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THE NEW ACTIVISM: FEDERAL HEALTH POLITICS REVISITED* LAWRENCE D. BROWN, PH.D. Professor and Head Division of Policy and Management Columbia University School of Public Health New York, New York

A MONG THE MANY AMBIGUOUS LEGACIES of Ronald Reagan's eight

A years in office one finds an especially striking puzzle in health policy.

As everyone knows, the Reagan years saw a curtailment of both the will and the resources for federal leadership in the health field, the former a consequence of a dogmatic conservative ideology, the latter of a huge budget deficit tolerated (perhaps welcomed) as a check on liberal adventures. In 1979 the Carter administration had talked semi-seriously about national health insurance and national ceilings on hospital spending. In 1981 everyone knew that hopes for significant expansion of program benefits and regulatory requirements were gone with the wind that swept the electorate in November 1980. But what everyone knew has turned out to be false belief. In 1983 the Reagan administration presided over the most important regulatory innovation in Medicare since its enactment in 1965, as the federal government began to set fixed prospective prices for inpatient care delivered to the program's beneficiaries. In 1988 Congress answered the president's call for a new package of catastrophic health care benefits in Medicare, the most significant expansion since it began. The rapidity of the program's demise (in 1989) only partly dispels the intrigue of its enactment. The Prospective Payment System and catastrophic provisions are the most salient departures from expectations, ideology, and past practice but they are only promontories in an impressive range of expansionist legislative and regulatory measures adopted during the Reagan years. Indeed, some sizable extension of the federal role in health care has become almost an annual event. In 1982 hospice provisions were added to Medicare, in 1983 PPS passed, in 1984 Medicaid benefits for pregnant women and poor children *A slightly revised version of a paper presented as part of the National Health Policy Seminar Toward a Health Care Financing Strategy for the Nation held by the sponsorship of the Committee on Medicine in Society of the New York Academy of Medicine from October 1986 to August 1988.

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were enlarged, in 1985 legislation (signed into law in 1986) required private employers to continue health insurance coverage for widows, divorcees, and laid-off workers, in 1986 Medicaid benefits were extended further, and in 1988 catastrophic health benefits became law. Political observers could easily cite a list of reasons why these outcomes were not supposed to occur. One is leadership: complex new initiatives generally come from the executive. Congress "oversees" by making various changes in the presidential program but -in general -it is unable to fashion law by itself in the absence of such a program and in the face of an antigovernmental animus as strong as the Reagan administration's. Another reason is ideology: the 1980 elections and the re-election of Ronald Reagan and a Republican Senate in 1984 seemed to signal the electorate's strong preference for conservative government. Freezing and if possible reducing the federal role in American society was, after all, the central theme of Reagan's message. A third reason is budgetary: as a result of the tax cuts Reagan won alongside his huge increase in military spending, the federal government quickly developed $200 billion-plus annual budget deficits. There was a virtual consensus in Washington that, ideology aside, the federal government simply lacked the money to embark on new programs. A fourth reason centers on the ease of opposition in these circumstances: faced with intense competition for available federal dollars in a conservative and debt-ridden climate, surely interested groups opposed to a larger federal role in health care would defeat those speaking for the general public (in the case of regulatory departures), for the poor served by Medicaid, and even for the elderly enrolled in Medicare, well-organized but also lately viewed as beneficiaries of an entitlement allowed to run amok. This essay argues that this conventional wisdom about the health politics of the 1980s is in many ways mistaken. Congress has been unexpectedly adept at generating health policy leadership of its own. The clash of ideologies has, in many cases, produced not stalemate and inaction but rather new pragmatic accommodations. Budget constraints have often stimulated creative new means of spreading costs. The positions of opposed (and for that matter supportive) interest groups have counted for less than the image of a policy community in the grips of "single issue special interest" organizations suggests. Exploration of these propositions may be valuable, not only to analysts trying to explain the politics of health policy, but also to practitioners seeking to steer those politics in new directions. Bull. N.Y. Acad. Med.

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THREE CASES In developing the argument it may be useful to concentrate on the "hardest" cases, those that entail a significant expansion of benefits for populations that are in some sense disadvantaged. The adoption of PPS, a regulatory innovation, largely fits the "revisionist" tenets summarized above, but this legislation can be and has been justified as an intervention needed to slow the growth of federal health spending. No such rationale is evident for programs that spend more on, or do more for, specific needy citizens. Among various candidates, three cases seem especially to reward detailed inspection both because they confer significant benefits on a sizable group and because they illustrate diverse routes to consensus and coalition-building. These are the expansion of Medicaid benefits for pregnant women and poor children in 1984, the mandated continuation of insurance coverage of 1985-86, and the addition of catastrophic coverage to Medicare in 1987-88. The Child Health Assurance Program (CHAP). Medicaid, originally intended mainly to help "welfare" families and individuals to cope with the costs of medical care, has always been a gap-riddled program. Because eligibility for the program is linked to eligibility for Aid to Families with Dependent Children (AFDC), over which states have large discretion, more than half the poor now fail to qualify for Medicaid benefits. Within broad federal limits, health services available to pregnant women, infants, and children vary from state to state. And increasingly Medicaid funds pay the nursing home bills of the poor elderly, leaving fewer dollars for the nonelderly poor. For years critics have charged that federal and state policies neglected deserving recipients-pregnant women, poor mothers, and their childrenwho would benefit from an expansion of relatively inexpensive, cost-effective prenatal and preventive care. For years these arguments have been honored more in theory than in practice for several reasons, including the political weakness of the constituency that would gain, the relative disinterest of provider and elderly lobbies in pressing for inexpensive, nonintensive, preventive and primary care services for the young, and disagreement within the child-and-youth lobbies as to what services and groups to emphasize. Nonetheless, reform efforts came close to fruition in the Carter administration, which proposed an expansive Child Health Assurance Program between 1977 and 1980. The measure twice passed the House of Representatives but Vol. 66, No. 4, July-August 1990

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twice died on the Senate floor, the last time at the end of the 96th Congress in 1980. During the first two years of the Reagan administration, prospects for new spending on maternal and child health services were bleak indeed. Central policy issues for Medicaid were how and how much to cut its budget (Congress rejected Reagan's call for a cap on Medicaid spending but did impose percentage cuts in its budget over three years) and how and how much to enlarge the discretion of the individual states in running the program. Meanwhile, maternal and child health services outside Medicaid were also cut, and tighter AFDC eligibility rules threw hundreds of thousands of recipients off the welfare and Medicaid rolls. Shortly, however, the political picture changed markedly. Medicaid cuts following the curtailment of AFDC eligibility seemed cruel and paradoxical in the wake of the recession of 1981-82, which caused soaring unemployment and much attendant loss of work-related health insurance. Many working poor were first thrown off "welfare" and then thrown out of work. The Children's Defense Fund and other groups highlighted evidence that the nation's infant mortality rate (on which the United States stands higher than about a dozen comparable nations) had begun to reverse its decline, and that the incidence of low-weight births and other problems accompanying unhealthy pregnancies in teen-agers and poor mothers was increasing in some regions. These data were of special concern to political leaders in southern states that tended to combine high rates of infant mortality and unhealthy births with low Medicaid eligibility and spending. The Southern Governors' Association began debating solutions. The administration saw no case for restoration, still less augmentation, of the federal role in this area, but Congress took a different view. The emergency jobs bill passed in 1983 increased spending for maternal and child health services (incorporated in a block grant since 1981) and added new funds for the supplemental food component of the Women, Infants, and Children program.1 Child and family issues began to seize the legislative imagination; one indicator was the creation in the House of a 25 member Select Committee on Children, Youth, and Families, chaired by George Miller (Democrat of California). The Congressional Budget Resolution adopted in 1983 for fiscal year 1984 even included $200 million in new spending for maternal and child health services. Sensing a new "window of opportunity,"2Henry Waxman (Democrat of California), chairman of the Subcommittee on Health and the Environment of the House Energy and Commerce Committee, worked with the Children's Bull. N.Y. Acad. Med.

