A structure by no means complete : a comparison of the path and processes surrounding successful passage of Medicare and Medicaid under Lyndon Baines Johnson and the failure to pass national health care reform under William Jefferson Clinton

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2009-08

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In this comparative policy development analysis, I utilize path-dependence theory and presidential records to analyze President Lyndon Johnson's success in passing Medicare and Medicaid and President Bill Clinton's failure to pass national health care reform. Findings support four major themes from the Johnson administration: 1) President Johnson had a keen understanding of the importance of language in framing debate; 2) He placed control of the legislative process in the hands of a small, select group of seasoned political operatives and career policymaking professionals; 3) He paid considerable attention to the details of negotiations and the policy consequences; and 4) He had a highly developed sense of the political and legislative processes involved in passing major legislation. The case study of the Clinton administration reveals five major themes: 1) There is a lack of evidence that President Clinton remained actively engaged throughout the policy development and legislative processes, instead choosing to delegate the process to the First Lady; 2) There was a naiveté on the part of the Clintons and many administration staff members with regard to the legal and political ramifications of their decisions; 3) The Clintons tried to make the plan fully their own, sharing little credit for its development with Congress; 4) Their attempts to incorporate existing corporate health care delivery structures with their vision for universal coverage proved unworkable; and 5) The extended time from task force launch to bill delivery gave opponents ample time to marshal their opposition forces. I conclude that in developing health care legislation, Johnson had the advantages of: 1) a small group of key policymakers; 2) multiple, simultaneous legislative initiatives which diffused the attention of a more limited media; and, 3) national crises which promoted an environment conducive to sweeping policy change. I suggest that major, national health care reform will not occur until: 1) an economic or geopolitical crisis sets the stage for change; 2) business interests and progressive interests find common ground; and, 3) Americans achieve a new cultural understanding of universal health care as both economically just and economically necessary.

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