Annurev Publhealth 25 101802 123126

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10.1146/annurev.publhealth.25.101802.123126
Annu. Rev. Public Health 2006. 27:195–233

doi: 10.1146/annurev.publhealth.25.101802.123126
Copyright c 2006 by Annual Reviews. All rights reserved
First published online as a Review in Advance on October 19, 2005
THE POLITICS OF PUBLIC HEALTH POLICY

Thomas R. Oliver
Department of Health Policy and Management, Johns Hopkins University, Baltimore,
Maryland 21205; email: toliver@jhsph.edu
Annu. Rev. Public Health 2006.27:195-233. Downloaded from www.annualreviews.org
Key Words agenda setting, incrementalism, health reform, policy entrepreneur,

implementation
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■ Abstract Politics, for better or worse, plays a critical role in health affairs. The
purpose of this article is to articulate a role for political analysis of public health issues,
ranging from injury and disease prevention to health care reform. It begins by examining
how health problems make it onto the policy agenda. Perceptions regarding the severity
of the problem, responsibility for the problem, and affected populations all influence
governmental responses. Next, it considers how bounded rationality, fragmented polit-
ical institutions, resistance from concentrated interests, and fiscal constraints usually
lead political leaders to adopt incremental policy changes rather than comprehensive
reforms even when faced with serious public health problems. It then identifies condi-
tions under which larger-scale transformation of health policy can occur, focusing on
critical junctures in policy development and the role of policy entrepreneurs in seizing
opportunities for innovation. Finally, it reviews the challenges confronting officials and
agencies who are responsible for implementing and administering health policies. Pub-
lic health professionals who understand the political dimensions of health policy can
conduct more realistic research and evaluation, better anticipate opportunities as well as
constraints on governmental action, and design more effective policies and programs.
INTRODUCTION
The essence of public health, in the eyes of most researchers and practitioners,
is a struggle to understand the causes and consequences of death, disease, and
disability. Often an even greater struggle emerges when policy makers attempt to
put that understanding to work, to translate knowledge into action for our collective
well-being. Science can identify solutions to pressing public health problems, but
only politics can turn most of those solutions into reality. Lindblom sets forth an
important distinction: “When we say that policies are decided by analysis, we
mean that an investigation of the merits of various possible actions has disclosed
reasons for choosing one policy over others. When we say that politics rather than
analysis determines policy, we mean that policy is set by the various ways in which
people exert control, influence, or power over each other” (104).
Politics, for better or worse, plays a critical role in health affairs. Politics is cen-
tral in determining how citizens and policy makers recognize and define problems
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196 OLIVER
with existing social conditions and policies, in facilitating certain kinds of public
health interventions but not others, and in generating a variety of challenges in pol-
icy implementation. It is essential that public health professionals understand the
political dimensions of problems and proposed solutions, whether they hold posi-
tions in government, advocacy groups, research organizations, or the health care
industry. This understanding can help leaders to better anticipate both short-term
constraints and long-term opportunities for change.
WHY HEALTH IS A POLITICAL ISSUE

Public health commonly involves governmental action to produce outcomes—

injury and disease prevention or health promotion—that individuals are unlikely
or unable to produce by themselves. Gostin argues, “A political community stresses

a shared bond among members: organized society safeguards the common goods
of health, welfare, and security, while members subordinate themselves to the
welfare of the community as a whole. Public health can be achieved only through
collective action, not through individual endeavor” (57).
Although this perspective is deeply ingrained in most public health students, re-
searchers, and practitioners, it runs counter to a fundamental emphasis on property
rights, economic individualism, and competition in American political culture. The
exceptionalism of the United States lies in its antistatist beliefs: Americans are less
concerned with what government will do to benefit individuals than what govern-
ment might do to control them (75, 84, 106, 117, 166). To the extent that Americans
support collective action in the pursuit of public health or any other social good,
they exhibit a strong preference for voluntary organization and participation (153,
166, 186).
Nonetheless, there are many reasons why the health of individuals and the gen-
eral public is a political issue, not merely a private matter. First, individual and
institutional actions often produce significant spillover effects—what economists
call externalities—some of which are beneficial and some of which are harmful. To
compensate for externalities associated with private actions such as smoking, vac-
cination, driving while intoxicated, sexual practices, and the manufacture and sale
of products requires political decisions about when and how to impose restraints
on individual liberties or commercial interests. In the eyes of John Stuart Mill, this
would be the sole principle justifying public health policy: “[T]he only purpose
for which power can be rightfully exercised over any member of a civilized com-
munity, against his will, is to prevent harm to others. His own good, either physical
or moral, is not sufficient warrant” (115). A prominent expression came a century
ago in the landmark Supreme Court case of Jacobson v. Massachusetts, validating
the city of Cambridge’s program of compulsory vaccination against smallpox.
Second, citizens look to government to identify and satisfy a variety of physical,
economic, and psychological needs that extend well beyond the means for survival
(182). The public may support certain “merit goods” that should be distributed to
POLITICS OF PUBLIC HEALTH POLICY 197
intended beneficiaries whether or not they have an ability to pay for those goods
(109). Such merit goods include elementary and secondary education, medical
care for the poor and elderly, and food assistance and require political decisions
to define their scope and substance, eligibility to receive them, and the source of
revenues to purchase them or provide them directly.
Third, protecting public health involves moral judgments that acquire legiti-
macy through political debate and resolution (98, 118, 119). Kersh & Morone
argue, “Despite myths about individualism and self-reliance, the U.S. government
has a long tradition of regulating ostensibly private behavior” (88). The appropri-
ateness of offering clean needles to injection drug users, funding stem cell research,
supporting medical uses for marijuana, ensuring access to contraception and abor-
tion, and legalizing physician-assisted suicide are among the moral issues that are
hotly contested in the political arena.
Fourth, a healthy population and workforce is vital to economic growth and

social order. Threats from AIDS or bioterrorism are not only public health problems
but also, when they reach a certain scale, may become national security issues and
thus a potential source of political instability (51, 58, 139, 202).
These justifications for public action have produced a body of law and a politics
of health that must balance “. . . the legal powers and duties of the state to assure
the conditions for people to be healthy, and the limitations on the power of the state
to constrain the autonomy, privacy, liberty, proprietary, or other legally protected
interests of individuals for the protection or promotion of community health” (57).
THE TRANSLATION OF HEALTH ISSUES INTO

POLITICAL ISSUES
From the perspective of policy makers, problems are conditions that people find
unacceptable and want to change (90). The translation of health conditions into
political problems, therefore, occurs when individuals recognize that their personal
needs and desires are shared with others and demand—through public opinion,
emergence of a social movement, interest group mobilization, or voting—that
public officials pay attention to their concerns (33, 40, 90). Whether and how
government responds depends heavily on the process of problem identification
and definition.
Risk Assessment
Problems come to be identified and defined through a variety of mechanisms, some
fairly routine and others quite unpredictable. Walker observes that policy debates
are stimulated when a “performance gap” arises from a crisis, from forecasting,
or from comparison with similar sectors or jurisdictions (194). Such a gap may be
self-evident to even casual observers, or it may be established through statistical
indicators, scientific research, or evaluation of existing programs (90).
198 OLIVER
The primary influence of health services research on public policy may be

through its role in problem “documentation”—statistical reporting and estimation
of health care use, costs, and quality (23). A recent example is the Institute of
Medicine’s report on patient safety, which concluded that medical errors in U.S.
hospitals were responsible for up to 98,000 deaths per year—more lives lost than
from motor vehicle crashes, breast cancer, or AIDS (80). The dramatic rise in the
proportion of the population that is overweight or obese, along with the staggering
number of deaths and amount of health care costs attributable to obesity, has pro-
duced a wide array of proposals for preventive and remedial action (138). Through-
out the history of Medicare, governmental officials began to craft a new payment
system when spending for a specific category of services—hospital, physician,

home health, or prescription drugs—accelerated more rapidly than the costs of
other health services (132, 137). The first major report on enrollment in the State
Children’s Health Insurance Program (SCHIP) led officials to compare progress

