, functional
environments, and continuous models conceptualize the policy
process as continuous, they differ on the flow of the stages. The
stages in the sequential model are separate, but linked. The
cyclical model describes the process as continually moving through
the policy stages. The continuous model describes the stages as
overlapping, with the next stage beginning before the previous
stage ends. All models conceptualize policy adoption as the most
political of the stages in the process. The continuous and
cyclical models emphasize the importance of negotiation and
building coalitions in the policy adoption stage.
Kingdon (1984) describes the agenda setting process as a
coupling of problems, policies, and politics. Advocates with
either a problem they want solved or a favored solution act to
couple the factors when a policy window opens. A policy window is
a propitious event, such as a crisis or election that results in
new actors assuming key political roles. Participants in the
agenda setting process are visible (President, Congress, ranking
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political appointees, the media) and hidden (congressional staff,
bureaucrats, researchers, academics). Anderson (1990) sees
problems and issues as competing for a slot on the agenda. The
factors that influence the selection process are key events (i.e.,
crises, the media, public mood), interest group pressure, and
political leadership. The President, Congress, and other leaders
place problems and solutions on the agenda for political
advantage, public interest, and political reputation.
Context is an important factor in focusing and
constraining the decisions of policy makers. Two aspects of
policy context are the overall influence of culture and conflict
in the policy arena. Anderson (1990) conceptualizes context as
encompassing the political culture of values and beliefs
concerning the role of government and socio-economic
characteristics. Wildavsky (1987) conceptualizes culture as
important to policy context. He focuses on the interaction of the
strength of group boundaries that make their decisions binding on
the individual with the number of prescriptions that constrain the
individual. Jenkins-Smith (1990) describes several contextual
factors of the policy arena which interact to produce conflict in
the policy analysis and adoption stages. Conflict occurs when
there is little consensus on core values of the belief system,
little agreement on data and theories about the issue, and an open
forum where participants have diverse educational and technical
backgrounds. Conflict in Congress is likely because it is an open
forum and consensus on core values is limited. Shifts from a
professional forum of shared beliefs at the analysis stage to the
open congressional forum of diverse beliefs intensify conflict at
the adoption stage.
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Theories About Approaches to Policy Analysis
The political approach (Stone, 1988) concentrates on
achieving a consensus among community groups as to the one policy
option that is in the public interest. Arguments and persuasion
are part of the coalition building which is dominant in the
political approach. Citizen involvement is essential to the
process of political analysis. The political approach uses a
strategic technique to select the preferred option. It creates a
forced-choice between a favored versus an unfavored option and the
decision is a foregone conclusion. Major advantages of the
political approach are that it emphasizes citizen involvement and
values. A major disadvantage is its bias toward the views of the
majority because the preferred option often reflects the views of
the dominant community groups.
The rational approach (Jenkins-Smith, 1990) examines all
options systematically in a standard metric. Dominant techniques
for the rational approach are statistics, mathematical modeling,
and cost benefit analysis. There is no citizen involvement in the
rational approach. Instead, it relies on technical elites to
identify and assess the policy options. The rational approach
applies an explicit decision rule, often of a quantitative nature,
to select the "best" option. A major advantage of the rational
approach is that it systematically examines the entire range of
options. A major disadvantage is that citizen's views and values
are not considered when developing the options.
The other approaches to policy analysis provide advice to
the decision maker. The dialectic approach (Majone, 1989)
consists of experts advocating preferred opinions in a structured
setting. The interpretive approach (Jennings, 1987) is political
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counsel about the meaning of shared problems to the community.
The critical approach (Hawkesworth, 1988) is an investigation and
assessment of the assumptions and evidence of opposing policies.
Arguments, persuasion, and critical thinking are the dominant
techniques for these analytic approaches. Values are an important
component and citizen involvement is high. The dialectic and
interpret ive approaches support the preferred option through
arguments and persuasion. The critical approach relies on
analysis of the option's evidence and arguments to inform the
decision maker about implications of the policy option.
A major advantage of the dialectic approach is that it
emphasizes values. A major advantage of the interpret ive approach
is its usefulness in examining policy failure and identifying new
options based on the behavior of key actors. A major disadvantage
of these approaches is bias toward the views of the majority. The
preferred option often reflects the views of the dominant
community groups. A major advantage of the critical approach is
that it can increase citizen involvement in decision-making. A
disadvantage is that so much critical information about the option
is available that decision makers can have difficulty choosing an
option.
Theories About Building Coalitions
Most theorists of the process of policy adoption agree on
the essential role of coalitions and interest groups in passage of
national legislation. Some emphasize the positive aspects (Stone,
1988; Radin & Hawley, 1988; Linowes, Zeigler S c Bennett, 1983), and
others emphasize the negative (Nakamura & Smallwood, 1980; Brewer
S c deLeon, 1983). On the positive side, bargaining and
compromising permit access to the decision making process by
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diverse interests. On the negative side, bargaining and
compromising can be endless and can make the decision to adopt a
policy difficult, even impossible. The vague goals needed for
building a coalition can make implementation problematic because
the adopted policy lacks specifics on means and ends.
In Stone's theory (1988) of the political community,
community interests, public interests, and coalitions are major
factors in the policy process. Coalitions develop through
collective mobilization and establish community interests. Values
are important factors in coalition building. Community members
create and join coalitions due to a combination of values and
other factors. In their case study of the passage of legislation
to create the Department of Education, Radin and Hawley (1988)
found that as issues arose in the policy adoption arena, the
players relied on negotiation, accommodation, and deal-making to
build coalitions in support of or in opposition to policy
proposals. Negotiation, accommodation, compromise, and deal-
making during policy adoption are critical. These activities
occur not only within Congress, but also among Congress, interest
groups, and the administration.
Several theorists have identified characteristics and
conditions essential to building coalitions. Brewer and deLeon's
(1983) theory of coalition building focuses on the characteristics
of the policy issue. To them, a coalition is easily built and
maintained when the number of issues is small and the importance
of the issues is high to a large number of actors in the policy
arena. When the number of issues is large, a diversity in policy
views may lead to an inability of the coalition to develop and
support policies to satisfy all of them.
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Nakamura and Smallwoood (1980) view vague, diverse goals
as important to coalition building. In comparison to very
specific goals, vague goals make it is easier to gain agreement
among groups. In some cases the goals are so diverse that they
are contradictory. Coalition-building is of such priority that
contradictions are set aside during policy adoption, to be
addressed in the implementation stage. Stone's (1988) theory also
supports the need for policy goals that are vague and diverse in
building coalitions. The more vague and diverse the policy goals
are, the larger the number of supporters mobilized, and the
greater the chance for the policy to be adopted. Therefore,
favored policy options are purposely ambiguous and dynamic.
Theories About Limiting the Extent of Policy Change
There are a variety of theories that identify factors
which influence policy makers to limit policy changes and maintain
the status quo. These factors include: approaches to policy
analysis which produce options that minimize change, recent
changes in the public policy process that have a chilling effect
on adopting policies which are sweeping changes from the status
quo, the risks inherent to adopting public policy which influence
elected policy makers to minimize policy change, and the policy
adopting milieu of the U.S. Congress.
Two approaches to policy analysis result in such limited
options that the status quo is maintained. They are disjointed
incrementalism and rational analysis. Disjointed incrementalism
(Lindblom, 1959; Braybrooke & Lindblom, 1953) focuses on only
those policy options of interest which are close to the status
quo. It is serial, involving a chain of small modifications to an
existing policy over a long period of time. Proponents of
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disjointed incrementalism view the limited impact of its policy
options as a major advantage. If the chosen option does not
achieve the goal or has negative consequences, the policy can be
undone easily, before much damage is done. Critics (Lustick,
1980) argue that problems of great complexity and size, such as
national health insurance or welfare reform, cannot be addressed
adequately because they require significant, rather than slight,
changes.
The rational approach to policy analysis is viewed as one
that produces policy options which support the status quo (Byrne,
1987; Jenkins-Smith, 1990). In the process of adopting policy,
conflict about appropriate values can be high and knowledge about
issues can be limited. Such conflict clouds and confuses the
policy debate so that policy makers are unwilling to adopt options
which differ significantly from current policy because their
impact is unpredictable. This is especially the case in the
social policy arena where knowledge is often not definitive. As a
consequence, it is rare for analysts to demonstrate conclusively
that their conclusion is correct. Often making a policy choice
cannot be justified and the status quo is maintained.
Recent changes in preferred policy strategy and the social
policy environment serve to maintain existing policies. Kirlin
(1984) argues that the preferred model of policy strategy in the
United States has changed in the last decade from a synoptic to a
strategic approach. The synoptic approach resulted in a preferred
policy strategy consisting of a universal, prescriptive solution.
The strategic model is more relevant to the fluid policy
environment which currently exists. The preferred policy strategy
is one that facilitates, rather than prescribes, solutions. The
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strategic approach results in a solution which is temporary,
reversible, and malleable. It can result in adopting new policies
with limited, rather than sweeping, changes from the status quo.
Reischauer (1990) identifies several important changes in the
policy environment over the past thirty years that constrain
policy making and can limit the extent of policy change. Changes
in the social policy environment have implications for adopting
social policy in the 1990s and can lead to support for the status
quo. Greater sophistication is needed not only in designing
social policies, but also in making political judgment to adopt
them. Adopted policies must fill only the gaps in the social
safety net. The constrained resource environment must be
addressed. Proposed policies that have no financing mechanism or
are highly re-distributive are not likely to be adopted. Self-
financed or pay-as-you-go mechanisms are likely to be more viable
financing approaches.
To Brewer and deLeon (1983), adopting policy is fraught
with uncertainty and a variety of risks. One risk is creating
serious unintended consequences. Other risks are obtaining public
support and maintaining voter support for their overall
performance as legislators. The milieu of the U. S. Congress
serves to limit the extent of policy change. Radin and Hawley
(1988) describe the preference to keep the extent of change to a
minimum. Those who want change must justify it strongly.
Interaction Between Advocates and
Congressional Staff Members
Views of congressional staff and advocates were
hypothesized to be the same based on existing theories about the
mutual exchange of ideas and information and their continuing
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interaction with each other during the process of adopting policy.
The literature relevant to these topics concentrates on types of
policy analysts and the client-analyst relationship. Analysts who
most often participate in the adoption stage of the policy process
are called entrepreneurs and advocates. According to Meltsner
(1976), entrepreneurs are both political and analytical. They
combine knowledge, communication, and coordination skills with
pragmatism in an attempt to influence policy. Kingdon (1984)
identified policy entrepreneurs as advocates who invest their
energy, reputation, and money to promote a policy option in
anticipation of future benefits. Radin and Hawley (1988) note
that policy analysts operating in the adoption stage emphasize
their political and negotiating skills rather than their
analytical expertise. Jenkins-Smith (1990) defines issue
advocates as analysts actively involved in the process of
influencing the content and adoption of their preferred policies.
Issue advocates are political actors who provide persuasive
arguments to gain wide support for their policy proposals.
Foster (1980) encourages members of the field of policy
analysis to acknowledge the existing tendency to advocate policy
positions rather than pretend advocacy does not exist. To Majone
(1989), the distinction made between policy analysts and policy
advocates is artificial and does not reflect what actually happens
in the policy process. Policy advocates use convincing arguments
and persuasion to support the acceptability of preferred policy
proposals.
In the milieu of the U.S. Congress, the real client of a
policy proposal is not always obvious. As the stage shifts from
policy formulation to policy adoption the clients shift from top
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level bureaucrats and ranking members of the administration to
members of Congress (Meltsner, 1976: Radin & Hawley, 1988: Majone,
1989). Advocates and their clients have a mutually dependent
relationship. Because advocates are seeking opportunities to
shape policy, they expect their clients to provide the power to
adopt the preferred policy. The clients expect the advocate to
provide policy proposals which take political feasibility into
consideration. Majone recommends conceptualizing "client" as an
"audience" of potential or actual recipients or users of policy
proposals.
To Meltsner (1976), communication skills are critical
because advocates must be able to interpret complex analyses to
technically unsophisticated clients. He sees the relationship
between the advocate-congressional staffer as complementary; the
advocates provide proposals and arguments that the congressional
staffers can use in negotiations and the staffers provide
political constraint assessments that the advocates can use in
modifying proposals and arguments and in building alliances.
Kingdon (1984) characterizes advocates as persons who merit a
hearing from decision makers either through expertise or because
they speak for powerful interest groups. Because of their
contacts with key actors in the policy arena, they serve as
brokers by negotiating compromises and creating alliances around a
policy proposal. The interaction between congressional staff and
advocates are exchanges between hidden participants in the policy
process. They form a loosely knit community of subject-matter
specialists who are knowledgeable about the issues in a specific
policy arena. They exchange ideas and positions about policy
proposals, and refine and recombine options. Most of their
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interactions are informal; phone conversations, face-to-face
meetings.
According to Radin and Hawley (1988), an essential skill
for both congressional staffers and advocates is the ability to
build coalitions. Skill is needed to build two different types of
coalitions; those around abstract principles and those around
diverse, often conflicting, goals. The relationship between
advisors and decision makers is often uneasy. Advisors struggle
to obtain specific reactions and commitments to preferred
proposals. Decision makers strive to remain non-committal about
proposals. They want to gauge the reactions of others first and
keep options open to allow themselves room for bargaining.
To Majone (1989), advocates use persuasion to redirect
attitudes, preferences, and cognitive beliefs of decision makers.
Persuasion is essential to gain the attention of decision makers
and the general public who ignore new ideas and approaches because
they are blinded by standard patterns of thinking, beliefs, and
stereotypes. Persuasion redirects thinking. Advocates use their
strongest, most persuasive arguments to support their proposals.
The congressional staffers role in this situation is to use the
arguments of rival advocates to assess multiple proposals and to
choose the preferred options.
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CHAPTER III
RESEARCH DESIGN AND METHODOLOGY
Case Study Method and Overview of Analytic Strategy
The case study method was selected as a relevant research
strategy for examining the features of policy proposals which
result in serious consideration being given to them in the process
of adopting national policy. Yin (1989) has defined a case study
as ". . . an empirical inquiry that investigates a contemporary
phenomenon within its real-life context. . . ." (p. 23).
Boundaries between the phenomenon and the context are fuzzy and
difficult to draw. Eisenhardt (1989) sees the case study strategy
as one that concentrates on understanding the dynamics which exist
within a particular setting. In this type of inquiry, there is no
control over behavioral events as there is in an experiment with
treatment and control groups. Various sources of evidence—
including documents, interviews, and direct observations— are used
to examine why a phenomenon occurred.
The analytic strategy for the case study included the
approaches of analytic generalization and pattern matching (Yin,
1989). The method of analytic generalization is a strategy in
which "... previously developed theory is used as a template
with which to compare the empirical results of the case study
(Yin, 1989, p. 38). Case study results were compared to existing
theories on the policy process (see chapter 2 for a presentation
of the theories) to identify areas where existing theories were
confirmed or were questioned. Comparisons to existing theory were
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made for each hypothesis. If hypotheses are supported, results
may suggest where existing theories could be extended. The method
of pattern matching is a strategy in which the empirical pattern
from the case study is compared to a predicted or hypothesized
pattern (Yin, 1989). If the two patterns coincide, the empirical
results are judged to "match" the predicted pattern. If the
predicted pattern is based on a pre-established hypothesis as it
was in the research presented here, than the match of patterns is
considered as empirical support for the hypothesis. If, in
addition, these empirical patterns do not match those of rivals to
the hypothesis under examination, then even stronger inferences
about causality can be made. An indepth discussion on analytic
strategy is presented in the subsequent section on the Analytic
Plan.
In Yin's view, the case study approach is the most
appropriate research strategy when three conditions exist. They
are; when questions about a phenomenon focus on process and
explanation, when control over behavioral events is not possible
or necessary, and when the focus is on contemporary events
(p. 17). This research on the political features of LTC policy
proposals which influence the adoption of national LTC legislation
met these conditions. Furthermore, this case study presented a
situation in which boundaries between the phenomenon and the
context were difficult to establish. The movement of the U.S.
Congress toward the passage of legislation on LTC is a phenomenon
that is currently under way as Congress begins to consider
legislation for health care reform. Issues about whether to
address LTC in health care reform legislation, what benefits to
provide, and how to pay for them are part of the on-going process
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of developing national policy and passing legislation. Boundaries
between passage of LTC legislation and its context are difficult
to delineate. The context for LTC legislation includes such
factors as national health care reform policy, deficit reduction,
tax-burden, and the responsibility of the family in providing LTC.
The timing of congressional elections and consideration of other
legislation are other factors. Groups affected by national LTC
legislation go beyond the elderly who need LTC to include their
families, younger disabled persons, providers of LTC in nursing
homes, the home, and the community, the health insurance industry,
and taxpayers. Federal and state governments are also affected
because they provide funds and have roles in implementing LTC
service delivery. These factors and groups interact in ways that
are complex and changing. Because of the related factors and
groups who are impacted, it is virtually impossible to separate
the process of adopting national LTC legislation from its context.
As Agranoff and Radin (1991) note, the case study is the most
appropriate mode of inquiry to investigate phenomena like the
policy process that are extremely difficult to investigate by
other methods.
As with all research strategies, the case study approach has
weaknesses as well as strengths. Case studies can result in a
staggering amount of data that can be difficult to organize and
analyze. If cases are not selected appropriately, the study can
result in conclusions that are idiosyncratic (Eisenhardt, 1989).
One of the greatest concerns for case study research is the lack
of rigor in that equivocal evidence or biased views can influence
the findings (Yin, 1989). In Yin's view, establishing a
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theoretical framework and analytic strategy a priori to data
collection is important to addressing these concerns.
One of the strengths of a case study approach is that it
provides a rich, in depth investigation of both variables and
processes (Issac & Michael, 1984) and explains why things happen
(O'Sullivan & Rassel, 1989). Reichardt and Cook (1979) view
qualitative methods as best for discovering or generating
theories. The strength of using a case study as a research
strategy is its ability to answer questions about process (how)
and explanation (why). Such questions can be answered because a
case study views contemporary events holistically by examining the
phenomenon within the real-life context (Yin, 1989; Eisenhardt,
1989).
Selection of Informants
Introduction
This research was a case study of congressional committees
and subcommittees with jurisdiction over LTC programs and their
financing because of their central role in adopting national
legislation on LTC. Informants were key actors in the LTC policy
arena who played influential, behind-the-scenes roles in the
process of adopting national policy. They were the staff members
of congressional committees and subcommittees with jurisdiction
over LTC and the advocates from organizations, including the
Administration, with significant LTC policy proposals. In some
cases, advocates developed, completely or in part, the LTC policy
proposals of their organizations.
Kingdon's (1984) conceptualization of visible and hidden
participants in the agenda setting stage of the policy process is
useful in describing the role of the key actors included in this
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case study. Visible participants are those who receive
substantial public and media attention. They include members of
Congress, the President, high-level political appointees, and key
actors in political parties. Hidden participants are specialists
who are knowledgeable about the issue in a particular policy
arena. They include congressional staff, researchers and
academics, career bureaucrats, and analysts who work for interest
groups (pp. 208-209). The role of the hidden participant is to
generate policy alternatives for consideration by the visible
participants. To generate these alternatives, hidden participants
must have expertise about the issue and must be willing to concern
themselves with minute detail (Kingdon, 1984, p. 74).
This case study focused on some congressional staff members,
advocates of interest groups, and political appointees of the
administration who are some of the hidden participants in the
process of adopting national LTC legislation. They play central,
behind-the-scenes roles in the process. They are usually subject-
matter experts in LTC. Because of their work responsibilities,
they are concerned with the precise details of relevant
legislation. Congressional staff members are frequently viewed as
sharing a policy outlook with the congressional representatives
they work for (Weiss, 1989).
The actors in this case study are not the only ones involved
in the process of adopting national LTC legislation or influential
to the process. Other actors who play visible roles in the
process of adopting national LTC legislation are:
• Members of Congress,
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• Political appointees at and below the top levels in the
executive branch whose responsibilities include LTC and
advisors to the President and the Congress, and
• Judges and the courts.
Other actors who play hidden roles in the process are:
• Congressional staff who do not work for any committees or
subcommittees with jurisdiction over LTC programs and
their financing (i.e., congressional staff who are not
eligible for inclusion in this case study),
• Academics and other researchers who focus their efforts
on LTC,
• Career bureaucrats in the executive branch of the federal
government and in the state governments who develop
regulations, set policies, and implement programs in LTC,
and
• Other influential members of the issue network, including
members of interest groups who represent consumers and
providers of LTC and who have positions about LTC policy
although they may not have detailed policy proposals.
Results from this case study represent the perspectives of some of
the key actors who work behind-the-scenes in the LTC policy
adoption process. However, the perspectives of other key actors,
most notably those who are visible participants, are beyond the
scope of this case study.
A goal of the case study was to interview one informant
representing the majority and the minority parties for each
committee (or subcommittee) and one informant for each advocacy
organization with a significant LTC policy proposal. The maximum
number of respondents for the case study was 19. This included a
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total of 14 congressional staff (one each from the majority and
minority parties of the 7 relevant congressional committees or
subcommittees) and 5 organizational advocates of LTC policy
proposals significant to the policy arena. The intent was to
interview the informant who was most knowledgeable about LTC
issues for that group. Details concerning the criteria for
selection of specific congressional staff members and the most
knowledgeable advocates of LTC policy proposals are discussed
below, beginning with the discussion on congressional staff and
then turning to the discussion on the advocates.
Congressional Staff
The list of congressional staff to interview was developed
in a two step process. First, House and Senate committees and
subcommittees with legislative or oversight responsibility for LTC
issues were identified through congressional directories of
committees and staff (Coombs, 1993). In most instances,
subcommittees had the first level of responsibility for LTC
issues. Next, committee and subcommittee staff who were assigned
responsibility for LTC issues were identified through telephone
calls to the committee or subcommittee. Several telephone calls
to each subcommittee were made at different dates to corroborate
the information. Because staff turnover can occur at any time,
telephone calls to verify and, if necessary, update the list were
made immediately prior to the interview. Table 10 presents the
seven committees and subcommittees of the U. S. Congress which
were selected because they have jurisdiction either on health
issues or on generating revenues for health legislation. The
chair, specific jurisdiction, and the parent committee of
subcommittees are also presented. The staff members with
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responsibility over LTC issues are not listed because of the
pledge of confidentiality given to them so they would not censor
their comments. The procedure was to interview the one committee
staff member who had LTC as a major responsibility for the
majority side and one for the minority side. After several
unsuccessful attempts to arrange for an interview of that
particular staff member, an interview was sought with the staff
member whose extent of responsibility for LTC was closest to that
of the unavailable staff member.
TABLE 10
U.S. CONGRESSIONAL COMMITTEES AND SUBCOMMITTEES WITH
RESPONSIBILITY FOR LTC LEGISLATION
U.S. House of Representatives
Subcommittee on Health and the Environment (Subcommittee Chair
Waxman)
Parent Committee: Committee on Energy and Commerce
(Committee Chair: Dingell)
Jurisdiction: public health and quarantine, hospital
construction, mental health and research, biomedical
programs and health protection in general, including
medicaid and national health insurance, foods and
drugs, drug abuse. Clean Air act and environmental
protection in general
Subcommittee on Health (Subcommittee chair: Stark)
Parent Committee: Committee on Ways and Means
(Committee chair: Rostenkowski)
Jurisdiction: Programs which provide payment for
health care, health delivery systems or health
research, health care programs of the Social Security
Act, and tax credits and deductions dealing with
health insurance premiums and health care costs.
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Table 10 (continued)
U.S. Senate
Committee on Labor and Human Resources (Committee Chair:
Kennedy)
Jurisdiction: measures related to education, labor,
health and public welfare; biomedical research and
development; handicapped individuals; occupational
safety and health; private pension plans; public
health. Note that the Committee has no subcommittee
on health. Instead, health legislation is considered
by the full committee.
Subcommittee on Aging (Subcommittee Chair: Mikulski)
Parent Committee: Committee on Labor and Human
Resources (Committee Chair: Kennedy)
Jurisdiction: matters related to education, labor,
health and public welfare of the aging.
Subcommittee on Disability Policy (Subcommittee Chair: Harkin)
Parent Committee : Committee on Labor and Human
Resources (Committee Chair: Kennedy)
Jurisdiction: matters related to education, labor,
health and public welfare of handicapped individuals.
Subcommittee on Medicare and LTC (Subcommittee Chair:
Rockefeller)
Parent Committee: Committee on Finance (Committee
Chair: Moynihan)
Jurisdiction: matters related to health programs under
the Social Security Act (i.e.. Medicare and Medicaid);
health programs financed by a special tax or trust
fund; national social security.
Special Committee on Aging (Committee Chair: Pryor)
Jurisdiction: to study of any and all matters related
to older people, including health and obtaining care
and assistance. The Committee has no legislative
jurisdiction and has no power to report by bill.
Of the seven committees and subcommittees, two were from the
House and five were from the Senate. Five of them were
subcommittees. Subcommittees are crucial to the development of a
bill and to moving it to the floor of the chamber for debate and
vote. Subcommittees hold hearings on the bill, can revise the
bill, and prepare the draft of the committee report about the
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bill. The subcommittee votes whether to send the bill to the full
committee for consideration. The subcommittee is the first gate
through which a bill must pass in the process of becoming law.
Generally, the full committee relies on the recommendations of its
subcommittees because the staff expertise for the specific issue
is at the subcommittee level (Anderson, 1990).
