1. Is This the Era of Health Care Reform?Is This the Era of Health Care Reform?
Why This Time is Different from AllWhy This Time is Different from All
Other TimesOther Times
Mark A. Peterson, Ph.D.
Professor of Public Policy and Political Science
Department of Public Policy
UCLA School of Public Affairs
Leonard Davis Institute of Health Economics
Health Policy Seminar Series
University of Pennsylvania
February 20, 2009

2. The easy out:
This time is not different
But not so fast…is there a reason to
anticipate that this time is different?

3. The Policy Window and Possible Triggers
(Based on John W. Kingdon, Agendas, Alternatives, and Public Policies)
PolicyPolicy
Politics
Politics Problem
s
Problem
s
PolicyPolicy
WindowWindow
Major Crisis?
(health care system/
economic system?)
Change in
Administration
(2008)
Change in Congress
(2006, 2008)
Viable Policy Options
(but no consensus)
Systematic Signs
of Decline or
Missed
Opportunities
Swing in the
National Mood
Social Movement?
Policy Image?
Power of Ideas?
Rearrangement of
Interest Group
Alliances?

4. “Google” the term “health care crisis”:
Over 500,000500,000 hits

5. Costs Coverage Consequence
Int’l
Mea-
sures
HC
Infla-
tion
Gov’t
Spend
Bus.
Spend
Indiv’l
Spend
Un-
insured
Under-
insured
Dispar-
ities
Quality/
Outcomes
Int’l
Rank
Pop
Health
1912 0 0 0 0 - 0 0 0 0 0 -
FDR 0 0 0 0 -- -/0 0 0 0 0 0
Truman 0 0 0 0 -+? -+ -+ 0 0 0 0
Nixon/
Ford
0 - - -? -+ -(+) - 0 0 0 0
Carter 0? -- --? -? -+ -(+) - 0 0 0 0
Clinton -- -- -- -- -- -- - -- - - 0
Now -- -- -- -- -- -- -- -- -- -- -
0 = No evidence or limited perception of problem - = widely recognized evidence of problem
-- = evidence of problem and getting worse -+ = evidence of problem but getting better
Rational Responses to Health Care System Problems?
© Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,”
book manuscript.

6. Institutional-Political-Economic-Policy Contexts
• The Institutional Context
• The Political Context
• The Economic Context
• The Policy Context
• Presidential/Administration Leadership
From: Mark A. Peterson, Legislating Together: The White House and Capitol Hill from
Eisenhower to Reagan (Harvard University Press, 1990).

7. Institutional-Political-Economic-Policy Contexts
• The Institutional Context
– Congress
Mark A. Peterson, Legislating Together: The White House and Capitol Hill from Eisenhower to
Reagan (Harvard University Press, 1990).

8. Types of Legislative Structure - Policy Effects
Policy Effects Centralized Decentralized Fragmented
Promotes
Policy
Change
Threatens
Policy
Change
Legislative
Majority Favors
Change
Legislative
Majority
Opposes
Change
Supportive
Chairs and
Committees as
Protocoalitions
Antagonistic
Chairs
Exercise
Baronial Veto
Multiple
Coalition
Strategies
Issue Complexity
Reinforces
Fragmentation
© Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,”
book manuscript.

9. Structure of the House of Representatives
During Four Periods of Reform Debates
Decentralization
Centralization
Fragmentation
Fragmentation
Centralization
Decentralization
Fragmentation
Centralization
Decentralization
Centralization
Decentralization
Fragmentation
1940s (Truman) 1970s (Nixon/Ford/Carter)
1993-94 (Clinton) Now (Obama)
The Senate?
© Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,”
book manuscript.

10. Institutional-Political-Economic-Policy Contexts
• The Institutional Context
– Congress
– Interest Groups
Mark A. Peterson, Legislating Together: The White House and Capitol Hill from Eisenhower to
Reagan (Harvard University Press, 1990).