from state to state and spurred new efforts to expand program outreach, simplifica-
tion of enrollment procedures, and other measures to increase participation (43).
Yet numbers alone are insufficient to push an issue higher on the governmental
agenda. Stone contends that, “Numbers in politics are measures of human activities,
made by human beings, and intended to influence human behavior. They are subject
to conscious and unconscious manipulation by the people being measured, the
people making the measurements, and the people who interpret and use measures
made by others” (182). Statistics and other products of professional research and
analysis can be used for either “enlightenment” or “ammunition” because decisions
are also based on ordinary knowledge and social interaction (105, 200).
A problem must be especially salient to important constituencies in order to
overcome public ambivalence about governmental intervention into what are or-
dinarily private affairs. Documentation that well over 30 million Americans were
uninsured in the late 1980s and early 1990s troubled the public and policy mak-
ers, but it was soaring premiums for insured individuals and the perception that
they might lose their insurance that produced an election issue, and led several
states and President Clinton to attempt plans for universal coverage (18, 64). The
number of uninsured Americans has grown by more than 10 million in the decade
since the demise of the Clinton plan; yet only recently, with the costs of private
insurance again significantly exceeding the growth in wages and other consumer
prices, have business leaders begun to call for government to address the problems
of the uninsured (34a).
For most health issues, a crucial step in agenda setting is articulation of a
scientifically and, more important, a socially credible threat (88, 120, 195). Gray
& Ropeik observe that some public health issues—bioterrorism, for example—
will command attention disproportionate to their epidemiological impact, because
the perception of risk and concern depends on other factors, including the degree of
public awareness, the uncertainty about risk exposure, whether the risk is personal,
how catastrophic the risk is, and whether it is voluntarily assumed or otherwise
controllable (61). Stone also notes the speculative nature of risk construction:
“Potential future needs often have a political potency far greater than actual needs,
because fear of the unknown plays a bigger part. The human imagination is capable
of creating infinite terrors, and terror explains why there is often an emotional
fervor to arguments about this type of need, even when the risks are described
in passionless statistics” (182). Due to this interpretive process, public awareness
and concern for public health capacity is highly unstable and tends to respond to
episodic threats, ideological shifts, and economic cycles (48).
Locus of Responsibility
The responsiveness of government to a problem depends not only on the perceived

level of risk but also on who is held responsible for the problem. The problems of the
uninsured are easier to neglect when citizens and policy makers endorse competing
images of access to health care as a societal right, a community responsibility, a

perk of a good job, a professional obligation, or a market commodity (55, 63, 161,
163, 181).
Political responses also depend on whether there is a clearly perceived cause of
a public health problem. In the late 1990s, dozens of private and public lawsuits and
governmental highway traffic safety statistics established that Ford Explorers had
a higher risk of rollovers than other sports utility vehicles. Once further analysis
established that much of the higher risk was attributable to tread separation of the
Firestone tires installed on most Explorers, the government forced recalls of the
tires by both Ford and Bridgestone, the manufacturer of Firestone tires. The contro-
versy over the belated recalls also resulted in enactment of new federal legislation in
2000 (191). At times, perceptions can become a political force even when they are
not grounded in widely accepted causal relationships. The lack of evidence linking
thimerosal, a preservative in some childhood vaccines, to the onset of autism has
not prevented some parents, including some prominent politicians, from asserting
that a causal link exists and prompting the U.S. Food and Drug Administration
(FDA) to recommend removal of thimerosal from new vaccines (44, 156).
“Causal stories” are most potent in triggering policy initiatives when harmful
consequences are viewed as intentional rather than accidental (182). Gun con-
trol advocates have been most successful in regulating or banning the purchase
of “Saturday night specials” or semiautomatic assault weapons, whose uses are
associated with criminal acts rather than recreational hunting. To date, advocates
have been less successful in their efforts to prevent unintentional injury or death—
especially to children—by requiring that the manufacturers of firearms equip their
products with personalized locks, indicators to show whether a gun is loaded or
not, and other technologies (192). Significant advances in tobacco control fol-
lowed the revelations of how cigarette manufacturers tailored their marketing to
lure teenagers into a lifelong addiction before they were even legally allowed to
smoke, and allegedly manipulated nicotine levels to increase the addictive power
of their products (73, 89, 120). Following the Food and Drug Administration Mod-
ernization Act of 1997, concerns arose whether the increased resources devoted
200 OLIVER
to expediting drug approval were inadvertently causing more postmarketing drug

safety problems (74, 82). Questions about the FDA’s regulatory capacity and com-
mitment to drug safety increased sharply, however, when in the wake of the recall
of several prominent pain medications, it was revealed that the manufacturers
had suppressed or distorted evidence about risks of serious side effects, including
heart failure, in their marketing materials and presentations to physicians (173,
197). This disclosure closely followed similar allegations that the FDA and man-
ufacturers had withheld data that most antidepressants were ineffective in treating
children and might cause some children to become suicidal (67).
Perceptions of a demon industry have fueled both litigation and legislation on
a number of other issues as well (88). Public officials, scientists, and critics have
linked the menus and marketing practices of fast food chains and other sources
of “junk food” to increasing rates of obesity (27, 88, 125, 164, 189). Prior to the
introduction of the Clinton plan, the mass media generally portrayed managed care
in favorable terms based on its capacity to save employers and consumers money
compared with an inefficient fee-for-service system. After opponents attacked the
Clinton plan on the basis that managed care would promote widespread rationing
of health care, media coverage shifted dramatically, both reflecting and amplifying
the public backlash against the denial of services or coverage commonly used to
achieve the savings associated with managed care (152).
At the heart of these causal stories is the issue of personal autonomy: “[P]eople
who act involuntarily, through either coercion or unavoidable ignorance, should
not be held responsible or blamed for their actions” (98). Conversely, personal
responsibility may be assigned to many health-related behaviors, and the freedom
to make choices—even unhealthy ones—is often fiercely defended (12, 93, 95, 177,
196). Thus, if a significant proportion of individuals with solid jobs and incomes
are perceived to be uninsured by choice, or overweight individuals are perceived
to reject healthier diets and opportunities for exercise that they know are in their
best interest, the conflicting public images diminish pressure for governmental
solutions to these problems, however serious they are.
Social Construction of Target Populations

Governmental priorities are influenced by perceptions of the population affected by
a given problem, as well as its severity and cause. Although the primary rationale for
governmental intervention is to protect the general public from the spread of illness
and injury or their financial costs, the actual targets of governmental assistance or
regulation are often easily identifiable. When public health problems are stratified
by income, age, race, gender, geographic location, or other markers, one group’s
problems may not be treated the same as another’s. Instead, the popularity of
affected individuals, occupational or social groups, or industry will influence the
likelihood and nature of governmental action (118).
Schneider & Ingram stress the importance of “cultural characterizations or
popular images of the persons or groups whose behavior and well-being are af-
fected by public policy” (165). They theorize that the social construction of target