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Defense Fund, the American Academy of Pediatrics, the American Public Health Association, the U.S. Catholic Conference, and other groups to cull from the defeated Carter CHAP measure provisions that were at once high priorities and "doable." Waxman then introduced a measure to provide full federal financing for expanded Medicaid coverage for women pregnant for the first time and for poor women and children in families whose main wageearner was unemployed. The measure, which would cost about $200 million, cleared the Commerce Committee and was included in its Medicare budget reconciliation bill in October 1983. In the Senate Finance Committee Senator Lloyd Bentsen (Democrat of Texas) introduced more modest legislation that would require the states to cover services for first-time pregnant women who would qualify for Medicaid, at existing matching rates, at a cost of about $20 million over two years. The committee reported the bill in July 1983.3 Waxman was prepared to argue that the small budget expansion he proposed was more than offset not only by the longer-term savings it would generate but also by reductions in the Medicare and Medicaid budgets since 1981. He knew, however, that these arguments might not persuade conservatives (especially important in the Republican-controlled Senate), who would condemn new federal domestic departures in the face of $200 billion budget deficits. To protect CHAP, Waxman therefore sought to attach it to Ways and Means Committee reconciliation proposals that would be taken up as part of a large tax bill. The strategy failed: angered in part by a proposed rule that would allow Waxman to offer CHAP as an amendment to an otherwise unamendable bill, the House voted the larger measure down in November, and it died with the close of the legislative session. Solid political support for CHAP was clear in 1984, however. Reviving the proposal, Waxman reiterated his themes: this modest new spending was amply offset by savings elsewhere in Medicare and Medicaid; by spending a little now society (and the states) would save a lot later in their budgets for welfare, special education for the retarded, and other social services. In pressing his case, Waxman enjoyed the support of predictable liberals, such influential moderates as James Jones, the Oklahoma Democrat who chaired the House Budget Committee, and two other forces that had been much less visible in the debate over Carter's version of CHAP four years earlier. First, the above-mentioned Southern state officials, concerting their voices in the Southern Governors' Association, worked hard to win the support of legislators from their region who might otherwise have resisted new federal spending for the poor so soon after the Reagan "revolution" had been launched. Second, whereas antiabortion riders had contributed to the downfall of CarVol. 66, No. 4, July-August 1990

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ter's CHAP, Waxman's contracted version found support among some ardent and influencial pro-life legislators. Henry Hyde (Republican of Illinois), the author of the famous "Hyde Amendment," a prohibition against the use of federal funds for abortions introduced annually in floor debates on the budget, endorsed CHAP because (in the words of an aide), "If you are pro-life, and you want to help low-income women to have their babies rather than have abortions, you have to give support for care of that child. ' 4Thomas Bliley, a conservative Republican from Virginia and an abortion opponent who served on the House Select Committee on Children, Youth, and Families, argued likewise that "In order to be fair, we are under some moral obligation to take care of the living."5 Waxman and his allies had convinced a solid phalanx of left and right that CHAP was both efficient ("If you think this is expensive, try not doing it," Miller warned skeptics)6 and morally right. In April 1984 the House approved a $400 million version of CHAP as part of its deficit reduction measure. In June the Senate endorsed a less expensive variant in its tax bill. The legislation that emerged from conference later that year authorized $270 million in new federal matching money for fiscal year 1985 and required the states to provide Medicaid coverage to poor women pregnant for the first time, to pregnant women in two parent families whose main wage earner is unemployed, and to poor children, born on or after October 1, 1983 in two parent families up to the age of five. The budget reconciliation measure adopted in 1986 went further, allowing the states to extend eligibility for Medicaid to certain families and individuals with incomes too high for AFDC or the Supplemental Security Income program, but below the federal poverty level. Mandated benefits. Since the enactment of Medicare and Medicaid led some observers to conclude that a broader program of national health insurance was "imminent," liberals have favored a system of benefits administered, funded, or both, by the federal government, while conservatives, opposing this approach as too costly and too regulatory, have countered with strategies that rely on the private sector, the source of most health insurance in the United States. In the early 1970s, pressured by the Health Security Plan backed by Senator Edward Kennedy (Democrat of Massachusetts) and organized labor, President Richard Nixon felt obliged to come up with an alternative. The results were the National Health Insurance Standards Plan and the Comprehensive Health Insurance Plan, which would have used federal authority to require employers to offer to their employees health insurance coverage meeting certain standards. Throughout the decade incipient coalitions for national health insurance splintered among the Kennedy-labor "craBull. N.Y. Acad. Med.

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dle-to-grave" approach, Nixon's strategy of publicly-mandated private benefits, and such other schemes as the catastrophic health insurance plan proposed by Democratic Senators Russell Long of Louisiana and Abraham Ribicoff of Connecticut.7 President Gerald Ford and Joseph Califano, Secretary of Health and Human Services in the Carter administration, floated variations on mandated benefits; both were hooted down by private sector employers opposed to this new regulatory imposition and by liberals determined to win a system based on social insurance mechanisms. With the election of Ronald Reagan in 1980, the swelling of the federal budget deficit, and the hardening of an antiregulatory mood in Washington, any lingering aura of imminence surrounding NHI rapidly vanished. The collapse of hopes for a comprehensive strategy, however, left Congress facing a range of special groups whose needs were not met by conventional insurance or by Medicare and Medicaid. As early as 1982 the legislators demonstrated their willingness seriously to consider new federal measures to help such groups by debating and nearly passing new protections for the unemployed who lost their health coverage with their jobs. Meanwhile, about half the states had adopted provisions that required employers to continue coverage for certain categories of exworkers and their dependents for a period of time. 8 In June 1985 Fortney "Pete" Stark (Democrat of California), newly appointed chairman of the Health Subcommittee of the House Committee on Ways and Means, and Edward Kennedy jointly proposed legislation that would require employers with more than 20 workers to offer continuing health insurance for one year at group rates to widows, divorcees, and laid-off workers who agreed to pay both the employer's and employee's shares of the premium. The provision was added to a huge list of health and other measures embodied in reconciliation legislation before the House and the Senate and, despite the absence of strongly supportive groups working for its passage, made its way into law with surprisingly little controversy, indeed with remarkably little debate. One explanation is the size and complexity of what came to be the Consolidated Omnibus Budget Reconciliation Act (COBRA). With about six dozen separate provisions in the bill pertaining to Medicare, Medicaid, and other health programs, changes that directly threatened benefits in existing programs and payments to providers attracted the most political attention. A second facilitating factor was that the measure struck most legislators as a prudent response to a pressing problem. A Senate staffer recalled that there was "an uncovering of the gaps, a sense that the holes in the so-called safety Vol. 66, No. 4, July-August 1990