In the House, the Subcommittee on Health and the Environment
(of the Committee on Energy and Commerce) has jurisdiction over
health and national health insurance. The Subcommittee on Health
(of the Committee on Ways and Means) has jurisdiction over
generating revenues for health legislation. In the Senate, health
legislation is considered by the full Committee on Labor and Human
Resources. This Committee has two subcommittees with jurisdiction
over LTC issues— the Subcommittee on Aging which deals with
matters related to the health of the aging and the Subcommittee on
Disability Policy which deals with matters related to the health
of the handicapped. Both populations are major users of LTC. The
Subcommittee on Medicare and LTC (of the Committee on Finance) has
jurisdiction over generating revenues for Medicare, Medicaid, and
health programs funded by special taxes. In contrast to all the
other committees, the Special Committee on Aging is an oversight
Committee. It has no legislative jurisdiction and no power to
report by bill. However, it is an effective forum for advocating
legislation. It also can influence the passage of legislation
because its members sit on legislative committees. For example.
Senators Pryor, Durenberger, Grassley, and Breaux are members of
the Committee on Aging and the Committee on Finance.
In some theories, committee and subcommittee staff are seen
as one of the important influences in the process of adopting
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national policy (Kingdon, 1984; Weiss, 1989; Jenkins-Smith, 1990),
According to Kingdon (1984), "... those who have the greatest
impact on the shape of public policy emerging from Congress are
committee staffers" (p. 43). For Weiss (1989), the greatest
impact is from the subcommittee staff. Because of their
specialization, they "deal with the substance of legislation"
(p. 142). Personal staff, in contrast, spend much of the time on
constituency and political matters. It is the subcommittee staff
who analyze bills, often revise them, and prepare the path for
enactment. Subcommittee staff are not only a major influence in
development of legislation, but they are also knowledgeable about
the views, concerns and reactions of the ranking subcommittee
members. This is because the chair of the subcommittee hires the
majority staff; and the ranking minority member hires the minority
staff. Staff are not civil servants and can be fired at any time.
Their employment and advancement depends on their responsiveness
to the agenda and careers of their employers— subcommittee chairs
or ranking minority members. One consequence of this situation
is that there is strong organizational allegiance of staff members
(Jenkins-Smith, 1990). Another consequence is that staff are
extremely knowledgeable about the potential reaction of the chair
(or ranking minority member) to policy proposals and to pending
legislation. Although the members of Congress are often too busy
to conduct their own in depth analyses, they provide the ideology
and criteria for analyses conducted by their staff members. This
situation creates a shared policy outlook between staff and
subcommittee chair (or ranking minority member). Because of staff
responsibilities for analysis and the shared outlook between them
and their subcommittee chair (or ranking minority member), staff
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are knowledgeable about the characteristics of policy proposals
that are influential in the process of adopting national
legislation (Weiss, 1989).
Advocates of LTC Policy Proposals
Five organizations, including the Administration, have made
significant LTC policy proposals. (See Table 11.) These were the
organizations whose advocates were included in the case study.
Except for the proposal associated with the Brookings Institution,
the LTC proposals selected represented the policy views of the
organizations which developed them. The proposal developed by the
staff of the Brookings Institution was published to stimulate
public discussion and is not the official policy of that
organization. In some cases, the advocates developed, in whole or
in part, the LTC policy proposals for their organizations. These
advocates represent their organizations when they interact with
members and staff of Congress as well as with others in the LTC
policy arena. They were identified through telephone calls to
personal contacts at the organizations and by noting who
represented the organizations in presentations about LTC at
professional meetings. For example, the person who presented the
Administration ^ s LTC policy proposal at the 1993 annual meeting of
the Gerontological Society of America was identified as a possible
respondent.
The advocate most knowledgeable about the organization's
proposal and with major responsibility for being the
organization's focal point on the issue of LTC was the preferred
respondent for the interview. In most cases, the advocate worked
on developing the proposal. The research design called for an
interview of one advocate for each policy proposal. Attempts
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TABLE 11
ORGANIZATIONS THAT HAVE SIGNIFICANT LTC POLICY PROPOSALS
AND THAT ARE INCLUDED IN THE CASE STUDY
Research and Public Policy Organization
The Brookings Institution
Bipartisan Congressional Committee
The Pepper Commission
Industry Representative
Health Insurance Association of America
Advocacy Group for the Elderly
American Association of Retired Persons
Administration Proposal
Health Security Act, Title II, Subtitle B, 1993, H.R. 3600,
S. 1757
were made to interview the advocates identified as most
knowledgeable and with major responsibility for LTC because of
their expertise about the issue, the proposal, and their
organization's position. If, after several contacts, that
advocate was not available, the next advocate on the list for that
organization was contacted for an interview.
The same advocates who played influential roles in the
development of the policy proposal of the Pepper Commission were
major focal points for the Administration's proposal. When these
advocates were interviewed, they were asked to respond based on
their unique situation as focal points for two different proposals
138
from different entities. They have shifted their perspectives as
they moved from roles as staff to a bi-partisan congressional
committee to ranking policy officials of the Administration. This
shift suggests the notion of the policy process as an iron
triangle in which policy is made as an interaction among
representatives of congressional committees, the federal
bureaucracy, and interest groups (Freeman, 1965). These
advocates, in shifting from one angle in the triangle to another,
may have strengthened their influence on the development of
national LTC legislation.
Field Procedures
Interview
The source of information about important political features
of LTC policy proposals which make them influential in the process
of adopting national legislation was a personal interview of key
actors working behind-the-scenes in the adoption process. The
actors identified as possible informants were staff from relevant
congressional committees (Table 10) or advocates of organizations
with significant LTC policy proposals (Table 11). Because the
congressional staff members and advocates are extremely
knowledgeable about the process of adopting national legislation
and are very articulate, an unstructured approach to the interview
was selected. Such an interview was strongly recommended as the
most appropriate way to obtain information from the informants (C.
H. Weiss, personal communication, August 11, 1993) based on
previous experience in interviewing congressional staff (Weiss,
1989). Weiss recommended taping the personal interview as a
backup, but not a substitute for written notes. In her 1989
research of Congress, Weiss did not ask congressional staff
139
specifically for permission, but placed the recorder in a
prominent position at the beginning of the interview. In her
experience, none of the congressional staff objected. She
emphasized the importance not only of assuring the informant of
confidentiality, but also of maintaining that confidentiality in
the research report. The procedures she recommended were followed
in this research except that, as a courtesy, the informant was
asked for permission to record the interview.
The framework of the interview was an open-ended question
related to each hypothesis. If a specific topic was not discussed
by the informant, a list of probe topics was included in the
protocol to prompt the informant. The interview was conducted in-
person, if it was possible. An in-person interview served to
minimize interruptions and to keep the attention of the informant
focused on the topic.
It was important to interview one informant for the majority
and minority parties of each congressional committee (or
subcommittee) and one for each organization with a significant LTC
proposal. If the rate of response to the interview was high, this
selection of the most knowledgeable informants helped to ensure
that the responses were comprehensive. The responses represented
the spectrum of views of hidden participants who are influential
in the development and passage of national LTC legislation;
congressional staff from committees and subcommittees with
jurisdiction over LTC and advocates from organizations with
significant LTC policy proposals. This spectrum of perspectives
also helped to assure that the case study encompassed multiple
views in the policy arena due to differences by chamber of
Congress, by program versus financing committee jurisdiction in
140
Congress, by majority versus minority party of congressional
committees, by congressional staff versus advocates, by consumers
versus industry representatives, and by researchers versus
advocates and lobbyists. Some see the congressional members and
their staff as sharing a policy outlook (Weiss, 1989). In so far
as this is the situation, responses of congressional staff can
suggest the views of members of the U. S. Congress with major
responsibility for LTC legislation (Weiss, 1989).
Protocol
The protocol for the interview is presented in Appendix A.
The topics addressed in the protocol were as follows;
• Part A: Introduction to the interview,
• Part B; Approach for policy analysis,
• Part C; Building coalitions,
• Part D: Limited extent of policy change,
• Part E: Interaction between advocates and congressional
staff,
• Part F; Other influential political features of LTC
proposals,
• Part G; Most important political feature,
• Section H; Additional materials requested, and
• Section I; Clarification and close.
In the parts of the protocol which obtained information to
address the hypotheses, the overall format was the same. First, a
general, open-ended question was used to obtain information to
address the hypothesis. Then, another open-ended question was
used to obtain information about whether comments apply equally to
all LTC policy issues or were more applicable to some and less to
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others. This information can suggest how applicable the results
of the research are to the spectrum of LTC policy issues.
Informants also were asked to consider the applicability of
their responses to other social policy issues. In so far as
informants reported that their conclusions were applicable beyond
LTC to other social policy issues, confirmation of hypotheses
about national LTC legislation can suggest future research toward
developing a nascent theory (Eisenhardt, 1989) about important
political features of policy proposals that influence the process
of adopting social legislation. A list of probe topics was
included in each part of the protocol to prompt the informant if a
specific topic was not mentioned. Open-ended questions were used
to gain knowledge about the context, reasons, and perspectives
behind the informant's judgment of the importance of the political
features of the LTC policy proposals under discussion.
Part A of the protocol was the introduction to the informant
and the pledge of confidentiality. Parts B through G of the
protocol were structured to obtain information to address the
research hypotheses and their applicability. Part H was to obtain
relevant papers and reports. Part I served to alert the
informants that the researcher may re-contact them if
clarification of the interviews was needed and to thank the
informants for their participation.
Table 12 presents sources of information in the interview
protocol to address the research questions and hypotheses. Part B
on approach for policy analysis relates to hypothesis 1 of
research question 1 on importance of the political model of
analysis. Part C on building coalitions relates to hypothesis 2
of research question 1 on the importance of creating coalitions.
142
Part D on limited extent of policy change relates to hypothesis 3
of research question 1 on the importance of limiting the extent of
change from existing policy. Part E on interaction of actors
relates to hypothesis 4 of research question 1 on the importance
of the skill of the advocates in interacting with congressional
staff members.
TABLE 12
SOURCES OF INFORMATION IN THE INTERVIEW PROTOCOL TO
ADDRESS RESEARCH QUESTIONS AND HYPOTHESES
Research Question 1 Part of Protocol
Hypothesis 1: Importance of political
model of analysis B, G
Hypothesis 2 : Importance of building
coalitions c. G
Hypothesis 3: Importance of limiting
extent of change from existing policy D, G
Hypothesis 4: Importance of skills of the
advocate in interacting with
congressional staff E, G
Research Question 2
Hypothesis 1: Differences in judgment
between advocates and congressional
staff B, C, D, E, F, G
Part F of the protocol, which asks for other influential
political features of LTC policy proposals, is collecting
information in an attempt to strengthen external validity by
disconfirming the hypotheses. Actually searching for information
to disconfirm a hypothesis can provide further support for the
143
hypothesis when disconfirming information is not found (Popper,
1959). For further discussion of this approach, see the section
on Internal Validity of the Analysis later in this chapter. Part
G of the protocol obtains information to determine the most
important political feature of LTC policy proposals which
influence their being given serious consideration in the process
of adopting national LTC legislation. This information was used
for pattern matching for hypotheses 1 through 4 of research
question 1. Parts B through G also address hypothesis 1 of
research question 2 concerning similar judgments between
congressional staff and advocates about important political
features of LTC policy proposals.
Reliability and Validitv of Research Design
and Collection
Introduction
Major criteria to judge the quality of a research effort are
reliability (replication of results) and validity (approximating
the "true" relationship among variables). Specific approaches to
assure reliability and validity are well developed for
quantitative research (see Cook & Campbell, 1979) and less so for
qualitative research. Yin (1989) has identified tactics in the
design, collection, and analysis phases to contribute to the
quality of case study research. This section describes his
recommended tactics for establishing the reliability and validity
of the design and collection phases of case study research. It
also identifies specific applications in this research.
Application of Yin's tactics to the analysis phase of the case
study is discussed in the subsequent section on the Analytic Plan.
144
Reliability of Research Design and Collection Phases
Reliability concerns the replication of study results. This
study includes two established case study tactics to contribute to
reliability in the design and collection phases of the research.
They are the use of a case study protocol and the development of a
case study data base (Yin, 1989). The interview protocol consists
of standard questions to assure that the same information is
collected from all respondents. (See Appendix A.) Questions were
developed to address each of the hypotheses in the research.
Links between the parts of the protocol and the individual
research hypotheses are presented in Table 11 in the Protocol
section of this chapter.
The case study data base included the typed interviews of
the informants, plus other documents such as papers on LTC
prepared by the informants, and archival records such as
congressional bills on LTC. The results from the interviews were
maintained with a code number assigned to each informant to assure
confidentiality. Other documents, such as committee reports,
background analyses, and the like, were organized in a
bibliography for easy reference and retrieval. More details about
the data base are described in the next section.
Validity of Research Design and Collection Phases
Construct validity is the approach recommended by Yin (1989)
to support the validity of the research design and collection
phases of case study research. Construct validity concerns the
use of appropriate measures to operationalize the concepts in the
research. Tactics which contribute to construct validity in a
case study are multiple sources of evidence and a chain of
145
evidence (Yin, 1989). There are several sources of evidence in
this research;
• Interviews. Interviews of key actors in the LTC arena
from relevant congressional committees and subcommittees
with jurisdiction over LTC and from advocacy
organizations which developed significant LTC policy
proposals.
• Direct observation of informants. Because most of the
interviews were in-person, evidence from direct
observation, such as opportunity for staff interaction
and clues as to the status of the informant in the
office, was gathered.
• Documents. Documents include reports describing LTC
policy proposals, papers by staff members addressing LTC
issues, and newspapers and other sources which comment on
LTC issues in Congress.
• Archival records. Records include reports from the
selected organizations as well as from congressional
committees on meetings or hearings which addressed LTC
issues, bills on LTC submitted to a subcommittee or
committee, speeches about LTC prepared for organization
representatives and for members of the committees or
subcommittees of interest.
A chain of evidence is essential to construct validity so
that others can determine independently how the research
conclusions were reached. A chain of evidence was built for the
data collection segment of the research by not only maintaining
the interview protocols, documents, and archival records, but also
146
by organizing them so they can be easily retrieved by someone who
wishes to examine the evidence.
Analytic Plan
Analytic Strategy
The analytic strategy for the case study included the
approaches of analytic generalization and pattern matching (Yin,
1989). The method of analytic generalization is a strategy in
which "... previously developed theory is used as a template
with which to compare the empirical results of the case study
(Yin, 1989, p. 38). Empirical results of the research were
compared to existing theories on the policy process to identify
areas where existing theories were confirmed or were questioned.
The existing theories that provide the template for the comparison
were discussed in chapter 2. Each hypothesis was compared to
relevant existing theories. For those hypotheses which are
confirmed, results may suggest where existing theory could be
extended.
Causal support for a hypothesis which matches an existing
theory can be even stronger if, in addition, empirical results do
not match a rival theory (Popper, 1959; Yin, 1989). For example,
hypothesis 1 or research question 1 states that a political
approach to analysis is important to the influence of a LTC policy
proposal in the process of adopting national legislation. A rival
theory (see chapter 2 on Theoretical Framework) is that a rational
approach is most influential (Jenkins-Smith, 1990). If the
empirical responses do not correspond to this rival theory and do
correspond to the expected theory, then causal support for
hypothesis 1 is even stronger. Therefore, the analysis included a
comparison to rival hypotheses where appropriate.
147
Coding is an important technique in case study research for
summarizing and analyzing the data (Miles and Huberman, 1984). In
such research "a code is an abbreviation or symbol applied to a
segment of words . . . in order to classify the words" (p. 55).
First-level codes are based on the hypotheses, key concepts, and
themes. They are tools for summarizing and highlighting data.
Second-level codes are meta-codes. They are "a way of grouping
summaries into a smaller number of overarching themes or
constructs" (Miles & Huberman, 1984, p. 68). By using these meta
codes, relevant information can be clustered and synthesized to
examine the hypotheses. Meta-codes were assigned to synthesize
the confirmation and disconfirmation of theories related to each
hypothesis. They also were assigned to synthesize similar
descriptions of processes and explanations. Information collected
during the interview was typed and coded for easy retrieval of
common codes and themes.
To support and augment the textual analysis in the final
case study, information was displayed in a variety of matrices and
figures. Miles and Huberman (1984) recommend such displays as a
useful and efficient way of summarizing case study results and
highlighting the conclusions (p. 79). Figures presented the
configurations and results of the pattern matching approach
described in detail below.
Pattern Matching
Pattern matching is an analytic approach in which the
empirical pattern from the case study is compared to a predicted
or hypothesized pattern. According to Yin (1989), if the two
patterns coincide, the empirical results are judged to "match" the
predicted pattern. If the predicted pattern is based on a pre
148
established hypothesis as it was in the research conducted here,
than the match of patterns is considered as empirical support for
the hypothesis. If, in addition, these empirical patterns do not
match those of rival hypotheses, then strong inferences about
causality can be made (Popper, 1959).
Yin views pattern matching as one of the most desirable
analytical approaches for a case study. For example, hypothesis 1
of research question 1 predicted that a political approach to
analysis is important to LTC policy proposals being given serious
consideration in the process of adopting national LTC legislation.
An illustration of an empirical pattern of informant responses
which support hypothesis 1 is shown in Figure 1, where X
represents a response by a single informant. Note that in this
illustration seven of the nine informants rated "a political
approach to analysis" as very important. Because hypothesis 1
states that a political approach to analysis is important to LTC
policy proposals being given serious consideration in the process
of adopting national legislation, it predicts that all responses
fall in the "very important" category. The hypothesized or
predicted responses are arrayed in Figure 2. The empirical
responses of the informants in Figure 1 are compared to the
hypothesized (i.e., predicted) array in Figure 2 to determine if
the patterns "match." In this case, the patterns match closely
and the empirical data are judged as supporting the hypothesis.
149
FIGURE 1
EXAMPLE OF EMPIRICAL PATTERN ON IMPORTANCE OF
POLITICAL APPROACH TO ANALYSIS
XXX
XXX XX
X
Very Important Somewhat Important Not Important
Importance of a Political Approach to Analysis
Note: X = response by a single informant.
FIGURE 2
EXAMPLE OF HYPOTHESIZED PATTERN ON IMPORTANCE OF
POLITICAL APPROACH TO ANALYSIS
XXX
XXX
XXX
Very Important Somewhat Important Not Important
Importance of a Political Approach to Analysis
Note: X = response by a single informant.
Yin gives no guidance about when a "match" is achieved, the
decision is a judgmental one. A case study presentation of
information which provides readers with concrete evidence
strengthens the internal validity of the study (Miles and
Huberman, 1984; Yin, 1989). This analysis includes figures,
similar to Figure 1, of the empirical responses so that readers
are able to make their own judgments about the extent of the
match. Pattern matching was used to analyze hypothesis 1 of
question 2 about differences in the views of congressional staff
versus advocates. In this situation, however, the analysis was of
two embedded units in the case study— the committee staff versus
150
the advocates. The empirical pattern of the congressional staff
was compared to the empirical pattern of the advocates to
determine if they matched. If they did not match, then the views
of the two groups were different, and the patterns indicated where
the differences existed.
Validitv of the Analvsis
Introduction
This section describes the general analytic tactics
identified by Yin (1989) to contribute to the validity of case
study analysis. It then identifies the specific analytic
applications in this research.
Analytic Strategy for Validity
Yin notes that there are few formulas or standard approaches
to use as a guide for validating the analytic strategy of a case
study. The first and most preferable strategy is to use the
concepts and propositions from available theory. Propositions of
existing theory focus attention on certain concepts and
explanations while de-emphasizing others. Conflicting theories
also define alternative explanations to be analyzed (Yin, 1989,
p. 106).
This research is grounded in existing theory about the
policy process in general and the stage of adopting policy in
particular as presented in chapter 2 on Theoretical Framework. A
variety of alternative theories were exEimined and were used as a
framework to establish the hypotheses examined in the research.
The Theoretical Framework chapter describes the concepts,
propositions, and alternate explanations upon which the hypotheses
were based.
151
Internal Validity of the Analysis
Internal validity of the analysis is the establishment of a
causal relationship (Yin, 1989). Tactics for supporting internal
validity concern the approach to data analysis. In this research,
a major approach to data analysis was pattern matching. This
entails matching the pattern of empirical results to
hypothetically predicted results for each hypothesis. If the
patterns match and the hypothesis is confirmed, then further
matching of the empirical pattern to a rival hypothesis can serve
to strengthen causal support if the empirical and rival hypothesis
patterns do not match. In other words, the empirical pattern
confirmed the research hypothesis and disconfirmed a rival
hypothesis. This approach is based on Popper's (1959) view that
in corroborating a theory, one should attempt to disconfirm or
falsify it.
Part F of the protocol which asked for other important
features which result in LTC policy proposals being given serious
consideration in the process of adopting national LTC legislation
provided information for possible disconfirmation of the
hypotheses. Identification of additional features by a majority
of the informants can suggest hypotheses for future research on
important political features of policy proposals that influence
the process of adopting national LTC legislation.
In addition, the analytical approach of pattern matching
strengthens the internal validity of the research because it
provides concrete evidence that can be observed by the readers of
the case study report (Yin, 1989). The readers can review the
patterns and draw their own conclusions about whether the
empirical and hypothesized patterns match. Furthermore, pattern
152
matching serves to minimize the reader's concern that the analyst
selected only those pieces of evidence that supported the
hypotheses and ignored the others.
External Validity of the Analysis
External validity deals with "the problem of knowing whether
a study's findings are generalizable beyond the immediate case
study" (Yin, 1989, p. 43). Yin sees the use of existing theory as
the best method for supporting the generalizability of case study
results. He labels this as the method of analytic
generalizability: "... previously developed theory is used as a
template with which to compare the empirical results of the case
study" (p. 38). This is analogous to the way a scientist
generalizes from experimental results to theory. Results of the
research were compared to existing theories on the policy process
(see chapter 2 for a presentation of the theories) to identify
areas where existing theories were confirmed or were questioned.
Each hypothesis was compared to relevant existing theories. If
hypotheses are supported, results can suggest areas where theory
could be extended.
Informants were asked to use LTC as their frame of reference
in considering the political features of policy proposals as they
influence adopting national LTC legislation. They also were asked
to consider whether their comments applied equally to all LTC
policy issues or were more applicable to some and less to others.
This information can indicate how applicable the results of the
research were to the spectrum of LTC policy issues. For example,
results may indicate that hypothesis 1 on the political approach
to policy analysis is confirmed for major LTC policy initiatives
such as a benefit for home and community-based care, but not for
153
minor ones. Informants also were asked to consider the
applicability of their responses to other social policy issues.
In so far as informants reported that their conclusions were
applicable beyond LTC to other social policy issues, confirmation
of hypotheses about national LTC legislation can suggest future
research toward developing a nascent theory (Eisenhardt, 1989)
about important political features of policy proposals that
influence the process of adopting social legislation.
The congressional committees and subcommittees included in
this case study play a pivotal role in shaping national LTC policy
by adopting national legislation. Nevertheless, they must obtain
a majority of votes in each chamber of Congress for their
preferred bills to be adopted. Nor are they the only forum where
national LTC policy is made or where legislation is developed.
LTC policy can also be made by the executive branch, the
judiciary, and state and local entities. This research is not
intended to be applicable to the process of adopting LTC policy in
these situations. LTC legislation can also be passed by state and
local governments. Because different political and administrative
structures operate at the state and local levels, results of this
research should not be assumed to be applicable to the process of
developing LTC legislation by state or local governments.
154
CHAPTER IV
FIELD EXPERIENCE
Introduction
This chapter presents the experience in the field for the
case study. It begins with a description of the actual
experience. Special attention is given to comparing the actual
experience to the established research design and methodology
described in chapter 3. Also described in this chapter are two
environmental influences mentioned frequently by informants.
These influences are part of the real-life context of adoption of
national LTC legislation. They are important to a fuller
understanding of the comments of the informants and of the process
of adopting national LTC legislation.
Field Experience
The field procedures and methodology for the research were
described in chapter 3. This section describes the actual field
experience in relation to the established procedures. This
permits an assessment of the quality of the information collected
in the case study.
Of the 19 expected informants, 17 of them were
interviewed. This is a response rate of 89 percent. This high
response rate assures that the information collected presents the
multiple views of key actors involved in adoption of national LTC
legislation. Fourteen (82 percent) of the informants were female,
and three (18 percent) were male. This sex ratio was the same for
155
advocates as for congressional staff members, and for majority
staff as for minority staff. Informants were experienced in their
jobs; seven of them (41 percent) had been employed in their
current positions for three years or longer.
Advocates of all five organizations were interviewed.
(See Table 11 in chapter 3 for the list of organizations.)
Advocate names have been removed from the list to honor the pledge
of confidentiality given in the interview. This pledge was made
so the informants would be willing to share their views and would
not censor their comments. Twelve of the 14 congressional staff
members were interviewed. They included staff from all the Senate
subcommittees and committees with jurisdiction over LTC and from
the Subcommittee on Health of the House Committee on Ways and
Means. See Table 9 in chapter 3 for the list of committees and
subcommittees. Here, too, the names of congressional staff were
removed for confidentiality reasons.
Staff from the Subcommittee on Health and the Environment
of the House Committee on Energy and Commerce were not
interviewed. The unavailability of a staff member knowledgeable
about LTC issues was a factor in the non-response of the majority
side of the Subcommittee. The staff member who had worked on LTC
issues for several years had taken a leave of absence to run for
public office. The staff member who had just been assigned to LTC
issues felt he was not an appropriate respondent because he had
not worked on the topic and was not knowledgeable about the
issues. He suggested interviewing the Subcommittee's staff
director who, he felt, was knowledgeable about LTC issues. She
never responded to the many telephone requests for an interview.
Neither did her counterpart on the minority side of the
156
Subcommittee. A likely reason for their non-response is that
these staff members had no time for interviews because they were
key actors in the Subcommittee's attempt to develop a bill on
health care reform. A consensus on this issue never coalesced,
and the Subcommittee did not approve a bill (Rich, 1994).