Figure 1 Social construction of target populations [from Reference (165)].
populations shapes both the policy agenda and the actual design of policy: “Public
officials find it to their advantage to provide beneficial policy to the advantaged
groups who are both powerful and positively constructed as ‘deserving’ because
not only will the group itself respond favorably but others will approve of the
beneficial policy’s being conferred on deserving people. Similarly, public officials
commonly inflict punishment on negatively constructed groups who have little
or no power, because they need fear no electoral retaliation from the group itself
and the general public approves of punishment for groups it has constructed neg-
atively.” Figure 1 illustrates how target populations are classified as advantaged,
dependents, contenders, or deviants according to the combination of their public
image, positive or negative, and their political power, high or low.
The face of AIDS has dramatically influenced public perceptions and policy
making for over two decades. Despite its catastrophic life-and-death consequences
and heavy toll in many urban areas, the response to HIV/AIDS largely followed
the social construction of its victims. At the onset of the epidemic, the focus
was on homosexual men. Although this group constituted a highly organized and
vocal political force in localities such as San Francisco and New York City, at the
national level it was socially constructed as deviant (negative image, low power)
(2, 39, 168). Significant federal assistance was delayed for years, save in the
form of disease surveillance and funding for biomedical research into the cause
of the disease; and those suffering from AIDS were commonly subjected to the
loss of employment and health insurance (180). Another group heavily at risk for
HIV/AIDS was injection drug users, and their deviant social construction helped
fuel objections to needle exchange programs on the grounds that, whatever their
effectiveness at slowing the spread of disease, such assistance amounted to a tacit
acceptance of dangerous and immoral behaviors.
202 OLIVER
As the risks of contracting HIV/AIDS spread to broader segments of the

population—often becoming known through sympathetic, “innocent” symbols
such as Ryan White, Kim Bergalis, and Arthur Ashe—the victims of the epi-
demic and, more importantly, its potential victims, were viewed as dependents
(positive image, low power) and stronger policies came into effect to safeguard
the supply of donated blood, to support local health and social services, and to
protect the legal rights of infected individuals (11, 34). The 1990 Ryan White Act,
perhaps the most visible federal AIDS relief program, reflected the different social
constructions that emerged in the course of the epidemic: It was unsupportive of
injection drug users, but contained special provisions for women and children with
AIDS (39). The failure of Congress to appropriate all the funding authorized under
the legislation demonstrated the weak political power associated with virtually all
HIV/AIDS victims at the national level, and predictably left lower levels of gov-
ernment and the private sector to cope with the social and financial costs of the
epidemic (11, 14).
In 2002, U.S. Senator Jesse Helms and conservative Christian groups—who
had for years opposed governmental assistance for AIDS victims in the United
States—adopted a missionary stance with respect to developing nations coping
with the devastating effects of the disease. They focused on how HIV/AIDS was
being transmitted involuntarily to many women, and from mother to unborn child,
and in the process was creating a generation of orphans in much of sub-Saharan
Africa. This new social construction helped mobilize critical support within the
Bush administration to launch a $15 billion emergency relief plan to combat AIDS,
malaria, and tuberculosis in 15 countries. The underlying morality also heavily
influenced policy design: The president’s initiative, in contrast to the global AIDS
fund created by the United Nations, expressly favored preventive measures such
as abstinence and monogamy over the use of condoms, consistent with religious
groups’ prescription for slowing the epidemic (29).
As activists shifted perceptions of smoking from a personal choice to an evil
habit, they were able to make greater headway in their tobacco control strategies,
including indoor smoking bans and sin taxes on cigarettes (98). As early as 1971,
Surgeon General Jesse Steinfeld urged a bill of rights for nonsmokers, including a
ban on smoking in “all confined public places.” After two more decades of scientific
study and political agitation, the social construction of smokers and the tobacco
industry became decidedly more negative and the well-being of those target popu-
lations was increasingly weighed against the health and rights of nonsmokers and
adolescent children, each positively constructed dependent groups (10, 120, 184).
These shifts fundamentally changed not only the size of the affected population
but also the perceptions of deservingness that previously impeded both legislation
and litigation in that area, particularly the adoption of restrictions on smoking in
workplaces and public places by state and local governments (86, 87, 184).
Despite growing social disapproval, overweight and obese individuals are not
yet viewed in the same way as smokers are—that is, as deviants or demon users—
in part because some individuals appear to be genetically predisposed to weight
control problems, and in part because it is more difficult to directly link their
behavior to a negative impact on others (88). Advocates of gun control also face
conflicting social constructions of the owners and users of firearms: They may pur-
sue preventive measures or penal sanctions against violent criminals (deviants) and
protective measures on behalf of children and other unintended gunshot victims
(dependents); but in so doing they must not directly challenge the prerogatives of
advantaged groups, including hunters passing down a generations-old pastime and
law-abiding citizens exercising their right to self-defense (177, 191). Nevertheless,
as the image of the National Rifle Association shifts from a “civic-minded collec-
tion of hunters” to a “radical organization that resists reasonable regulation” and
at times is allied with militia groups, at least certain types of gun control become
more feasible (28).
The positively constructed populations of women and children have been the
primary beneficiaries of several health care initiatives in recent years. In the midst
of a general backlash against managed care plans, one of the earliest and most
visible public policy responses was to prohibit so-called drive-through deliveries
by guaranteeing mothers and their newborn babies a minimum length of stay in the
hospital (35). Other initiatives secured an expansion of women’s health research at
the National Institutes of Health and FDA as well as grants to the states for breast
and cervical cancer screening and detection programs (7, 30, 100, 199). Begin-
ning in the 1980s, federal officials enacted legislation requiring states to expand
Medicaid eligibility for pregnant women and children under the age of 19. Then in
1997, SCHIP was created to establish coverage for children of low-income, work-
ing families. A key Republican legislator, Nancy Johnson, described the program
as a benefit for “families with uninsured children who are working hard, paying
taxes and playing by the rules. They need and deserve our help.” By offering states
more generous matching funds and allowing them to establish programs that op-
erated separately from Medicaid, SCHIP represented a clear effort to distinguish
between the deserving poor and less-deserving welfare recipients (20, 158, 172).
SOURCES OF INCREMENTALISM IN HEALTH

POLICY MAKING
Even when there is broad consensus on the severity of a public health problem and
the appropriateness of governmental action, there is a strong tendency for political
leaders to adopt incremental policy changes rather than comprehensive reforms.
Incrementalism pervades nearly every area of public health policy. In surveying
the development of health insurance in the United States, for example, Anderson
described the unmanageable complexity of a patchwork quilt with different seg-
ments of the population placed in different programs, each with their own benefits,
budget, and sources of financing (3). Depending on their age, gender, source of
employment, and legal status, members of a single family might enroll in four or
five different health insurance programs (99). Almost by default, Medicaid has
204 OLIVER
become the primary source of support for not only pregnant mothers and children,
but also the elderly in need of institutionalized long-term care, individuals infected
with HIV, and services delivered by safety net providers to the uninsured (26, 198).
Bounded Rationality
There are many reasons why public policy typically develops in small steps. Lind-
blom’s theory of “disjointed incrementalism” contends that, because of limited
time and information, policy makers are subject to bounded rationality in think-
ing about both problems and solutions. As a result, they tend to build on existing
policies and programs rather than attempt system-wide reforms. Reinforcing this
tendency is the probability that agreement can be more easily reached when inter-
ested parties make only modest adjustments to the status quo, rather than suffer the
uncertainty and potential instability inherent in larger-scale innovation. Another

characteristic of disjointed incrementalism is that the political debate and result-
ing policy will tend to focus on discrete, short-term outputs rather than broader,
long-range outcomes. The objective of the process becomes agreement on means,
not ends (68, 103).
Hence, improving access to health insurance becomes an exercise in negotiat-
ing eligibility by criteria such as household income or firm size, the appropriate
scope of benefits, and the acceptable variation in premiums. In most states and in
the Health Insurance Portability and Accountability Act of 1996 (HIPAA), health
care reform boils down to assuring the portability and renewability of coverage, but
not its affordability. Congress annually earmarks funds to provide antiretroviral
therapy through the AIDS Drug Assistance Program, but individuals infected with
HIV must rely on other sources of assistance to cover the costs of other medica-
tions and health services. Managed care plans must guarantee minimum lengths
of stay in the hospital for deliveries and other specified procedures, but are not
prohibited from imposing restrictions on hospital admission and length of stay for
other patients and procedures. A ban on federal funding for stem cell research
applies only to newly cultured embryos, not existing lines already established. Re-
strictions on smoking must be extended from workplaces to restaurants and bars
and other public spaces, as the impacts on health, business, and civil liberties are
constantly reassessed. By narrowing the scope of debate and policy formulation,
it is possible to lessen conflict over the core values and beliefs that are likely to
produce political deadlock (154).
Political Institutions
Another source of incrementalism is the institutional design of our political system,
which disperses power and the capacity for policy development. The system of
checks and balances devised by the framers of the U.S. Constitution and emulated in
almost every state is intended primarily to prevent the tyranny of popular majorities.
Alexander Hamilton justified the fragmentation of power with the opinion, “The
injury which may possibly be done by defeating a few good laws will be amply
compensated by the advantage of preventing a number of bad ones” (66).
Members of each branch of government represent and are accountable to dif-