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net were getting worse over time. There was this sense of a worsening problem, which moves politicians, changes their perceptions. No one was prepared to go very far, but they kept hearing about these 35 million people without coverage and kept asking, 'who are they'? And they got word that some of them were widows and such who lost coverage just because someone's employment status changed. The members could understand this. They came to view it [mandating] as a good idea, a way to fill a gap. They'd ask, as politicians do, 'who'll be hurt'? and 'what'll it cost'? and the answer to the first was 'no one' and to the second, 'nothing'." A third, equally important, factor is that the interest with the largest stake in opposing mandated benefits-the business community-failed to do so effectively. A staffer on the Labor and Human Resources Committee conjectured in an interview that business might well have defeated the measure if it had mobilized against it before it left the committees of jurisdiction. But, preoccupied with the unfolding drama of tax reform and other issues, the Chamber of Commerce and the National Association of Manufacturers turned out to be "asleep at the switch," training their wrath on the measure only after it was securely nestled in the vast folds of the reconciliation bill and not easily removable. When Congress finally reached agreement on the contents of COBRA in April 1986, the law required that employers with 20 or more workers continue health insurance coverage for workers' widows, spouses, and dependents who would otherwise lose coverage after death or divorce for up to three years, and for laid-off workers for up to 18 months. The covered individuals would pay both the employer's and employee's share of the premium, which could not exceed 102% of the group rate. Employers who failed to comply could lose their right to claim health insurance costs as a business expense on their taxes. Mandates may prove to be an increasingly popular approach to filling gaps in the health insurance system. The reconciliation bill for fiscal year 1987 extended coverage to retirees or dependents who lose insurance because their employer goes bankrupt, leaving business fearful that, in the words of an employer's bulletin, the COBRA provision may be "just the first in a series of congressional initiatives pointing toward a national health insurance policy ... a policy that could end up costing your company even more time and money. " 9 Catastrophic coverage. The wisdom of a federal program to assist elderly people facing unusually high ("catastrophic") costs of care has been debated since the early 1970s. Proponents contend that such a program is a rational way to target scarce resources on those with the greatest needs. Critics counBull. N.Y. Acad. Med.

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ter that catastrophic costs are visited on relatively few Medicare beneficiaries while routine costs (including those imposed by long-term care) burden many, and that catastrophic coverage, in the absence of deeper and broader reforms, would give providers incentives to overuse high technology procedures. Action on catastrophic coverage was stalemated along with other NHI options throughout the 1970s and into the 1980s. In 1986 the idea's time suddenly arrived. Cuts in Medicare payments to providers were partly passed along to beneficiaries; this, coupled with other increases in out-of-pocket payments, was putting a heavier burden on beneficiaries, a point the senior lobbies drove home. High technology procedures, often prolonged and costly, proliferated. Increases in medical costs outpaced the general rate of inflation. The danger that serious illness could bankrupt the elderly in spite of Medicare coverage was increasingly plain. The trends were much on the mind of Otis Bowen, a physician and former Governor of Indiana, whom Reagan appointed Secretary of Health and Human Services in December 1985. Bowen made it clear to the press and the president that protection against the catastrophic costs of illness for the elderly would be a high priority during his tenure. On November 19, 1986 he outlined his ideas on the subject, proposing that the proceeds of increases in Medicare Part B premiums finance a cap on out-of-pocket beneficiary costs at $2,000. The approach found instant favor on Capitol Hill. Edward Kennedy, chairman of the Labor and Human Resources Committee after the November elections returned control of the Senate to the Democrats, announced that catastrophic coverage would be at the top of his committee's agenda. Soon Lloyd Bensten, chairman of the Senate Finance Committee, was at work on a bill of his own, as were Pete Stark and William Gradison (Republican of Ohio), ranking minority member on the House Ways and Means, Health Subcommittee, and members of the House Select and Senate Special Committees on Aging. In his State of the Union address on January 27, 1987 President Reagan vaguely reiterated his commitment to a solution to the problem of catastrophic costs. '0 The question, however, was whether he would support the Bowen plan, which expanded Medicare, or tilt toward ideological conservatives in the administration, who favored a private-sector strategy that did not threaten existing Medigap products and avoided enlarging the federal role in health financing. Late in January Gradison warned that unless Congress had a Reagan bill within five or six weeks the administration would be "out of the game. " I I At the end of January -little more than two months after Bowen first sketched his preferred approach- Congressional Quarterly concluded Vol. 66, No. 4, July-August 1990

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that it was "no longer a question of whether Congress will do something about catastrophic health insurance, but when and what it will do." 12 On February 12 Reagan overruled his conservative advisors and endorsed Bowen's plan, whose wide bipartisan appeal was unmistakable. Throughout 1987 several legislative committees labored to "perfect" the measure. There was little doubt that Bowen's general approach would be the foundation of the new program; disagreement centered on several proposed variations on his theme. Everyone agreed that increases in Part B premiums would be a central source of revenue; but controversy arose over Stark's proposal for a means test, that is, funds raised from supplemental premiums levied on the affluent elderly according to the value of their Medicare benefits. There was predictable disagreement on the dollar ceiling at which the program would assume responsibility for additional costs. Most divisive were the "add-ons" -outpatient mental health services, home health care, and, especially, drug benefits, which House Speaker Jim Wright (Democrat of Texas) strongly supported as a means of putting the Democrats' stamp on the administration's proposal -that came and went in committee drafts. Conservative critics, the White House, and Bowen himself objected to these expansions, but proponents enjoyed two formidable resources: they could point to the enthusiastic support of the organized elderly (who objected to meanstesting but intimated that they might be willing to swallow it if it were sweetened with additional drug benefits),13 and they could insist that the program was self-financing and therefore budget neutral. Despite episodic efforts by Claude Pepper (Democrat of Florida) and a few other liberals to broaden the measure to embrace a range of reforms in longterm care, the House completed action quickly. By June the House Ways and Means, and Energy and Commerce committees had reported the bill favorably, and Ways and Means, had given separate approval to drug benefits. On July 25 the full House voted approval, 302-127. Although the Senate Finance Committee approved its version of the measure on May 29, objections that the add-ons, especially the drug benefits, would drive costs up and inevitably demand government subsidies slowed its progress to the floor. When the White House threatened to veto an expansive measure and Bowen declared that he might recommend a veto, a group led by Senators David Durenberger (Republican of Minnesota), John Heinz (Republican of Pennsylvania), and George Mitchell (Democrat of Maine) tried to negotiate a resolution that would make peace. Their efforts bore fruit in October and were ratified when the Senate, on October 27, approved catastrophic health insurance by a vote of 86-11. When Congress resumed its work in 1988 a conference committee Bull. N.Y. Acad. Med.