Congressional staff respondents were equally split between
the majority and minority parties. In all cases except one, the
informant was the key staff member who had major responsibility
for LTC issues. The one exception was for the minority side of
the Subcommittee on Aging of the Senate Committee on Labor and
Human Resources. The staff member had broken two appointments
and did not appear for the third appointment. Instead, another
staff member of the Subcommittee was substituted. The substitute
had several years of experience in health care legislation, but
less in LTC. This substitution was consistent with the rule for
selecting the "best" respondent discussed in the methodology
chapter.
The high response rate, the participation of virtually all
the key actors who had responsibility for LTC in their
organization or committee, and the participation of congressional
staff members from both majority and minority parties assure that
responses to the research are comprehensive. This spectrum of
perspectives assures that the research encompasses multiple views
of actors who are key to the adoption of national LTC legislation.
In so far as Congress members and their staff share a policy
outlook (Weiss, 1989), staff responses can suggest the views of
members of Congress who shape LTC legislation.
The initial three interviews took about 60 minutes each
and followed the interview protocol in Appendix A. However, in
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subsequent telephone calls to arrange for interviews, all
congressional staff and some advocates would only agree to a 30-
minute interview. As a consequence, most respondents (82 percent)
were asked a comprehensive question about applicability at the end
of the interview, rather than repeating the individual questions
after each political feature was discussed. Evidence indicates
that this change did not impact on whether the informants provided
information about applicability. Of those ten informants who gave
an indepth response to the applicability questions, 90 percent
were asked the comprehensive version.
Fourteen of the 17 respondents had interviews with the
comprehensive question on applicability. Their interviews lasted
from 20 to 45 minutes, with an average of 30 minutes. All
interviews were conducted in person except for one which was
conducted by phone. After several broken appointments, the
informant proposed a phone interview, saying that she was so busy
that she could participate only if she were interviewed
immediately by phone. The interview went just as well by
telephone as it did in person.
Confidentiality was a major concern; two advocates and two
congressional staff members preferred not to be taped. In all
interviews, respondents were cooperative, cordial, thoughtful, and
responded to all the questions in the interview protocol.
Complete responses to each question assure that the information
collected about each hypothesis encompasses the multiple views of
key actors involved in the process of adopting national LTC
legislation.
158
Real-Life Context of
Adopting National LTC Legislation
Introduction
A strength of the case study approach is that it ". . .
investigates a contemporary event within its real-life
context. ..." (Yin, 1989, p. 38). This is crucial to an
investigation of the political features which influence the
adoption of national LTC legislation because its context cannot be
eliminated as is done in a laboratory or held constant as is done
in statistical analysis. Often the boundaries between the event
and the context are fuzzy and difficult to delineate. An
awareness of major influences within the real-life context can be
useful in understanding the dynamics of adopting LTC legislation.
Two major influences were mentioned repeatedly by the informants:
health care reform and the Medicare Catastrophic Coverage Act.
This section provides some information about these influences as
background in understanding the informant's comments and the
environment in which the adoption of national LTC legislation is
operating.
Health Care Reform
The first influence was on-going congressional action on
health care reform. Because the Administration's proposal
included a LTC component, LTC has been placed on the agenda when
health care reform is being discussed. There is a possibility
that LTC legislation will be enacted as part of health care
reform. During the interview period of late March to late April,
three subcommittees of the House began preliminary work on health
care reform with the goal of approving a bill and sending it to
the full committee. Two of the subcommittees address LTC
159
legislation and were included in this case study. They are the
Subcommittee on Health of the Committee on Ways and Means and the
Subcommittee on Health and the Environment of the Committee on
Energy and Commerce. (The third Subcommittee on Labor-Management
Relations is not responsible for LTC legislation.) As of April 12
when 41 percent of the informants had been interviewed, an overall
consensus on health care reform was not developing in Congress
(Rich, 1994). The Subcommittee on Health and the Environment was
unable to reach agreement on a bill to send to the full Committee
on Energy and Commerce. The Health Subcommittee had approved a
bill and sent it to the full Committee on Ways and Means. The
appropriate Senate committees and subcommittees had not begun the
formal process of developing bills.
While no bills were reported out of Committee, informal
discussions in both the House and Senate were being held. The
head of the Republican Health Task Force in the House indicated
that the Republicans wanted to develop approaches to include LTC
in health care reform, concentrating on home health care (Broder,
1994b). Also under consideration by Congress were health care
reform packages with fewer benefits. LTC, along with mental
health care, was viewed as the most likely to be excluded (Priest,
1994b).
These influences indicate the lack of a congressional
consensus not only on health care reform, but also on whether LTC
is to be a part of it. This uncertain, fluid situation concerning
LTC was mentioned frequently by informants. Most informants
concluded that some legislation, content unknown, on health care
reform would be passed before the October recess. All informants
indicated that it was impossible to determine whether health care
160
reform legislation would include LTC and, if so, what type of
benefits would be covered.
Whenever the informants spoke of LTC as part of health
care reform legislation, they were reminded that the framework for
discussions was the entire range of LTC issues, not just those
related to health care reform. A subsequent section of this
chapter presents the informants' responses to a question about
whether, upon reflection, their comments applied equally to all
LTC policy issues. The general conclusion was that, although the
informants used health care reform in many of their examples, they
used a broader set of LTC issues as a frame of reference.
Repeal of the Medicare Catastrophic Coverage Act
The second important influence in the environment which
occurred during the data collection period was a Washington Post
article on the effect of the Medicare Catastrophic Coverage Act on
Congress. When 10 of the 17 informants had not yet been
interviewed, the Washington Post published an article about how
the repeal of the Medicare Catastrophic Coverage Act of 1988
(P.L. 100-360) negatively influences activities in health care
reform (Broder, 1994a). This article presented explanations of
the repeal from the perspective of policy makers. It raised the
issue of the repeal and helped to generate comments in subsequent
interviews of the impact of the repeal on the adoption of LTC
policy. In addition, the impact of repeal seems to be of such
consequence that several informants raised it in the interviews
which occurred before the article was published. Informant
comments on the repeal appear in the presentations of research
results for several hypotheses: building coalitions, limiting the
161
extent of change from current policy, and interactions between
advocates and congressional staff.
The Act was passed by Congress with substantial margins in
July 1988 as the first significant addition to Medicare. It
covered catastrophic expenses for prescription drugs, extended
hospital stays, and physician visit co-payments. It did not cover
LTC expenses. The Act was repealed, again by a substantial
margin, in November 1989 before taking effect due to negative
reaction of the elderly, the very constituency it was designed to
help. The AARP was a major supporter of the legislation. The
National Committee to Preserve Medicare and Social Security used
mass mailings, some accurate and some exaggerated, to create a
grass roots movement for repeal (Broder, 1994a).
Technical analysis identified several factors for the
repeal (Rice, Desmond & Gabel, 1990). Many elderly disliked
paying the additional taxes to fund the benefits. In many cases
the elderly were already covered for these catastrophic costs by
supplemental insurance provided as a retirement benefit. The
elderly did not understand the benefit and, when it was explained
to them as part of the research, did not support the legislation
(p. 80).
The Washington Post article (Broder, 1994a) was notable
because it presented comments about the policy implications of the
repeal from the perspectives of policy makers involved in the
enactment and repeal. Waxman, current chair of the Health and
Environment Subcommittee of the House Energy and Commerce
Committee said: "Those of us who went through that battle have it
very much in mind. There was over promising in that bill, so
people reacted very negatively when they were stirred up."
162
Rother, the legislation and policy director of AARP at present and
during the adoption and repeal of the Act, described himself as
"at the center of the hurricane . . . Almost everything we are
doing now on health reform is based on that experience." The
elderly who already had catastrophic expense coverage from
insurance provided as a retirement benefit were the most vocal in
demanding repeal. Rother says that from this experience he has
come to believe; "you have to be honest about the need for
sacrifice" (Broder, 1994a, p. A14) .
163
CHAPTER V
RESEARCH RESULTS
Introduction
This chapter presents the research results for each
hypothesis. Informants' comments about other important political
features, the most important feature, and applicability of the
research results also are discussed. In the analysis, the
empirical results about each hypothesis were compared to relevant
theories about the policy adoption process. This approach is the
method of analytic generalization where ". . . previously
developed theory is used as a template to compare the empirical
results of the case study" (Yin, 1989, p. 38). Pattern matching
provided additional evidence to examine each hypothesis. The
pattern of the hypothesized relationship was compared to the
pattern of empirical results. A close match of the empirical to
the hypothesized pattern was additional evidence to support the
hypothesis.
Evidence from the interviews is presented to support the
conclusions of the analysis. Such evidence is important in a case
study to indicate the basis for the conclusions (Yin, 1989). This
evidence is in the form of verbatim quotations of the informants
on relevant topics. In the course of the interview, informants
often made elliptical comments and referred to previous concepts
and comments. As a consequence, text has been added in brackets
to reference the informants' previous comments, explain their
abbreviations, and to complete their elliptical phrases. A few
164
specific references to particular members of Congress and to
specific interest groups have been deleted and replaced by
brackets to honor the pledge of confidentiality given to the
informants so they would not censor their remarks. With the
exception of the text in brackets, the informants' comments are
verbatim.
Research Results for Hypothesis 1;
Political Approach to Analysis
Introduction
Hypothesis 1 of research question 1 states;
Key actors in the LTC policy arena judge that LTC policy
proposals are given serious consideration in the process
of adopting national LTC legislation when they were
formulated by a political approach to analysis.
This presentation of research results summarizes the
informants' responses to two questions. Informants were asked
about which approach to policy analysis is important to
formulating proposals which get serious consideration when
adopting national LTC legislation. As part of the question, the
researcher defined the approaches to policy analysis so that the
informants could consider all of them before responding to the
question. The definitions were:
• Rational analysis ; a systematic analysis of a
comprehensive set of options using techniques like
statistics, mathematical modeling, cost benefit
analysis.
• Political analysis: negotiating among groups to develop
a preferred option. Data and arguments are
strategically selected to support the option.
165
• Incremental analysis; making small changes to existing
policy.
• Dialectic approach; experts advocate preferred options
and choice is based on their competing arguments.
• Interpretive approach: political counselors focus on
the meaning of the policy to the community.
• Critical approach; critical assessment of the
assumptions and evidence of various proposals.
In their responses, some informants used the labels provided in
the definitions. Other informants did not use labels in
describing the approaches. Instead, some spoke of developing
policy based on expert testimony at committee hearings (dialectic
approach), on mathematical modeling (rational approach), and on
criticizing the assumptions and options of proposals (critical
approach). In these instances, the researcher assigned the
appropriate label to the informant's description.
Once informants selected an analytic approach, they then
were asked how important the approach is in formulating
influential LTC proposals. Evidence from these two questions
permits analysis not only of hypothesis 1 on political analysis,
but also of rival hypotheses about other approaches to policy
analysis. Yin (1989) has emphasized the importance of examining
rival hypotheses in case study analysis. This analysis of results
begins by examining the importance of the political approach to
analysis in formulating influential LTC proposals. Next, evidence
is examined about the importance of rational analysis and about a
combination of analytic techniques. The analysis ends with an
assessment of the match between the hypothesized pattern and the
empirical responses for the political approach and with a
166
conclusion of whether the evidence supports hypothesis 1.
Tentative conclusions are also presented about what the evidence
may suggest for alternative hypotheses.
Importance of Political and
Other Approaches to Analvsis
This section presents a summary of the evidence on which
approaches to analysis are important and how important they are.
Table 13 presents the informants' judgments about which approach
to policy analysis is important to formulating LTC policy
proposals which get serious consideration when adopting national
LTC legislation. Forth-seven percent of informants selected
rational analysis as being important to the formulation of
influential LTC policy proposals. Thirty-five percent of
informants selected political analysis as important. Twelve
percent of the informants selected a combination of analytic
techniques as the most important approach. The combinations
included a linkage of rational and political analyses and a menu
of models, case studies, and dialectic and critical approaches.
One informant (6 percent) concluded that there was no approach to
policy analysis that was important.
Table 14 provides information about the informants'
assessment of how important the approach to analysis they selected
is to formulate influential LTC proposals. For those eight
informants who selected rational analysis, 75 percent judged it as
very important and 25 percent as somewhat important to formulating
influential LTC policy proposals. This is in contrast to the
responses of those six informants who selected political analysis.
They were equally divided about how important the approach was.
Two of the informants who selected the political approach to
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TABLE 13
WHICH APPROACH TO POLICY ANALYSIS IS IMPORTANT TO
FORMULATE INFLUENTIAL LTC PROPOSALS?
Approach to
Policy Analysis
Number of
Informants
Percent of
Informants
Rational 8 47%
Political 6 35%
Combination 2 12%
None 1 6%
All
Approaches 17 100%
Note: the combination approach includes a variety of techniques-
political, rational, case studies, dialectic approach, critical
approach.
158
TABLE 14
HOW IMPORTANT THE SELECTED ANALYTIC APPROACH IS TO
FORMULATE INFLUENTIAL LTC PROPOSALS
Approach to
Policy
Analysis
Very
Important
Approach
Somewhat
Important
Approach
Not
Important
Approach
Rational 75% 25% 0%
Political 33% 33% 33%
Combination 100% 0% 0%
None 0% 0% 100%
All
Approaches 59% 24% 18%
Note; the combination approach includes a variety of techniques—
political, rational, case studies, dialectic approach, critical
approach. Figures may not total to 100 percent due to rounding.
analysis then assessed it as not important to influential LTC
policy proposals getting serious consideration in the process of
adopting national LTC legislation. Both informants commented that
members of Congress give minimal, if any, consideration to the
approach used for policy analysis when they decide to support a
bill. The two informants who selected the combination of
techniques approach judged it as very important.
Political Approach to Analysis
This section presents evidence to examine hypothesis 1 on
the importance of political analysis. The evidence was obtained
from interviews with the 35 percent of the informants who selected
169
political analysis as important to formulating proposals which get
serious consideration in the process of adopting national LTC
legislation. All six informants were congressional staff members.
Four of them worked for Congress members from the minority party.
Most of them were experienced congressional staff; four had been
employed in their current positions for at least three and one-
half years. Two brought a dual perspective to their comments
because they had worked previously on similar issues in other
settings. One had worked for several interest groups, and the
other had worked in the executive branch of the federal
government.
Informants mentioned some common themes; preferred
policies of members of Congress, strategic selection of
information, and coalition building were identified frequently as
essential aspects of analysis. Comments of informants supported
Wildavsky's view (1979) of policy analysis as a craft where policy
preferences, as opposed to evaluation of all options, are
important. Comments also supported Radin and Hawley's view (1988)
that the culture of politics, where information is strategically
selected to support the preferred option, is dominant in Congress.
A Senate staff member emphasized the strength of the preferred
policy in formulating influential LTC policy proposals;
I don't think the [analytic] approach [results
in enactment] because most Senators will not
be aware of analytic models or strategy. They
just hear the policy and like it. It depends
on what data support it. Always need data to
support policy. For most Senators, it's
policy that attracts, not the analysis.
Another congressional staff member spoke of the preferred policy
and its link to coalitions;
Need costs and cost benefit data to sell it
[proposal], but it's not [important] as to how
170
the proposal is developed. On the front-end,
most [members of Congress] don't think about
policy analysis. [It is] not something that
is used. It is issues, working with groups,
setting goals [that are important]. Cost
benefit data comes along with these things.
Effectiveness is the concern.
Another recurrent theme is what Stone (1988) describes as the
emphasis on cooperation and shared concerns through the building
of coalitions and alliances. A congressional staff member focused
on the development of proposals by coalitions;
The best approach to developing LTC proposals
is to make sure every major constituency—
people with disabilities and aging groups—
look at it and go on record to support
it. . . . The best approach is not to touch
base with a group, but to have them
participate in developing it [LTC proposal]
and owning it.
A congressional staff member highlighted Stone's view that "policy
analysis is political argument and vice versa" (p. 306);
Must have good public policy which gets
political support. [This is] because good
policy and language that explains it caters to
the political heart-strings of the right
groups to build a consensus. Bills that have
the worst public policy get through [adopted]
on pure politics. . . . It comes down to
debate over whether it's the best policy, but
debate is actuallv about politics. Politics
shapes people's policy. The level of
government intervention [in policies] is
shaped by differences between Democrats and
Republicans about the role of government. So
policies likely support politics about the
role of government.
A Senate staff member spoke of the influence of the
culture of politics on policy analysis she does for her
subcommittee ;
If I were in a different office, I might only
use high tech modeling to develop policy
proposals. But [this is] not true in this
office. We allow for more personal
interaction and real life situations rather
than just pure numbers.
171
Rational Approach to Analysis
Because the rational approach to analysis was selected by
more informants (47 percent) than any other approach, it provides
a viable alternative to hypothesis 1 of research question 1 about
the importance of the political approach to analysis. In keeping
with Yin's emphasis (1989) on examining rival hypotheses, this
section presents evidence from interviews of those eight
informants who selected rational analysis as important to
formulating influential LTC policy proposals.
Informants who selected rational analysis as important
were evenly divided between advocates and congressional staff
members. Most of the congressional staff members worked for
Congress members of the majority party. These characteristics
were in distinct contrast to those informants who selected
political analysis as important. All of them were congressional
staff members and most worked for the minority party. This
difference in the analytic approaches selected between staff
working for the majority (rational approach) and minority
(political approach) parties suggests why the evidence and
arguments of one party are not viewed as compelling by the other.
This may make finding common ground upon which to build coalitions
even more difficult. The majority of informants who selected
rational analysis as important were female. About half of the
informants had been in their current jobs at least three years.
Two brought dual perspectives to their comments because they had
worked as researchers in the executive branch of the government.
Jenkins-Smith (1990) described the steps in the rational
approach to analysis as; identifying the problem, goals and
options; estimating the effect of the options; and choosing the
172
"best" solution. He sees the approach as having an economic core
with cost benefit analysis (Rivlin, 1979; Weimer & Vining, 1989)
as a standard technique.
Several congressional staff members stressed the
importance of the rational approach. One commented;
Yes, I do [think type of analysis is
important]. Although few proposals come with
the rational type of analysis that I think is
important. . . . You need as much analytic
support as you can get to justify the
[selected] option. . . . It helps to move a
policy forward if it has strong analytic
support.
Said another;
One needs a quantitative approach. It is the
most solid bet. . . . It must be quantified,
not just words, but meat.
A third spoke about the differences in the techniques used for
analysis between initial and final stages of policy formation;
Sometimes the approach depends on what point
in the [policy analysis] process it is used.
Need some data early-on to demonstrate that
the issue is a problem, the way proposed to
solve it is best, the proposal can clear up
the problem with no messes, and the opponents
positions is not as optimal. . . . You can get
by [when you say that] 'about one-half the
people do "X" at the beginning [of the
process], but at the end you must be more
specific and analytical, not just use one
dimensional, descriptive data.
Radin and Hawley (1988) characterized the culture of
analysis as one where information, analyses, and causality are
central. Rather than argue over values, the arguments in the
culture of analysis are about information and analytic techniques.
An advocate described the culture of analysis when he noted:
In the Washington setting, the way groups make
their case is by broadcasting their studies.
Lots of battles are battles of
information. . . . Given the ideological base,
[the proposal] depends on affordability,
costs, and who benefits. Therefore, modeling
173
the questions [about LTC policy] is a
contribution to the LTC debate.
A congressional staff member described the scrutiny given to the
sources of data in the culture of analysis:
The approach to analysis is combined with
where the data come from. If a group comes in
with a paid-for study and I look at its
results, I might discount some. A study by
the Congressional Budget Office (CBO) is more
objective, and I can use these numbers. I
look for objective studies. Even if you agree
with someone you think is objective, you will
be questioned on the source of the numbers.
It is hard to make an argument if it is not
solid data. In LTC, modeling has been used
most often with cost benefit analysis. Cost
benefit helps to make decisions about what is
a good idea. When you look at benefits and
costs that CBO puts numbers to [estimates
costs for], it's very useful. Coalitions'
cost benefit numbers are not as useful.
Cost benefit analysis and the role of CBO in estimating
costs of proposed legislation were identified by several
informants as crucial to LTC policy proposals being taken
seriously in the process of adopting national LTC legislation.
One congressional staff member commented:
To get anything through [enacted], must go
through the green eyeshades: CBO, the Joint
Economic Committee, the Office of Management
and Budget. They look at it in[side] and out.
Said another:
Another critical factor [of analysis] is that
you can't enact without a CBO cost estimate.
A Senate staff member explained why cost benefit analysis was an
important analytic approach:
CBO shows you their numbers [about cost of the
bill]. If you make changes to the bill and
save money, it goes through [is adopted] like
that [informant snaps fingers]. Over the long
term, the analysis focuses on financial
issues. . . . Bills need to be budget neutral.
It is difficult to add to the deficit and
increase benefits. Cost benefit analysis data
174
is usually fought over. . . . Cost benefit
analysis is worthwhile and important.
Another Senate staff member noted the strong relationship
between rational analysis and the role of CBO in policy adoption;
If one starts with; this is the problem, how
one wants it fixed, and how one gets from here
to there, then one has to do modeling and
analysis. You can't change the problem, it
remains the same. Only thing you can change
is how to get there [solve the problem]. . . .
If legislation works, you need modeling and
analysis. You can't do anything up here
without CBO giving it numbers [estimating the
cost]. You need a thoughtful structure on how
the [policy] works. Otherwise, CBO can't
score it [estimate the cost] or scores it very
high. Take your pick, but you don't really
have much choice [about doing a rational
analysis].
Combination of Techniques and Other
Approaches to Policv Analysis
One advocate spoke of policy analysis as a combination of
techniques, in particular as a linking of the rational approach to
the political approach. The rational approach is used to develop
the basic policy option, and the political approach is used to
refine it to increase its chances of enactment. This combination
of techniques can be viewed as a link between Radin and Hawley's
(1988) culture of analysis and culture of politics. The culture
of analysis is one where information is a focus and the culture
of politics is one where negotiating agreement on policy is a
focus. An advocate described this link of the two cultures;
You can't get [LTC policy] enacted without
both [political and rational] approaches. We,
with our leadership, decide goals, and strive
toward an objective analysis from the
perspective of [our members] and the good of
the country. We look at the facts. . . . The
problem [is] identified. [We] define policy
options, discuss them, and come to our policy
recommendation. This is a very logical
approach done with every set of [our]
recommendations. To put [recommendations]
175
into law, the political strategy comes into
it. [We] look at goals and ask questions; is
it the correct year to push this? incremental
[change] versus the radical approach? attach
to an existing bill or not? So we do analysis
and then this political strategy.
A menu of approaches was the important analytic strategy for a
Senate staff member. This approach is similar to Majone's (1989)
dialectic approach where policy proposals are openly advocated
through a selection of evidence, argument, and persuasion tailored
to a specific audience. She commented;
No particular kind of analysis [is more
influential] to enactment of LTC policy. One
looks at numbers, cost benefit, and cases like
a study of states doing something innovative.
We look at charts, tables, and more
sophisticated number crunching. Senator "X"
has a clear view and if evidence is there to
support it, that's great. [Analysis] is both
inductive and deductive. We take it all in;
for example, if 17 people made the same point,
maybe we should attend to it and fit it in
[the bill]. We do not depend on any one
approach. We are incorporating a number of
ways to get information to make policy. There
are a menu of approaches.
Majone's theory of the importance of arguments to persuade
decision makers was supported by a House staff member ;
We use argument to get support and win swing
votes or to coerce people on both sides [of
the issue]. [This includes;] members of
Congress, the media, public opinion. We use
data to challenge groups with opposing
opinions.
Pattern Matching
Hypothesis 1 focuses on the importance of a political
approach to policy analysis to formulate proposals which are
influential to the process of adopting national LTC legislation.
The pattern matching technique (Yin, 1989) was used to examine
hypothesis 1. The pattern of the hypothesized relationship was
compared to that of the empirical results to determine if they
176
matched. The hypothesized relationship is presented in Figure 3.
The empirical pattern for the political approach to analysis is
presented in Figure 4. It is based on only the responses of those
six informants who identified political analysis as important to
formulating influential LTC proposals. This figure shows that 33
percent of these informants rated the political approach as very
important. Another 33 percent rated the political approach as
somewhat important. Overall, 66 percent rated the political
approach to analysis as either very or somewhat important. The
remaining 33 percent of informants rated this approach as not
important. When the empirical pattern in Figure 4 is compared to
the hypothesized pattern in Figure 3, they do not match closely.
Hypothesis 1 is not supported by the pattern match or by the
empirical evidence just presented. LTC policy proposals are NOT
given serious consideration in the process of adopting national
LTC legislation when they were formulated by a political approach
to analysis.
Yin has emphasized the importance of examining rival
hypotheses when conducting a case study analysis. A rival
hypothesis is suggested by the fact that rational analysis was
selected most frequently as an important type of analysis (see
Table 13). The rival hypothesis states;
LTC policy proposals are given serious consideration in
the process of adopting national LTC legislation when
they were formulated by a rational approach to analysis.
177
FIGURE 3
POLITICAL APPROACH TO ANALYSIS: HYPOTHESIZED PATTERN
OF THE IMPORTANCE TO INFLUENTIAL LTC PROPOSALS
XXX
XXX
XXX
XXX
XXX
XX
Very Important Somewhat Important Not Important
Importance of a Political Approach to Analysis
Note: X = response by a single informant.
FIGURE 4
POLITICAL APPROACH TO ANALYSIS: EMPIRICAL PATTERN
OF THE IMPORTANCE TO INFLUENTIAL LTC PROPOSALS
XX XX XX
Very Important Somewhat Important Not Important
Importance of a Political Approach to Analysis
Note: X = response by a single informant.