ferent constituencies, and the staggering of terms (two years in the House of
Representatives, six years in the Senate, four years as president, and lifetime ap-
pointments as federal judges) cools all but the most potent of temporary passions.
No one branch of government can act alone in the design and execution of public
policy: The separate institutions share powers by virtue of the legislative power of
the purse, executive vetoes and legislative veto overrides, and judicial review of
legislative and executive actions (68, 126). The power of minorities is enhanced
further by extraconstitutional rules and norms allowing filibusters and individual
holds on bills and nominations in the Senate. The built-in constraints on policy
initiatives are compounded by frequent periods of divided government, during

which neither of the major political parties controls both houses of the legislature
and the presidency.
Through his command of media attention, leadership of his party, political ap-
pointments, and other institutional resources, the president is effective in setting
the national agenda, including health policy (102, 167, 201). In contrast to many
other political systems, however, the power of the chief executive in policy for-
mulation is particularly weak and the chief source of influence is not the formal
authority but the power to persuade others inside and outside of government (126,
140).
It is common for presidential initiatives to die or undergo substantial alterations
in the hands of the legislature or the courts (71). After his landslide election in
1964, President Johnson pushed hard for Medicare, but it was the large increase in
Democratic majorities in Congress that made its passage inevitable. Even then, the
Johnson administration only proposed to establish a hospital insurance program; it
was House Ways and Means Committee chairman Wilbur Mills who expanded the
legislative package to include Medicare coverage for outpatient physician services
and the Medicaid program for impoverished Americans (111). President Nixon
endorsed federal support for development of health maintenance organizations
(HMOs), in part to offer a market-oriented approach to health care reform that
would contrast with the command-and-control regulatory approaches offered by
Senator Ted Kennedy and other liberal Democrats. The administration’s ideas
were co-opted by the liberals, however: the Health Maintenance Organization
Act of 1973 provided legal and financial support to prepaid health plans but in
exchange required comprehensive benefits, open enrollment, and other features
that would put HMOs at a competitive disadvantage with indemnity insurers (22,
46). President George W. Bush proposed that Medicare beneficiaries be offered
prescription drug benefits only if they joined a private managed care plan; but
senators representing rural states where enrollment in managed care was minimal
successfully demanded that all beneficiaries, including the large majority in the
traditional fee-for-service Medicare program, be offered comparable drug benefits
(137).
President Clinton saw major initiatives for universal health insurance, tobacco
control, and a patients’ bill of rights vis-à-vis managed care plans all die in
Congress. In addition, his administration’s effort to assert FDA authority to
206 OLIVER
regulate the sale and marketing of tobacco products was rejected by the Supreme
Court (38, 89). Steinmo & Watts consider the demise of the Health Security Act
not as a personal or strategic failure of the president and his advisors, but as a
natural outcome of the institutional context: “America did not pass comprehensive
national health care reform in 1994 for the same reason it could not pass it in 1948,
1965, 1974, and 1978. . . . American political institutions are structurally biased
against this kind of comprehensive reform” (179). The bias stems, in particular,
from the multiple points of access that special interests enjoy and the multiple veto
points that their access and influence create in the policy process (68). Miscalcula-
tions about the institutional roadblocks doomed both Clinton and, soon thereafter,
Republicans who hoped to dramatically restructure and scale back Medicare and
Medicaid after they assumed majority control in both houses of Congress in 1995
(143).
Accompanying the constitutional checks and balances at each level of govern-

ment is the division of responsibilities among the states and federal government.
Federalism raises normative questions about where health policy should be formu-
lated and empirical questions about where it is actually formulated. It also raises
questions about the responsiveness and effectiveness of public health policy (4,
19, 96, 134, 151, 182).
There is no single pattern of federal-state relations across all areas of health
policy or even issues within a given area of health policy (4). Depending on the
issue, federalism can either promote or inhibit governmental action to address
public health problems (140). In areas such as tobacco and gun control, health
insurance market reforms, and a patients’ bill of rights, state action has arguably
lessened the pressure for additional reforms, and federal proposals have either
failed or been reduced to essentially providing a national floor for governmental
regulation.
There is much rhetoric to suggest that states serve as “laboratories of democ-
racy” for testing new polices, the most effective of which will be emulated by other
states or adopted for the nation as a whole. In fact, many policy ideas are developed
and disseminated among state organizations like the National Governors’ Associ-
ation, the National Conference of State Legislatures, and the Association of State
and Territorial Health Officers. States have broken ground in such areas as regional
health planning, prospective payment systems for hospital care, children’s health
insurance, managed care carveouts for mental health services, organization and
financing of care for AIDS patients, restrictions on the sale of handguns, indoor
smoking bans, health insurance purchasing cooperatives, comprehensive health
insurance reforms, and public investment in stem cell research.
Yet in most situations, the metaphor of states as laboratories is misleading for
many reasons (134, 138, 175). First, states and the federal government share a
fairly common agenda, influenced by market dynamics in the health care sys-
tem and by changing perceptions of social problems, population groups, and in-
dustries. Almost every major health policy issue in the past decade—including
HIV/AIDS, tobacco control, expanding health insurance coverage, gun policy,
regulation of managed care, mental health parity, prescription drug assistance, and
bioterrorism—has been the subject of debate and policy proposals throughout the
political system. Second, the federal government often supports critical research
and development—for example, in risk adjustment of capitation payments—that
enables development of new state and local programs. Moreover, much state health
policy is heavily influenced either by regulatory federalism in the form of constitu-
tional or legislative mandates or by fiscal federalism in the form of federal matching
funds and grants (4, 201). Third, most policy innovations are not thoroughly tested
before similar policies are adopted in other jurisdictions, or even before they are
modified in the state of origin. Fourth, relatively simple policies such as insurance
mandates, drunk driving protocols, or indoor smoking bans may spread quite easily
across states and communities, yet more complex or controversial innovations do
not readily diffuse to other jurisdictions. In reforms that subsequently unraveled,
Massachusetts, Oregon, Washington, and California all followed the example of