11. Changing Interest Group Communities
Policy
Monopoly
(1940s)
Polarized
(1970s)
Fragmented
(Open to multiple coalition
strategies)
(1990s, Now?)
“The Challengers”
Poorly Mobilized Well Mobilized
“TheExis
Allied
Split
© Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,”
book manuscript.

12. Interest Group Positions on Clinton’s Health Security Act
0
10
20
30
40
50
60
70Endorsed
Favored
Mixed
Opposed
Fought
Percent
GOP Target Groups
Neither
Dem Target Groups
© Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,”
book manuscript.

13. Institutional-Political-Economic-Policy Contexts
• The Institutional Context
– Congress
– Interest Groups
• The Political Context
– Presidential Election Returns
Mark A. Peterson, Legislating Together: The White House and Capitol Hill from Eisenhower to
Reagan (Harvard University Press, 1990).

14. Election Results Supporting the President

15. First Election of the President—Popular Vote Percentage
0
10
20
30
40
50
60
70
% Popular Vote
Percent
FDR 1932
Eisenhower 1952
Obama 2008
Clinton 1992

16. Institutional-Political-Economic-Policy Contexts
• The Institutional Context
– Congress
– Interest Groups
• The Political Context
– Presidential Election Returns
– Congressional Election Returns
Mark A. Peterson, Legislating Together: The White House and Capitol Hill from Eisenhower to
Reagan (Harvard University Press, 1990).

17. Democratic and Republican Seats in the U.S. House

18. Democratic and Republican Seats in the U.S. Senate
Cloture (1917-74)
Cloture (1975 - )

19. Party Unity U.S. House and Senate
From Nolan McCarty, Keith T. Poole, and Howard Rosenthal, Polarized America: The Dance of
Ideology and Unequal Riches (MIT 2006) [http://polarizedamerica.com/]

20. Comparison of Three Democratic Presidents
and “Solid Votes”
(Majority = 218)
President First Year Democratic Seats
Democratic Party
Unity
“Solid
Votes”
Carter 1977 292 X .67 195
Clinton 1993 258 X .85 219
Obama 2009 257 X
.96
(110th
Congress)
247
Economic
Stimulus: 246
© Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,”
book manuscript.

21. Net Change in Number of Democratic Congressional Seats
-10
0
10
20
30
40
50
60
Net Change House Seats Net Change Senate Seats
NumberofSeats
1990+1992 2006+2008

22. Institutional-Political-Economic-Policy Contexts
• The Institutional Context
– Congress
– Interest Groups
• The Political Context
– Presidential Election Returns
– Congressional Election Returns
– Public opinion
Mark A. Peterson, Legislating Together: The White House and Capitol Hill from Eisenhower to
Reagan (Harvard University Press, 1990).

23. Timing—Dynamism of Domestic Policy Mood
Updated from James A. Stimson, Public Opinion in America: Moods, Cycles, and Swings, 2nd Ed.
Boulder: Westview 1999 (updated data set—Mood5204.xls—at www.unc.edu/~jstimson)

24. Most individuals in the United States currently get health insurance coverage through their employer or
through a family member’s employer. Some people believe that employer-based health insurance is an
effective way to provide health coverage and will remain so in the future. Other people believe that the
employer-based approach will not continue to work in the future because of changes in our economy.
When thinking about the future of employer-based insurance, for each of the following statements do you
think the issue is--Not a problem for employer-based insurance; A potential threat to employer-based
insurance; Certain to lead to the failure of employer-based insurance; or Don’t know? (Pre-Election Survey)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100
%
Multiple Employers in
Course of Work Life
Rising Cost of Health
Care
Decline of Large
Manufacturers
Fewer Employers
Provide Coverage
Not a Problem Potential Threat Certain Failure Don't Know
Source: Blue Sky module, UCLA Team, 2006 Cooperative Congressional Election Survey, N=1,000

25. Public Support for Major Health Care System Change
0
10
20
30
40
50
60
70
80
90
100
1982 1984 1988 1990 1993 1994
(9/94)
1998 2000 2006
Percent
Defeat of Clinton’s HSA