The empirical pattern for the rational approach is presented in
Figure 5. It is based on only the responses of those eight
informants who identified the rational approach as important to
formulating influential LTC proposals. This figure shows that 75
percent of these informants rated the rational approach as very
important. Another 25 percent of them rated it as somewhat
important. Overall, 100 percent rated the rational approach to
analysis as either very or somewhat important. A rival hypothesis
178
FIGURE 5
RATIONAL APPROACH TO ANALYSIS: EMPIRICAL PATTERN
OF THE IMPORTANCE TO INFLUENTIAL LTC PROPOSALS
XXX
XXX
XX
Very Important Somewhat Important Not Important
Importance of a Rational Approach to Analysis
Note: X = response by a single informant.
was not developed and pattern matching was not done for the
combination of techniques approach because only two informants
selected it as important to formulating influential LTC proposals.
The comparison of the empirical pattern in Figure 5 to the
hypothesized pattern in Figure 3 for the rival hypothesis suggests
that the rational approach to analysis may be important in
formulating proposals which are influential in the process of
adopting national LTC legislation. Additional research is
necessary for a thorough examination of this rival hypothesis that
the rational approach to analysis is important to formulate
influential LTC proposals.
Research Results for Hypothesis 2t Creating Coalitions
Introduction
Hypothesis 2 of research question 1 states:
Key actors in the LTC policy arena judge that LTC policy
proposals are given serious consideration in the process
of adopting national LTC legislation when they create or
strengthen coalitions.
179
This presentation of research results summarizes the
informants' judgment of the importance of building coalitions on
influential LTC policy proposals. It also addresses the impact of
coalitions on the process of adopting LTC policy and on the goals
of LTC policy. It ends with a presentation of the match between
empirical responses and the hypothesized pattern and the
conclusion of whether or not the evidence supports the hypothesis.
Importance of Building Coalitions
Informants were asked about the importance of building
coalitions that result in serious consideration being given to LTC
policy proposals in the process of adopting national LTC
legislation. Responses of 76 percent of them concerning the
importance of building coalitions were positive and unequivocal.
Summary comments on importance included; "essential," "critical,"
"definitely important," "without a coalition nothing goes in the
Senate, nothing happens," "the best idea in the world," "the best
shot at getting LTC legislation." The reasons the informants gave
for this importance focused on the impact of coalitions on members
of Congress as well as on public opinion and grass roots support.
A Senate staff member emphasized the dual nature of the appeal to
Congress and the public:
Any policy proposal that a number of different
groups and types of organizations push has a
better chance and wider appeal. It appeals to
members of the Senate and answers to
constituents.
An advocate put it even more strongly:
Coalitions are definitely important because
there are so many disparate groups with vested
interests in LTC. To the extent one can
encourage coalition building, the greater the
opportunity to get a bill passed.
180
Coalitions were seen as more important in the current political
environment of constrained spending than they were in the past.
Several informants mentioned the need for diverse support to
influence Congress to pass an expensive policy, like LTC, in an
era of budget constraints.
Although the informants acknowledged the importance of
coalitions, several informants expressed reservations about
coalitions accurately representing the views of their members.
Some of this concern was related to the congressional experience
with the Medicare Catastrophic Coverage Act. A congressional
staff member described her reservations and how she dealt with
them:
It is a very typical [Capitol Hill] assumption
that Washington officials of coalitions
represent their constituents and do not get
ahead of them. In the coalitions I work with,
I always go outside the Washington
organization to touch base with [grass roots]
to be sure what the Washington group is saying
is accurate.
Said another:
There is some disconnect between advocacy
groups and groups [constituents] they purport
to represent. If AARP membership figures out
what the national organization advocates, they
would be shocked.
A staff member identified a reason for these reservations :
The problem with coalitions is that members of
Congress felt coalitions spoke with the voice
of their constituents. Congress does not feel
this way since the repeal of catastrophic.
They may discount what the coalition thinks
their people [constituents] want [because it
is] not what they reallv want.
In spite of these reservations, coalitions were judged as a
powerful factor in the process of national LTC policy adoption.
181
Building Coalitions and LTC Policy Adoption
Most theorists on the policy process (Nakamura &
Smallwood, 1980; Brewer & deLeon, 1983; Radin & Hawley, 1988;
Stone, 1988) agree on the essential role of coalitions to the
policy adoption process. They highlight the importance of
negotiating, accommodation, and compromise. However, these
theorists give limited attention to the underlying process of how
coalitions influence policy adoption. The specifics of how
coalitions influence the adoption of national LTC legislation is a
re-occurring theme in the interviews of informants. The
informants described two aspects of the influence of building
coalitions upon proposals which are influential to the process of
adopting national LTC legislation. They were:
• Coalitions of interest groups and their influence on
members of Congress, and
• Coalitions of members of Congress and their influence
on adopting LTC legislation.
Coalitions of Interest Groups
Informants frequently discussed LTC coalitions consisting
of interest groups. Coalitions that went beyond interest groups
of the elderly to include groups representing children and working
age adults with LTC needs were identified by informants as
important to frame the issue of generational equity. They felt
that such a coalition was essential to the success of interest
groups of the elderly in influencing LTC policy. It helps them
overcome the image of the "greedy geezers" demanding yet another
publicly-financed benefit.
The high cost associated with many LTC policy proposals in
an era of budget deficits was an issue related to coalitions. One
182
congressional staff member who supported adopting LTC legislation
summed up the cost issue vis a vis the influence of coalitions:
Many accept LTC as a good thing, but it can be
expensive. Because LTC looks like a high
cost, it is politically vulnerable. So it
becomes an issue of: LTC is a great idea, but
when we get the dollars we can do it. But
[LTC is] not the first concern of Congress.
This is why coalitions are important.
Coalitions attempt to influence members of Congress to
adopt LTC legislation in two ways. The first way is to appeal to
their altruism by raising their interest in helping vulnerable
groups. A congressional staff member described this approach:
Coalitions have the ability to personalize
issues. They put a face of someone in the
Congress member's district or state on the
issue.
The Alzheimer's Association was identified several times as an
interest group that created opportunities to personalize LTC.
They held receptions for Congress members and their staff to meet
the victims of Alzheimer's Disease and their families. Families
talked about their struggles in caring for their members with
Alzheimer's Disease who needed supervision 24 hours a day.
The second way that coalitions attempt to influence
members of Congress to adopt LTC legislation is by applying
political pressure at the grass roots level. A congressional
staff member gave an illustration of this approach which she
labeled as an example "in gross political terms":
A variety of people of children's groups,
family groups, Alzheimer's Association, and
the AARP go together into a Congress member's
office. They say: "We are from your state or
your district. We are here to tell you that
LTC is important, and we will make our
decision in the next election on your actions
on this issue."
183
Of course, not all representatives of interest groups are from the
Congress member's state or district. When interest groups and
grass roots representatives do not work together for a common
goal, tensions between the two can arise. A Senate staff member
described the consequences of the tensions:
The connection between grass roots and
Washington interest groups is an eternal
dilemma. The political currency of interest
groups comes and goes. Children's advocacy
groups are the vogue now. Before, it was
elderly's advocacy groups. Interest groups
can't be pitted against meaningful grass roots
[concerns]. Grass roots lose if interest
groups with resources lobby [the Senate].
Informants identified the specific actions of coalition
representatives that influence Congress as members consider
adoption of national LTC policy. Lobbyists can serve in a variety
of roles: analyst, liaison, and policy maker. One staff member
described the role of the lobbyist as analyst or advisor:
Lobbyists explain problems [of policy
proposals] to members and staff. They explain
the effect of various proposals on the
member's constituents. They can give a
realistic picture of what the up and down
sides are. The best lobbyists do that so
congressional representatives do not get
blind-sided.
Radin and Hawley (1988) noted the importance of interest groups in
linking the stages of the policy process. Informants described a
similar linkage occurring within Congress. A congressional staff
member described the role of the lobbyist in linking members of
Congress together to form a congressional coalition :
Coalitions help bridge gaps between members,
especially those who are not used to working
together and are not ideologically compatible.
For example, lobbyists say: "Representative X
supports this proposal due to . . ."
A third staff member focused on the lobbyist as policy-maker and
negotiator:
184
Coalitions can help to come up with
compromises in a bill. This is because they
talk to all the parties.
Coalitions of Members of Congress
Coalitions within Congress were identified as a critical
factor in adopting national LTC legislation. Coalitions were seen
as even more critical to the Senate because of the possibility of
filibuster. The building of coalitions among members with common
interests and even among what one staff member called "odd
bedfellows" were common themes of the informants. An example of a
LTC coalition of key members of the Senate is illustrated by the
letter in Appendix B. Five Senators signed a "Dear Colleague"
letter as a strategy to create a coalition of Senators supporting
LTC. One aspect of the strategy was to support LTC coverage in
health care legislation that is expected to pass this year.
Another aspect of the strategy was to include the chairs of the
Senate Committees and Subcommittees concerned with LTC issues and
the health of families. The intent of the letter was to show that
these Committee and Subcommittee chairs who are knowledgeable
about LTC see it as an issue of importance to the entire Senate.
There is a significant omission from the list of sponsors. It is
the chair of the Senate Committee on Labor and Human Resources
(Kennedy). The full Committee on Labor and Human Resources
considers health legislation, including LTC issues. Also missing
from the list of sponsors is any attempt at a bipartisan strategy.
The ranking minority members of the appropriate Committees and
Subcommittees are not included.
The building of coalitions within Congress differs by
chamber. Because 60 votes are needed in the Senate for cloture of
a filibuster, coalition building within the Senate is critical to
185
adoption of legislation. One Senate staff member who had worked
previously in the House highlighted the differences:
The House builds on traditional coalitions in
terms of natural and strategic allies to move
specific legislation. But in the Senate, the
determination of one member can lead to a
filibuster. So the Senate also needs
coalitions to bring Republicans along due to
the Senate's nature, filibuster rules, and the
slim Democratic margin. So the Senate has an
additional hurdle. That is where things get
tricky and tough: to find overall issues that
are powerful enough to bring Senators on board
and support things a member wants or does not
want. It is harder for Senators to get the
one thing in legislation that they want. It
is much harder (to build a coalition] in the
Senate. Senate coalitions need every member
to get the 50 votes needed to cut debate and
vote on the bill. There is a different kind
of coalition building in the Senate on much
more specific issues. [Members supporting a
proposal] need to find issues powerful enough
to bring other Senators on board.
When a coalition within the Senate cannot be built, the approach
for adopting legislation that contains the specifics desired by a
member is less strategic and more one of chance and opportunity.
The outcome of this approach is less certain, and the strategies
to obtain the preferred provisions emerge as the situation
unfolds.
A Senate staff member described the approach:
We have to scale back the proposal and water
it down so the core provision passes and try
to get back [what we gave up] during the
conference. One can get a little back in
conference if one really cares about the
provision. Though you never want to hope for
the conference [as a strategy], often times
you are relegated to that. It depends on if
something is substantially in the House bill
and is not a deal breaker in the Senate.
Then, the Senators can vote on the conference
report.
186
Coalitions and Policy Goals
The need of a coalition to gain policy consensus often
results in goals that are vague, diverse, and sometimes
conflicting (Nakamura & Smallwood, 1980; Radin & Hawley, 1988;
Stone, 1988). Excimples provided by informants confirm the
conclusions of these theorists. One advocate noted:
Getting specific when designing a [LTC]
program can make or break a coalition. There
is a level at which everything makes a
difference, depending on the interest groups.
It depends on who joined the coalition and
what the goal is.
One congressional staff member observed that:
A problem with coalitions is that one is
forced to be so specific to include a
particular one's issue or so general to
include everyone's issue that it can adversely
affect the proposal.
Another staff member commented on vague goals:
Anytime you have a coalition, a bill may not
be as sharp as it might be. From the
standpoint of getting the coalition to come
together, it makes the bill more squishy so
everyone can agree.
Several informants described problems with the political
feasibility of policy goals developed by coalitions. Some
coalitions were seen to have limited impact on LTC policy
adoption. Their positions were so expensive, and so extreme in
demands that they were not politically feasible. A congressional
staff member spoke of his experience in trying to create a LTC
coalition among similar interest groups. Their common perspective
resulted in "a feeding frenzy where participants try to out-
radical each other." They try to out-do each other in proposing
radical, expensive provisions for the coalition's policy goals.
The staff member viewed this phenomenon as occurring because "few
187
members [of interest groups] want to be bad guys by being
[politically] realistic."
Pattern Matching
Hypothesis 2 focuses on the importance of building
coalitions to proposals which are influential to the process of
adopting national LTC legislation. The pattern matching technique
(Yin, 1989) was used to examine hypothesis 2. The pattern of the
hypothesized relationship was compared to that of the empirical
results to determine if they matched. The hypothesized
relationship is presented in Figure 6. The empirical pattern
based on the informants' responses is presented in Figure 7. This
figure shows that 13 of the 17 informants (76 percent) rated
building coalitions as very important. Three informants (18
percent) rated building coalitions as somewhat important.
Overall, 94 percent rated building coalitions as either very or
somewhat important. Only one informant (6 percent) rated this
feature as not important. A comparison of the empirical pattern
to the hypothesized pattern highlights the extremely close match
between the two.
Because of the extremely close match of patterns and the
empirical evidence which supports— and expands— on theories about
the importance of coalitions to policy adoption, hypothesis 2 of
research question 1 is very strongly supported. LTC policy
proposals are given serious consideration in the process of
adopting national LTC legislation when they create or strengthen
coalitions.
188
FIGURE 6
BUILDING COALITIONS: HYPOTHESIZED PATTERN OF THE
IMPORTANCE TO INFLUENTIAL LTC PROPOSALS
XXX
XXX
XXX
XXX
XXX
XX
Very Important Somewhat Important Not Important
Importance of Building Coalitions
Note: X = response by a single informant.
FIGURE 7
BUILDING COALITIONS: EMPIRICAL PATTERN OF THE
IMPORTANCE TO INFLUENTIAL LTC PROPOSALS
XXX XXX X
XXX
XXX
XXX
X
Very Important Somewhat Important Not Important
Importance of Building Coalitions
Note: X = response by a single informant.
Research Results for Hypothesis 3:
Limiting Policy Change
Introduction
Hypothesis 3 of research question 1 states:
Key actors in the LTC policy arena judge that LTC policy
proposals are given serious consideration in the process
of adopting national LTC legislation when they limit the
extent of change from existing policies.
189
This presentation of research results summarizes the
informants' judgment of the importance of limiting the extent of
policy change on influential LTC policy proposals. It addresses
why limited policy change is influential in the process of
adopting LTC policy and examines incremental policy change as a
strategy for adoption. It also examines the impact on policy
change of the risks inherent in making LTC policy choices,
especially the influence of the repeal of the Medicare
Catastrophic Coverage Act. It ends with a presentation of the
match between empirical responses and the hypothesized pattern and
the conclusion of whether or not the evidence supports the
hypothesis.
Importance of Limiting the Extent of Policy Change
Informants were asked about the importance of limiting the
extent of policy change that resulted in serious consideration
being given to LTC policy proposals in the process of adopting
national LTC legislation. Because informants consistently used
the term "incremental" to describe proposals which limit the
extent of policy change, that term will appear frequently in the
analysis. Seventy-six percent of the informants judged
incremental policy change as very important to LTC policy
proposals being influential in the process of adopting national
LTC legislation. Eighteen percent (3 of the 17 informants) had
the opposite view that incremental policy change was not
important. A congressional staff member saw it as a standard
policy approach of Congress:
Traditionally on the Hill [they] have some
sort of incremental reform because it is
easier to pass, more likely to pass.
Another congressional staff member said:
190
Incremental policy change is important to
enactment. [There is) not much stomach in
Congress to create a new entitlement. . . .
The incremental approach is much more doable.
A third congressional staff member linked incremental policy
change to interest groups:
Yes, incremental legislation is important
because it hampers, but does not decrease the
power of interest groups. But, groups bitch
and moan about incremental legislation because
it does not give them the provisions they
want.
Radin and Hawley (1988) noted that the milieu of the Congress
serves to limit the extent of policy change. The political
advantages and the political costs of a proposal are major
considerations that are weighted carefully. A congressional staff
member provided insight into incremental policy and the
congressional milieu:
Limited extent of change makes enactment more
likely because Republicans and moderate
Democrats are not as afraid of them. The
American public is not as afraid of them.
When LTC policy is proposed, lots of people
believe it is great, but they do not want to
pay for it. Incremental changes in policy are
easier to enact. . . . Over time, people on
the Hill become more incrementally oriented.
[Those with] radical views get shot down so
much, they become incrementalists. [There is]
more tendency for Congress to be
incrementalists in this milieu.
Informants related the environment of constrained
resources to the influence of incremental change on LTC policy
proposals that are seriously considered in the process of adopting
national LTC legislation. Costs in a political environment of
constrained resources was one of the crucial factors identified by
Reischauer (1990) in his theory about the impact of changes in the
political environment on the adoption of contemporary social
policy. One advocate commented: "from the perspective of money.
191
incremental policy is easier." Said another: "It makes enactment
more likely because the policy is cheaper and builds on 'what is'
without major change." A third advocate said:
From what I observe, unless there is a huge
public consensus and agreement on what to do—
an absolute ground swell— we need incremental
policy in tight budget years.
Another advocate commented on the cost issue in relation to LTC
policy:
Incremental approaches are more politically
feasible because of financial issues.
{Congress] is not able to spend money [given
the deficit]. If it wants to do a
comprehensive solution, it would be much more
expensive. Incremental policy changes are
tied in with costs. Lots of people feel some
reform has to happen, and incremental changes
would be easiest to happen now.
Congressional staff members made similar judgments. One
commented:
For the past ten years. Congress has tinkered
with incremental changes in LTC policy, like
Medicaid, quality assurance and, especially,
home care. But [policies] with large
expenditures are more risky.
Even within incremental policy options, costs were an issue. An
informant said: "incremental changes with little or no costs are
easier to enact than those with big costs."
The Strategy of Incremental Policy Changes
Some informants saw incremental policy change as part of a
broader strategy for enactment. One enactment strategy related to
incremental changes was in restricting policy changes so they
belonged under the jurisdiction of only one congressional
committee. One advocate said:
Importance of jurisdiction [is critical] in
Congress. Programs that have incremental
change don't step on jurisdictional "toes."
For example. Medicare is an established
192
program for which incremental changes are
handled by Energy and Commerce [Committee]
which has jurisdiction versus new programs
where one doesn't know where they belong. The
jurisdiction issue is important, especially if
the proposal is only relevant to one
committee. For example, Stark's subcommittee
developed a Medicare Part C proposal [for
health care reform] because it is responsible
for Medicare legislation. Look at Waxman's
subcommittee and its incremental strategy for
Medicaid legislation.
Another strategy was to enact incremental policy changes
in stages so that over several years comprehensive changes were
adopted. A congressional staff member commented: "incrementalism
is a way to move through steps to larger LTC policy changes."
Waxman's incremental approach over the past decade in expanding
Medicaid to cover more services and additional groups of
beneficiaries (Morgan, 1994) was given as an example by several
informants of the impact that yearly incremental changes in policy
can have over the long run.
Most informants agreed that incremental policy change was
influential to LTC proposals being taken seriously in adopting
legislation. However, some saw incremental policy change as
ineffective. A few viewed incremental change as so ineffective
that it created an impetus for comprehensive change to address
public problems. In this view, incremental policy change is a
genesis for comprehensive policy change. A congressional staff
member said:
There is a tendency of Congress to pass
incremental change and try a number of
different incremental changes until they
realize that incremental change does not
address the problem. Then they pass more
dramatic change.
One Senate staff member from the majority side discussed the
genesis of comprehensive policy change from incremental change:
193
In health policy, its history has been
incremental. But, this has brought us to
comprehensive health care reform [policy].
Since over time we have built up an elaborate
and complex system that still doesn't fix the
major problems. Slow [incremental] Medicaid
expansion could never attempt to solve larger
problems of the under insured. [Congress is]
continually burdening the system with
incremental improvements. But it's the best
one can do in a Republican administration
given the President's veto power. To hold on
[to existing policy] is a miracle given the
numbers of supporters in the Senate. So
incremental is what we have seen [enacted].
Eventually it has a stopping point where
something more significant has a better
chance. Health care reform is an example.
[There is] not a lot of disagreement that if
Congress only does minor changes, like tort
reform and easy insurance reform, [the
country] can end up with single payor [health
reform] down the road. But people are
suffering in the meantime. If we cover a few
more every year [by incremental legislation],
it's better than letting the system implode.
Another congressional staff member spoke of an incremental
strategy for LTC policy which could be the genesis of a more
comprehensive policy:
With a LTC proposal like this [comprehensive
change], it is just as important to layout the
framework it will be build upon. It is
unlikely we will have dramatic policy change
in LTC. We can work now on better criteria to
set out a framework to build on in the future.
A third staff member commented on this same strategy:
The impact of incrementalism [on enactment]
has to do with the continuum of policy change.
Anything in LTC can be changed in a step-wise
process. It may not be the most fair and
equitable thing to do, but it could be done.
An additional issue [raised by this approach]
is if I start by using an incremental approach
to policy change, will I reach my goal. But
this is a different question.
Two advocates and one congressional staff member saw the LTC
policy option in the Health Security Act as a lever to gain
194
support for adoption of the Act. The congressional staff member
described the strategy:
[You] need seniors behind you to pass health
care reform legislation. If its financing
goes to [depends on] Medicare and Medicaid
[savings] and Medicaid does not have a
political constituency, supporters [of the
legislation] need to have grass roots behind
them. If they cut Medicare by $100 billion,
must give something back to the elderly in
return. The President struck a good political
balance [in the Health Security Act]. The
elderly can get something for the Medicare cut
back— drugs and LTC.
One advocate who spoke of this strategy admitted that it had
serious problems :
The problem with this scenario is that LTC
makes things more expensive and the lack of
[grass roots] support for it.
Risks Inherent in Policv Adoption
Risks inherent in making decisions about what policies to
adopt are seen as a major factor influencing incremental policy
making (Brewer & deLeon, 1983). The process of policy adoption is
fraught with uncertainty, uncertainty about the balance between
facts and values, about unintended consequences, and about
maintaining voter approval. Often the risks seem so great that
negative public policy is the result (Brewer & deLeon, 1983;
Anderson, 1990). Negative public policy is an active choice by
policy makers not to make a policy decision.
The risk of unintended policy consequences in LTC was a
recurring theme in the discussion of adopting incremental policy.
These risks generally are associated with two factors: limited
information and lack of a consensus about private-public
responsibilities for financing. Information is limited about who
would use a comprehensive LTC public benefit if it were available.
195
The concern is that the cost of the policy would be much higher
than projected because the estimate of the number of beneficiaries
was too low. No public consensus exists about whether the
financial responsibilities for LTC belong to the government or to
the individual who would rely on privately purchased insurance to
cover catastrophic costs. One congressional staff member
commented on risks and incremental policy:
Incremental policy is important to enactment
because I don't think most people view radical
change as favorable. [This is ] because the
level of uncertainty is unimaginable and
defends the status quo, [We need to] lead
people gradually. Most successful policies
have blind effects and [a policy maker] is not
sure the policy is [solves the problem] as
expected.
Kirlin (1984) described a shift in public policy strategy
to a temporary, reversible, and malleable policy to deal with
changeable, ill-defined, and difficult public problems. A
congressional staff member highlighted the ability of incremental
changes to minimize the negative impact of enacting policies where
the effects of making many untested changes are unknown:
It is easier to get [incremental LTC policy]
enacted because there is less anxiety about
outcomes so [we] can evaluate policy and
change it. There are lots of unknowns when
dealing with federal legislation. I know when
[we] provide a societal "good" with a
proposal, it can still wreak havoc with half a
million lives. The more incremental, the
better the proposal. People trust them. [We]
must consider how rarely with bills there are
100-percent winners, or where people are left
neutral [unaffected]. [There is] anxiety
about the unknown. Future risks are hard to
predict and [can] wreak havoc with lots of
lives. For example, in health care reform we
are clue-less about who incremental change
will affect, and there are 4,000 changes.
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Estimating the cost of LTC policies in the future was seen as a
major risk resulting in preferences for adopting incremental LTC
policy. One congressional staff member commented:
The future risks of increasing cost is huge.
[The fear in Congress] of an uncapped
entitlement program gone awry is a big
problem. No good numbers for estimating costs
and for what happens with universal coverage.
Now 80 percent of LTC is informal [provided by
family and friends]. Estimating new large
entitlement for new services scares members of
Congress, LTC insurers, and number crunchers.
Another staff member said:
If [Congress] implements a comprehensive
program with all pieces in it, we rely on each
other to look at the demographic effects [of
the future growth of the disabled elderly
population]. It is frightening to consider.
It [financing] can all fall apart. We need to
look beyond the current Congress and
administration. When I listened to Gail
Wilensky [administrator of the Health Care
Financing Administration in the Bush
administration] talk about Medicare and how
their projections of costs were way off [under
estimated], I see it [happening] now for LTC.
So incrementalism is the most likely and the
most useful [approach].
As Brewer and deLeon (1983) indicated, making policy decisions is
associated with a risk of losing voter approval. The shadow of
the congressional experience with the repeal of the Medicare
Catastrophic Coverage Act was identified by informants as
influencing the adoption of an incremental LTC policy. Radin and
Hawley (1988) noted that the political milieu of Congress
emphasized concern with political advantages and political costs.
One congressional staff member noted that Congress is "not sure
what the elderly really want." A Senate staff member commented on
political costs:
Few Senators are willing to go on the line for
LTC because they don't want to fail and expend
their political capital for an issue that has
a small chance of succeeding.
197
Although the long-range effects of the negative grass roots
reaction are unclear, the risk of losing voter approval left
Congress uneasy. It may have a chilling effect on future
legislation targeted to the elderly. A House staff member spoke
of the impact:
There is a risk. The House was embarrassed
with catastrophic care repeal. Members do not
know what to do about [preventing a similar
occurrence], but the problem is in the back of
their minds. I don't thing catastrophic
appeal has a dampening effect [on LTC].