Hawaii by enacting somewhat different mandates for employers to offer health
insurance to their workers, and pursued dramatically different approaches in other
legislative provisions. Despite its relative political and policy success, nothing
resembling the Oregon Health Plan’s prioritization of health benefits has been
seriously considered in another state (97, 129, 138).
What federalism typically produces is wide variation in policies to address a
common problem. Evidence of such variation can be found in children’s health
insurance (20, 43, 185), other health insurance reforms (41, 76, 133), teen access
to tobacco products (87, 169), mental health (53, 94), regulation and penalties for
illicit drug use (32), and bioterrorism and other forms of public health preparedness
(59).
The strength of state health policies can be measured by the degree of income
redistribution, regulation of industry or individual behavior, or other features of
policy design. They are largely determined by factors such as per capita income,
administrative capacity, political will, earlier efforts to address the problem, fed-
eral financial support, and intergovernmental bargaining (65, 138, 174, 185). In
addition, state-to-state variations in political, financial, and technical support for
federal policies can significantly impair the effectiveness of policy implementa-
tion, as seen in national policies to rapidly administer vaccines for swine flu and
smallpox (69, 127); require local law enforcement officials to screen purchasers
of guns under the provisions of the Brady Law (36); and halt various means of
reimportation of lower-cost prescription drugs from Canada, Mexico, and other
countries (13).
Concentrated Interests
According to many observers, perhaps the major source of incrementalism—and,
often, inaction—is an inequality of political resources (68). Most public health
policy is formulated, adopted, and amended over time within a relatively small
network of elected officials, legislative and administrative staffs, interest group
208 OLIVER
leaders, researchers, and reporters whose knowledge and activities are devoted
principally to a specialized policy area (42, 70, 90, 194, 205). The activity of
government in this area is virtually invisible to the general public, as governors,
party leaders, and the mass media focus on broader policy initiatives. As a result,
the course of policy making is dictated by the balance of political resources and
energy exerted by the attentive public, organized around economic, geographic,
or ideological interests (33, 114, 147, 159, 206). Interest groups play an important
role in nearly every aspect of health policy, lobbying legislators and administrative
agencies, instigating or assisting with litigation in the courts, stimulating grassroots
political activity, and participating in election campaigns (201).
The groups outside of government, but closely connected, include trade associ-
ations, individual corporations, and other membership organizations representing
physicians, hospitals, nurses, health insurers, drug companies, nursing homes,
large and small businesses, labor unions, senior citizens, and other groups whose
material well-being is closely linked to the trillion-dollar health system; public
interest groups such as Consumers Union, Children’s Defense Fund, and Public
Citizen’s Health Research Group; single-issue groups such as Mothers Against
Drunk Driving, National Alliance for the Mentally Ill, Campaign for Tobacco
Free Kids, National Abortion Rights League, AIDS Coalition to Unleash Power,
and National Rifle Association; and intergovernmental lobbies representing state
governors, county and municipal governments, and other public officials (90, 145,
201).
Even when an issue is highly salient, like national health insurance, supportive
public opinion often does not produce commensurate policies, and hence critics
turn their attention to special interests as the culprits responsible for sabotaging
reform proposals (123). Indeed, some analysts argue that elected officials and
interest group leaders seldom use public opinion as a guide to setting priorities
and formulating proposals, and instead employ “crafted talk” to generate public
endorsement of policy proposals in which they have already invested their re-
sources (85). Market-oriented conservatives have long labeled their plans to pro-
mote enrollment of Medicare beneficiaries in private health plans as “improvement
and modernization” and have effectively reinvented high-deductible, catastrophic
health insurance as “consumer-driven” health plans and health savings accounts,
despite considerable evidence that few health care consumers have any interest in
either model of reform (110, 122, 128, 162, 172).
Under what conditions do interest groups—individually or in concert with
others—influence the policy process? An expansive literature identifies a num-
ber of group characteristics that confer advantages in the political marketplace:
(a) credible information on social conditions, available policy options, and likely
impacts; (b) recurrent interactions with policy makers; (c) large and geographi-
cally dispersed membership; (d ) group cohesion and unified positions on priority
issues; (e) organizational resources such as staff size and expertise; ( f ) electoral
resources including campaign funds and political intelligence; and (g) strategic
position in a policy niche and recognition as a coalition leader (37, 68, 144, 145).
At times in the past, the influence of certain peak interest groups like the Ameri-
can Medical Association (AMA) or the Tobacco Institute were considered so strong
that observers referred to an “iron triangle” in which the mutually reinforcing goals
of the interest group, together with the legislative committees and administrative
agency with primary jurisdiction over that issue, would steer the course of policy
irrespective of any consideration of the public interest (31, 107, 144). It was the
reputed power of the AMA, based on its successful opposition to national health
insurance in the Roosevelt and Truman administrations, and the strategic position
of physicians and hospitals that led Congress in 1965 to proclaim that the Medicare
program was not to interfere with the practice of medicine, in order to remove any
chance of a boycott as the new program got under way. The consequence was that
Medicare officials accepted generous payment methods that launched the modern
era of health care cost inflation (47, 111). The tobacco industry was a formidable
opponent because it constituted “one of the largest, richest, longest standing, best
organized, and most single-mindedly consistent groups in world history” (73, 92).
In contemporary politics, however, a single-interest group seldom if ever has su-
perior numbers, resources, cohesion, and political connections relative to all other
organized interests. The growth in the number of interest groups, especially more
specialized trade associations and single-issue groups, has led scholars to conclude
that political influence is generally more dispersed across loosely organized “issue
networks” or “policy communities” that focus their attention on health, education,
transportation, or other areas of public policy (70, 90, 141, 144). Shifting images
of who is affected or what is at stake have also altered interest group participation
and venues for decision making, thereby helping to bring about the destruction
or significant erosion of “policy monopolies” in tobacco, medical care, and gun
control (1, 9, 28, 188).
The politics of an issue are determined in large part by how it distributes the
benefits it confers and the costs it imposes (5, 206, 207). The perceived distribution
of benefits and costs depends on their magnitude, timing, and certainty. Any pro-
posed change to policy threatens the existing distribution of benefits and costs, and
groups with an identifiable stake in the outcome will organize themselves in the
political system according to the pattern of changes being proposed. Concentrated
interests systematically outweigh diffuse interests in the politics of policy making.
Also, politicians expect punishment for decisions that impose costs or take away
existing benefits far more than they expect reward for providing new benefits.
Based on Wilson’s conceptual framework, shown in Figure 2, the most politi-
cally feasible environment for policy change is one of client politics, which offer
relatively concentrated benefits—large, direct, and immediate assistance for an
identifiable group of citizens, service providers, or manufacturers—while impos-
ing only diffuse costs across other groups and taxpayers. The Hill-Burton hospital
construction and modernization program, the National Institutes of Health and
their extramural research programs, support for training of health professionals,
and tax breaks for employer-sponsored health insurance are all examples of the
client politics that helped build the massive medical-industrial complex in the
210 OLIVER
Figure 2 Framework for analysis of policy design and political feasibility [based on ty-
pologies suggested by Wilson (206–208) and Arnold (5). Adapted from Reference (138)].
United States. Proposals that involve client politics are so numerous and success-
ful because they create loyal, mobilized supporters and attract very little organized
opposition.
In contrast to client politics, many public health initiatives present a political
feasibility problem based on their distribution of perceived costs and benefits. They
are classic examples of entrepreneurial politics—where costs must be imposed on a
concentrated segment of the population (recipients of vaccines, motorcycle riders,
manufacturers, employers, insurers, individuals with infectious disease, polluters)
in order to provide broad, often unpredictable benefits for a broader segment of the
population. Governmental actions or proposals of this kind are often weak or fail
altogether because they meet severe opposition or they do not receive enthusiastic
support from the intended, often unknowing beneficiaries—or the beneficiaries, if
identifiable, are considered undeserving of governmental intervention. Scientific
evidence, even if it strongly predicts net benefits, does not necessarily translate
into sufficient political support.
At the outset of the AIDS epidemic in San Francisco and New York, for example,
it was impossible to pursue traditional public health practices such as contact
tracing, quarantine, or mandatory blood testing because of the perceived imbalance

between the harsh constraints on liberty and privacy and the inadequacy of other
policies to support those found to be HIV-positive. Facing opposition by gay rights
organizations, public health officials made a conscious commitment to rely on
noncoercive measures such as mass education, voluntary testing, and counseling
to avoid driving the epidemic underground (11, 168, 183).
As private and public expenditures on health services accelerated throughout
the 1970s and 1980s, the chief problem in health care politics became how to
impose costs on a concentrated group of health care providers in order to lessen
the financial burden on the larger groups that receive and underwrite those services
(112). Entrepreneurial politics in pursuit of budget containment produced a series