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resolved such issues as the limit on out-of-pocket costs, the details of the drug benefit, financing by means of other matters, whereupon Reagan signed the measure into law. (Part B premiums and a new supplemental premium but differ on specifics), and the discretion granted to HHS to hold the costs of the program within limits (a Senate provision that grew out of negotiations with the White House and other conservatives). EXPLAINING THE CASES

The previous section reviewed briefly three policy outcomes that might have been thought impossible if the customary readings of political leadership, ideology, budget constraints, and interest group obstructionism in the Reagan years were accepted. If this conventional interpretation is wrong, what is the right one? Leadership. The view that the presence in the White House of a dogmatic conservative adamantly refusing to launch executive initiatives that would enlarge welfare state benefits all but ensures inaction fails to recognize the remarkable increase in the 1980s both of the number of congressional health "leaders" and of their motives and opportunities to strike out on their own. In the 40 years since the federal government began seriously to intervene in the U.S. health care system, the number of committees, subcommittees, and individual legislators with a claim to a leadership role has risen steadily. In the 1940s and 1950s congressional health policy centered mainly on two bodies, the Labor-HEW Appropriations Subcommittees of the House and Senate Appropriations Committees. For most of these years the House Subcommittee was chaired by John Fogarty (Democrat of Rhode Island) and its Senate counterpart by Lister Hill (Democrat of Alabama). In 1965 the House Ways and Means, Committee and Senate Finance joined the action with the passage of Medicare and Medicaid. Ways and Means, however, had no subcommittees and no conspicuous health leaders apart from its powerful chairman Wilbur Mills (Democrat of Arkansas), and Senate Finance Committee chairman Russell Long did not often choose to don the mantle of a health leader. In the 1970s the extension of the federal health policy agenda into reorganizational and regulatory ventures -The National Health Service Corps, Health Maintenance Organizations, Professional Standards Review Organizations, Health Systems Agencies, and more-coincided with the implementation of congressional reforms that weakened the powers of committee chairmen, increased the numbers and autonomy of subcommittees, and encouraged the participation of individual legislators in decision making. 14 In Vol. 66, No. 4, July-August 1990

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the Carter years this policy individualism was somewhat tempered by the president's efforts, largely futile, to enact an ambitious program of his own, which included a national hospital cost containment plan and a version of national health insurance. But once the Reagan budget cuts had been enacted in 1981 and a promised comprehensive procompetitive initiative in the health field had failed to emerge from the White House by 1982, congressional health leadership began to blossom in striking profusion. As one moves along the cases from 1983 to 1988, the cast of congressional characters grows larger-presumably a testament to the sense that important tasks went unaddressed, that the electorate was increasingly receptive to policy solutions, and that action would have to come from Congress. In the Medicaid expansion of 1984 the key leaders were Henry Waxman and Robert Dole (Republican of Kansas) who, as chairman of the Senate Finance Committee, quietly helped to advance the measure. In the adoption of mandated benefits in 1985 Edward Kennedy and Pete Stark were joined by David Durenberger and John Heinz, among others, in introducing and negotiating legislation. In the catastrophic case, Kennedy, Stark, Durenberger, and Heinz all helped shape the outcome and were joined by Lloyd Bentsen, Jim Wright, Daniel Rostenkowski (Democrat of Illinois), Robert Dole, George Mitchell, and Bill Gradison among others. In an interview a Senate staffer went down this list of leaders and then extended it: "Max Baucus (Democrat of Montana) is into rural health, Bill Bradley (Democrat of New Jersey) has done a lot with programs for pregnant women and infants and home health, Daniel Inouye (Democrat of Hawaii) focuses on policies toward nurses, John Chafee (Republican of Rhode Island) works on the mentally retarded and NHI for children." The diffusion of subcommittee power and the enlargement of staff mean that, as David Whiteman remarks, a "health leader" need no longer be a "health specialist," but rather may be a legislator with a particular interest in one or two issues. 15 This wide ranging specialization on health issues encourages legislators to defer to one another's expertise (and pet projects), and the omnibus budget reconciliation bills of the 1980s have proved to be useful garments in which to cloak the various "priorities" of specialized, mutually deferential legislators. 16 Given these widely dispersed power bases and the continuing temptation to put them to use, the absence of an executive initiative may not be (as some theories of legislative-executive relations would have it) a check on legislative activism but rather an invitation to it. A president's program can to some extent focus congressional deliberationsthough the reception given to Carter's hospital cost cap plan and the creative Bull. N.Y. Acad. Med.

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surgery performed on Reagan's proposal for catastrophic coverage show how limited an extent this can be. But in the "new" Congress the absence of such initiatives in salient policy arenas such as health strongly invite myriad chairman/staff "teams" to put their stamp and their names on proposed legislation and see how much support (and publicity) they can garner. Ideology. There is no inherent reason why multiple legislative initiatives launched by a host of subcommittee chairs and other self-declared health specialists should find their way into law. The result, after all, could as well be a chaos of weakly-supported measures going nowhere. Congressmen are continually tossing into the hopper bills they know will never receive hearings, let alone have a serious chance of enactment; they do it to reassure constituents or groups (or themselves) that they are busy devising ways to advance the public interest. One might expect that health care-an expensive, controversial locus of welfare state entitlements under attack -would be a particularly fertile field for ideological stalemate in not only a divided government but also (until 1987) a divided Congress. In fact, legislative activists in the 1980s have been remarkably successful in tempering and compromising ideological positions. The reason is an irony that parallels the one about leadership mentioned above. Instead of freezing legislative agenda-setting, Reagan's refusal to lead in the health field stimulated it. Instead of sending liberals to the sidelines in despair, the ideological "revolution" or "realignment" of 1980 and 1984 led them to reconsider their nostrums and seek common ground with moderates and conservatives. When the sky is the limit, some think it immoral not to aim for the sky. Had the Reagan "revolution" not narrowed the confines of plausible policy debate, liberals might have gone on stalemating each other's work as they did so persistently in the 1970s in debates over the expansion of health coverage and benefits. With national health insurance plainly off the agenda and support for comprehensive reforms evidently lacking, activists who had disdained "salami tactics" in the 1970s began wandering back to the delicatessen in the 1980s. No longer insistent on "kiddie-care" or other large additions to maternal and child health programs, liberals were pleased to win the Medicaid expansions of 1984, which drew selectively from Carter's CHAP proposal. Benefit-expanders who thought it both right and cost-effective to offer better preventive services and early treatment for disadvantaged women and children joined conservatives who were convinced that further availability of such services weakened the arguments, and perhaps the demand, for abortions. The notion that the federal government should require ("mandate") that employers provide more health coverage for their workers and depenVol. 66, No. 4, July-August 1990