Members just don't know what to do with
information about the repeal. For
Representative X, catastrophic repeal is in
the back of his mind, but it does not dampen
his initiative, does not discourage him from
doing things.
A Senate staff member commented:
With all the Senate health care reform debate,
I don't hear catastrophic mentioned that
often, so I don't know its impact. If LTC
were only focused primarily on the elderly, I
think catastrophic would have an impact. If
LTC is broad based [covers all ages], then
catastrophic has less impact.
Pattern Matching
Hypothesis 3 focuses on the importance of limiting the
extent of policy change to proposals which are influential to the
process of adopting national LTC legislation. The pattern
matching technique (Yin, 1989) was used to examine hypothesis 3.
The pattern of the hypothesized relationship was compared to that
of the empirical results to determine if they matched. The
hypothesized relationship is presented in Figure 8. The empirical
pattern based on the informants' responses is presented in Figure
9. This figure shows that 13 of the 17 informants (76 percent
rated limiting the extent of policy change or incremental change
198
FIGURE 8
LIMITING THE EXTENT OF POLICY CHANGE: HYPOTHESIZED
PATTERN OF THE IMPORTANCE TO INFLUENTIAL LTC PROPOSALS
XXX
XXX
XXX
XXX
XXX
XX
Very Important Somewhat Important Not Important
Importance of Limiting the Extent of Policy Change
Note: X = response by a single informant.
FIGURE 9
LIMITING THE EXTENT OF POLICY CHANGE: EMPIRICAL
PATTERN OF THE IMPORTANCE TO INFLUENTIAL LTC PROPOSALS
XXX X XXX
XXX
XXX
XXX
X
Very Important Somewhat Important Not Important
Importance of Limiting the Extent of Policy Change
Note: X = response by a single informant.
as very important. One informant (6 percent) rated it as somewhat
important. Overall, 82 percent rated limiting the extent of
policy change as either very or somewhat important. Three
informants (18 percent) rated this feature as not important. A
comparison of the empirical pattern to the hypothesized pattern
highlights the close match between the two.
Because of the close match of patterns and the empirical
evidence which supports— and expands on— theories about the
199
importance of incremental change to policy adoption, hypothesis 3
of research question 1 is supported, but with some reservations.
The reservations concern the fact that the pattern is not as
strong as that for building coalitions. Ninety-four percent of
informants judge building coalitions as either very or somewhat
important (see Figure 7). The comparable figure for limiting the
extent of policy change is 82 percent. The conclusion, with
reservations, is that LTC policy proposals are given serious
consideration in the process of adopting national LTC legislation
when they limit the extent of change from existing policies.
Research Results for Hypothesis 4; Skillful Interaction
of Advocates With Congressional Staff
Introduction
Hypothesis 4 of research question 1 states;
Key actors in the LTC policy arena judge that LTC policy
proposals are given serious consideration in the process
of adopting national LTC legislation when the advocates
of the proposals are skillful in interacting with
congressional staff.
This presentation of research results summarizes the
informants' judgment of the importance of skillful interaction of
advocates with congressional staff on influential LTC policy
proposals. It examines the various roles of advocates in their
interaction with congressional staff. It addresses the impact of
skillful interaction of advocates on the process of adopting LTC
policy. It also examines the relationship between advocates and
congressional staff members. It ends with a presentation of the
match between empirical responses and the hypothesized pattern and
200
the conclusion of whether or not the evidence supports the
hypothesis.
The Roles of Advocates in Their Interaction
With Congressional Staff
Informants were asked about the importance of advocates
being skillful in interacting with congressional staff in
influencing which LTC policy proposals are given serious
consideration in the process of adopting national LTC legislation.
Seventy-one percent of the informants judged skillful interaction
of advocates as very important to LTC policy proposals being
influential in the process of adopting national LTC legislation.
Several theorists have addressed the roles of the advocate
in the policy adoption process. Meltsner (1976) labeled advocates
as entrepreneurs when they were not only analysts, but also
excellent communicators. Jenkins-Smith (1990) called them issue-
advocates because they are actively involved in influencing the
adoption of their organization's preferred policy. In Majone's
view (1989), the distinction between policy analyst and advocate
is artificial. Both roles are performed by the same individual.
His view is supported by the comments of informants who made no
distinction between analysts and advocates. Informants identified
a variety of roles for advocates who interacted with them about
LTC policy. They were most frequently identified as educators.
They were described less often as either technical assistants or
actual authors of legislation.
From the perspective of some congressional staff members,
the role played by advocates in their interactions on LTC policy
was as an educator. Said a congressional staff member:
I know where advocates are [i.e., their
views]. I listen because I can learn
201
something.
people.
I need knowledge from these
Said another:
[When I talk with advocates], I have an
information gathering campaign to anticipate
pitfalls in drafting new policy and problems
that policy as currently written have.
A House staff member described the skills of an advocate who plays
an educator's role:
Some advocates are more effective that others.
It varies by person, by their knowledge base,
and by the information they present. I want
information. I like people to give me
information as long as they know their
material. [They get] no time if they scream a
lot [about their policy preferences], but if
they don't, [discussions with them] are
helpful.
One congressional staff member was straightforward in identifying
a reason for this emphasis on the educational role of advocates.
She commented:
Certainly interaction has impact. It depends
on what the information is. Whenever I am
visited by a lobbyist I get a certain amount
of education. Normally, what I do is accept
certain ideas and reject others through my
political, philosophical, and financing
beliefs. This is different from [the
description in] newspapers. The way they
define "influence" [on Capitol Hill] is as
"bought" rather than "educated."
Some congressional staff members described skillful
interaction of advocates as a two-way dialogue and an approach to
develop a common position on an issue. This role supports the
findings of Radin and Hawley (1988) on the emphasis on consensus
building. A congressional staff member described the process in
general:
We look to advocates for expertise and
appraisals, to evaluate proposals and
[determine if] they meet the needs of
constituents. We try to address the problems
[identified]. It is a two-way dialogue. We
202
try to generate consensus. Achieving
consensus is always hard, but it depends on
the proposal.
Another congressional staff member gave a specific example which
highlights the difficulty of building a consensus :
We tried to work with AARP and said "try to
develop a fall- back position (to your LTC
proposal]. Look at something less that a new
non-means tested benefit [you propose]. Think
of a fall-back position of a program of means
tested benefits and improvements of
Medicaid. . . . Consider both approaches so we
have a fall-back position." It falls on deaf
ears. At the last minute [when enactment is
near], they may want to compromise.
Advocates, in contrast, had a variety of perspectives on
their role in interacting with congressional staff. Some saw
their role as educator, others as technical assistant, and still
others as providing language for LTC bills. One advocate spoke
specifically of the educational role;
Interaction helps the congressional staffers
get a better picture of what's out there. It
is an education and briefing of staff members
to tell staff the issues of the future. We
come in and explain expenses, costs, public
programs, and costs of public-private
partnerships.
Another advocate spoke of a technical assistance role;
(My interaction] with congressional staffers
is of a technical assistance variety. I have
not provided language or rewritten a LTC bill.
I respond to questions to clarify the proposal
I advocate or to clarify differences with
alternative approaches, both the conceptual
and empirical sides. It is seen as technical
assistance to the House and Senate. Some
staffers are from the minority side, but my
interaction if mainly with the majority
staffers.
Other advocates described entrepreneurial roles in
influencing legislation. They spoke of helping to shape LTC
legislation. One advocate described the process :
203
I have some interaction with House Committees
X and Y and with Senate Committee Z. I have
discussions with them. I would like to think
it helped shape things, influence them to some
extent. But, the people I talk to are
ideologically inclined in the way they want to
go. The problem is that they face
constraints. What [bills] they can get out of
their Committee and how much money they are
told to "think about" are major constraints.
I describe the extent [that their proposals]
are inadequate [so they are] sure of the
limitations of what they are proposing.
Another advocate spoke of more direct influence on LTC
legislation:
A lot of what I do [analysis] makes its way to
the Hill. For example, I did an analysis of
LTC aspects of X's bill which made them change
things [provisions]. I exchanged a paper with
congressional staff about LTC benefits and
options. I went to meeting with staff and had
some involvements with Y's proposal on LTC.
The Impact of Skillful Interaction on
Adoption of LTC Legislation
Congressional staff described how the skillful interaction
of advocates influenced LTC policy adoption. Several spoke of how
they and, through them, members of Congress were influenced by
interaction. The interaction influenced their views and, in some
cases, their decisions about LTC policy. Majone (1989) described
the critical role that persuasion plays in interaction by
redirecting attitudes, preferences, and beliefs of decision
makers. He saw persuasion by advocates as essential to overcome
standard patterns of thinking and stereotypes of decision makers.
A Senate staff member described the influence of advocates on
members of Congress:
In my job, I gather information from people
[advocates] who have different opinions. I
sort through it and advise Senator X about who
thinks what. He makes the decisions. My boss
may agree or not with [advocates], but he uses
their information to make his decisions.
204
The influence of skillful interaction of advocates was not
confined to the Senate. A House staff member commented:
I feel policy interaction [with advocates]
influences me in a positive way. I learn from
people. They provide me with an education.
Information from a policy or political
perspective affects my judgment and the
judgments of the members of Congress.
Another Senate staff member commented on how the skill of a
specific advocacy group in interacting with Congress can influence
LTC policy adoption:
Some of the people I listen to are from AARP.
I want to know what they are saying because we
have to make people happy about our laws. For
example, AARP is making a full court press for
the positive [LTC] provisions [in health care
reform]. And the Committee wants to know
where AARP is coming from. If five members of
the Committee [support AARP's view], then AARP
has influence [in enactment of LTC
legislation]. AARP has good technical people.
A House staff member described the impact of interaction
with advocates of coalitions on the willingness to enact or re
authorize a law:
I view my job as a service oriented job. I
help people, and I do not do [help enact] laws
for nobody. Coalitions are a way to say who
you do a law for. Usually people [advocates]
come up [to see me]. Changing a law is a long
process. It takes six years for changing any
law. We do a law change to solve problems.
Then if advocates feel we have not fixed the
problem, it is a waste of time.
Advocates agreed with the views of congressional staff
members on the impact of skillful interaction and persuasion on
LTC policy adoption. One saw interaction as crucial:
Interaction [between advocates and
congressional staff] is the ball game. The
more congressional staff that are players, the
more likely you are to interact and involve
them. [This is] important because Congress
enacts the legislation, and the proposal has
to be something they want to do.
205
Another advocate described the influence of skillful interaction
on both the staff and members of Congress, but felt that the
impact was not a certainty;
Interaction could influence [enactment of LTC
policy] to the extent that it makes provisions
clear and makes a case for them. This
influences the congressional staff position
and ultimately influences the Congress
member's position. There is a better chance
if one has dialogue [with congressional
staff], but it does not necessarily affect
outcome [enactment].
Relationships Between Advocates and
Congressional Staff Members
Theorists have identified a tendency for advocates to seek
out like-minded clients (Jenkins-Smith 1990; Weimer & Vining,
1989). Meltsner (1976) described a mutually dependent
relationship between the two. Advocates seek clients to provide
the power to adopt the preferred policy. The clients, in this
case the congressional staff members, expect the advocate to
provide policy proposals which take political feasibility into
consideration. Meltsner identified shared general values, such as
the view of the role of government, as critical to building
confidence and a mutually dependent relationship between advocate
and client. His views about the relationship and shared values
are supported by the emphasis that congressional staff members
gave to the ideology of the advocates. Congressional staff
commented frequently about the influence of the advocates'
ideology on the information they provided. A Senate staff member
spoke of strong ties based on shared values and a mutually
dependent relationship;
Some advocates have a special relationship
with the Senator as a function of their
pushing hard on [previous] LTC bills and
developing them over time.
206
One congressional staff member identified how differences in
values among the key actors in the LTC arena influenced her
reactions to their proposals:
I think we all learn from each other. [There
are] different camps of thought. AARP wants a
full social program regardless of costs. . . .
[Administration officials X and Y] have a
specific background, and they have a bias
against LTC insurance. . . . I can appreciate
how they got to [their proposal] and not agree
with it philosophically. They used some
[questionable] assumptions and bad data. Data
adds to credibility. They had a different
idea of basic assumptions.
Another staff member made similar comments about the impact of
ideology:
Washington lobbyists, for what they are worth,
can give good information about what they are
working on and their needs. [They do this]
through their discussions and their
information, although their philosophy is
attached to it.
The negative impact of advocates seeking like-minded clients was
discussed by a congressional staff member from the minority side
of a Senate subcommittee:
It is very curious that many groups never call
[me]. I am here [working for the
Subcommittee] for four years. I know that
many interest groups know that I am the LTC
representative. It is the decent [competent]
lobbyist's job to talk [to appropriate staff].
It's not just me, I work for the minority
party and my colleagues do not have
interaction either. How can there be
bipartisan consensus if one of two parties is
not included in the discussion? . . . I don't
know if some [advocates] really are interested
in compromise. I don't see them working both
sides of the isle. This upsets the Republican
members of Congress.
Meltsner (1976) characterized the relationship between
advocates and clients as complementary. The advocates provide
proposals and arguments that congressional staff can use in
negotiating and staff members provide political constraint
207
assessments to advocates to use in modifying their proposals.
However, the complementary relationship is not without its
tensions. Radin and Hawley (1988) characterized the relationship
as often uneasy. Advocates want specific reactions and
commitments to their preferred policy proposals, while decision
makers strive to remain non-committal to allow room for bargaining
and compromise. Informants' comments emphasized the tensions and
uneasiness of the advocate-congressional staff relationship. A
congressional staff member commented:
What bears on the process [of interaction] is
to weed out the issues that are self-serving
from what are policy-oriented and applicable
on a national level.
Another staff member expressed the frustration that can occur with
interaction:
The most striking thing I find about advocates
is that they say one thing to me on the phone
or in my office and then a different thing in
a public forum. In their business they are
not as forthright when the camera starts
rolling. Every group advocates policies with
their last breath. They say they are
concerned about the economy and fiscal
strength. Senator X, my member, is extremely
fiscally conservative. Advocates agree on the
phone [with his fiscally conservative
position], but not when they come up to
Capitol Hill to lobby.
A Senate staff member gave a specific example of the tensions
inherent in interacting with advocates to try to develop a
compromise. She describes the process of developing legislation
about paying for the cost of nursing home care under Medicaid.
One provision was to protect the healthy spouse from
impoverishment when the ill spouse "spends down" assets to become
eligible for nursing home care under Medicaid. Another provision
was to prevent elderly from transferring assets to adult children
208
to become eligible for Medicaid. She spoke of the tensions during
the process and the uneasy relationship that is its aftermath:
For the spousal impoverishment issue I thought
we would be murdered. It is a terrible public
policy to impoverish the spouse. Another
troubling issue was well-off elderly gaming
the system and going to a nursing home at
public expense because they did not want to
drain off the money for inheritance for their
adult children. . . . Before the bill goes to
the Committee, we talk with interest groups X,
Y and Z. After one hour of talking with them,
the Committee staff decided that both aspects
need to be taken into account: spousal
impoverishment and prevention of asset
transfer. At the end of the meeting,
[interest groups] had to choose either both
[provisions] or nothing. Their answer was
"nothing." But, this interaction ultimately
helped us write [exemptions to] the law, like
transfer of assets to a disabled adult child.
I guess it was better than nothing. It colors
our relationship now.
Pattern Matching
Hypothesis 4 focuses on the importance of skillful
interaction of advocates with congressional staff members to
proposals which are influential to the process of adopting
national LTC legislation. The pattern matching technique (Yin,
1989) was used to examine hypothesis 4. The pattern of the
hypothesized relationship was compared to that of the empirical
results to determine if they matched. The hypothesized
relationship is presented in Figure 10. The empirical pattern
based on the informants' responses is presented in Figure 11.
This figure shows that 12 of the 17 informants (71 percent) rated
skillful interaction of advocates as very important. Five
informants (29 percent) rated it as somewhat important. Overall,
100 percent rated skillful interaction of advocates as either very
or somewhat important. A comparison of the empirical pattern to
the hypothesized pattern highlights the match between the two.
209
FIGURE 10
ADVOCATES SKILLFUL IN INTERACTION WITH CONGRESSIONAL
STAFF: HYPOTHESIZED PATTERN OF IMPORTANCE TO
INFLUENTIAL LTC PROPOSALS
XXX
XXX
XXX
XXX
XXX
XX
Very Important Somewhat Important Not Important
Importance of Advocates Who Are Skillful In
Interacting With Congressional Staff
Note: X = response by a single informant.
FIGURE 11
ADVOCATES SKILLFUL IN INTERACTION WITH CONGRESSIONAL
STAFF: EMPIRICAL PATTERN OF IMPORTANCE TO
INFLUENTIAL LTC PROPOSALS
XXX XXX
XXX XX
XXX
XXX
Very Important Somewhat Important Not Important
Importance of Advocates Who Are Skillful In
Interacting With Congressional Staff
Note: X = response by a single informant.
Because of the close match of patterns and the empirical
evidence which supports— and expands on— theories about the
importance of skillful interaction of advocates with congressional
staff members, hypothesis 4 of research question 1 is supported,
but with some reservation. The reservation concerns the fact that
only 12 informants (71 percent) rated skillful interaction of
210
advocates as very important. The conclusion, with reservations,
is that LTC policy proposals are given serious consideration in
the process of adopting national LTC legislation when the
advocates of the proposals are skillful in interacting with
congressional staff.
Research Results for Research Question 2 1
Similar Judgements by Congressional Staff and Advocates
Introduction
Hypothesis 1 of research question 2 states:
Judgments about the important political features of LTC
policy proposals that result in serious consideration
being given to them in the process of adopting national
LTC legislation are the same for congressional staff
members and advocates of policy proposals.
This presentation of research results compares the
judgments of congressional staff to advocates on the importance of
each of the political features of LTC policy proposals examined in
research question 1. These features are:
• Political approach to analysis,
• Building coalitions,
• Limiting the extent of change from existing policy, and
• Advocates who are skillful in interacting with
congressional staff.
This analysis concentrates on the matching of patterns
between responses of congressional staff members and those of
advocates. Each feature is analyzed separately. A conclusion
about the overall hypothesis is also presented. The similarities
and differences between the judgments of congressional staff
members and advocates are examined in this section. A discussion
211
of the implications of any differences between the two groups of
informants is presented in a subsequent section on implications of
research results.
Views of congressional staff and advocates were
hypothesized to be the same because of existing theories about
their similar skills, knowledge, and activities. Because the
theory has been discussed at length in the preceding analysis of
hypothesis 4 on interaction, a summary of only the most relevant
theories is presented here. The skills, knowledge, and abilities
to communicate and negotiate are important qualifications of both
advocates and congressional staff members (Meltsner, 1976;
Kingdon, 1984; Majone, 1989; Jenkins-Smith, 1990). Kingdon (1984)
noted that policy entrepreneurs could be, among others, lobbyists,
members of Congress, and congressional staff. They not only
generate policy positions, but also act as policy brokers by
creating coalitions. Majone (1989) considers the distinction
between analysts and policy advocates as forced and as not
reflecting what actually happens in the policy process.
These theories about similarities between congressional
staff members and advocates are supported by evidence provided by
the informants when they described their previous work experience.
Advocates spoke of previous employment in different policy
settings: Capitol Hill, the executive branch of the federal
government, and research organizations. Congressional staff
members also spoke of previous employment in different policy
settings: interest groups, the executive branch of the federal
government, and research organizations. These shifts in policy
settings occurred for about half of all the informants. Two of
the five advocates had worked in three different policy settings:
212
on Capitol Hill, for the executive branch of the federal
government, and in research organizations. Another advocate had
worked for the executive branch of the federal government and for
research organizations. Two of the congressional staff members
were ranking policy staff in the executive branch in previous
administrations. Another two were staff of research
organizations, and one had worked for over a decade for interest
groups. These shifts in policy settings indicate that
congressional staff and advocates in this case study have first
hand experience about the perspectives and preferences of the
actors in different policy settings.
Research Results
Hypothesis 1 of research question 2 concerns the extent of
similarity in judgments of congressional staff and advocates about
important political features of influential LTC policy proposals.
Their judgments are compared on the importance of the following
political features of LTC proposals:
• Political approach to analysis,
• Building coalitions,
• Limiting the extent of change from existing policy, and
• Advocates who are skillful in interacting with
congressional staff.
The pattern matching technique (Yin, 1989) was used to examine
each part of the hypothesis. For each political feature under
analysis, the pattern of the judgments of the congressional staff
members was compared to the pattern of the advocates.
The first part of the analysis of this hypothesis concerns
those six informants who identified a political approach to
analysis as important. This analysis addresses the similarity of
213
judgments of congressional staff and advocates about how important
a political approach to analysis was to formulating influential
LTC policy proposals. The empirical pattern for judgments of
congressional staff members is presented in Figure 12 and the
pattern for advocates in Figure 13. No advocates selected the
political approach to analysis as being either very or somewhat
important to influential LTC proposals. In contrast, four of the
six congressional staff members judged the approach as very or
somewhat important. As noted previously, most of the six
congressional staff members worked for the minority party. The
patterns do not match. The judgments of congressional staff
members and advocates about the importance of the political
approach to analysis are NOT similar.
The hypothesis on the importance of a political approach
to analysis had a rival hypothesis which addressed the importance
of a rational approach to analysis. This rival hypothesis was the
result of the fact that nearly half (8 of the 17) of the
informants selected the rational approach to analysis as important
to influential LTC policy proposals. This analysis addresses the
similarity of judgments of congressional staff and advocates about
how important a rational approach to analysis is. The empirical
patterns about the importance of a rational approach to analysis
are presented in Figure 14 for congressional staff members and in
Figure 15 for advocates. Three of the four congressional staff
judged the rational approach as very important, and so did three
of the four advocates. The patterns are identical. As noted
previously, most of the congressional staff worked for the
majority party. This is in sharp contrast to the preponderance of
congressional staff working for the minority party who selected
214
FIGURE 12
POLITICAL APPROACH TO ANALYSIS: CONGRESSIONAL STAFF MEMBERS'
JUDGEMENT ABOUT THE IMPORTANCE TO INFLUENTIAL LTC PROPOSALS
CC CC CC
Very Important Somewhat Important Not Important
Importance of A Political Approach to Analysis
Note: C = response by a single congressional staff member.
FIGURE 13
POLITICAL APPROACH TO ANALYSIS: ADVOCATES'
JUDGEMENT ABOUT THE IMPORTANCE TO INFLUENTIAL LTC PROPOSALS
Very Important Somewhat Important Not Important
Importance of a Political Approach to Analysis
Note: A = response by a single advocate. Figure is blank because
no advocates selected the approach as important.
FIGURE 14
RATIONAL APPROACH TO ANALYSIS: CONGRESSIONAL STAFF MEMBERS'
JUDGEMENT ABOUT THE IMPORTANCE TO INFLUENTIAL LTC PROPOSALS
COG C
Very Important Somewhat Important Not Important
Importance of a Rational Approach to Analysis
Note: C = response by a single congressional staff member.
215
FIGURE 15
RATIONAL APPROACH TO ANALYSIS: ADVOCATES'
JUDGEMENT ABOUT THE IMPORTANCE TO INFLUENTIAL LTC PROPOSALS
AAA A
Very Important Somewhat Important Not Important
Importance of a Rational Approach to Analysis
Note: A = response by a single advocate.
the political approach to analysis as most important. This
evidence suggests that the judgments of congressional staff
members and advocates about the importance of the rational
approach to analysis are similar. However, the judgments of
congressional staff working for the majority and minority parties
differed about which approach to analysis is most important.
Staff working for the majority party selected the rational
approach, and staff working for the minority party selected the
political approach. Additional research is necessary for a
thorough examination of the rival hypothesis on the importance of
rational analysis and the influence of the majority versus the
minority parties.
The second part of hypothesis 1 of research question 2
addresses the similarity of judgments of congressional staff
members and advocates about the importance of building coalitions.
Results of a preceding analysis indicate that the building of
coalitions was seen as very important when the judgments of all
informants were examined. The empirical pattern for judgments of
congressional staff members is presented in Figure 16 and the
pattern for advocates in Figure 17. Ten of the twelve
216
, FIGURE 16
BUILDING COALITIONS: CONGRESSIONAL STAFF MEMBERS'
JUDGEMENT ABOUT THE IMPORTANCE TO INFLUENTIAL LTC PROPOSALS
ccc C c
ccc
ccc
c
Very Important Somewhat Important Not Important
Importance of Building Coalitions
Note: C = response by a single congressional staff member.
FIGURE 17
BUILDING COALITIONS: ADVOCATES'
JUDGEMENT ABOUT THE IMPORTANCE TO INFLUENTIAL LTC PROPOSALS
AAA AA
Very Important Somewhat Important Not Important
Importance of Building Coalitions
Note: A = response by a single advocate.
congressional staff judged building coalitions as important, as
did three of the five advocates. The patterns are a close match.
Of the ten congressional staff who judged building coalitions as
most important, five worked for the majority party and five for
the minority party. This evidence supports the hypothesis that
the judgments of congressional staff members and advocates about
the importance of building coalitions are similar.
The third part of the hypothesis addresses the similarity
of judgments between the two groups of informants about the
importance of limiting the extent of policy change. Results of a
217
preceding analysis indicate that limiting the extent of policy
change was seen as important when the judgments of all informants
were examined. The empirical pattern for judgments of
congressional staff members is presented in Figure 18 and the
pattern for advocates in Figure 19. Nine of the twelve
congressional staff judged limiting the extent of policy change as
important, as did four of the five advocates. The patterns are an
extremely close match. This evidence strongly supports the
hypothesis that the judgments of congressional staff members and
advocates about the importance of limiting the extent of policy
change are very similar. A difference in judgments between staff
working for representatives of the majority versus the minority
party was identified. All staff working for representatives of
the minority party saw limiting policy change as very important.