of prospective payment systems for hospitals, physicians, home health, and nursing
homes under the Medicare program (132, 171, 172). In the private sector and in
state Medicaid programs, this brand of politics led by resurgent business groups
resulted in a vast and rapid expansion of managed care (17, 148).
Incrementalism is a natural product of what Wilson characterizes as interest
group politics, where there are concentrated benefits and concentrated costs at
stake in a proposed policy change. With clear winners and clear losers, the level
of conflict is high and the outcome of any single proposal is highly unpredictable.
Over time, tobacco control has advanced in many forms as science and economics
have created more concentrated beneficiaries: nonsmokers themselves; prestigious
organizations such as the American Cancer Society, the American Lung Associ-
ation, and the American Heart Association; providers of smoking cessation pro-
grams; pharmaceutical firms that make nicotine patches for individuals trying to
quit smoking; and governmental officials trying to recoup the costs of treating
smoking-related disease in public health insurance programs (38, 87, 116).
Proposals that spread both benefits and costs across relatively large segments
of the population create an environment of majoritarian politics. The chief issues
here are the desirability of a significant redistribution of economic benefits or civil
rights, and the appropriate role of government in achieving that outcome. Medicare,
Medicaid, and universal health insurance all fit into this category. This type of
politics is driven by ideology as much as interests, bringing party leaders into the
conflict along with issue specialists and affected constituencies (111, 143, 170).
Some issues and policy proposals involve several types of politics at once.
The political feasibility of redistributive reforms often depends on bundling them
with provisions delivering concentrated benefits. Although politicians frequently
refer to senior citizens as the third rail of American politics, efforts to secure out-
patient prescription drug coverage under Medicare failed repeatedly over nearly
four decades. One explanation for this lengthy delay was the opposition of another
group with strategic advantage, substantial resources, and considerably more cohe-
sion than AARP—the Pharmaceutical Researchers and Manufacturers of America
(PhRMA) (81). PhRMA finally agreed to support new Medicare prescription drug
benefits when it received assurances that private health insurers, not the federal
Centers for Medicare and Medicaid Services (CMS), would have primary control
212 OLIVER
over the design and administration of the benefits; that there would be no direct
price setting or negotiation by the federal government; and that the existing ban
on drug reimportation would remain in effect pending further study of safety and
quality issues by the FDA. Thus, the most publicized benefits of the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003 went to several
million low-income Medicare beneficiaries who had no supplemental source of
insurance coverage through retiree benefits, Medigap plans, or Medicaid. But the
most successful client of all was the pharmaceutical industry, which would directly
benefit from tens of billions of dollars in annual subsidies for its best customers
and, at least for the time being, few restrictions on its practices. Also, employers,
managed care plans, rural health care providers, and teaching hospitals received
over $125 billion in short-term subsidies (78, 137).
By focusing on the distribution of costs and benefits, it becomes clear why
the principal power of interest groups is to block policies they oppose, exploiting
the multiple veto points provided by political institutions (68, 90). Anti-abortion
groups were able to prevent mifepristone (RU-486) from entering the U.S. market
for many years by threatening a boycott against its manufacturers (83). Advocates
for the disabled successfully thwarted federal approval of the Oregon Health Plan,
objecting to services that technically would not be covered by Medicaid under
its new priority list, until after President Clinton took office (24, 50). In order
to stop implementation of state laws requiring employers to offer and contribute
toward health insurance for their workers, business groups have lobbied hard to
keep Congress from amending the Employee Retirement Income Security Act of
1974—or exempting any state other than Hawaii from its provisions (201). The
NRA relies on its zealous grassroots base, its ties to key public officials, and
litigation to prevent passage of gun control legislation and regulation (177).
Fiscal Constraints
A final source of incrementalism in health policy is the fiscal capacity of govern-
ment to take on additional responsibilities. Financial affordability is an important
factor in assessing political feasibility of a policy proposal (90). The constraints
placed on policy development differ in the states and federal government.
By statute, 49 of the 50 states must balance their budgets by the end of the fiscal
year. In addition, most states are prohibited from borrowing for operating expenses
such as payroll and social services (201). In an economic downturn, therefore, states
face a dilemma of needing to increase spending on Medicaid and safety net health
care programs at the very time tax revenues are declining. As states struggled to
balance their budgets in recent years, many chose to convert their share of the
funds owed by the tobacco industry under the terms of the 1998 Master Tobacco
Settlement into a one-time payment. Because the money was not earmarked, less
than 10% of the money went to smoking prevention programs, and many states
used it to fill budget gaps and fund unrelated programs and capital projects (38).
At the federal level, fiscal constraints stem primarily from the politics of taxes
and deficit spending and, in addition, procedures and rules in the congressional
budget process. In the 1980s and 1990s, members of Congress strengthened the
budget reconciliation process established in 1974 in order to limit and eventually
reduce annual budget deficits. Under a series of bipartisan agreements for deficit
reduction, particularly pay-as-you-go rules adopted under the Budget Enforcement
Act of 1990, financial affordability assumed greater importance. Advocates had
to demonstrate that new policies and programs would be budget neutral or even
reduce net governmental outlays so that policy makers would not be forced to
identify new revenue sources or cut other programs (160, 203).
The focus on deficit reduction created serious problems for two major federal
health initiatives. President Reagan, at the urging of his Secretary of Health and
Human Services Otis Bowen, proposed a modest expansion of Medicare to protect

against the costs of catastrophic illness; but Democrats in both houses of Congress
greatly expanded the new benefits until even Bowen opposed the new legislation.
Nonetheless, Reagan agreed to support the legislation as long as it added nothing

to the deficit, and added a further condition that the benefits would have to be self-
financed, paid for entirely by beneficiaries. These constraints limited the amount
of prescription drug coverage and other benefits that members of Congress wanted
to include in the Medicare Catastrophic Coverage Act, and the resulting increases
in Part B premiums, together with a supplemental premium for higher-income
beneficiaries, helped fuel the political backlash that led Congress to repeal the act
in 1989 (72).
Operating under even more stringent budget rules, President Clinton sought to
achieve universal health insurance without having to raise taxes. His formula of
“competition within a budget” was intended to achieve that goal and secure his im-
age as a New Democrat, but the Congressional Budget Office ruled that employer
mandates and other provisions should be treated as new spending. The backstop
provisions for controlling health insurance premiums through price controls were
cited by critics as evidence that the Clinton plan was going to vastly expand
governmental regulation and require rationing of health services (64, 170, 179,
203).
The procedures for budget reconciliation have at times facilitated health pol-
icy innovation by bundling reforms opposed by some concentrated interests into
omnibus, must-pass legislative packages. But the innovation has been biased in
favor of cost containment and against expansion of benefits and other initiatives
that would increase public spending. An exception to this pattern is SCHIP, which
was enacted as part of the Balanced Budget Act of 1997 and added $40 billion in
new federal spending over ten years even as other provisions reduced projected
outlays for Medicare and Medicaid by many times that amount (158, 172). The
periodic projections of insolvency in Medicare’s trust funds have served as false
alarms that empower advocates who propose to scale back the entitlement and
enroll more beneficiaries in private health plans (204).
It was only when the pay-as-you-go rules were eased after the federal govern-
ment ran a short-lived budget surplus in the late 1990s that policy makers were able
to substantially expand proposals for prescription drug coverage under Medicare.
Even then, the arbitrary limit of $400 billion set aside in the budget resolution for
214 OLIVER
the total cost of the reform package forced legislators to design a massive “dough-
nut hole” in the coverage. In the first year of the new Part D program, beneficiaries
would have to pay all of their annual drug expenses between $2250 and $5100.
Overall, Medicare would cover only about one quarter of projected drug spending
by beneficiaries during the first decade of the program (137). With the return of
record deficits since 2001, pressure for fiscal constraint is again increasing and will
make any effort to improve the generosity of the Part D program more difficult.
SOURCES OF HEALTH POLICY INNOVATION

Despite the forces arrayed against most public health initiatives, theories of the
policy process and the historical record identify conditions under which larger-
scale transformation of health policy can occur. The basic capacity for policy
innovation is subject to broad social, political, and economic forces (45, 124,
154). Health reforms, in particular, depend on the degree of economic prosperity
and the national mood, whether liberal or conservative (110). The course of action,
however, is also driven by leaders with specific ideas about the proper direction of
public policy. The activities of strategically placed individuals can greatly influence
the likelihood of policy change and especially the policy options given serious
consideration when opportunities for reform arise.
Critical Junctures in Policy Development