26. People have different views about what affects their own health and the health of their families.
Some people believe that health is an individual matter, determined by their own preferences,
decisions, and actions (“we’re on our own”). Let’s say that they are 1 on a five-point scale. Other
people believe that health is a community matter, with their own health affected by the health and
well-being of others (“we’re in this together”). Let’s say that they are 5 on the five-point scale. On the
scale below, please indicate where you would place yourself. (Pre-Election Survey)
0
5
10
15
20
25
30
35
40
We're on Our
Own
2 3 4 We're in this
Together
Percent
11%
Source: Blue Sky module, UCLA Team, 2006 Cooperative Congressional Election Survey, N=1,000
The truly
Rugged
Individualists

27. When you consider the best way to think about health care services (provided by doctors,
nurses, other health professionals, clinics, hospitals, etc.), which one of the following three
statements comes closest to your own opinion? Health care services are “private goods” that
people should buy somewhat like cars and televisions, and based on what they can afford;
Basic health care services that should be available to everyone, like public education, but
people who can afford to should be able to buy more or better care, similar to paying for
private schools; or All effective health care services should be universally available, provided
to everyone as a right of citizenship and based on the services they need. (Pre-Election
Survey)
11
34
50
5
0
10
20
30
40
50
60
Private Goods Basic Services
for All
Provided as a
Right
Don't Know
Percent
Source: Blue Sky module, UCLA Team, 2006 Cooperative Congressional Election Survey, N=1,000

28. Institutional-Political-Economic-Policy Contexts
• The Institutional Context
– Congress
– Interest Groups
• The Political Context
– Presidential Election Returns
– Congressional Election Returns
– Public opinion
• The Economic Context
– Growing Resources vs. 0-sum constraint vs. Crisis
Mark A. Peterson, Legislating Together: The White House and Capitol Hill from Eisenhower to
Reagan (Harvard University Press, 1990).

29. Resources and the Politics of Policy Change
Growing Economy/
Rising Revenues
Economic CrisisStagnant Economy/
Budget Deficits
ProspectsforMajorPolicyChange
LBJ
Nixon,
Carter,
Clinton
(1993-94)
FDR,
[Reagan],
Obama
© Mark A. Peterson

30. Institutional-Political-Economic-Policy Contexts
• The Institutional Context
– Congress
– Interest Groups
• The Political Context
– Presidential Election Returns
– Congressional Election Returns
– Public opinion
• The Economic Context
– Growing Resources vs. 0-sum constraint vs. Crisis
• The Policy Context
-- Regulatory & Redistributive: high conflict
• Presidential Leadership
Mark A. Peterson, Legislating Together: The White House and Capitol Hill from Eisenhower to
Reagan (Harvard University Press, 1990).

31. Political Hurdle #1:
Ideological Positions on House Roll Call Votes, 93rd Congress (1973-74)
0
10
20
30
40
50
60
70
-1 -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8 1
DW-Nominate Scores (1st Dimension)
NumberofRepresentatives
Republicans
Democrats
Source: Gary Jacobson, “Public Opinion and the Impeachment of Bill Clinton,” 1999.
About 1/3 could
be either Dem
or GOP

32. Political Hurdle #1:
Ideological Positions on House Roll Call Votes, 110th Congress (2007-08)
(Source: Poole and Rosenthal, http://voteview.uh.edu/dwnomin.htm)
0
10
20
30
40
50
60
70
-1 -0.8 -0.6 -0.4 -0.2 0 0.2 0.4 0.6 0.8 1
DW-Nominate Scores (1st Dimension)
NumberofRepresentatives
Republicans
Democrats
4 of the 5
defeated
in 2008
15 of the 26
defeated/
departed
In 2008

33. Political Hurdle #2:
The Fear Arc
Time
© Mark A. Peterson: From “Getting to Health Reform: Institutions, Politics, and Lessons from the Past,”
book manuscript.

