In light of the skirmishes happening at town hall meetings over health reform, I decided to post a previous piece I wrote back in February 2007, which explores E.E. Schattschneider’s book The Semisovereign People and examines the role of democratic conflict in implementing health reform.
The Role of Democratic Conflict in Implementing Universal Coverage
Policy change in the United States is inherently incremental. Our system of government is designed with a series of checks and balances that attempts to give equal weight to two competing ideas: the first, to make progress, and the second, to maintain the status quo. The end result is that changes are made deliberately and gradually, rather than haphazardly and hastily. Of course, there are always exceptions to the rule, and at certain times, the political landscape is such as to permit a marked change in policy, akin to a paradigm shift.
The question addressed here is whether efforts to reform the health care system and introduce universal coverage are more likely to be successful through incremental policy changes to the current system or through the sudden introduction of a policy or set of policies that essentially replaces the current system with an entirely new one. E.E. Schattschneider’s work on the contagiousness of conflict within a democracy is used here to provide a conceptual framework for the consideration of this question.
As Schattschneider points out, “the central political fact in a free society is the tremendous contagiousness of conflict….[which] consists of two parts: (1) the few individuals who are actively engaged at the center and (2) the audience that is irresistibly attracted to the scene.” He goes on to say that “the outcome of every conflict is determined by the extent to which the audience becomes involved in it.”
What does this mean for an effort at implementing universal coverage? It means that the proponent of a new policy of universal coverage is actively engaged in a political conflict with the proponent of maintaining the status quo or the proponent of a competing policy proposal. It is in the best interest of the proponent of universal coverage to use the “audience” (i.e., interest groups, other politicians, the media, and the public) to her advantage. But what does this entail?
According to Schattschneider, “conflicts are frequently won or lost by the success that the contestants have in getting the audience involved in the fight or in excluding it, as the case may be.” Thus, if our candidate wants to advance her agenda of universal coverage without raising too many eyebrows or drawing too much opposition out of the audience and into the fray, an incremental approach is more likely to go unnoticed and less likely to become a divisive political issue. Conversely, if our candidate puts forth a policy proposing comprehensive reform, the audience has been given an open invitation to enter the conflict and battle lines will be drawn.
At first, then, it seems that an incremental approach is clearly favorable as it flies “under the radar.” While this may be the case if our candidate’s proposal is not being strongly challenged, it is important to note Schattschneider’s point that “the balance of forces in any conflict is not a fixed equation until everyone is involved.” Therefore, if our candidate feels challenged by her opponent’s proposal, but confident that the audience supports her stance, she will benefit the most from going public and enlisting members of the audience to fight for her proposal. In essence, this could help tip the scales permanently in her favor by solidifying her base and swaying the undecided audience members who were biding their time and waiting to throw their weight behind the “sure thing.”
One way to make incremental policy change and keep the audience out of the conflict indirectly suggested by Schattschneider is to keep politics local. Thanks to federalism, the states act as laboratories to test out new ideas. At least this is how the issue is typically framed. Thus, Congress often grants a limited amount of funds for certain “demonstration projects” or grants flexibility for states to administer programs (e.g., Medicaid) within broader federal guidelines, with the goal of allowing states the opportunity to explore alternatives. Then, if the alternative turns out to be effective and successful, other states will decide to follow suit, and eventually a nationwide program can be modeled after the successful demonstration. This is incrementalism at its finest. On the other hand, a surefire way to bring the audience into the conflict is to nationalize the issue.
Ultimately, universal coverage is a national issue by definition. It would seem, however, that the most effective approach to take in pursuing a policy of universal coverage is one of quiet incrementalism, keeping the audience uninvolved until such time when they may be needed to support the cause in the face of strong and legitimate opposition. This is interesting to keep in mind when looking at what is actually occurring with universal coverage in this country.
With the 2008 presidential elections looming on the horizon, Democratic candidates such as Sen. Hillary Clinton and Sen. Barack Obama have put universal coverage on their platform. In essence, they have nationalized the issue, and will depend on the public to enter the conflict and fight for their cause.
Meanwhile, five states have implemented or are working to implement universal coverage in their state. Four of the five proposals were spearheaded by Republican Governors. Might they be taking an incremental approach now, positioning the party to effectively challenge the Democrats in 2008 by making universal coverage their own issue, even though they would undoubtedly seek to implement said policy through private market mechanisms? In the end, the outcome of the conflict will all depend on what the audience believes and how involved the crowd becomes.