Policy Success After Passage

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Hacker focuses largely on the political factors (interest groups, Congressional composition, key stakeholders, public opinion, polarization) and larger events (recession) influencing the discussion and eventual passage of the Affordable Care Act (ACA). Hacker's ACA topic is a useful one for analyzing policy success. Despite Hacker's detailing of how the act was watered down before passage, champions and supporters celebrated its passage and remarked on its eventual historical impact. Yet how many of us could give an accurate update on ACA implementation? I suspect no one (and if you can, please help the rest of us). I think this is because policy implementation is a largely unpublicized, often uninteresting process (at least to non-wonks). It typically involves public administrators who receive the law's language and are tasked with implementing the policy with varying degrees of autonomy. This makes the quality of implementation very difficult to predict and monitor, especially when you add so many arenas as is the case with the ACA (hospital administration, state agencies, private insurers, etc). As Patashnik notes, "...institutional shifts clearly affect reform sustainability...the institutional structures established to protect reforms may conflict with the mandates from pre-existing institutions, or they may lack the necessary incentives or capacities" (167)

Earlier in the semester, Arnold Meltsner noted that feasibility analysis should lead to policies that can be implemented. Yet it seems much of the discussion around feasibility is around the development (and ideally, eventual passage) of policy. What I often see missing from that discussion is consideration for exactly how a given program or policy will reach the individuals it's designed to affect. Implementation scholars point to analyzing how initial implementers (often bureaucrats) receive the policy - is there support among professionals in the given policy arena? Have concerns voiced by program recipients been truly considered in policy development? I would argue that the answers to these questions are quite relevant to analyzing policy "success", because they define whether or not a program or policy does what Hacker's list of political players worked hard to influence on the front end of policy making.

Though perhaps I'm overstating their importance. Can policy makers and "front-end" players as I've described them create policy in ways that ensure successful implementation? Do you think policy makers consider these questions?

I've chosen a complicated policy area in the ACA to make my point. Are there policy arenas where success is easier to identify or define?

6 Comments

Nice post, Michael. Though I definitely agree that implementation doesn’t get much press (definitely less than it deserves), there are some outlets that devote more attention to it than others. For your ACA example, the Wonkblog on the Washington Post has updates on it fairly regularly: see eg:
http://www.washingtonpost.com/blogs/wonkblog/wp/2013/03/18/whats-it-like-building-d-c-s-obamacare-exchange-organized-chaos/
or:
http://www.washingtonpost.com/national/on-leadership/rolling-out-the-affordable-care-act-in-the-field/2013/04/08/98375a10-a078-11e2-82bc-511538ae90a4_story.html

Good points, Michael. While I definitely agree that implementation doesn’t get as much press as it deserves, there are some news outlets that are better than others. For your ACA example, the Wonkblog on the Washington Post has updates on it fairly regularly: see eg:
http://www.washingtonpost.com/blogs/wonkblog/wp/2013/03/18/whats-it-like-building-d-c-s-obamacare-exchange-organized-chaos/
or:
http://www.washingtonpost.com/national/on-leadership/rolling-out-the-affordable-care-act-in-the-field/2013/04/08/98375a10-a078-11e2-82bc-511538ae90a4_story.html

These are great questions, Michael, and I think you and I have gone back and forth a bit on implementation before in this class. My sense is that policymakers do not think enough about implementation. As you point out, they focus on what is feasible to get their own provisions passed, whether or not that means including infeasible aspects too. However, I’m not sure this is necessarily a bad thing. I believe the point you made a few weeks back in reference to this was that government agencies are the experts in their areas and better equipped than lawmakers to know how to implement policies within their jurisdiction. Sure, party affiliation of leaders like the mayor, governor or president are important to who is running the departments and what they value. However, lawmakers are not experts on all subjects (or even any subject in cases) and cannot be expected to know the most apt strategies for policy implementation within such disparate areas as health, public safety, natural resources, etc.

I would go so far as to say it is almost preferable at times that laws be made a bit more vague and allow for interpretation among policy implementers. As a counter example, in 2012 the legislature updated Minnesota Statute 121A.23 – Programs to Prevent and Reduce the Risks of Sexually Transmitted Infections and Diseases. The original law required school districts to develop and implement HIV/AIDS prevention and risk reduction curriculum, while the new version goes beyond to include STIs/STDs and “helping students abstain from sexual activity until marriage”. The STI/STD addition is an important win, but it is countered by a mandate for emphasizing abstinence until marriage, which is not a realistic proposition for most Minnesotan students. Abstinence is an effective tool that should be taught in addition to condom usage and contraception. However, adding the “until marriage” phrasing makes me wonder if even school districts that use comprehensive sex ed curriculums are going to have to modify them to emphasize waiting until marriage or will just switch to abstinence-only curriculum which has not been proven to be evidence-based. Now this provision of waiting until marriage is encoded in our state law and as evidence builds for the most effective curriculums, our hands will be tied. Then again, maybe I’m just being overly paranoid about the power of those two words – “until marriage”.

I think what you have to say about implementation being overlooked is very important to consider. The ACA is such an enormous law, and many of the provisions were not even ironed out before it passed; HHS has been continually issuing "final rules" for many different provisions. This indicates to me that there was no clear view of implementation, just a broad idea of the goals. Setting inflexible timelines on the one hand ensures that the setup will occur, but they also prevent high quality systems and processes for being put in place. To add another layer to the complexity of implementation, at every level of government across the country various provisions must be implemented, this is going to result in a very wide variety of successes and shortfalls.

The ACA is a great example of a piece of legislation that became incredibly politicized. I wonder what effects that will have on the implementation end? Are implementers and recipients of the legislation affected by the politics of the law? Will the mid-level bureaucrat who leans republican turn the political gamesmanship of the laws passage into a self-fulfilling prophecy on the implementation end, and unknowingly sabotage any chance of the ACA’s success? It’s interesting to think about anyway.

Great responses gang. Adding to your point Josie, I think that there are many instances in which implementers should be afforded autonomy. Much like one argues that giving lower levels of government discretion in spending results in individuals with knowledge of local needs being able to tailor policy accordingly, implementers can finesse contentious aspects of policy, or target communities most likely to participate, efforts that certainly make policy success more likely.

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