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dents had been central to the Nixon-Ford initiatives of the early and mid 1970s. In the mid-1980s Kennedy was a leading advocate of the mandating approach; he was joined by the AFL-CIO, which had opposed it a decade earlier. In the middle and late 1970s catastrophic health insurance was, like mandating, a lower cost alternative to comprehensive national health insurance, attractive to such conservatives as Russell Long and such cost-conscious liberals as Abraham Ribicoff. In 1987 Kennedy, Stark, and other mainstream liberals stood foursquare beyond catastrophic provisions; visionary voices calling for the inclusion of long-term care benefits and other expansive reforms found little audience. Nor could many conservatives bring themselves to oppose measures they had touted as conservative "alternatives" lo these many years. Congressman "Pete" Stark nicely embodies the tenor of the times: a solid liberal with a profusely bleeding heart, Stark has a strong taste for governmental solutions and a strong distaste for indulgence toward providers. Stark is also a pragmatic legislator who is adept at compromise, works well with Republican colleagues, negotiates effectively with providers, and has not hesitated to press the case for means testing as a source of financing for catastrophic health insurance in Medicare. 17 Most legislators have understood that the superficially compelling evidence of a more ideological electorate in the voting returns of 1980 and 1984 is an untrustworthy guide to the practical problems of public policy. In the three cases reviewed here (to which could be added the adoption of PPS, Congress's refusal to endorse a cap on the exclusion of employer-paid health insurance premiums from workers' income taxes, and other cases) conservatives recognized that the popularity of Reagan's persona did not translate proportionately into support for Reaganism as a political ideology. Liberals saw that the election returns carried a dual message, at once a reproach to their own enthusiasms and an invitation to seek social progress at a more measured pace and with shorter steps. The net result of this ideological agitation within the electorate has been that, in Bowler's words, "In several respects, the ideological positions that seemed to harden in the 1970s appear to have blurred somewhat in the 1980s."...18 No longer at war over proposals to do big new things on a few fronts, legislators have been working to do small new things on many fronts; as the cases examined here attest, they have had some success. Budgets. Ideological antipathy was not the Reaganites' only bulwark against an expanding federal role. Would-be activists might have risen to the Bull. N.Y. Acad. Med.

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occasion and reached agreement on the content of expansionary measures only to find themselves paralyzed by unprecedented federal budget deficits. In these three cases, however, the legislators showed how fiscal necessity can be the mother of political invention. In all three, the new program created or extended a "partnership" that permitted the federal government to extend its role without further encumbering its resources. The expansion of Medicaid, a program in which the federal government matches state spending on a formula that varies with the population and poverty levels of the states, required states that did not already do so to cover a specific set of services for delimited groups. A modest $270 million were authorized for the federal share in fiscal year 1985, and this, proponents contended, was offset by savings elsewhere in the budget Congress adopted. The federal mandate for continuing insurance coverage is a classic instance of "breakthrough displacement;" 19 using regulatory power, policymakers obliged the private sector to assume burdens the federal government could not afford to shoulder. New catastrophic coverage was financed mainly by increases in the premiums Medicare beneficiaries pay. Whenever skeptics protested that the (growing) package of benefits was becoming too expensive, proponents replied, consistently but mistakenly, that the measure was budget-neutral and cost no more than the elderly were willing to pay for it. These diverse "partnerships" with the states, the private sector, and program beneficiaries -proved to be serviceable vehicles for coalition building. Further permutations and combinations are endless. For instance, the mandated benefits case suggests that the threat of the loss, or the promise of the restoration or extension, of tax preferences can be a powerful incentive to business to take steps -prefunding pensions for retirees, say-that it might otherwise reject.20 Groups. However appealing these partnerships, coalition building is never simply endogenous to the Congress. Groups opposed in principle to a larger federal role (such as the free market types in and around the Reagan White House who argued against new catastrophic benefits in Medicare) or upset at the burdens to be imposed on them (the business community in the case of mandated benefits) might be expected to enjoy a strong voice, if not an outright veto, in an antigovernmental age. In reality, opposition groups were surprisingly few and ineffective in these cases, and carried less weight than the porousness and accessibility of the U.S. policy process would lead one to predict. A major, though not exclusive, explanation for the limited role of interest groups in these three cases is the nature of the reconciliation process, a provision of the Budget Reform Act of 1974 that lay unused until 1980 but has Vol. 66, No. 4, July-August 1990

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since proved to be a major fulcrum for consensus building. In essence, reconciliation requires that legislative committees make spending cuts in general conformity with the instructions of the Budget Committees.21 By and large, the legislative committees have complied, perhaps because the instructions they receive specify amounts to be cut but leave the contents of the cuts largely to their discretion. What constitutes a "cut" in congressional budgeting is ambiguous; a cut is defined as any decision that leaves spending lower than it is (otherwise) projected to be over one to three years under various assumptions about how present spending trends should be extrapolated. In reality, says Schick, an accurate estimate of savings "is an almost impossible task."22 The opportunities for creative accounting have not been lost on would-be activists who have argued that new provisions that add little (Medicaid) or nothing (mandates) to federal spending are justified ("offset") by savings wrung elsewhere in the budget.23 Once the committees of jurisdiction reach agreement on such measures they can be removed from a reconciliation bill only with considerable difficulty. The bill goes before the parent chambers as a total package. Individual programs and sums are not voted up or down individually, and debate and amendments are limited. Moreover, reconciliation bills are generally voluminous documents covering long lists of programs whose funding and provisions have been hastily compromised by committees (especially their staffs) working under reporting deadlines and the pressure of a heavy workload. In this decision-making milieu interest groups may have trouble winning a hearing, still less formal hearings, in which to air their views. A Senate staffer underscored this aspect of the reconciliation process: "Really it's been the only way to make anything exciting happen here these last five years. The COBRA [mandating] provision is a good example. If this had been put out there in a free standing bill with Kennedy's name on it, to sit for eight months and have hearings and all that, with people coming out of the woodwork to attack it and the NAM sniping at it, it would've been dead." Reconciliation entails quick deliberations, relatively little publicity, a reduced role for outside influences, and an enhanced focus on the committees and subcommittees of jurisdiction and their staffs.24 It is the first major sustained attempt to institutionalize redistribution as a decision-making norm in federal budgeting, insisting, at least in principle, that new spending for one purpose or group (say, expanded Medicaid services for pregnant women) be offset by savings imposed in another area of the budget (say, payments to providers). In the hands of would-be congressional health activists with a willingness to compromise on ideology and a sharp sense of timing, the Bull. N.Y. Acad. Med.

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process can be a significant tool for leadership. It is not, however, the only such tool. The ill-fated catastrophic health insurance bill of 1988 was a freestanding piece of legislation, not a provision in a reconciliation bill. In this case, interest group opposition was deterred by the measure's budget-neutral character, the supposed support for it among the well-organized elderly, and the breadth of bipartisan legislative sponsorship, which gave passage an aura of inevitability. THE NEW ACTIVISM IN THE NEW FEDERALISM

The patterns depicted here are not confined to the realm of legislativeexecutive relations in Washington. They appear to be taking root in the policy system more broadly and, with due modifications, the explanatory variables discussed above can help account for a new and surprising activism at the state level on behalf of the medically uninsured. Those to the left of center have often viewed the states as thoroughly unpromising vehicles for improvement in the lot of the poor. The states compete with each other for economic advantage, which means, among other things, keeping taxes low. They fear that generous welfare programs will attract the mobile poor. They are strained by Medicaid spending and eager to slash it. They protest their inability to innovate while fixing their gaze eternally on Washington, the Mecca of fiscal relief. Who then would have predicted in 1980 that over the coming decade many states would move on their own to address the problems of the medically uninsured and indigent? Yet by 1987 24 states expanded Medicaid eligibility to include more pregnant women and children, 15 states have created special high risk pools to assist those who could not obtain health insurance, and New York, New Jersey, Indiana, Minnesota, New Hampshire, Rhode Island, Washington, and other states adopted various new measures to help the uninsured.25 Prominent among the pioneers were such unfamiliar progressives as Florida, South Carolina, and West Virginia. Part of the explanation is leadership. Many states, especially Southern ones, are run by a new breed of governors (and legislators) who view their role as considerably more than balancing the budget and assuring restless corporations that their state has a sound business climate. Examples of the mid-1980s include former Governors Bob Graham of Florida, Mark White of Texas, and Richard Riley of South Carolina, each of whom was troubled by his state's standing near the bottom of the list of the 50 states on measures of AFDC and Medicaid eligibility and benefits, by its limited maternal and child health services, and by its depressing statistics on the incidence of infant Vol. 66, No. 4, July-August 1990