Incremental policies can use up political capital, dissipate public pressure and,
intentionally or unintentionally, build up sources of resistance to more compre-
hensive reform (41, 113, 179). But in some cases incremental changes may lay
the groundwork for a broader transformation of politics and policy making (103,
142, 187). Policies may be small in the scope of their design or scale of resources
relative to the magnitude of the problem, yet because they establish a new role for
government they are precursors of a subsequent, broader set of initiatives. Brown
distinguishes between breakthrough policies and rationalizing policies, and argues
that both are important and necessary sources of innovation (21).
Thus, the series of legislation in the 1980s expanding Medicaid eligibility to
pregnant women and children, as well as the growing dependency of the elderly
on long-term care benefits, have sufficiently altered the image of the program such
that some analysts consider it a plausible stepping stone to universal coverage
(62). Even though SCHIP has only about one-tenth the number of enrollees as
Medicaid, it too is regarded as an important breakthrough in the politics, design,
and implementation of health insurance programs. In 1965, the federal government
started a new program to develop neighborhood health centers as part of the War
on Poverty. The public funding and community governance made it a poster child
of “socialized medicine,” but over time the operators and beneficiaries cultivated
bipartisan political support and, renamed as the community health centers program,
it has become an integral part of the nation’s health care safety net (157).
The contemporary rise of managed care and market competition has its roots
in earlier, often disappointing episodes of reform. Kaiser Permanente and the
government program built to foster its market share, the Federal Employees Health
Benefit Program, served as models for three prominent policy initiatives: federal
support for HMOs in the 1970s, the Consumer Choice Health Plan pursued in
the 1980s, and the Clinton administration’s Health Security Act in the 1990s (130,
135). Even though Congress adopted the HMO Act of 1973, it was routinely viewed
as an obstacle for the development or expansion of prepaid health plans (22, 178).
The other two proposals for comprehensive market reform failed altogether. Yet
business leaders—the “fat kid on the seesaw” of health politics—widely adopted
managed care as the best way to slow health care inflation, and federal and state
policy makers followed suit for Medicare and Medicaid (17, 148). Through the
interaction of political and corporate elites, the intellectual, economic, and political
seeds planted in the 1970s grew into a new paradigm in health policy by the early
1990s (135).
Political Opportunities and Leadership

Kingdon argues that whereas incremental responses to problems are the norm,
certain features of the policy process sometimes lead to surprising departures from
the status quo. Figure 3 illustrates how this can occur when two conditions are met.
First, an abrupt shift in how a problem is perceived or in who controls the levers
of governmental power opens a “window of opportunity” for policy innovation.
Figure 3 Model of agenda setting and policy change [from Reference (90)].
216 OLIVER
Second, there is a convergence of three relatively independent “streams” in the

policy process: problems, policies, and politics. If advocates are able to couple their
preferred policy alternative with the prevailing problem definition and the priorities
of political leaders, organized interests and public opinion, then significant policy
innovation can occur within a short period of time (90).
The least predictable but probably the most powerful source of policy inno-
vation is the stream of problems that press themselves onto the already-crowded
governmental agenda. The Gun Control Act of 1968, the first major federal effort
in that area of public policy, came in response to the assassinations of civil rights
leader Martin Luther King, Jr. and presidential candidate Robert F. Kennedy ear-
lier that year. The attempted assassination of President Reagan in 1981 did not
lead directly to any new gun control policies, but it did result in the mobilization
of gun control advocates led by Handgun Control, Inc., in partnership with Sarah
Brady and her husband James, the president’s press secretary who was wounded
and left permanently disabled by the attack. The rise of a countervailing power
to the NRA made possible a slow progression in gun control efforts such as the
assault weapons ban and the Brady Handgun Violence Prevention Act in the early
1990s (28, 36, 177).
There is often sufficient ambiguity in the nature of the problem or what can be
done about it so that a leader can offer his or her proposal as a plausible solution.
The greater the uncertainty, the more likely the leader will be able to define a
situation and offer a corresponding solution (9, 138). The rationing scheme and
the accompanying blueprint for universal coverage developed under the Oregon
Health Plan originated in such a situation. John Kitzhaber, the president of the
Oregon State Senate and an emergency room physician by profession, recognized
the futility of basing health policy on the rescue principle. When a seven-year-old
boy died from leukemia after the state Medicaid program stopped covering organ
transplants, the easy solution would have been to restore the transplant funding. But
Kitzhaber demonstrated the inherent ambiguity of a situation that initially seemed
quite clear to most of his fellow Oregonians. He redefined the issue from uncaring
government—which would require policy makers to come up with money to pay
for identifiable needed services without respect to other unmet needs—to an issue
of fair allocation of scarce resources and how to establish an ethically defensible
process for determining which medical needs are most deserving of governmental
assistance (66, 91, 130, 138).
Similarly, in 1976, the death of a single soldier at Fort Dix in New Jersey set
off a chain of events that led the director of the Centers for Disease Control, David
Sencer, to recommend an urgent nationwide vaccination campaign against the
swine flu. He and other public health experts convinced President Ford to approve
and personally promote the program and then struggled to implement it even as
the epidemic failed to materialize as feared (127).
The terrorist attacks of September 11, 2001, in New York and Washington and
the anonymous letters laced with anthrax spores the following month served as
focusing events that highlighted the nation’s lack of preparedness for many forms of
terrorism. One response was the Project Bioshield Act of 2004, to create a Strategic
National Stockpile of new vaccines and other therapies against biological agents.
Another was to launch a national smallpox vaccine program, despite the fact that
the disease was eradicated decades earlier and the only known sources of smallpox
were U.S. and former Soviet defense agencies.
Politics-driven opportunities arise from shifts in the national mood, anticipation
of and reaction to elections, interest group pressure, and the ideological preferences
and priorities of key officials (90, 146). The Medicare reforms of 2003 illustrate the
importance of these factors. The problem of rising drug costs and resulting decline
in the ability of Medicare beneficiaries to secure and maintain supplemental cover-
age was serious and growing worse. The policy option of private sector pharmacy
benefits management was especially important, as it allowed Republicans and their
allies in the drug industry to support new benefits without appearing to support an
expansion of governmental authority and bureaucracy. Most important, however,

there was sufficient political capacity and will to finally address this problem.
A new window of opportunity opened when Republicans regained majority
control of the Senate after the 2002 elections. At that point, President Bush made
Medicare reform one of his administration’s highest domestic priorities. Two of
his party’s most powerful legislators, Senate Majority Leader Bill Frist and House
Ways and Means Committee Chairman Bill Thomas, also considered Medicare re-
form to be a top priority and were in a position to shepherd it through the Congress.
Those leaders concluded that they could claim credit for a prescription drug benefit
and, since they controlled both the legislative and executive branches of govern-
ment, they could face negative consequences in the 2004 election if they failed to
deliver on Bush’s earlier campaign pledge on this issue. They were still willing
to commit $400 billion to get legislation enacted in 2003, despite the mounting
costs of the war with Iraq and an unprecedented budget deficit. Democrats, in turn,
faced a use-it-or-lose-it choice since that amount of money would not be available
again anytime soon. President Bush invested considerable resources to win over
skeptical allies, including the pharmaceutical industry and fiscal conservatives.
Despite the clear opportunity for reform, it took all the resources and tactical ma-
neuvering of the president and other Republican leaders, as well as favors for key
constituencies, to overcome ideological misgivings and secure political agreement
for a complex package of reforms (78, 137).
Policy Entrepreneurs and Investors

