Deborah’s Policy Analysis

“causal stories and the formation of policy agendas”

There is an old saw in political science that difficult conditions become problems only when people come to see them as amenable to human action.  Until then, difficulties remain embedded in the realm of nature, accident, and fate — a realm where there is no choice about what happens to us.  The conversion of difficulties into problems is said to be the sine qua non of political rebellion, legal disputes, interest-group mobilization, and of moving policy problems into the public agenda. Continue Reading…


“health insurance in one easy lesson”

In most other nations, insurance for medical care is called sickness insurance, and it covers sick people.  In the United States, we have “health insurance,” and its major carriers — commercial insurers, large employers, and increasingly government programs — strive to avoid sick people and cover only the healthy. This perverse logic at the heart of the American health insurance system is the key to reform debates. Focusing on sick people versus healthy people might seem a strange way to view the coverage issue. Most discussions of insurance categorize people into other groupings: the insured versus the uninsured; Caucasian whites versus other racial and ethnic groups; men versus women; poor and low-income people versus everybody else; children, adults, and the elderly; or citizens versus immigrants and undocumented aliens. Continue Reading…


“behind the jargon, moral hazard”

Moral hazard is the foundational idea of health economics, and it has been extremely influential in shaping American health policy. Here’s the idea: when people have health insurance, they use more medical care than they would without insurance. They use more care because insurance lowers their cost. In a sense, moral hazard is just the law of supply and demand applied to medical care: when price goes down, demand goes up. Proponents of the concept believe (or at least claim) that moral hazard is a technical term. “The problem of ‘moral hazard’ in insurance has, in fact, little to do with morality but can be analyzed with orthodox economic tools,” wrote Mark Pauly in his classic 1968 article, “The Economics of Moral Hazard” (Pauly 1968). But for a technical term, moral hazard does Herculean moral and ideological work. Continue Reading…


 “How Market Ideology GUARANTEES Racial INEQUALITY”

Race has always fractured American politics. The United States never had the kind of strong class-based politics common to Western European nations in large part because the American working class was divided by race. Elites could exploit whites’ racial fears to foment hostilities and quell any nascent working-class mobilization. At the same time, class differences and the prospect of upward social mobility hindered black political movements. 1 Black political equality has been stymied in no small measure by America’s  commitment to preserving economic differences – all in the name of liberty. Continue Reading…


 “Struggle for the soul of health insurance”

The politics of American health insurance is a struggle over which vision of distributive justice should govern: the solidarity principle or the logic of actuarial fairness. Actuarial fairness is central to American private health insurance. It is both an antiredistributive ideology and a method of organizing mutual aid by fragmenting communities into ever-smaller, more homogeneous groups, leading ultimately to the destruction of mutual aid. This fragmentation is accomplished by fostering in people a sense of their differences and their responsibility for themselves, rather than their commonalities and interdependence. Actuarial fairness developed as a business strategy for gaining market share. Medical underwriting, which is far more extensive than commonly known, is the information technology used for implementing actuarial fairness. Despite significant changes in the political context of health insurance which are leading toward restraints on underwriting, the logic of actuarial fairness is so deeply embedded in the structure of  competitive markets in insurance and so deeply consonant with social divisions in American society that eradicating it will take more than any current reform proposals contemplate. Continue Reading…


 “Policy paradox in action”

People have often asked me to demonstrate how Policy Paradox works by applying it to a policy issue. I’ve been intrigued by this challenge, but also,frankly, a little reluctant. What if my better mousetrap didn’t catch very many mice? My sense of intrigue won out, helped along by a sense of fairness, for this is essentially the assignment I give my students.

But what policy problem should I tackle? If I took on the assignment, I wanted to think about the issue I consider the most important and most difficult in any polis, especially the American polity: How can a democracy based on majority rule respect and protect minorities? How can we have universal laws and coherent policies yet foster different cultural beliefs, mores, and ways of life? This is not exactly a crisp, well-defined problem. Was I trying to catch an elephant with a mousetrap? Continue Reading…


 “counting the poor”

The poverty line is a stock figure of American statistical and political culture. Most of us are at least dimly aware that it is an official level of income used to separate the poor from the non-poor, that the government somehow sets it, that it changes from time to time, and that it is the topic of periodic political fights. Even those who know its arcane details, however, usually forget that our official measure of poverty was once crafted by a real person with a passion and a pencil. The person was Mollie Orshansky. In 1963, she published an article about poverty that set the U.S. government on a new path. Continue Reading…


“the false promise of consumer choice”

Faced with mounting costs of health insurance for its employees, the state of Missouri hired a consultant from PriceWaterhouseCoopers to help it figure out what to do. The consultant concluded that there were no answers to be found in other states, nor would it help to shop the state’’s business around to different insurance carriers.2 Instead, the consultant suggested that Missouri offer ““two plan choices”” to its employees, in order to, as a Wall Street Journal reporter put it, ““try to soften the rising cost for employees.”” One plan had low monthly premiums but high co-payments. The other had high monthly premiums but lower co-payments. The idea, of course, was that healthier employees would choose the plan with lower monthly premiums, and sicker employees would choose the one with the lower co-pays. Continue Reading…


 “values in health policy”

Two powerful ideals — fairness and efficiency — tower over health policy. These ideas unite us around lofty goals, only to divide us the minute we get down to details. That’s not only because there is an inherent tension between fairness and efficiency, but also because each has multiple meanings. Different inter­pretations of fairness and efficiency define different kinds of community. They draw different boundaries, gather different memberships and offer different levels of inclusiveness. In the shadow of these grand ideals lurk many dilemmas for those who would use them as yardsticks for policy evaluation. Continue Reading…

 

 

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