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mortality and low birth weight babies. With no federal solution on the horizon, these governors pressed for state-based answers, firmly declaring their commitment to improved health services for the disadvantaged, and (equally important) assigned top staff to develop legislation. Today the states, fulfilling their fabled role as a laboratory of experimentation and innovation, are eager consumers of academic and other studies of the nature of the problem(s) of the indigent and uninsured, and show keen interest in one anothers' deliberations and doings. Working with like-minded legislators, these modernizing governors play at the state level a role analogous to the subcommittee chairs resolved to be health leaders at the federal level-the role of sparkplugs who identify problems and insist on answers. These activist governors (and legislators) have achieved concrete results in assisting the uninsured partly because they reflect and advance a new pragmatism that rejects both the averted gaze of laissez faire and the utopian's perpetual willingness to abandon the good in the quest for the ideal. The new leaders, neither big-spending liberals nor latter-day Social Darwinists, are "modernizing moderates," ready to spend when persuaded that a little more money for (say) prenatal care could save more spending on welfare later on, prepared to constrain when convinced that managed care, gatekeeping, restrictions on free choice of provider, and the like might hold down program costs. As in the U.S. Congress, the constraining of the conceptual agenda has led, ironically, to a liberating of the practical agenda: conservatives increasingly acknowledge that they might do well (save money in the long term) by doing good (extending services to pregnant poor women and children, for example), and liberals increasingly recognize that the good they would do (by committing public dollars to an assault on social problems) ought also to be done well (with close attention to issues of program design, cost, and administration). The tangible expression of this softening of ideology has been new partnerships akin to those improvised at the federal level. Florida, South Carolina, and West Virginia, for instance, converged independently on a political quid pro quo in which the state alloted new monies to Medicaid while the hospitals contributed comparable sums by an assessment on their revenues. The funds thus raised matched new federal Medicaid dollars, extended on highly favorable terms to these (and other poor Southern) states. Costs were spread; the sacrifice and the glory were shared. Legislators who doubted that the state could afford new Medicaid outlays were won over by the hospitals' willingness to swallow a "sick tax. " Hospital leaders soothed angry constituents by emphasizing the faster and higher payments, and the reductions in uncomBull. N.Y. Acad. Med.

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pensated care the new public monies would buy. Other states have been equally innovative, pursuing such strategies as revenue pools to assist hospitals with high burdens of uncompensated care, redistribution of revenues among hospitals by means of rate setting programs, mandated benefits, and the development of new health insurance products directed at small businesses whose employees lack health coverage. State activists have lacked the procedural advantages that accompany reconciliation in the Congressional budget process, but they have often enjoyed considerable leverage over interest groups that might have derailed initiatives in the past. Hospitals never welcome a revenue assessment ("sick tax") and sometimes - in Texas, for example - manage to defeat one. In other states, however -Florida and South Carolina are again cases in point -they came to accept this approach because they wanted to arrest bad publicity about dumping, saw a chance to "level the playing field" vis-a-vis surging for-profit competitors who shunned the uninsured, or hoped to win points with state officials in future negotiations on this and other issues. Proposals for mandated benefits may pit the state against the business community, but many businessmen have come to recognize that they bear in their health insurance premiums the costs of serving the uninsured, like it or not. Revenue pooling and redistributions by means of rate setting give the state very substantial power over hospitals. The other major strategy -new health insurance products designed for uninsured employees of small businesses - sells itself as the last voluntaristic refuge on the road to mandating. Though hardly freed of the shackles of "interest group liberalism/conservatism," the states have enjoyed stronger leadership resources than the power of the beneficiary group or the antigovernmental tenor of the times might lead one to predict. WHY GOVERNMENT IS NOT ABOUT TO WITHER AWAY IN THE HEALTH FIELD

For several reasons the new activism may not be an aberration but a trend. One basic factor is what Wildavsky calls "policy as its own cause.' '26 Once government enjoys sufficient political support to embrace a policy goal, it is much more likely to be drawn in further than it is to withdraw from the field. To be sure, government may divest programs on the grounds that the objective has been won (hospital construction in Hill-Burton) or lost (health planning). Far more typical, however, are the patterns examined here. State and federal governments spend large sums on acute care for Medicaid recipients; over time the conviction spreads that small additional spending on preventive programs and early treatment might save money. The federal government's Vol. 66, No. 4, July-August 1990

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huge outlays drive the Medicare program to the edge of bankruptcy and generate a new prospective payment system with incentives for more efficient management of hospitals. The new efficient management style leaves fewer slack resources to cover cases of uncompensated care. The comforting view that no one who is sick enough, waits long enough, and tries hard enough will go absolutely without care begins breaking down, and new government measures -mandated benefits, hospital revenue assessments, expansions in Medicaid, and more-begin taking hold. Medicare's inpatient coverage fails to keep pace with rising costs and enhanced technology, leaving more beneficiaries vulnerable to the costs of severe illness; in time a new federal program to assist them finds a long (albeit fickle) list of champions. The accumulation of "rationalizing" policies, plainly evident in the evolution of such cost containment measures as PSROs and PROs, state rate setting programs and the federal PPS, is also visible on the benefit side of the ledger. The nature of medical science will strengthen government's temptation to amend old policies and fashion new ones. Biomedical research, basic and applied, continually invents new, better, and costlier techniques and treatments for which the public clamors. The approach taken to renal dialysis in 1972- add to existing law a wideranging benefit, guess at its cost, and then watch it exceed projections -is no longer acceptable. In the 1990s control of technology may replace price competition as the consensus candidate for "the key" to containing health care costs. Even a cursory look at what such controls might mean suggests sizable new roles for government. Control might entail: constraints on the introduction of new techniques (randomized controlled trials, new tests by the Food and Drug Administration or other public sources, "technology assessment" imposed in public or private insurance programs as a precondition for covering new or old procedures); constraints on the diffusion of technology (capital caps, global budgets, revitalized CON, or planning guidelines); constraints on the clinical application of technology (rationing of equipment, explicit criteria for the allocation of organ transplants); or constraints on the withholding of technology (living wills, infant care review committees, do not resuscitate orders). Few such controls can, should, or will arise in the market or in the voluntary sector; if society decides to bite the bullet on the costs of technology, government will have to supply the teeth. This probably implies new governmental ventures in rationing down the road.27 Demography will also enhance government's role in expanding old and inventing new benefits. With an ever-larger percentage of the population living to be old, very old, and very very old, policymakers may sooner or Bull. N.Y. Acad. Med.