34. Issue
Visible “Polled”
Attitude
Model CModel C
Implication 9
Implication 7
Implication 8
Model BModel B
Implication 6Implication 6
Implication 4Implication 4
Implication 5Implication 5
Model AModel A
(current dominant)(current dominant)
Implication 3Implication 3
Implication 1Implication 1
Implication 2Implication 2
© 2006 Frameworks Institute—Susan Bales and Frank Gilliam
Strategy: Without Framing and Reframing—People Default to
the Dominant “Pictures in their heads”

35. Issue
Visible “Polled”
Attitude
PreventionPrevention
Healthy others
mean healthier me
Stay healthy
Self financing
Inter-
dependent
Current system inefficient and unreliable
Every one is in this togetherEvery one is in this together
Need an infrastructureNeed an infrastructure
ConsumerConsumer
Reform: “Do me no harm”Reform: “Do me no harm”
Private goodPrivate good
Personal cost issuePersonal cost issue
© 2006 Frameworks Institute—Susan Bales and Frank Gilliam
(amended)
Strategy: Without Framing and Reframing—People Default to
the Dominant “Pictures in their heads”

36. The Individual Cognitive Process
• Duality of Individuals’ Information Processing
Based on Drew Westen, The Political Brain (PublicAffairs, 2007)
– “Rational”
But also…
– “Emotional”
• Kahneman and Tversky: “Prospect Theory”

37. People Need Values Cues
(Based on George Lakoff)
 Level One: Big ideas (and Emotional
Connectons), like freedom, individual
rights/responsibilities, justice, prevention,
family, equality, security, and opportunity
 Level Two: Issue-types, like women’s
rights, the environment, children’s issues,
work, health care
 Level Three: Specific proposals, like the
earned income tax credit, day care, minimum
wage, individual health insurance mandate
© 2006 Frameworks Institute—Susan Bales and Frank Gilliam
ThisDirectionDoesNotWork

39. Retooling Obama's campaign machine for
the long haul
The vast network that helped elect Obama will be tapped to lobby lawmakers
on behalf of the president, with an eye toward reelection. A service
organization as a nonprofit arm is also considered.
By Peter Wallsten
January 14, 2009
Reporting from Washington — As Barack Obama builds his administration and prepares to take office next week, his political
team is quietly planning for a nationwide hiring binge that would marshal an army of full-time organizers to press the new
president's agenda and lay the foundation for his reelection.
The organization, known internally as "Barack Obama 2.0," is being designed to sustain a grass-roots network of millions that
was mobilized last year to elect Obama and now is widely considered the country's most potent political machine.
Organizers and even Republicans say the scope of this permanent campaign structure is unprecedented for a president. People
familiar with the plan say Obama's team would use the network in part to pressure lawmakers -- particularly wavering Democrats
-- to help him pass complex legislation on the economy, healthcare and energy.
Retooling Obama's campaign machine for
the long haul
The vast network that helped elect Obama will be tapped to lobby lawmakers
on behalf of the president, with an eye toward reelection. A service
organization as a nonprofit arm is also considered.
By Peter Wallsten
January 14, 2009
Reporting from Washington — As Barack Obama builds his administration and prepares to take office next week, his political
team is quietly planning for a nationwide hiring binge that would marshal an army of full-time organizers to press the new
president's agenda and lay the foundation for his reelection.
The organization, known internally as "Barack Obama 2.0," is being designed to sustain a grass-roots network of millions that
was mobilized last year to elect Obama and now is widely considered the country's most potent political machine.
Organizers and even Republicans say the scope of this permanent campaign structure is unprecedented for a president. People
familiar with the plan say Obama's team would use the network in part to pressure lawmakers -- particularly wavering Democrats
-- to help him pass complex legislation on the economy, healthcare and energy.
© Los Angeles Times

41. Presidents in Political Time
(Stephen Skowronek, The Politics Presidents Make: Leadership from John Adams to Bill Clinton)
• Reconstruction of the political order
– FDR
– [Reagan]
– Obama?
• Articulation of the political order
– LBJ
• Preemption of the political order
– Nixon
– Clinton
• Disjunction of the political order
– Hoover
– Carter
– [Bush II?]

42. http://www.blueskyhealthinitiative.org/