In contrast, only half of the staff for the majority party saw
limiting change as very important.
The last part of the hypothesis addresses the similarity
of judgments between the two groups of informants about the
importance of advocates who are skillful in interacting with
congressional staff. Results of a preceding analysis indicate
that advocates who are skillful in interacting with congressional
staff were seen as important when the judgments of all informants
were examined. The empirical pattern for judgments of
congressional staff members is presented in Figure 20 and the
pattern for advocates in Figure 21. Nine of the twelve
congressional staff judged that advocates who are skillful in
interacting with congressional staff were very important, as did
three of the five advocates. The patterns are a very close match.
Of the nine congressional staff who judged the skill of advocates
218
FIGURE 18
LIMITING THE EXTENT OF POLICY CHANGE: CONGRESSIONAL STAFF
MEMBERS' JUDGEMENT ABOUT THE IMPORTANCE TO INFLUENTIAL
LTC PROPOSALS
CCC
ccc
ccc
C CC
Very Important Somewhat Important Not Important
Importance of Limiting the Extent of Policy Change
Note: C = response by a single congressional
FIGURE 19
staff member.
LIMITING THE EXTENT OF POLICY CHANGE: ADVOCATES'
JUDGEMENT ABOUT THE IMPORTANCE TO INFLUENTIAL
LTC PROPOSALS
AAA
A
A
Very Important Somewhat Important Not Important
Importance of Limiting the Extent of Policy Change
Note: A = response by a single advocate.
219
FIGURE 20
ADVOCATES WHO ARE SKILLFUL IN INTERACTING WITH
CONGRESSIONAL STAFF: CONGRESSIONAL STAFF MEMBERS
JUDGEMENT ABOUT THE IMPORTANCE TO INFLUENTIAL
LTC PROPOSALS
CCC CCC
ccc
ccc
Very Important Somewhat Important Not Important
Importance of Advocates Who Are Skillful In
Interacting With Congressional Staff
Note: C = response by a single congressional staff member
FIGURE 21
ADVOCATES WHO ARE SKILLFUL IN INTERACTING WITH
CONGRESSIONAL STAFF: ADVOCATES'
JUDGEMENT ABOUT THE IMPORTANCE TO INFLUENTIAL
LTC PROPOSALS
AAA AA
Very Important Somewhat Important Not Important
Importance of Advocates Who Are Skillful In
Interacting With Congressional Staff
Note: A = response by a single advocate.
as very important, there was little difference in the number
working for representative of the majority versus the minority
party. This evidence supports the hypothesis that the judgments
of congressional staff members and advocates about the importance
of advocates who are skillful in interacting with congressional
staff are very similar.
220
Results of the pattern matching support the conclusion
that the judgments of congressional staff and advocates are
similar about the importance to influential LTC proposals of the
following political features:
• Building coalitions,
• Limiting the extent of change from existing policy, and
• Advocates who are skillful in interacting with
congressional staff.
In addition, the pattern matching concerning the rival hypothesis
about the type of policy analysis suggests that the rational
approach to analysis merits further research to examine thoroughly
the similarities and differences between the two groups of
informants. This evidence supports hypothesis 1 of research
question 2 that judgments about the important political features
of influential LTC policy proposals are the same for congressional
staff members and advocates.
When judgments of congressional staff working for
representatives of the majority party were compared to those for
the minority party, there was little difference in the importance
of building coalitions and of advocates who are skillful in
interacting with congressional staff. In contrast, limiting the
extent of policy change was judged as very important by all
minority staff, but only by half of the majority staff. The
judgments between staff working for the majority versus the
minority party differed on which approach to policy analysis was
most important. Most staff for the minority party selected the
political approach, while most staff for the majority party
selected the rational approach.
221
other Political Features Important To LTC Policy Adoption
Informants were asked if there were other political
features, besides the four already discussed, which were important
to LTC proposals being adopted or influencing legislation. This
question was asked in order to conduct a comprehensive study of
the important political features of influential LTC policy
proposals. Three characteristics were identified most often as
important political features:
• Grass roots support,
• Constrained financing approach, and
• A horse, i.e., a member of Congress deeply committed to
adopting a specific policy.
Ten of the 17 informants (59 percent) identified grass roots
support for LTC policy as another important political feature.
They also identified polls as a tool to assess grass roots
reaction and to shape policy An advocate said:
It helps to have grass roots support, either
spontaneous or mobilized. No one has done it
on LTC. Check this is used elsewhere.
A congressional staff member spoke of the impact of grass roots
support on members of Congress:
[You] need constituent interest. The Senator
votes on the readings of his constituents. In
health care reform legislation, unless his
locals demand it [LTC], he will not do
anything comprehensive. If one makes middle-
class, middle-aged people scared about their
parents needing LTC and their own [future]
needs, then we would have LTC [enacted].
Another advocate identified the mobilization of grass roots
support as important:
[We need] some way to build public consensus
to increase taxes around health and LTC. We
have polling data about LTC and the increased
willingness of elderly to pay taxes. How
much, and who pays [are the issues].
222
Some congressional staff members discussed approaches to mobilize
grass roots support. One spoke of the importance of concerned
citizens educating others:
[You need to] make the case that this policy
is meaningful to the largest possible
population and to those who feel most
desperate about it. Use them to help educate
[others] about the importance of the
legislation.
Another congressional staff member spoke of the role of the media
in mobilizing grass roots support:
Major reasons issues come to the government
and will be addressed [is that] somehow in the
private sector the needs are not being
met. . . . Press does expose and Americans
write to Congress. We have hearings and
bills. Advocacy groups build membership on a
common cause and the process feeds on this.
Press is a big factor. The more complex the
issue, the harder for the press to digest it
and make a top news story every day.
A third described the joint role of grass roots support and the
media:
The degree to which LTC gets on the public
agenda is judged through media coverage and
polling data. If the members of Congress
perceive the problem as one the public expects
them to address, it makes members more likely
to enact it.
Polls were identified as a tool to shape LTC policy to mobilize
grass roots support. One advocate said:
Polling information helps a lot. You have
proposals and you don't know how people feel
about them, your view is just based on your
feelings. . . . If the people want a benefit,
[we] need to know what is important so we can
have a better sense of what changes to make in
the proposal to make it more popular.
Another congressional staff member agreed:
Polling data is important. We live and
breathe polls [here], not necessarily just to
change policy, but to get a reaction of how
people felt last week. . . . In the process of
223
getting data from polls, you develop the
policy, its problems, and its arguments.
Five of the 17 informants (29 percent) identified a
constrained financing approach as an important political feature.
The informants conceptualized a constrained financing approach for
LTC as legislation that contained financing that did not add to
the deficit, was not re-distributive, and was not labeled as a
tax. Some spoke of limiting the costs, although the definition of
"limited" LTC costs varied considerably by informant. In his
discussion of changes in the social policy environment, Reischauer
(1990) noted that resource constraints play an important role.
Policies with no financing or that are highly re-distributive are
unlikely to be adopted. Self-financing or pay-as-you-go
mechanisms are more viable. An advocate summed up the constrained
financing issue in LTC:
The cost of LTC is real money, big chunks of
dough. [Congress] needs to raise money from
other programs or [legislate] new taxes.
[There is] lots of resistance to that.
Congressional staff members spoke of the impact of LTC policy
costs on Congress. One said:
The only way for LTC to be enacted is if the
public is willing to support financing, is
willing to pay for it.
Another talked about the future impact on the federal budget of
adopting LTC legislation:
Members of Congress in today's climate worry
about costs. When boomers hit age 65, they
will have real [federal budget] problems if we
have a new LTC entitlement.
Negative voter reaction to the financing mechanisms of legislation
is also an issue in dealing with resource constraints. A
congressional staff member commented:
224
[Voters feel that] legislation should not
affect the pocket book. Interest groups and
the general public mobilize around this. The
repeal of catastrophic care legislation is an
example. Interest groups mobilized the
elderly who felt they had to pay for something
they already had.
Five of the 17 informants (29 percent) spoke of a "horse"
(a congressional supporter of the legislation) as an important
political feature for influencing adoption of LTC policy. One
congressional staff member defined a horse and described the tools
a horse uses to influence adoption of policy:
[You] need a horse, a member of Congress
willing to be a champion and put lots of
personal energy into the cause of LTC. Lots
of bills get enacted based on sheer
personality of a member of Congress. Horses
relate to other members on both side of the
isle, work with others to develop bipartisan
consensus, and work the floor. They have
interpersonal and other kinds of techniques:
nagging, charming, threatening, quid pro quo.
So it depends on [their personal] tools. A
chairman has things to give, but younger
members do not. It depends on the member's
personality.
One Senate staff member explained the genesis of personal interest
and commitment that can create a horse :
Also important is the Senator's own bias,
personal experience, and interaction with LTC
and home care. I hear it all the time in the
Senator's speeches. The Senator has
experienced the LTC system because a parent
had Alzheimer's. This colors the way the
Senator looks at how best to make a program
that will work.
This staff member also spoke of the impact of the congressional
milieu:
Another part is member priorities. How wedded
is any one member in making sure a particular
program is in legislation? [What are] the
political compromises a member wants to make?
Members of Congress sit in a room and say, "it
is important to do X," and another says, "it
is important to do Y." There are logrolling,
deals, and tradeoffs.
225
Another congressional staff member agreed on the importance of the
horse:
The other thing that influences policy is the
existence of a spokesperson, Claude Pepper
did a lot. He was respected, and drove
policy. [We] don't really have someone like
that today except maybe for Senator X who is a
spokesperson for elderly issues. Some member
needs to push a policy and get everyone
interested in it.
A third staff member identified the importance of the status of
the horse in adopting legislation;
[Another important feature is] if an
influential member of Congress sponsors the
bill, someone like the Chair of Ways and Means
or of Energy and Commerce. It helps to have
good political backing to add credibility to a
bill.
Most Important Political Feature To LTC Policy Adoption
Introduction
Informants were asked to select the most important
political feature to LTC proposals being adopted or influencing
legislation. To be certain that the informants considered all
features under discussion as they made their selection, the list
of features previously discussed was repeated directly after the
question was asked. The list included the four political features
which had been discussed earlier in the interview plus those
features informants naimed as "other important features."
Although the notion behind this question was that one
political features would be selected as most important, nearly
half (47 percent) selected a combination of features as most
important. This section begins with a summary of those features
selected as most important. Next, it presents comments of those
informants who selected one feature as most important. It ends
226
with a presentation of the combinations of features selected as
most important.
Features Selected As Most Important
Table 15 summarizes the results concerning the most
important feature. It presents the number and percent of
informants who selected specific features as most important. The
percent exceeds 100 because some informants selected a combination
of features. Grass roots support was selected most often as most
important, 47 percent of the informants choose it. Coalitions
were selected next most frequently by 41 percent of the
informants. A constrained financing approach was the third most
frequently selected feature with 35 percent, and analysis was
fourth with 24 percent. As described previously, the informants
defined a constrained financing approach as LTC legislation that
contained financing that did not add to the deficit, was not re
distributive, and was not labeled as a tax.
The One Feature Selected As Most Important
Fifty-three percent of informants selected only one
political feature as most important. Grass roots support and
building coalitions were tied for the most frequently selected
political features. Constrained financing approach was the third
most frequently selected feature; and analysis, regardless of
approach used, was the fourth. Explanations of informants who
chose each of the four most frequently selected features are
presented below, beginning with the most frequently selected
features (grass roots support and building coalitions) and ending
with the fourth most frequent (analysis).
227
TABLE 15
POLITICAL FEATURES SELECTED AS MOST IMPORTANT TO
INFLUENTIAL LTC POLICY PROPOSALS
Political Feature
Number of
Informants
Percent of
Informants
Grass roots support 8 47%
Coalitions 7 41%
Constrained financing 6 35%
Analysis 4 24%
Incremental change 2 12%
Advocate interaction 2 12%
Note: Percent exceeds 100 because nearly half of informants
selected multiple features. Excludes those features selected only
once.
An advocate spoke of the power of grass roots support to
LTC policy adoption and the difficulty in mobilizing it for LTC:
Grass roots support. If you have it, you can
do anything else, like get the leadership in
an organization [to support a proposal] and
get dollars [i.e., funding] from other
programs or new taxes. Can you get major
grass roots support without mobilizing [it]?
Is it spontaneous or does it need to be
mobilized? It is not there for LTC. . . . At
this point in history, grass roots support for
LTC needs to be mobilized. LTC is not like
crime or acute care issues where grass roots
support [already exists].
228
A congressional staff member who selected coalitions said:
Coalition building is first, and all other
things fit into it. If you do coalition
building right, all else should work.
A Senate staff member who selected a constrained financing
approach as the most important provided this look at congressional
tensions concerning costs and benefits:
All [political features] are essential aspects
of the process. It is hard to choose. The
bottom line is economic realities. On the
floor of the Senate, dollars are what we fight
about. . . . How much is the government's
responsibility, and how much is the
individual's responsibility? What is an
entitlement versus a safety net? It's all
economics.
Another advocate saw policy analysis as the most important
feature:
[The most important features is] that policy
analysis sets appropriate goals and is able to
defend these goals. Need to have facts
straight and a purposive argument. Problems
[occur] if analysis [is] fuzzy. . . . [One
interest group's] credibility for facts and
goals comes from policy analysis.
Combinations of Features Selected As Most Important
About half (47 percent) of the informants selected 2-5
political features as most important. They concluded that a
combination of features was essential to influence LTC policy
adoption. While individual political features are important, each
on its own may not be sufficient to result in influential LTC
policy proposals. The patterns of the selected political features
are useful in understanding what combination or combinations of
political features result in influential LTC policy proposals.
Figure 22 presents the combinations of features selected.
Combination A at the left of the figure has the most features (5)
and combinations G and H at the right of the figure have the least
229
FIGURE 22
COMBINATION PATTERNS OF POLITICAL FEATURES SELECTED AS
MOST IMPORTANT TO INFLUENTIAL LTC POLICY PROPOSALS
Political Features
A B c* D E F G H
Grass roots support X X X X X
Coalitions X X X X X
Constrained financing X X X X X
Analysis X X X
Incremental change X X
Advocate interaction X X
Other X X X X
Note: X = selection by those informants who choose a combination
of features. Each column represents the pattern selected by one
informant.
*Pattern C is the "standard" combination.
(2). Four political features appeared most often in the
combinations: grass roots support, coalition building, constrained
financing, and analysis, regardless of the approach used.
Combination C is an illustration of this "standard" pattern.
These were also the features selected most frequently by those
230
respondents who chose only one feature as most important.
Incremental policy change and skillful interaction of advocates
with congressional staff members, although judged as important
features when considered individually, appear less frequently in
these combination patterns. This less frequent appearance in
combination patterns may reflect the fact that hypotheses about
the importance of incremental change and skillful interaction of
advocates were supported, but with reservations.
Explanations of informants who selected combination
patterns provide insight into understanding this phenomenon of the
influence of multiple political features. Explanations begin with
the informant who selected the "standard" pattern of the most
frequently selected combination of political features. A House
staff member explained her selection of the "standard" combination
(see pattern C in Figure 22):
My list of the most important features are:
first, coalitions because you need a broad
based group of people to support something.
Second is grass roots support and funding
support. Third is analytic support [which is]
required to support what to do [i.e., the
policy options].
A congressional staff member selected a combination of
four features. The combination was a slight variation from the
"standard" (see pattern B in Figure 22). The difference was that
her combination included incremental change and excluded grass
roots support. She spoke about the importance of this variant
combination when constrained financing was less of an issue. She
said:
If financing is not an issue because the
proposal does not cost much, then these other
three factors are just as important : interest
groups and coalitions . . ., incremental
approaches to policy, and analysis.
231
A Senate staff member who selected five features for a combination
choose three from the "standard' combination: grass roots support,
coalitions, and analysis. Her combination excluded one feature of
the "standard" pattern, constrained financing. Instead, it
substituted advocate interaction. She spoke of the importance of
this combination pattern (see pattern A in Figure 22):
If it is on the public agenda, or the people
say it is on the public agenda, then [you]
need four things: first to make the political
environment ripe for change, second need good
information to analyze problems, third need
coalitions, and fourth need interaction with
advocates [and congressional staff].
Patterns E, F, and H include both grass roots support and
constrained financing, two of the four features in the "standard'
combination. An advocate spoke of the importance of this
combination (see pattern H in Figure 22):
Political feature are the most important in
enactment. I just think where members of
Congress respond to their constituents and the
extent [that] they hear a hue and cry around a
proposal, they go with that. Also
[constrained] costs are equally important.
Nothing else comes close.
Further research is necessary to establish the combination
patterns of political features which have the greatest impact on
developing influential LTC policy proposals. This phenomenon of
combinations of political features suggests Kingdon's model (1984)
of the agenda setting process. Agenda setting is the result of
the coupling of three streams: problems, policies, and political
receptivity. None of the streams is sufficient in and of itself
to place an issue on the policy agenda. But when a policy window
opens (i.e., a precipitating event occurs) and the streams are
coupled, the issue is placed on the policy agenda. Kingdon notes
that the coupling process is not linear. It is unpredictable, but
232
not random, in that each stream has it own processes, patterns,
and constraints. Kingdon's model can provide a framework for
conceptualizing additional research about the combination or
combinations of political features which have the greatest impact
on developing influential LTC policy proposals. Future research
to understand the phenomenon of the influence of multiple
political factors can suggest a nascent theory about its impact on
the adoption of national LTC legislation.
Applicability of Judgements To All
LTC Issues and To Other Social Policy
Informants were instructed to consider all types of LTC
issues when they responded to the interview questions. They were
also asked if their comments applied to other social policy
issues. The first question was asked to confirm that the
respondents had used a broad spectrum of LTC issues, as requested,
as the frame of reference. This confirmation is also evidence to
assess if the results of the research apply to a broad spectrum of
LTC issues or more to some issues and less to others. The second
question was asked to gauge if results from this case study can
suggest future research toward developing a theory about important
political features which are influential in adoption of national
social policy. These questions provide measures of the external
validity of the case study analysis.
As noted in the section on field procedures, the interview
was shortened because informants, especially congressional staff,
would only agree to a 30-minute interview. As a consequence, most
respondents (82 percent) were asked a comprehensive question about
applicability at the end of the interview, rather than repeating
the individual questions after each political feature was
233
discussed. Evidence indicates that this change did not impact on
whether the informants provided information about applicability.
Of those ten informants who gave an indepth response to the
applicability questions, 90 percent were asked the comprehensive
version.
Overall, the informants concluded that their comments
about political features of LTC proposals which made them
influential in adopting national legislation were applicable to
all LTC policy issues. They also concluded that their comments
were applicable to other social policy issues as well. One
congressional staff member saw her comments as applicable to
issues beyond the scope of social policy:
Yes, [my comments are] applicable to all LTC
issues and all health and social policy
issues. [They are] applicable to tax policy
as well.
Another considered the issue of exceptions to his comments:
Probably some unique issue to seniors exists
[where my comments are] not applicable. But,
it's not very important overall. Features [we
discussed] are crucial, all LTC issues apply
to all of them.
Some congressional staff members identified situations in
which the process of adoption of specific types of LtC legislation
was "easier." In these few cases, the political features of
policy proposals were judged as not essential. But, the general
conclusion was that in most instances these political features
were critical to adoption. Two congressional staff members
commented on specific cases. One said:
All LTC issues fall under what we talked
about. But some issues, such as standards for
LTC insurance, are not as difficult to push
through because they do not cost much money.
In general, I see my comments as applicable to
all LTC issues.
234
The other commented:
It depends on the policy. (These features
are] especially [important] for larger
programs. [They are] not as important for
technical change. If nursing home lobbyist
gives me an example of a regulation that is
expensive and not working for the benefit of
the nursing home and its patients, I make
calls [to verify the problem]. If lobbyist is
right, to get this changed you do not need
coalitions or other features.
Another congressional staff member distinguished between micro and
macro LTC issues:
Some LTC issues are easier to do than others.
For example, tax clarification for LTC
insurance does not involve macro politics and
does not require these things [i.e., political
features].
The bulk of the evidence supports the conclusion that the research
results apply to a range of LTC policies. This conclusion is
based on the perspective of congressional staff and advocates who
are some of the key, behind-the-scenes actors in the process of
adopting national LTC legislation. Building coalitions, limiting
the extent of policy change, and advocates who are skillful in
interacting with congressional staff are important political
features for LTC proposals that cover a broad spectrum of issues.
Responses to the question about applicability of research
results to other social policy were all affirmative. Informants
sometimes gave examples of social policy areas where their
comments on political features applied. The most frequent example
was health care reform. Housing and public health issues were
also used as examples. Informants' reports about the
applicability of their conclusions to other social policy suggest
the utility of future research toward developing a nascent theory
about the influence of these political features on the adoption of
national legislation on social policy.
235
Summary of Results
Introduction
This section presents a summary of the research results.
Such a summary is a useful tool in synthesizing the findings and
in relating results for individual hypotheses to one another. This
section begins with a summary of the results for the hypotheses of
research questions 1 and 2. It also presents a summary of the
results for the questions about other political features of
importance to influential LTC proposals and about the most
important feature. It ends with a summary of the applicability of
findings to a spectrum of LTC issues and to other social policy.
Implications of the results are discussed in chapter 6 on overview
and conclusions of the research.
Summarv of Findings for Research Question 1
Research question 1 asks:
What are the important political features of LTC policy
proposals that result in serious consideration being
given to them in the process of adopting national LTC
legislation?
Hypotheses 1-4 address the importance of specific political
features. A summary of the findings for the individual hypotheses
of research question 1 is presented in Table 16. Hypothesis 2 on
the importance of building coalitions was very strongly supported
by the comments of the informants and the extremely close match of
the empirical to the hypothesized pattern. Hypothesis 3 on the
importance of limiting the extent of policy change was supported,
but with reservations. Reservations are indicated because several
(18 percent) of the informants judged this feature as not
important. Hypothesis 4 on the importance of advocates who are
236
TABLE 16
SUMMARY OF FINDINGS FOR RESEARCH QUESTION 1
Political feature
Support for hypothesis Strength of
pattern match
Political
analysis
(Hypothesis 1)
None None
Rational analysis
(Rival to
Hypothesis 1)
Results suggest this
rival to political
analysis hypothesis is
strongly supported.
Further research is
recommended.
Identical match
Build coalitions
(Hypothesis 2)
Very strong. 94
percent of informants
judged feature as very
or somewhat important.
Extremely close
Limit policy
change
(Hypothesis 3)
Supported with
reservations. Some
informants judged
feature as not
important.
Close
Advocate skillful
in interacting
with
congressional
staff
(Hypothesis 4)
Supported with
reservations. Fewer
informants judged
feature as important
compared to hypotheses
on coalitions and on
limiting policy
change.
Close
skillful in interacting with congressional staff was supported,
but also with reservations. Reservations were indicated because
fewer informants judged this feature as very important in
comparison to the judgments for hypotheses 2 and 3.
Hypothesis 1 on the importance of the political approach
to analysis was not supported. Few informants judged this type of
analysis as very important. Because the rational approach to
237
analysis was most frequently selected as important, a rival to
hypothesis 1, focusing on the rational approach to analysis, was
examined. Results from this preliminary examination of the rival
hypothesis suggest that a hypothesis about the importance of a
rational approach to analysis may be supported. Future research
is recommended for a thorough examination of this rival
hypothesis.
Summarv of Findings for Research Question 2
Research question 2 asks:
Do judgments about the important political features of
LTC policy proposals that result in serious
consideration being given to them in the process of
adopting national LTC legislation differ by whether the
actors are staff members of the U.S. Congress or
advocates of policy proposals.
The hypothesis for this research question states that the
judgments of these two groups of actors are the same. Table 17
presents a summary of the findings on the extent of similarity in
judgments between congressional staff and advocates for each of
the four political features under study. Judgments were not
similar for the importance of political analysis, reflecting the
findings for hypothesis 1 of research question 1 that political
analysis was not important to influential LTC proposals. There
was a strong similarity in judgments for a rival to hypothesis 1
concerning the importance of a rational approach to analysis. The
patterns for congressional staff and advocates were identical.
Research on this very strong similarity in judgments is suggested
as part of the future research recommended previously on this
rival to hypothesis 1.
238
TABLE 17
SUMMARY OF FINDINGS FOR RESEARCH QUESTION 2
Political feature
Similarity of judgments
of congressional staff
and advocates
Difference by
political party
Political
analysis
None. No advocates
judged this feature as
important.
Extreme
difference.
Mostly
congressional
staff working for
minority judged
feature as
important.
Rational analysis Identical Extreme. Mostly
congressional
staff working for
majority judged
feature as
important.
Build coalitions Close similarity None
Limit policy
change
Extremely close More
congressional
staff working for
minority judged
feature as very
important.
Advocate skillful
in interacting
with
congressional
staff
Very close similarity None
There was a very strong similarity of judgments for the
importance of limiting the extent of policy change. The patterns
for congressional staff and advocates were an extremely close
match. There were similarities of judgment for the importance not
only of building coalitions, but also of advocates who are
skillful in interacting with congressional staff. Patterns for
congressional staff and advocates were a close match, although the
239
pattern match was somewhat closer for skillful advocates that for
building coalitions. This evidence supports hypothesis 1 of
research question 2 that judgments about the important political
features of influential LTC policy proposals are the same for
congressional staff and advocates.
Research question 2 was concerned with similarity of
judgments between congressional staff and advocates. Data also
were available to examine similarities among congressional staff
by whether they worked for congressional representatives of the
majority or minority party. Such information may provide useful
background to understanding differences in perspectives influenced
by political party philosophy.