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later overcome their current fixation on the cost of reform and start addressing cost effective (though nonetheless perhaps quite costly) alternatives to inpatient care and nursing homes as dominant modes of long-term care. The AIDS crisis, too, is a powerful magnet that will attract new governmental interventions. In coming years government is likely to enjoy political opportunities as well as policy motives for a steady, cautious activism. The "new" and more decentralized Congress is the home of health leaders who divide among their numerous selves (and staffs) the labor of innovation on such issues as congregate care housing, insurance for long-term care, bioethical problems, technology assessment, and more. The decentralization, perhaps disintegration, of the U.S. party system invites governors from states large and small to seek higher office by building a record on (among other issues) efficient management of Medicaid and success in addressing the problem of indigent care. A president prepared to lead in the health field will have to do business with these congressional power centers and with articulate spokesmen for the states, increasingly vocal and organized, individually and as an intergovernmental lobby. A president disinclined to lead will not check the expansion of government's role but merely cede decisions about its pace and direction to others. The softening of ideology and the new pragmatism that ensues will probably continue to pique the imagination of these new leadership sources. In U.S. politics sharp ideological shifts usually restore equilibrium among value elements (guns versus butter, morality versus liberty, and so on down a lengthy list) that sizable blocs of the electorate view as out of balance. Once balance is restored, ideological zeal usually abates-which is usually about the time pundits feel moved to declare that the system has entered a new "age of ideology. " The easing of ideological tensions, which began when the 1982 recession undermined Reaganomics, and was far advanced when the voters restored control of the Senate to the Democrats in 1986, will probably proceed. A Senate staffer sketched the basics of this new centrism. As for the left: "People on the Hill who remember the 60s and 70s have less confidence in government now. They've seen things tried that haven't worked out, so they see that having government do x or y isn't the answer. You can distrust the private sector without concluding that the answer is all government. There is no one answer, so you look for mixtures." Among moderates and conservatives: "In the early 1980s there were large cuts. Then -and Dole had a lot to do with this- there was a sense that cuts had gone far enough. These Vol. 66, No. 4, July-August 1990

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programs have basically been off limits since then and have even been increased a little. Basically these people have bought the rhetoric about the safety net, and Dole, Mitchell, Bensten, and some others view it at a certain level and won't let it go below that." Moreover, most of the issues likely to stand high on the government agenda in the 1990s skew and confound traditional ideological tenets. Expanded maternal and child health services appealed to benefit-minded liberals like Henry Waxman and to abortion foes like Henry Hyde. Conservatives who resist "big spending" programs such as national health insurance may have trouble explaining to liberals why they would also oppose further mandating of benefits, the old Nixon-Ford alternative. The gravity of the problems of medical indigency and uncompensated care is as evident to the business man sitting on the board of a hard-pressed hospital as to the spokesman for a poverty group. Few conservatives sought to block the extension of social insurance financing to catastrophic coverage; few liberals insisted that action wait upon agreement on comprehensive reform of long-term care. Conservatives, not liberals, led the campaign to enmesh the federal government in medical decisions about the care of handicapped newborns. Ideology offers little useful guidance to the policy choices surrounding AIDS. Many, perhaps most, health policy issues today have this ideologically amorphous character. Belief systems that assign "the role" in problem-solving exclusively to the private, voluntary, or public sectors are likely to fare poorly in future policy debates. Coalition-building success will go to those most adept at improvising partnerships that bridge these sectors by spreading costs and diffusing credit among them. The cases examined here illustrate some possibilities: CHAP, mandating, and (in its way) catastrophic coverage show the creative uses of (respectively) the grant-in-aid system, regulation, and social insurance in enlarging government's role without inflating its budget. The states' innovative approaches to the medically indigent show further eclectic variations. Health coverage for the elderly, says Senator John Heinz, is a "threelegged stool," comprised of "government, employers and individuals.' '28 Balancing benefits and costs among the requisite "legs" is the essence of the

policymaker's art. Given the size, cost, and salience of government's present range of interventions, the steady pressure of technological and demographic imperatives, the proliferation of leadership energies, the crumbling of ideological ramparts, growing skill at intricate balancing of saving and spending in large "redistributive" packages, and the attractiveness of eclectic strategic partBull. N.Y. Acad. Med.

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nerships, interest groups will probably play a smaller shaping and blocking role in health policy than they have in the past.29 Government is now too large a fiscal presence in the health field to play umpire in the group struggle; increasingly, it is the largest and best heeled protagonist in that struggle. "In the old days," a congressional staffer told David Nexon, "we had to prove that we should do something; now the lobbies have to prove that we shouldn't.' '30 When government has a large hand in defining the demand for the funds it supplies, Marmor's "political market" grows less "imbalanced. "31 Groups with influence in one forum (say one legislative subcommittee) may have little in another. Groups that fail to be "constructive" in addressing someone else's problem may lack good will when-as now happens with increasing frequency -a problem of their own is under debate. When a range of eclectic, pragmatic answers to pressing problems is on the table, the special interest that cannot find something to be "for" may discredit itself as intransigent or hopelessly reactionary. Confused ideological implications and motley strategic proposals may impede the creation of a united front within interest groups and thus complicate their public position taking. The interplay between programs and problems creates new and (by past standards) strange coalitions and cleavages, as (for example) provider groups join forces with liberal advocacy groups to resist cuts in Medicare and Medicaid, and large employers who offer health coverage to their workers and share the costs of serving the uninsured view mandated benefits as a means of leveling the playing field between themselves and other employers who offer little or no coverage. "Action-forcing" processes such as reconciliation in congressional budgeting curtail the opportunities groups enjoy for pressing their case. The fragmentation of group influence, like the fragmentation of leadership, ideas, and resources, is not (or at any rate not only) a symptom of institutional decline but rather (or also) a stimulus to political innovation. THE LIMiTS OF THE NEW AcTIvIsM

There is no intention here to offer up the new activism as a celebration of the inexhaustible genius of American politics. The programmatic innovations of the 1980s may be viewed as testament to an enduring realism that insists on facing facts that conflict with temporarily hegemonic ideologies, but they may equally be read as evidence of the political system's chronic capacity to delude itself about the bearing of means on ends. The discovery of imputed budget savings, used to offset new expenditures, permitted incremental extensions of Medicaid services, but while federal health care spending conVol. 66, No. 4, July-August 1990

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tinues to post high annual growth rates, the federal budget deficit remains large, and such massive encumbrances as the saving-and-loan bailout impend, savings are likely to be too small, and contested by too many claimants, to sustain more than marginal benefit extensions by means of an "offsetting" strategy. The federal government can realize policy goals at little or no public price by requiring the private sector to shoulder the costs of new benefits, as it did by extending health insurance coverage in COBRA, but precisely because the strategy is so inviting, it runs and obvious risk of overuse and political backlash. If, for example, Washington employs such mandating to extend broad, costly new civil rights protections to disabled Americans, it will probably be that much less prepared to mandate new private health insurance coverage for the vast majority of the more than 30 million uninsured Americans who work or are dependent of workers. Self-financing within a universalistic framework of social insurance remains an appealing vehicle for expanding benefits for the elderly, but the imbalance of the catastrophic coverage provisions, added to Medicare in 1988 and unceremoniously exercised in 1989, shows that when significant benefit expansion demands meanstested departures from universalism there is no consensus within public or political opinion on the practical meaning of equity. When the better off elderly began to denounce their income-related surcharge on the basic premium, the same diffusion of congressional leadership that had encouraged creativity in expanding benefits and dividing costs when formulating the new program generated dozens of mutually incompatible proposals to rescue it and defied effective coalition building around any one of them. In short, budget-neutral expansion can have but a limited application given current budget conditions, private sector mandating can be invoked only so often, and self-financing as a vehicle of major change may have run out its political rope. Meanwhile, Medicaid needs significant redesign if not a comprehensive overhaul, the problems of the medically uninsured linger on without effective political intervention, and the need to fashion in earnest a longterm care system grows more pressing as the population grows older. Beyond these cases lie the homeless, the mentally ill, people with AIDS, the disabled, drug addicts, and other groups with severe and costly problems. Nor should the political forces invoked here as explanations for the new activism be viewed as vehicles of inevitable progress. That executive leadership is not always necessary does not mean that it is never necessary. Congress can (and did) expand Medicaid at the margin, but comprehensive departures in financing may well require strong presidential commitment. Pruning the ideological extremes may force convergence on what is practical Bull. N.Y. Acad. Med.

