47 4.9 – CASE STUDY: SETTING THE HEALTH CARE AGENDA
- CASE STUDY: SETTING THE HEALTH CARE AGENDA
President Obama signed the Patient Protection and Affordable Care Act (ACA), also known as Obamacare, in March of 2010. Health care reform was a priority for President Obama, even before taking office. On the campaign trail, he often promised to make access to quality and affordable health care the centerpiece of his policy agenda. Shortly after his inauguration, President Obama made good on his promise to elevate health care reform to the top of his policy agenda by working with Congress to develop a plan. Passage of the ACA came after a year of tense and grueling debate to determine what the new law should include and who would be affected.
How did health care reform end up on the agenda? Bill Clinton had campaigned on the promise of reforming health care more than a decade earlier. In fact, universal healthcare was the linchpin of Clinton’s first-term agenda. Opposition to Clinton’s plan came from conservatives and, most notably, the healthcare industry, which made a concerted effort to rally public opposition to the plan. Support from Democrats was tepid, and, instead of rallying behind Clinton’s proposal, several Democrats submitted plans of their own. Eventually, Democrats and even some Republicans settled on a compromise bill, but that bill never received the support it needed to become law (Clymer, 1994). Health care reform was not seriously considered again in the U.S. until President Obama took office in 2009.
Public support for government-provided health insurance decreased immediately following President Clinton’s attempt to pass a universal health care policy and remained low until Clinton left office. By 2009, the Gallup Organization reported that the American public named access to health care the most urgent healthcare concern facing the country (Saad, 2010). Over 44 million Americans lacked health insurance before the ACA (Kaiser Family Foundation). Additionally, Americans had become increasingly supportive of government intervention in health insurance reform during the ten years prior to the passage of the ACA, primarily viewing health care coverage as a responsibility of the government (Conway, 2013). While public support for government intervention ranged between 54 and 64%, that number fell to less than 50% as the ACA made its way through the political process. Even with a Democratic majority in the House and Senate, reform proved to be more complicated than planned. Republicans and even some Democrats opposed health care reform. As political and public support began to dwindle, President Obama decided to address Congress and the American public directly to sell his plan to fix the nation’s health care system. President Obama used the “bully pulpit” as a tool to advocate for his agenda and, to some degree, was able to change public perception of the plan. Fahmy et al. (2013) found that the “more speeches that President Obama gave on the health care act in any given month, corresponded with an increase in the positive tone of articles discussing this bill.” Likewise, data showed that the public was less supportive of the ACA during months when President Obama did not give any speeches promoting the ACA.
Framing the health care debate. Once President Obama took office, health care reform moved quickly from the agenda universe to the decision agenda. Recall that this stage in the agenda setting process comprises all the issues that the government is actively debating and considering. The decision agenda is a precarious stage for a controversial policy. At any point, a strategic and cunning opposition group could frame the policy in a way that resonates with the public, thwarting plans for bill passage. Framing influences the way the public understands an issue and can lead to higher levels of support or opposition. Much to Obama’s credit, he remained the top news source throughout the entire debate process, which allowed his arguments to frame the policy in a more positive light (Fahmy, 2013).
Support for a policy often hinges on media support, which, in turn, influences public opinion on an issue. The media framed the health care debate in one of several ways. The first and most dominant frame focused on the politics or policy implications of health care reform. More specifically, media framing concentrated on controversial claims made by opposition groups, such as assertions that the policy would result in “death panels.” The second most utilized frame defined health care reform as an economic transaction, either as an economic necessity or as an overly expensive economic policy. Conservative news sources argued that the plan would increase the national debt and cause damage to the economy. Competing interests argued that there were economic benefits to insuring all Americans and advocated for a plan that prohibited private insurance. However, the media spent little time explaining the implications of the proposed reforms or what changes might mean for Americans (Fahmy, 2013).
The amount of media effort spent on reporting the controversial and political aspects of the policy, such as the intense conflict between Republicans and Democrats, led many to argue that had the media focused on other aspects of the plan, public opposition would not have been a concern: “For without the public being on board with specific . . . policies, it is quite difficult for any public health program to achieve its maximum health impact” (Parekh, 2017, Gollust et al., 2017). The focus on partisanship, affordability, and even misinformation likely contributed to lower levels of overall support for the ACA. Interestingly, polling data suggests that some aspects of the ACA were attractive to both Republicans and Democrats, such as allowing young adults to stay on their parent’s plans until they are 26 or no care exclusions for preexisting conditions. Had these messages been tailored to the correct audience, one could speculate that the general public may have been more receptive. When promoting an agenda, the goal of policymakers should always be to match audiences with the most suitable message.
Multiple Streams. John Kingdon (2011) argues that three conditions must be satisfied before a policy idea gains traction. He describes these conditions as the three “streams” of the agenda setting process: (1) the problem stream, (2) the policy stream, and (3) the political stream. If the conditions laid out in the various streams are met, a brief “window of opportunity” will open, and policy has a greater likelihood of becoming law. Before passage of the ACA, more than 44 million people were without health insurance; the largest groups of uninsured Americans were low-income and people of color. Several health indicators revealed that even those who were insured spent a high percentage of their income on medical care. While it was clear that the poor lacked adequate coverage, inadequate coverage had begun to affect the middle class as well (Garfield, Orgerea, and Damico, 2019). Couple this information with an American public that was open to government intervention and had increasingly viewed access to quality care as the most pressing health care issue facing the country (Gallup Poll, 2009). It is no wonder that policymakers were convinced that the problem stream was satisfied. One could also argue that the policy stream was in play. Massachusetts enacted a similar program three years prior that included an individual mandate and an insurance exchange. While President Obama had a basic plan going into office, his administration used the Massachusetts plan as a guide during the policy development phase. Furthermore, the ACA incorporated components—the individual mandate, for example—that had already been promoted by conservative groups. The final stream of Kingdon’s model was complete when President Obama was elected into office, along with a Democratic majority in Congress that supported sweeping health care reform. Opposition groups were relentless, using strategic framing in an attempt to change the debate and alter the public’s perceptions. In the end, though, each policy stream aligned, opening a brief window of opportunity that led to passage of the ACA.