There were no differences in judgments by whether
congressional staff worked for representatives of the majority or
the minority party for building coalitions and skill of advocates.
In contrast, more staff working for the minority party judged
limiting the extent of policy change as very important. There
were major differences by political party for judgments about the
importance of a specific approach to analysis. More staff working
for representatives from the majority party judged rational
analysis as important. In contrast, more staff working for the
minority party judged political analysis as very important.
Other Important Features and Most Important Feature
Table 18 presents a summary of the comments from
informants about other important features and the most important
feature for influential LTC policy proposals. The political
feature identified most often as other important feature was grass
roots support (59 percent).
240
TABLE 18
FINDINGS FOR OTHER IMPORTANT FEATURES AND MOST
IMPORTANT FEATURE
Research issue
Research findings
Other important features Grass roots support.
Constrained financing approach
(i.e., does not add to deficit, is
not re-distributive, is not labeled
as a tax).
Horse or member of Congress to be a
champion for the legislation._______
Most important feature:
One feature
Combination of features
Selected as most important by 53
percent of informants. Grass roots
and building coalitions tied for
first place. Constrained financing
in third place.
Selected as most important by 47
percent of informants. "Standard"
pattern included: grass roots
support, building coalitions,
constrained financing, and analysis,
regardless of approach. Further
research is recommended on which
patterns have the greatest impact on
influential LTC proposals.
While the notion was that informants would select only one
political feature as most important, only 53 percent of the
informants did so. Grass roots support and building coalitions
were tied for first place. Constrained financing was in third
place as most important feature.
A combination of political features was selected as most
important to influential LTC proposals by 47 percent of the
informants. A "standard" pattern emerged. It was the most
frequently selected combination: grass roots support, coalition
241
building, constrained financing, and analysis. Further research
is recommended to determine if this, and any other, combination of
political features has the greatest impact on formulating
influential LTC proposals.
Applicability
Informants were asked to consider if their comments
applied equally to all types of LTC policy issues or more to some
and less to others. This is a measure of the external validity of
the case study analysis as discussed in chapter 3 on research
design and methodology. Generally informants concluded that their
comments were applicable to a broad spectrum of LTC issues. While
some technical changes to legislation were seen as so easy that
political considerations were not important, most informants
concluded that their comments about political features under
discussion applied to all LTC issues. All informants concluded
that their comments were applicable to other social policy areas
as well. The most frequent examples they gave of other social
policy areas were health care reform, housing, and public health
issues. These conclusions suggest the utility of future research
toward developing a nascent theory about the influence of these
political features on the adoption of national legislation on
social policy.
242
CHAPTER VI
OVERVIEW OF THE RESEARCH AND CONCLUSIONS
Introduction
This chapter presents an overview and the conclusions of the
research. It describes the objectives of the research and
summarizes the results for the two research questions and related
hypotheses. It also presents results about the most important
political features and applicability of the research. It then
discusses the implications of the results, presents other
knowledge provided by the research, and describes the researcher's
application of the results. It ends with recommendations for
future research based on the case study results.
Objectives
Considerable attention has been given to development of
comprehensive theories about the public policy process and its
individual stages, including the adoption stage. Limited
theoretical attention has been given to a synthesis of the
political features of policy proposals that make them influential
in the process of adopting national legislation. Theories of the
overall policy process that concentrate on a political perspective
emphasize that a proposal's technical merit often is not
sufficient to result in enactment. They recognize that political
features of policy proposals can influence the policy adoption
process. A review of these theories identified some political
features as influential to the policy adoption process. However,
243
theories which present a synthesis about political features of
proposals that are influential in the process of adopting national
legislation are not available.
The objective of this research was to determine which
political features of LTC policy proposals result in serious
consideration being given to them in the process of adopting
national LTC legislation. Such knowledge about the critical
political features of LTC policy proposals is useful to both
policy analysts and policy makers in developing better strategies
for success in adopting national LTC legislation.
The research concentrated on the following political
features of LTC policy proposals:
• The development of the policy proposals by a political
approach to analysis,
• The ability of the policy proposals to create or
strengthen coalitions,
• The ability of the policy proposals to limit the extent
of change from existing policies, and
• The skill of the advocates of the policy proposals in
interacting with congressional staff.
Because an intent of the research was to assist both policy
analysts and policy makers in the process of adopting national LTC
legislation, the research addressed the extent of agreement about
influential political features between representatives of these
groups.
The research was a case study of committees and
subcommittees with jurisdiction over LTC programs and their
financing because of their central role in adopting national LTC
legislation. LTC was selected as a frame of reference for the
244
informants because the issue will grow in importance as the baby
boom population ages. Informants were some of the key actors who
play central, behind-the-scenes roles in the process of adopting
LTC legislation. They were congressional staff members from
committees and subcommittees with jurisdiction over LTC programs
and advocates from a variety of organizations, including the
Administration, with significant LTC policy proposals.
Conclusions About Support for the Hypotheses
Empirical results about each hypothesis were compared to
relevant theories about the policy adoption process. This
approach to case study analysis is the method of analytic
generalization in which existing theory is used as a reference
point with which to compare the empirical results (Yin, 1989).
Additional evidence to examine the hypotheses was provided by
pattern matching. The pattern of the hypothesized relationship
was compared to that of the empirical results. A close match of
the patterns was evidence to support the hypotheses.
The results from the analytic generalization to existing
theories and the pattern matching confirmed the following
relationships. From the perspective of some of the key actors who
play central, behind-the-scenes roles in adopting LTC legislation,
LTC policy proposals are influential in the process of adopting
national legislation when:
• They create or strengthen coalitions;
• They limit the extent of change from existing policy; and
• Advocates of the proposals are skillful in interacting
with congressional staff.
Table 19 provides information about the support for each
hypothesis of research question 1. Hypotheses are ranked by the
245
TABLE 19
SUPPORT FOR HYPOTHESES OF RESEARCH QUESTION 1
Feature Hypothesis Very
important
Some
what
impor
tant
Not
impor
tant
Extent
of sup
port
Build
coalition
2 76% 18% 6% Very
strong
Limit
policy
change
3 76% 6% 18% Sup
port
with
res
erva
tions .
More
support
than
for
hypoth
esis 4.
Advocates
skilled in
inter
action
with
congres
sional
staff
4 71% 29% 0% Support
with
res
erva
tions.
Less
support
than
for
hypoth
esis 3.
Political
analysis
1 33% 33% 33% None
Rational
analysis
Rival to
hypothesis
1
75% 25% 0% Very
strong.
Merits
future
re
search.
Note: Percents may not total to 100 due to rounding
245
extent of support; the hypothesis with the strongest support is
listed first. This presentation is useful in designing strategies
for advocates on developing influential proposals and for
congressional staff for selecting LTC proposals more likely to
lead to influence in the process of adopting national LTC
legislation. These strategies are discussed in the section on
implications of the research.
The extent of support was assessed by two considerations :
• First considering the percent of informants who judged
the feature as very important ; and
• Next considering the percent who judged it as somewhat
important.
Building coalitions, hypothesis 2, had the strongest support of
these behind-the-scenes policy actors as an important feature to
influential LTC policy proposals. Seventy-six percent judged it
as very important and another 18 percent as somewhat important.
Limiting the extent of policy change, hypothesis 3, ranked second
in the extent of support. Seventy-six percent of informants
judged limiting policy change as very important. This was
identical to the percent of informants judging building coalitions
as very important. However, only 5 percent judged limiting policy
change as somewhat important, while the comparable figure for
building coalitions of 18 percent was 3 times higher. Hypothesis
4, advocates who are skillful in interacting with congressional
staff, was ranked third because the 71 percent of informants who
judged it as very important was lower than the comparable percent
for coalitions and for limiting policy change. The importance of
political analysis, hypothesis 1, was not supported. The rival to
this hypothesis on the importance of rational analysis is placed
247
at the end of the table because evidence to assess this hypothesis
was limited. This limited evidence suggests that rational
analysis had strong support, 75 percent judged it as very
important. However, only eight of the 17 informants (47 percent)
provided data about this approach. The remainder selected
political and other analytic approaches as important. This
feature merits future research to identify its impact on
influential LTC policy proposals. Proposed research is discussed
in greater detail in the subsequent section on future research.
Support for the hypothesis of building coalitions was the
strongest. Building coalitions is not limited to groups outside
of the Congress. Instead, building coalitions is an essential
activity within Congress. This is especially the case in the
Senate. The slim Democratic margin and the filibuster rules make
building coalitions across party lines essential. The threat of a
filibuster is a real one. Sixty votes are required to invoke the
cloture rule to end a filibuster. Several congressional staff
members commented on the greater difficulty of building coalitions
in the Senate. One cited the special attention given to specific
issues as an important factor. It may be that the longer terms of
Senators permit them to be issue-oriented and, therefore, more
independent in their voting. They are less subject to the
pressures of constituents, interest groups, political parties, and
other Senators. While congressional staff working for Senators
have a major role in building coalitions, advocates also have an
important role. Several congressional staff commented on the
ability of advocates to build coalitions through negotiations.
This is because the advocates interact with members who usually
248
did not deal with each other and were able to negotiate agreements
on the proposed legislation.
Table 20 provides information about the results for research
question 2. It presents information on the similarity of
judgments between congressional staff and advocates about the
importance of each feature. It also presents information about
the similarity of judgments between congressional staff working
for the majority and minority parties. Features are ranked by the
strength of similarity, with the feature with the greatest
similarity in judgments listed first. The strength of similarity
was assessed in a comparable way as was done for the extent of
support for the hypotheses of research question 1 in Table 19.
The differences between the percent of congressional staff and the
percent of advocates who judged the feature as very important was
considered first. In the situation where percent differences were
the same for two features, a second consideration was introduced
to determine the strength of the similarity. The percent who
judged the feature as somewhat important was compared for the two
groups.
249
TABLE 20
SIMILARITY OF JUDGMENTS OF CONGRESSIONAL STAFF
AND ADVOCATES
Feature Informant Very
important
Some
what
impor
tant
Not
im
por
tant
Similarity
Build
coalition
Congress.
staff 83% 8% 8%
Close
Advocates 60% 40% 0%
Limit
policy
change
Congress.
staff
Advocates
75%
80%
8%
0%
17%
20%
Extremely
close.
Chosen as
very
important
more often
by staff
for the
minority.
Advocates
skilled
in inter
action Congres
sional
staff 75% 25% 0%
Very close
Advocates 60% 40% 0%
Political
analysis Congres
sional
staff
Advocates
33%
0%
33%
0%
33%
0%
None.
Chosen
mostly by
staff for
the
minority.
Rational
analysis
Congress.
staff
Advocates
75%
75%
25%
25%
0%
0%
Identical.
Chosen
mostly by
staff for
the
majority
and
advocates.
Note: percents may not total to 100 due to rounding.
250
The similarity between judgments of congressional staff and
advocates was extremely close for limiting the extent of policy
change. There was only a 5 percent difference between the percent
of congressional staff (75 percent) and the percent of advocates
(80 percent) who judged it as very important. Limiting the extent
of policy change was chosen more often as very important by staff
for the minority party. This may be a consequence of the
conservative political philosophy of the Republican party. The
similarity was very close for advocates who are skillful in
interacting with congressional staff with a 15 percent difference
between congressional staff and advocates who ranked it as very
important. The similarity was not as close for building
coalitions with a 23 percent difference between the two groups.
There was no similarity for political analysis because no
advocates judged it as an important feature. It was chosen as
important mostly by staff for the minority party. The percents
for the congressional staff and advocates were identical for
rational analysis. Rational analysis was chosen as important
mostly by staff for the majority. As noted above, the evidence to
assess the rival to the hypothesis on the importance of the
political approach to analysis was limited because only some
informants (47 percent) provided data about this approach. These
identical judgments between congressional staff and advocates on
the importance of rational analysis merit further research. The
subsequent section on future research provides details.
Table 21 presents results for research questions 1 and
research question 2 so that they can be examined in conjunction
with one another. Building coalitions had very strong support as
a feature important to influential LTC policy proposals. The
251
TABLE 21
COMPARISON OF SUPPORT FOR RESEARCH QUESTIONS 1 AND 2
Feature
Research Question 1 Research Question 2
Build coalitions Very strong support Similar judgments
Limit policy change Support with
reservations
Extremely similar
judgments
Advocate skillful
in interaction
Support with
reservations
Very similar
judgments
Political analysis None Not similar
judgments
Rational analysis Very strong.
Merits future
research.
Identical
judgments
agreement between judgments of congressional staff and advocates
was close, but not extremely so. Congressional staff were more
likely to rate it as very important. The importance of limiting
policy change and of skillful advocates was supported with some
reservations, and the agreement between congressional staff and
advocates was extremely close.
Results for the political approach to analysis were very
different. The political approach was not judged as important to
influential LTC policy proposals. Furthermore, the judgments of
congressional staff and advocates were divergent. No advocates
rated this approach as important. Most of the congressional staff
who rated it as important worked for representatives of the
minority party.
252
The limited evidence about the rational approach to analysis
suggests that the approach is very important and that
congressional staff and advocates agree on its importance. Most
of the congressional staff who rated the rational approach as very
important worked for representatives of the majority party. This
limited evidence highlights the need for additional research to
examine theses relationships in depth.
Other Important Features
In an attempt to conduct a comprehensive study of the
important political features of influential LTC policy proposals,
informants were asked to identify features other than those
already discussed that were important and to select the most
important feature. Other features most frequently mentioned were:
grass roots support (59 percent), constrained financial approach
(29 percent), and a "horse" (29 percent). A constrained financing
approach is one that does not add to the deficit, is not re
distributive, and is not labeled as a tax. A horse is a member of
Congress who makes special efforts to enact certain legislation
because of a deep commitment to a specific issue or policy.
While a constrained financial approach can be a challenge to
prepare, it is achievable. However, the other two features, a
horse and grass roots support, are less cimenable to development
and control. Horses emerge more from personal views, experience,
and considerations of political advantage and disadvantage.
Efforts to mobilize grass roots support can be difficult, as well
as expensive. The outcome can be uncertain. Such efforts are
usually undertaken by interest groups because they have the
resources to devote. Some grass roots efforts are successful, for
example, the repeal of the Medicare Catastrophic Coverage Act.
253
others are unsuccessful. For example, the Democratic National
Committee recently abandoned its efforts to generate grass roots
support for health care reform.
Examples of the application of these results for advocates
and congressional staff are presented in a subsequent section on
implications of the research.
Most Important Feature
When asked to select the most important political feature
for proposals to be influential in the process of adopting
national LTC legislation, about half of the informants named a
combination of features. The specific patterns are useful in
understanding this phenomenon of the influence of a combination of
political features. The most common or "standard" pattern
identified by informants included the political features of grass
roots support, coalition building, constrained financing approach,
and analysis, regardless of the approach used. Two of these
political features were a focus of this case study: coalition
building and policy analysis approaches. The other two were
identified by informants when they were asked about other
important political features : grass roots support and constrained
financing approach. Incremental policy change and skillful
interaction of advocates with congressional staff members, though
judged as important by informants when considered individually,
appeared less frequently in these combina:tions. This less
frequent appearance in combinations may reflect the fact that
hypotheses about the importance of incremental change and skillful
interaction were supported, but with reservations.
The finding of the importance of a combination of political
features disproves the notion that one overriding political
254
feature can result in influential LTC policy proposals. This
finding highlights the complexity of the process of adopting
national LTC legislation. It also highlights the difficulty that
participants in the policy adoption process have in influencing
the process. This difficulty occurs for both hidden participants,
like congressional staff and advocates, and visible participants,
like members of Congress and political appointees.
Figure 23 is an illustration of the influence of the
"standard" combination of political features. It presents the
combined impact that grass roots support, building coalitions,
constrained financing, and analysis have on shaping LTC policy
proposals that are influential in the process of adopting national
legislation. Results of this case study indicated that each of
three political features is important individually to influential
LTC policy proposals. However, the preliminary findings about the
most important feature indicate that it is a combination of
features that can shape an influential LTC policy proposal.
Each of these political features has its own dynamics in
terms of processes, patterns, and constraints. For example,
building coalitions often results in revising goals so they are
vague enough to appeal to different groups. Furthermore, the
development of a coalition can take more time and effort that
developing a constrained approach to financing for the proposal.
The differences in the dynamics of each of these political
features result in a complex, messy, and fluid process for shaping
an influential LTC policy proposal. Implications of these
findings for additional research are discussed in a subsequent
section on future research.
255
FIGURE 23
COMBINATION OF POLITICAL FEATURES HOST IMPORTANT
TO INFLUENTIAL LTC POLICY PROPOSALS
GRASS ROOTS
SUPPORT
B U IL D
C O A L IT IO N S
IN F L U E N T IA L
LTC P O L IC Y
PROPOSALS
CONSTRAINED
F IN A N C IN G
A N A LY S IS
256
This case study produced definitive findings in support of
the importance of three political features to shape influential
LTC policy proposals: building coalitions, limiting the extent of
policy change, and advocates skillful in interacting with
congressional staff. It also produced some preliminary evidence
about the importance of a combination of political features. It
may be that while each of these three political features is
necessary to an influential LTC policy proposal, it is not
sufficient. It is only when political features are in combination
that they are sufficient to result in an influential LTC policy
proposal.
Applicability
Informants were instructed to consider a variety of LTC
issues when they responded to the questions so that results of the
research would be applicable to a spectrum of LTC issues. To
confirm that this was the case, they were asked to consider if
their comments applied equally to all LTC policy issues or were
more applicable to some and less to others. They indicated that
the results of the research were applicable to the spectrum of LTC
policy issues. A few informants began their comments to this
question by mentioning that some unique situation or minor
legislative change may exist where political features were not
important. However, they concluded that for virtually all LTC
issues the political features they identified as important were
applicable to shaping influential LTC proposals.
Informants also were asked to consider the applicability of
their responses to other social policy issues. This question was
asked to gauge if results from this case study could suggest
future research toward developing a theory about important
257
political features influential in adoption of national legislation
about a spectrum of social policies. All informants reported
their conclusions as applicable to other social policy areas.
Some informants provided examples of the other social policy areas
where their comments applied. Health care reform was the most
frequent example, and housing and public health issues were also
mentioned. One informant felt her comments transcended social
policy and applied to tax policy as well. From the informants'
point of view, LTC was a distinct social policy issue separate
from health care reform.
This distinction may have been made because goals and
services of LTC differ from those of health care. LTC for the
elderly focuses on caring for, but not curing, the severely
disabled. It includes a variety of social services, such as home
making, transportation, shopping, and money management. These
services are usually provided by low-skilled personnel, mostly
nurses aides. Payment for LTC is covered by out-of-pocket
expenditures and by Medicaid, but only when the individual meets
the legislative definition of poor.
In contrast, health care focuses on preventing and curing
acute conditions of much younger population. It includes high-
technology, intensive services provided by highly-skilled
personnel. Payment for health care is covered for a majority of
the population though employment-based insurance. These
differences between LTC and health care give rise to a very
different set of issues. For example, quality of care from low-
skilled personnel is a major issue in LTC. In contrast, the costs
of high-technology equipment and of training highly-skilled
personnel are major issues in health care.
258
Another possible reason for the distinction made by
informants between LTC and health care policies may be the
influence of health care reform. For many of the health care
reform proposals which were considered in Congress at the time of
the interviews, LTC was not included as a benefit. Because LTC
was treated as distinct from health care by these proposals, this
distinction could have been adopted by the informants.
Public health policy was viewed as a different social policy
area by the informants. This is because it covers a set of issues
different from those for LTC and for health care. Public health
issues include concerns about clean water and sanitation,
epidemiology, and data and surveillance to identify health
problems which need attention.
Implications of the Results
Introduction
This section discusses the implications of the results from
differing perspectives of the advocates, the congressional staff
members, and the field of public administration. The research
confirmed the importance of building coalitions, incremental
policy change, and interaction skills of advocates. It suggested
that grass roots support and a constrained approach to financing
are also important. It also suggested that a combination of
political features, rather than a single feature, is critical. It
may be that while each political feature is necessary to an
influential LTC proposal, it only becomes sufficient in
combination with several other features. Research results are
from a particular perspective, that of congressional staff and
advocates who have critical, behind-the-scenes roles in the
process of adopting national LTC legislation. This unique
259
perspective is important to bear in mind as the implications based
on the research are considered. The results of this research can
assist advocates of LTC policy proposals and congressional staff
working on LTC issues, but for different reasons as described
below.
Implications for Advocates
For advocates of LTC policy proposals, the results provide
guidelines on formulating LTC policy proposals to be more
influential in the process of adopting national LTC legislation.
Advocates can use the research results to develop a strategy to
target their resources to those political features which are
influential in strengthening the influence of their LTC policy
proposals. They can devote sufficient attention and resources to
build coalitions, to limit the extent of policy change, to employ
analysts who are skilled in interaction, and to give high priority
to their interaction with congressional staff. They can also
devote resources to improving the communication and negotiation
skills of their analysts to strengthen their interaction with
congressional staff.
If resources are limited, advocates can develop and refine
their strategies for formulating proposals based on research
results. When there are not enough resources to take appropriate
action on all three features, advocates should target their
efforts first to building coalitions. This is because it had the
greatest support as being important to influential LTC policy
proposals. (See Table 19 for information on support for each
political feature.) They also could refine their strategies by
targeting the biggest share of their available resources to
building coalitions and the smallest share to advocates skilled in
260
interaction with congressional staff because of the reservations
in the support for this feature.
The tentative findings about other important features
provide additional suggestions about shaping influential LTC
policy proposals and using them in the process of developing
national LTC legislation. Advocates can give special attention to
developing a constrained financing approach for their LTC
proposals. Proposals with a financing approach that does not add
to the deficit, is not re-distributive, and is not labeled as a
tax are more likely to be influential in the process of adopting
national LTC legislation. Another suggestion is that approaches
to mobilize grass roots support for their LTC proposals should be
considered seriously and implemented as resources permit.
Advocates should consider targeting their LTC policy proposals to
a specific member of Congress most likely to serve as a horse by
making special efforts for enactment. Targeting could include
devoting special attention to interacting with those congressional
representative and their staff members with a history of interest
in a specific issue. For exaimple, advocates could target a LTC
policy proposals with benefits for persons with Alzheimer's
Disease to those congressional representatives who have supported
previous legislation on the issue. Targeting also could include
adding a horse's favorite issue to a proposal to increase
commitment to it.
An important theme of the literature about policy analysts
is their difficulty in determining who is the client for the
policy proposal (Meltsner, 1976; Radin & Hawley, 1988; Majone,
1989). A major reason for this difficulty is that as the proposal
shifts from the formation to the adoption stage of the policy
261
process, the immediate client shifts also. At the formation
stage, the client is likely to be an executive of the organization
where the advocate works. The members of the organization also
could be considered as a client of the proposal. At the adoption
stage, the clients are multiple. Some of the important clients
include: congressional staff, members of Congress, and interest
groups concerned about the issue. If the proposal concerns an
issue of public interest, the media and the general public are
also important clients. While considering the concerns and
reactions of such a diverse group of clients can be a challenging
task for an advocate, doing so can result in a proposal that is
extremely influential in the process of adopting national LTC
legislation.
The match between judgments of congressional staff and
advocates concerning the importance of the political approach to
analysis showed a telling difference. Of the 35 percent of the
informants who selected political analysis as influential, all
were congressional staff and none were advocates. Most of the
staff worked for representatives of the minority party. This
difference has some significant implications for advocates when
they formulate their LTC proposals. Because of the importance
that congressional staff assign to the political approach,
devoting some attention to it when formulating proposals may
result in proposals with more influence in the process of adopting
national LTC legislation. This preference by staff working for
the minority party for a political analysis may indicate that they
prefer to focus on the general issue of the role of government in
LTC rather than on evaluating options to respond to specific LTC
issues. Advocates may want to keep the preference in mind as they
262
interact with congressional staff working for the minority party.
Advocates also may want to keep in mind the strong preference of
staff for the minority for limiting policy change. This could be
an important factor not only in preparing policy proposals but
also in negotiations.
Implications for Congressional Staff
For congressional staff members responsible for LTC issues,
the research findings can provide guidelines on selecting
influential LTC policy proposals. Such proposals can be used, in
whole or in part, to develop bills which are more likely to be
influential in adopting national LTC legislation. While
congressional staff have an intuitive sense of what constitutes an
influential proposal, an articulated set of guidelines about
political features can be helpful in providing a systematic
approach to selection. Guidelines can be used to systematically
review proposals to identify those that can be the most
influential. Research results support the use of LTC proposals
which build coalitions and limit the extent of policy change as
the basis for developing proposals for adopting LTC legislation.
The tentative findings about other important features
provide additional suggestions about selecting influential LTC
proposals for use in shaping proposed LTC legislation. One
suggestion is to select those LTC proposals with constrained
financing approaches or to modify proposals to contain such an
approach. Another suggestion is to select those LTC proposals
which have strong grass roots support. Congressional staff should
try to use, when possible, those LTC proposals which include
issues of special interest to their particular member of Congress.
This is because a member may want to act as a horse or major
263
supporter of a bill because of special commitment to the issue or
because the issue has the potential of providing other political
advantage.
Preliminary evidence about the most important political
feature suggests that a good strategy may be to select proposals
that combine political features of grass roots support, building
coalitions, constrained financing, and analysis. When proposals
include some, but not all, of this combination of political
features, these research findings can be used to pinpoint the
areas where the proposal needs strengthening. They can also be
used to develop a strategy for preparing proposed legislation.
For example, one strategy could be to modify a proposal to
increase its influence by limiting the extent of policy change or
constraining the financing approach. Another strategy could be to
synthesize the important political features of several proposals
into one comprehensive LTC bill and work to build a coalition
among the supporters of the individual proposals.