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and doable, but the consequences of consensus may be a series of interventions that are minor because the contending factions could agree on nothing major. Budgetary pressures may concentrate policymakers' minds on value for money and artful implementation on public program; they may also deny a place on the agenda to problems that badly need new money "thrown" at them. Reconciliation and other inner-directed processes may contain the free play of group politics, but, as the catastrophic case proves, groups that, under the temporary spell of highly complex and technical legislation, fail to bark may return to bite politicians who stand accused retrospectively of violating self-interested norms of fairness. Finally, state-level innovation can go only so far -so far as antitax sentiment, competition to improve the corporate climate, and the vagaries of revenue collections and budgetary outlays permit. Massachusetts' bold plan to secure or provide universal coverage for its citizens was formulated in the best of times (an economic "miracle" and a governor running for president), implemented in the worse of times (severe budget deficits and a lame-duck Governor repudiated first by the national electorate and then by much of the state's public opinion). Viewed from hindsight in 1990, the new activism of the 1980s was both a commendable set of practical improvisations in the face of an intransigent inactivist dogma and a political drop in a deepening policy bucket. Such variations on these themes as may unfold in the 1990s may further exhibit the system's resourcefulness in helping the needy despite a political consensus that favors tax- and budget-cutting. Or instead they may make plain the basic fatuousness and futility of problem-solving in a society that has convinced itself that it need neither commit new nor redistribute existing resources on behalf of its millions of disadvantaged citizens. ACKNOWLEDGMENT

I am grateful for the suggestions of Eugene Feingold and Daniel Fox. NOTES AND REFERENCES 1. Kosterlitz, J.: Concern about children. Nat. J., September 20, 1986, p. 2257. 2. The phrase comes from Sara Rosenbaum, director of the health division of the Children's Defense Fund, quoted above. 3. Congressional Quarterly Almanac, 1983, p. 421. 4. Kosterlitz, op. cit., p. 2258, quotation by Donna Harper. 5. Congressional Quarterly Weekly ReVol. 66, No. 4, July-August 1990

port, November 19, 1983, p. 2415. 6. Ibid., p. 2416. Italics original. 7. For a mid-1970s discussion and critique of leading proposals see Davis, K.: National Health Insurance: Benefits, Costs, and Consequences. Washington, D.C., The Brookings Institution, 1975. On the politics of the debate see Bowler, K. et al.: The political economy of national health insurance. J. Health Pol. Law 100-33, 1977; reprinted in Marmor,

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leadership have grown stronger and less T.R. and Christianson, J.B.: Health intermittent in the "new" Congress. Care Policy: A Political Economy Apthe profile in Kosterlitz, J.: Working See 17. 1982, CA, Sage, Hills, proach. Beverly with Stark. Nat. J., July 5, 1986, pp. pp. 83-124. 1666-69. 8. Kosterlitz, J.: States increasing their regulation of health plans' benefits, eligi- 18. Bowler, M.K.: Changing politics of federal health insurance programs. PS bility rules. Nat. J., December 21, 20:207, 1987. 1985, p. 2915. 9. Quotation from flier advertising the Em- 19. The term is taken from Brown, L.D.: New Policies, New Politics: Governployer's Health Benefits Bulletin, no ment's Response to Government's date. Growth. Staff paper. Washington, 10. Reagan had earlier made a vague referD.C., The Brookings Institution, 1983, ence to a search for a solution to the costs p. 40. of catastrophic illness in response to a question at a press conference on Janu- 20. Kosterlitz, J.: "Disaster" stories may spur Congress to protect health benefits ary 7, 1986. See Fuchs, B.C. and for retirees. Nat. J., July 27, 1985, pp. Hoadley, J.F.: Reflections from inside 1743-46. the Beltway: How Congress and the president grapple with health policy. PS 21. This account of reconciliation and health policy draws heavily on Schick, A.: 20:213, 1987. In his State of the Union Controlling the "Uncontrollable:" Budaddress a month later (February 4) he geting for Health Care in an Age of Huand Health of Secretary ordered the Megadeficits. In: Charting the Future of man Services to produce a report on the Health Care, Meyer, J.A. and Lewin, topic. M.E., editors. Washington, D.C., 11. Quoted in Congressional Quarterly American Enterprise Institute for Public Weekly Report, January 31, 1987, p. Policy Research, 1987, pp. 13-34. 206. 22. Ibid., p. 28. 12. Ibid. 13. Congressional Quarterly Weekly Re- 23. Bowler, op. cit., pp. 209-10; Nexon, D.: The politics of Congressional health polport, June 27, 1987, p. 1414. icy in the second half of the 1980s. Med. The 14. For background see Sundquist, J.L.: Care Rev. 44:82, 1987. Decline and Resurgence of Congress. and Hoadley, op. cit., pp. 217-19. Fuchs 24. InstiWashington, D.C., The Brookings 25. The New York Times, November 22, tution, 1981. 1987. 15. Whiteman, D.: What do they know and when do they know it. Health staff on the 26. Wildavsky, A.: Policy as Its Own Cause. In: Speaking Truth to Power: The Hill. PS 20:225, 1987. Art and Craft of Policy Analysis. Bos16. This is not of course an entirely new role. ton, Little, Brown, 1979. The question is rather one of degree. Congress launched the Hill-Burton pro- 27. On rationing, new and old, see Merrill, J.C. and Cohen, A.B.: The emperor's gram and the expansion of the National new clothes: unraveling the truths about Institutes of Health in the late 1940s rationing. Inquiry 24:105-09, 1987. when President Harry Truman differed in Kosterlitz, "Disaster" stoQuoted 28. with the American Medical Association ries, op. cit., p. 1746. over national health insurance. In the 1970s it invented the Professional Stan- 29. For an overview see Tierney, J.T.: Organized interests in health politics and poldards Review Organization program and icy-making. Med. Care Rev. 44:89-118, plan Nixon's much transformed Richard 1987. for federal encouragement to health op. cit., pp. 78-79. Nexon, 30. short, In organizations. maintenance and their imbalance Congress is usually an activist force in 31. On political markets in the health field see Marmor and Christhe health field. The argument here is tianson, op. cit., chapters 3 and 4. that the opportunities for legislative

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