Congressional staff, especially those working for the
minority party, need to communicate better with advocates about
the importance of the political approach to policy analysis. They
need to give examples of the utility of the approach and emphasize
their preference for its use when formulating policy proposals.
Convincing advocates to use a political approach to analysis,
either alone or with a rational approach, may result in stronger
LTC proposals for use as the basis of proposed legislation.
Implications for the Field of Public Administration
Results of this study provide insights into understanding
which political features of LTC policy proposals can strengthen
their influence in the process of adopting national LTC
264
legislation. From the perspective of congressional staff and
advocates who play central, behind-the-scenes roles in the process
of adopting national LTC legislation, evidence suggests that it is
a combination of political features that result in a LTC proposal
being influential. Kingdon's agenda setting model of a
combination of features and a precipitating event may provide a
theoretical template for re-conceptualizing the influence and role
of political features in the adoption of national LTC legislation.
The comments of the informants about the applicability of their
judgments to other social policy issues can serve as a springboard
for future research that looks more broadly at the influence of
political features on the adoption of national legislation in the
social policy arena.
Two results of this research raise issues about graduate
education in the area of policy analysis. One result is the
judgment that analysis, regardless of the approach used, is one of
a combination of important political features. The other is the
preference of congressional staff, but not of advocates, for the
political approach to analysis. Rational analysis is the dominant
model in the field (Jennings, 1987). It is the basis of the
curriculum of many graduate schools and of some leading textbooks
in policy analysis. Yet, congressional staff, especially those
working for the minority party, emphasize the importance of the
political approach to policy formulation. This suggest that the
curriculum for the study of policy analysis would benefit from a
review to assure that sufficient emphasis is given to
understanding the strengths of the political approach to analysis
and to using it.
255
other Knowledge Provided By the Research
Introduction
In addition to providing knowledge specifically to address
the research questions, the research provided knowledge about
several other topics related to the process of adopting national
LTC legislation. One topic concerns the impact of the repeal of
the Medicare Catastrophic Coverage Act on pending legislation for
the elderly. Another topic concerns the impact of the CBO on the
importance of analysis to influential LTC proposals. The third
topic concerns the preponderance of women who are developers of
LTC legislation.
Repeal of the Medicare Catastrophic Coverage Act
Congressional staff identified the repeal of the Medicare
Catastrophic Coverage Act as having implications for adopting
legislation. This repeal was seen as an important influence when
members of Congress consider enactment of programs targeted to the
elderly. These were two common themes about the repeal in the
informants' interviews. One theme was the concern that interest
groups do not accurately represent the views of their members.
This probably stems from AARP's major role in serving as the voice
of the elderly in the passage of the Medicare Catastrophic
Coverage Act and its inability to prevent the repeal. This
concern about interest groups accurately representing the views of
their members may be a basis for the informants' emphasis on the
importance of grass roots support. Informants spoke of the
importance of polls and frequent contact with constituents as
approaches to determine grass roots views on the need for new
legislation and on the specifics of that legislation.
266
The second theme about the repeal is the confusion that it
created about gauging the political advantage of supporting a bill
that seemed to be in the best interest of the elderly. Because a
large proportion of the elderly vote, members of Congress often
can gain a political advantage by supporting bills the elderly
favor. Conversely, they can create a political disadvantage by
supporting bills the elderly dislike. Passage of the Medicare
Catastrophic Coverage Act created a situation for Congress in
which a presumed political advantage shifted into an actual
political disadvantage. Hence, the repeal of the legislation.
This congressional experience may have a chilling effect on
adoption of legislation, like LTC, which is heavily targeted to
the elderly. It may also result in an even stronger preference by
Congress for limited policy change so that any legislation that is
enacted does not generate major political disadvantage.
Impact of the Congressional Budget Office
The research provided knowledge about the growing importance
of the role of analysis in formulating influential LTC proposals.
In a study of congressional users of analysis where data were
collected in 1983 and in 1986-1987, Weiss (1989) found that the
substantive impact of analysis was relatively limited. She
predicted, however, that it might grow in the future (p. 429).
A common theme of informants was the importance of analysis
to influential LTC proposals. Congressional staff cited the
requirement that CBO estimate the costs of proposed legislation as
a key factor to the importance of analysis. Some congressional
staff spoke of the importance of analyzing the costs and benefits
of a policy proposal. Such an analysis provides the opportunity
to make revisions in the policy to address specific financing
267
issues. Several congressional staff felt that analysis was a
useful tool for developing arguments to support their proposals
and discredit the proposals of others and for disputing the CBO
cost estimates of the proposals. The research finding that
analysis is important to influential LTC proposals may be an
indication that Weiss's prediction is becoming a reality;
congressional staff are moving toward more substantive use of
analysis.
LTC As a Women's Issue
All but one of the informants in this case study had major
responsibility for LTC issues, either in their congressional
committee or in their organization. The majority of these key
informants (82 percent) were women. This proportion of women was
the same for advocates as for congressional staff, and the same
for staff working for the majority party as for the minority.
This preponderance of women working as developers of LTC
legislation may be because LTC is an issue that resonates with
women, more than with men.
There are several reasons for this. The first reason is
that the majority of elderly recipients of LTC are women. This is
not only because of their longer life expectancy, but also because
of their greater disability than elderly men (National Center for
Health Statistics, 1993; Verbrugge, 1984). Because women
generally marry older men, women are widows by the time they
become so seriously disabled that they need the help of another
with performing everyday activities. This lack of a spouse and
severe disability at older ages is a major reason why the majority
of nursing home residents are women aged 85 and over (Hing,
Sekscenski & Strahan, 1989).
268
The second reason is that the majority of LTC providers are
women. Providers fall into two categories. One category is
formal providers of LTC, like nursing home care, home health care,
homemaker service, and transportation services. These formal
providers are often nurses aides, home health aides, and nurses.
The majority are women. The other category is informal providers
of LTC, such as spouse, other family, and friends who provide
assistance with everyday tasks. Most of the assistance is unpaid.
Informal caregivers provide the majority of LTC services. They
are usually wives, daughters, and daughters-in-1aw (Stone,
Cafferata & Sangl, 1987).
This predominance of women as both the providers and
receivers of LTC may draw congressional staff members and
advocates who are women to the issue of LTC for several reasons.
Although most of these particular women are too young to be
providing LTC to their parents, they still may have first-hand
experience with LTC. They could have seen, and even assisted,
their mothers in providing LTC to older family members, most often
grandparents. Several informants spoke of receiving letters from
home in which their parents wrote about the help they were
providing to grandparents with LTC needs. Another reason is the
expectation of these women that they will be called upon to
provide LTC to parents, as their mothers are doing now for their
own parents. Several of them mentioned this in their interviews.
A third reason is their concern that they might need LTC when they
become elderly. The experience, expectations, and concerns these
women have about LTC may result in a greater interest in working
on the issue. It could also result in a stronger commitment to
addressing policy problems of LTC. Although it is an open
269
question whether personal interest and professional
responsibilities will result in their shaping legislation to solve
the serious problems women face with LTC, the potential is there.
The Researcher's Application of Results
This section describes the application of the research
results to my own job. I work at the National Center for Health
Statistics as a health researcher. The mission of this federal
agency is to collect, analyze, and disseminate data about the
health of the nation. Increasing the relevancy of reports for
policy making has recently been identified as a goal for the
National Center. Application of the results of this research
provide a strategy for moving toward this goal in my own work.
My job includes the analysis and publication of reports on
the health of the elderly. A major aspect of the job is
synthesizing data from 10 different national survey about health
(e.g., surveys of death, health status, and use of health care) to
analyze crosscutting topics like disability and LTC. The intended
audience for these reports includes researchers, public health
professionals, and policy analysts. However, the reports, like
those produced in other parts of the agency, treat topics in great
depth. As a consequence, the reports are more applicable to
researchers and public health professionals (for example see Van
Nostrand, Furner & Suzman, 1993) and less to policy analysts.
This is not surprising given that recommendations about the topics
and content of the agency's reports are generally made by a formal
advisory group consisting mainly of researchers and public health
professionals.
Research findings support the importance of analysis to
influential LTC proposals. Findings highlight the differences
270
between these who see political analysis as important (mostly
congressional staff working for the minority side) and those who
see rational analysis as important (advocates and mostly
congressional staff working for the majority side). I can apply
these results to increase the relevancy of the reports I analyze
and publish. The reports should have a better balance between
rational and political analysis. The amount of detailed data
should be reduced and the essential information synthesized for
easy retrieval and use.
Rather than produce the usual reports which are heavy on
descriptive analysis, analysis should be issue-oriented. This
issue orientation could increase the utility of the reports for
building coalitions in two ways. One way is that once an issue of
concern to an interest group is identified, congressional staff
and advocates can use relevant data on the issue as part of their
arguments to convince the group to join the coalition. Another
way is to select data to focus on issues of interest to particular
members of Congress. Because informants have reported that the
focus on building coalitions in the Senate is mainly on specific
issues, an issue-oriented report can be a useful tool in gaining
support within the Senate for enactment.
Data on costs, benefits, and need should be included in
reports and should be emphasized in the analysis. Demand for such
data has been increasing because of the requirement that CBO
estimates the costs of proposed legislation. Such data is useful
to congressional staff and advocates as they shape policy
proposals to constrain financing and develop arguments to support
their proposals and to criticize those prepared by others.
271
Another application of the research results to my job
relates to the research finding on the importance of the skill of
advocates in interacting with congressional staff This finding
also is applicable to me because I provide information to
congressional staff and advocates. Strengthening my communication
skills in presenting information in informal settings could
increase the use of the data produced by the National Center for
Health Statistics in shaping LTC policy proposals. This personal
strategy of preparing issue-oriented reports and strengthening
communication skills could result in producing reports which have
a greater impact and influence in the process of adopting LTC
legislation.
Future Research
This section presents several recommendations for future
research. Some recommendations concern issues specifically raised
by the results of this case study. Other recommendations concern
broadening the applicability of the results. Still other
recommendations concern simultaneously addressing issues
specifically raised by the results and applicability.
Initial recommendations for future research concern issues
specifically raised by research results. The importance of
formulating a policy proposal by a political approach to analysis
was not confirmed as important for a proposal to be influential in
the process of adopting national LTC legislation. A rival
hypothesis, that a rational approach to analysis was important,
was examined because it was selected as important by more
informants (nearly half) that any other analytic approach.
Results from the analysis and pattern matching suggest that the
rational approach may be important to formulating influential LTC
272
proposals. However, additional research is necessary for a
thorough examination of this rival hypothesis. The research
should be designed so that the respondents comment on use and
importance of all approaches to analysis, not just the approach
they prefer or consider most important. Such a design should
result in sufficient information to evaluate more thoroughly the
importance of various approaches to analysis. The research also
should be designed to explore differences found in this case study
between congressional staff and advocates on the approach to
policy analysis that is most important. This research found that
congressional staff working for the majority and advocates mostly
selected the rational approach, while congressional staff for the
minority mostly selected the political approach. Because some of
the informants identified both political and rational approaches
as important, additional research should examine the importance of
combination approaches to analysis to formulate influential LTC
policy proposals.
Other recommendations for future research concern broadening
the applicability of the results of this case study. The support
for hypotheses about the importance of building coalitions,
incremental policy change, and skillful advocate interaction
suggests potential for generalizing the results in two ways. The
first way to generalize the results is by expanding the
applicability of the current findings to other groups of actors
who have important roles in the process of adopting national LTC
legislation. Future research should include other classes of
participants, beyond those in this case study, who work behind-
the-scenes in the process of adopting national LTC policy. These
other classes of hidden participants include: congressional staff
273
from committees which do not have responsibility for LTC programs,
technocrats in the executive branch of the government who develop
and implement programs in LTC, academics and other researchers who
do not work for interest groups, and representatives of interest
groups who speak for consumers and providers of LTC beyond those
included in this case study. Future research also should include
visible participants in the process of adopting national LTC
legislation. Congressional representatives who are members of the
committees responsible for LTC should be included because of their
role in shaping proposed LTC legislation. In addition, those
representatives who do not sit on these committees should be
included because they vote on the proposed legislation. Political
appointees at the top levels in the executive branch who have
program responsibility for some aspects of LTC should be included.
Some of these appointees are: the Assistant Secretaries for Aging
and for Health as well as the Administrators of the Social
Security Administration and the Health Care Financing
Administration. This research can move toward the development of
a nascent theory about the importance of these three political
features to influential LTC proposals from the perspectives of all
major participants in the policy adoption process.
The second way to generalize the results of the research is
by expanding the applicability of findings to other social policy.
Confirmation by informants that their conclusions were applicable
to other social policy issues suggests building on and expanding
the results of the preceding research about LTC legislation.
Additional research could examine the importance of these
political features in adopting national legislation about a
spectrum of social policies.
274
The final recommendations for future research concern both
applicability and issues specifically raised by the case study
findings. About half of the informants identified a combination
of political features as the most important to an influential LTC
proposal. The "standard" pattern included four political
features: grass roots support, coalition building, constrained
financing approach, and analysis. This phenomenon of a
combination of political features is illustrated in Figure 23.
The dynamics of the phenomenon suggest Kingdon's model (1984) of
the agenda setting process. In Kingdon's model, agenda setting is
the result of the coupling of three streams : problems, policies,
and political receptivity. None of the streams is sufficient in
and of itself to place an issue on the policy agenda. But when a
precipitating event, like a crisis or problem, occurs and the
streams are coupled, the issue is placed on the policy agenda.
Kingdon notes that the coupling process is not linear. It is
unpredictable, but not random, in that each stream has it own
processes, patterns, and constraints. Kingdon's model can provide
a framework for conceptualizing additional research about the
combination of political features which has the greatest impact on
developing influential LTC policy proposals. Future research to
understand the phenomenon of multiple political features can
suggest a nascent theory about the impact of a combination of
political features on the adoption of national LTC legislation.
If findings of this recommended research support a nascent
theory concerning LTC legislation, additional research should
attempt to generalize the theory to other social policy areas.
Such a general theory can provide guidelines for policy analysts
to strengthen their proposals so they are more likely to be
275
influential in the legislative process. It also can provide
guidelines for policy makers to identify proposals and modify
them, if necessary, so they are more likely to be enacted. If a
general theory could be developed, it could make an important
contribution to our understanding of the process of adopting
national legislation and our ability to impact on it.
275
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284
APPENDIX A
INTERVIEW PROTOCOL
285
Interview Protocol
A. Introduction to the Interview
PURPOSE ; Conduct research to determine which political features
of LTC policy proposals make them so influential that they are
given serious consideration in the process of adopting national
LTC legislation. Political features under study are the approach
to policy analysis, coalition building, the extent of change from
existing policies, and interaction about LTC proposals between you
and:
(TO CONGRESSIONAL STAFF) advocates of organizations with
major LTC proposals, researchers, and Administration
officials
(TO ADVOCATES) staff of congressional committees and
subcommittees with jurisdiction in LTC, such as those
committees of Waxman, Stark, Kennedy, Mikulski, Harkin,
Rockefeller, Pryor.
FOCUS OF RESEARCH: Research is focused on LTC because it is an
important issue currently and for the future. LTC will be a major
issue on the nation's public policy agenda over the next 50 years
as the baby boom generation ages.
WHO ARE INFORMANTS: Knowledgeable staff from congressional
committees and subcommittees with jurisdiction on some aspects of
LTC, advocates of groups with major LTC proposals, and
Administration officials and researchers who focus on LTC. Your
knowledge of LTC issues and expertise about the political process
of adopting national legislation gives you a special perspective
on the topic of political features of LTC policy proposals
influential to adopting national LTC legislation.
286
NEED AND RESULTS; We both know that LTC policy proposals with
technical merit often fail to influence the process of adopting
national LTC legislation. Not much has been codified about the
influence of political features on the process of adopting
national legislation. I hope this research can be helpful to you:
(TO CONGRESSIONAL STAFF) in identifying those LTC policy
proposals which could assist you in successfully adopting
LTC legislation.
(TO ADVOCATES) in developing LTC policy proposals that are
even more influential in the process of adopting national
LTC legislation.
AUSPICES : I cim working on the research as a candidate for a
doctorate in public administration at the University of Southern
California, Washington Public Affairs Center.
PLEDGE OF CONFIDENTIALITY: I would like to assure you that your
responses are confidential. Your name, position, or any other
identifying information will not be associated with the written
results. Most of the results will be presented in aggregate so
that no person can be identified. If a particular insight is
included, it will be presented anonymously.
FRAME OF REFERENCE : As we discuss the issues, bear in mind that
you should be considering the political features of LTC policy
proposals for the entire range of LTC issues and as prepared by a
variety of sources. For example, you should consider issues such
as social insurance, home and community-based care, LTC insurance,
asset transfer, welfare aspects of Medicaid, etc. You should
consider such LTC proposals as:
(TO CONGRESSIONAL STAFF) bills introduced in Congress or
bills under consideration by your committee (subcommittee)
287
and by others, proposals of the Administration, AARP,
Pepper Commission, HIAA, the staff of Brookings
Institution, and so forth.
(TO ADVOCATES) the one developed by (advocate's
organization), as well as bills introduced in Congress or
bills under consideration by appropriate committees and
subcommittees, LTC proposals of the Administration, and of
other groups (AARP, Pepper Commission, HIAA, the staff of
Brookings Institution, and so forth.)
B. Approach for Policv Analysis
GENERAL; What approach to policy analysis would help LTC
policy proposals get serious consideration when
adopting LTC legislation?
PROBE TOPIC IF INFORMANT DOES NOT DISCUSS
1. Importance (How important is the approach to policy analysis
in developing a proposal that is considered seriously?)
2. Model of analysis: scientific/rational versus political/
strategic
3. Extent of policy change: incremental, major
4. Values (such as equity, freedom, efficiency)
5. Extent of conflict in the issue-network over values
6. Citizen access to decision making
7. Whose interests? community, coalition, individual
8. Approach for decision making: explicit rule/
argument/coalition option/critical review
9. Role of analyst : advocate, technical elite, community
representative
10. Standard metric to compare options: cost-benefit analysis
288
APPLICABILITY: Now that you have been considering this issue,
do your feel that your comments apply equally
to all LTC policy issues, or are they more
applicable to some issues and less to others?
PROBE t Which comments apply? To which issues?
Do your feel that your comments apply equally to
other social policy issues, such as welfare reform,
crime, and so on?
PROBE ; Which comments apply? To which social policy issues?
C. Building Coalitions
GENERAL ; Are LTC policy proposals taken seriously when
adopting LTC legislation when they provide the basis
for building or strengthening coalitions?
PROBE TOPIC IF INFORMANT DOES NOT DISCUSS
1. Importance (How important is the ability to build or
strengthen coalitions in determining which proposals are
considered seriously when adopting LTC legislation?)
2. How to build a coalition
vague, diverse goals
abstract principles
symbolism
values and community norms
tools: negotiate, compromise, deal-making
3. How to gauge the strength of a coalition
4. When are coalitions easier to build
5. Strengths of coalition building in the policy adoption
process
6. Drawbacks of coalition building in the policy adoption
process
289
7. Model: issue networks versus iron triangle
APPLICABILITY : Now that you have been considering this issue,
do your feel that your comments apply equally
to all LTC policy issues, or are they more
applicable to some issues and less to others?
PROBE : Which comments apply? To which issues?
Do your feel that your comments apply equally to
other social policy issues, such as welfare reform,
crime, and so on?
PROBE : Which comments apply? To which social policy issues?
D. Limited Extent of Policv Change
GENERAL: Are LTC policy proposals taken seriously when
adopting LTC legislation when the proposals limit
the extent of change from existing LTC policies?
PROBE TOPIC IF INFORMANT DOES NOT DISCUSS
1. Incremental changes
2. Maintain the status quo
3. Risks in judging what public wants
4. Risks in predicting future impacts, especially costs and
implications for future generations
5. Lack of consensus for
role of public sector
role of the family
public in general
policy arena in particular
6. Changed policy-making environment
APPLICABILITY : Now that you have been considering this issue,
do your feel that your comments apply equally
290
to all LTC policy issues, or are they more
applicable to some issues and less to others?
PROBE ; Which comments apply? To which issues?
Do your feel that your comments apply equally to
other social policy issues, such as welfare reform,
crime, and so on?
PROBE ; Which comments apply? To which social policy issues?
E. Interaction Between Advocates and Congressional Staff
GENERAL ; What interaction do you have with:
(to congressional staff) advocates of organizations with
LTC policy proposals, and with Administration officials and
researchers who focus on LTC? How does your interaction
with them influence which proposals you consider seriously
when adopting legislation?
(to advocates> congressional staff members concerning LTC
policy proposals? How does interaction with them influence
which proposals they consider seriously when adopting
legislation?
PROBE TOPIC IF INFORMANT DOES NOT DISCUSS
1. Importance (How importance is interaction in determining
which proposals are considered seriously?)
2. Previous experience with advocates\congressional staff that
influenced you
3. Extent of interaction
4. Major concerns of advocates\congressional staff in adopting
legislation
5. Broker role in coalition building
6. Seek like-minded client\advocate
7. Share general values, beliefs
291
8. Nature of relationship (comfortable\uneasy)
9. Trust between congressional staff and advocate
10. Definition of success for advocate\congressional staff in
adopting legislation
11. Qualities of a strong argument
12. Bend problem\shade analysis to preferred option
APPLICABILITY : Now that you have been considering this issue,
do your feel that your comments apply equally
to all LTC policy issues, or are they more
applicable to some issues and less to others?
PROBE ; Which comments apply? To which issues?
Do your feel that your comments apply equally to
other social policy issues, such as welfare reform,
crime, and so on?
PROBE ; Which comments apply? To which social policy issues?
F. Other influential Political Features of LTC Policv Proposals
GENERAL; So far, we have talked about four political features
that could influence whether LTC policy proposals
are considered seriously when adopting legislation.
Are there other political features you consider
important?
PROBE TOPIC IF INFORMANT DOES NOT DISCUSS
1. Why is (feature) important?
2. How important is it?
APPLICABILITY: Now that you have been considering this issue,
do your feel that your comments apply equally
to all LTC policy issues, or are they more
applicable to some issues and less to others?
PROBE : Which comments apply? To which issues?
292
Do your feel that your comments apply equally to
other social policy issues, such as welfare reform,
crime, and so on?
PROBE; Which comments apply? To which social policy issues?
G. Most important Political Feature
GENERAL; Of the (insert number) political features we have
discussed, which is the most important in
influencing whether LTC policy proposals are
considered seriously when adopting LTC legislation?
PROBE TOPIC IF INFORMANT DOES NOT DISCUSS
1. Why is (selected feature) the most important?
2. Is there another political feature we have discussed which
comes close to (selected feature) as the most important?
3. Why does it come close?
APPLICABILITY : Now that you have been considering this issue,
do your feel that your comments apply equally
to all LTC policy issues, or are they more
applicable to some issues and less to others?
PROBE : Which comments apply? To which issues?
Do your feel that your comments apply equally to
other social policy issues, such as welfare reform,
crime, and so on?
PROBE; Which comments apply? To which social policy issues?
H. Additional Materials Request
GENERAL; An important part of my research is understanding
the context for the passage of LTC legislation. I
am interested in relevant documents. Do you know of
any documents that are important?
293
PROBE TOPIC IF INFORMANT DOES NOT DISCUSS
1. Reports of meetings/hearings
2. Speeches written for committee/subcommittee members or key
figures of the organization/Administration
3. Reports for related issues/legislation
4. Bills submitted to congressional committee/subcommittee
5. How to obtain copies?
I. Clarification and Close
GENERAL: As I mull over our conversation, I may have some
questions. If so, I may call you to resolve them? Thank you for
your time and for sharing your insights and knowledge with me.
294
APPENDIX B
LETTER TO CREATE AN LTC COALITION IN THE SENATE
295
Bnitd States ^oiatc
WASHINGTON. DC 205 10
Dear Colleague: February 28, 1994
As Chairs of the Senate Committee and Subcommittees
concerned with the health and well-being of American families,
people with disabilities and older Americans, we ask you to join
us to ensure that health care reform addresses a critical missing
piece of the current system— long term care.
People of all ages with chronic illnesses and disabilities
like Multiple Sclerosis, Alzheimer's disease, spinal cord injuzry
and mental retardation have essential health care needs just as
much as those who have cancer, heart disease, or pneumonia. But
because the care they require is not provided in doctors' offices
or hospitals, it is often not included in our current health care
system. They and their families are left to pay the bills on
their own, if they can. Most cannot, and thus are either left
without the health care they need, or they are forced to
impoverish themselves to become eligible for a public program
that has limited options.
The American people do not understand the irony of a health
care system that will pay $500 a day for hospital care but
refuses to pay $50 a day for home or community care. They do not
understand or accept the false distinction between health care
and long term care. That is why a January 1994 survey of 1775
adult Americans found that:
48% would be store likely to support a health care reform proposal
that included coverage for heme and community care, and
43% would be much less likely to support a proposal that does not
include long term care coverage.
Our Committees and Subccnsaittees have held numerous hearings
about the need for long term care. We have considered various
proposals to meet that need. The current health care debate
finally provides us the opportunity to act now on long term care.
We urge you to join us to” assure that the health care legislation
we pass this vear includes meaningful long term care coverage.
Tom Harkin Barbara A. Mikulski David H. Pryor
Chair,ySubcommittee^*j Chair, Subcommittee Chair, Special
on Disability Poljwdyy , on Aging Committee on Aging py. comm: tT
Jo>m D. Rocker «.1er "Donald W. Riegley/'Jr.\ Joan D. RockerAler IV
Chair, Subcommi^ee ga Health Chair, Subcommittee on Medicare
for Families an& insured and Long-Term Care
296
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Toward adoption of long term care policy for the elderly: Political features of long term care policy proposals influential to adoption, national legislation
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