These episodes illustrate an inherent unpredictability in the policy process, where
ideas, individual leaders, and the context for debate are often as influential as con-
ventional political interests in determining the scope and substance of the agenda
and the translation of proposals into policy. Because there is considerable room
for argument about appropriate means to accepted ends, leadership and strategy
become central variables in determining whether and how government responds
to a pressing public health problem.
218 OLIVER
At the center of the fluid process of policy innovation are “policy entrepreneurs,”
a particular brand of leaders who bring their own ideas for policy change to those
in positions of authority and power. Policy entrepreneurs “recombine intellectual,
political, and organizational resources into new products and courses of action for
government and other institutions that deliver public services” (131). In addition
to developing and promoting their policy products, policy entrepreneurs attempt
to manipulate the dimensions of a policy debate, reshaping their ideas to fit the
political and economic constraints of the moment and to gain access to policy-
making venues. It is through their drive and imagination that the matching of
problems, policy options, and political support occurs to move issues higher on
the governmental agenda and improve the chances for successful reform (9, 90,
138, 194).
Policy entrepreneurs often come from positions outside of government, so their
success depends on recruiting “investors,” government insiders who have key po-
sitions and the political capital—in the form of staff, financial resources, authority,
and personal commitment—to move their proposals forward (138). The efforts of
entrepreneurs and investors focus on three strategies: (a) persuading other partici-
pants in the policy community of the necessity, appropriateness and efficacy of the
proposed action by establishing a favorable image of potential beneficiaries and
better defining and documenting the potential benefits; (b) identifying the most
advantageous decision-making venues and procedures for pursuing their propos-
als; and (c) modifying proposals to generate more support or reduce opposition,
such as adding or dropping provisions, changing the mix of policy instruments,
delaying or speeding up policy implementation, broadening or narrowing the target
populations, or other aspects of policy design (5, 138, 140).
The tasks of policy entrepreneurship can be carried out by a few identifiable
individuals, a loosely connected set of groups, a formal coalition, or governmental
body. Tufts University physicians Jack Geiger and Count Gibson, Jr., promoted
neighborhood health centers as a source of comprehensive ambulatory services,
jobs, community participation, and planning for low-income areas. The Johnson
administration incorporated the centers into its antipoverty program, led by the
Office on Economic Opportunity (157). Many of the intellectual and political
foundations for the rise of managed care and health care competition were created
through the efforts of Paul Ellwood, a physician and head of InterStudy, a think
tank in Minneapolis, and Alain Enthoven, a business school professor at Stanford
University (130, 131, 135). Ellwood and his colleagues provided the blueprint
for HMOs to the top health officials in the Nixon administration in 1971, then
worked with members of Congress on the ensuing legislation (22, 46). Together
with Enthoven and Lynn Etheredge, Ellwood later formed the Jackson Hole Group
whose proposals established the basic approach of managed competition taken by
the Clinton plan and a rival bill introduced by Rep. Jim Cooper in 1994 (64, 185).
Abraham Bergman, a pediatrician based at the University of Washington, worked
closely with his home state senators Warren Magnuson and Henry Jackson to es-
tablish the Consumer Product Safety Commission, the National Health Service
Corps, federal research into sudden infant death syndrome, and an expansion of
the Indian Health Service to Native Americans living away from tribal lands (15,
16, 150). John Goodman, a professor at the University of Dallas, promoted the
concept of medical IRAs to build on an Internal Revenue Service ruling in 1984
that granted modest tax benefits for flexible spending accounts. Over the next two
decades, he and his colleagues at the Texas-based National Center for Policy Anal-
ysis worked in concert with a few insurance companies, organized medicine, and
Republican leaders in Congress. The fruit of their efforts is a series of legislative
provisions attached to the Health Insurance Portability and Accountability Act
of 1996, the Balanced Budget Act of 1997, and the Medicare Modernization Act
authorizing varying forms of tax-free personal health savings accounts (108, 122).
The “collective entrepreneurialism” of breast cancer patients, female journalists,
and other activists helped form the National Breast Cancer Coalition. They per-
suaded members of the Congressional Women’s Caucus and women in leading

executive branch positions take a more assertive role and were able to greatly
accelerate the development of women’s health research and treatment programs
(30). Similarly, the joint efforts of individual trial attorneys, scientific experts,
FDA commissioner David Kessler, and especially the state attorneys general sig-
nificantly reframed the issue of smoking and compelled the tobacco industry to
negotiate the 1998 Master Settlement Agreement (89, 116, 176).
Linkage of Multiple Venues in Health Reform

In practice, public policy is a not a single act of government but a course of action
that involves individuals and institutions in both the public and private sectors,
and encompasses both voluntary activities and legal injunctions (131). The same
constitutional design that offers multiple veto points for any given initiative allows
policy entrepreneurs to try alternative venues, in effect seeking the path of least
resistance to their policy goals and specific proposals. Baumgartner & Jones em-
phasize the importance of venue shopping to explain how policy change and social
reform can proceed despite temporary obstacles in one jurisdiction or institutional
setting. Policy entrepreneurs “may identify particular venues, such as congres-
sional committees, state government organizations, courts, private businesses, or
any other relevant institution, in their search for allies.” Even with only episodic
success, therefore, “new ideas or policy images may spread rapidly across linked
venues, thereby setting in motion a positive-feedback process” (9).
Ellwood and Enthoven not only conceptualized a more competitive health care
system, but also pushed their ideas simultaneously in the public and private sec-
tors. Their persistent efforts to persuade medical and business leaders as well as
policy makers helped create elite norms, institutional capacity, and new stakehold-
ers in the market approach to health care reform (185). Using his authority as the
president of the Oregon Senate, Kitzhaber created a new legislative committee
to avoid a skeptical committee chairman and gain more favorable reception for
the package of legislation involved in the Oregon Health Plan. His strategy also
220 OLIVER
included a series of public meetings across the state and the appointment of an
independent commission to improve the legitimacy and credibility of the priori-
tization process (49). Commissions have also served to strengthen the technical
and political feasibility of reforms in other states and in the Medicare program
(25, 132, 138). Tobacco control advocates found that it was far more difficult for
the industry to fend off regulation at the local level than in state legislatures or
Congress (54, 120). Once the FDA and attorneys general opened up new venues
of regulatory activity and litigation, the tobacco control movement gained consid-
erable momentum (38, 86, 161). Advocates on both sides of the obesity issue are
establishing a similar process, involving legislation, regulation, and litigation at
all levels of government (196). In response to the continuing federal ban on the
reimportation of less-expensive prescription drugs, state and local governments
across the country are setting up their own international purchasing programs, and
customs officials are not screening senior citizens who take bus trips to buy drugs
in Canada. As a result, a different system of prescription drug pricing, purchasing,
and quality control is likely to emerge in the coming years.
POLITICS OF POLICY IMPLEMENTATION
Bardach summarizes the basic challenge awaiting the officials and agencies who
are asked to implement and administer governmental policies: “It is hard enough
to design public policies and programs that look good on paper. It is harder still to
formulate them in words and slogans that resonate pleasingly in the ears of political
leaders and the constituencies to which they are responsive. And it is excruciatingly
hard to implement them in a way that pleases anyone at all, including the supposed
beneficiaries or clients” (8).
The primary responsibility for policy implementation usually rests with a dif-
ferent set of governmental actors than the ones who dominated agenda setting and
policy formulation. Yet the program analysts and managers who will be judged
on the effectiveness and efficiency of policies seldom find themselves insulated
from politics. In fact, there will be ongoing communication and pressure from
many masters: legislative sponsors and members of budget, appropriations, and
oversight committees; policy and budget advisors to the president or governor;
affected organizations and interest groups; and political appointees in charge of
the agency (201). Both agency heads and career civil servants must juggle policy,
politics, and management priorities amid high expectations (101, 149). Gaps be-
tween intentions, actions, and outcomes are almost inevitable, and they arise for a
number of reasons.
Ambiguity in Policy Design

Laws are often ambiguous because legislators and their staff lack the information
or expertise to design policies with precision. In addition, there are often vague or
even contradictory provisions because the legislation is intended to serve multiple

goals. Finally, legislators may delegate major decisions to administrative agencies
in order to keep from offending an important constituency and risking defeat of the
proposal. The costs of negotiating political agreement and the costs of information
about policy performance will strongly influence how much legislators are able
and willing to specify both the goals of a new policy and the procedures for
implementation (79).
Such a situation arose in the implementation of Medicare’s new physician pay-
ment system in the early 1990s. Members of Congress approved the adoption of
a fee schedule with payments determined by a resource-based relative value scale
(171, 132). The idea was to improve the fairness of payments across different spe-
cialties and services provided by physicians. To improve the political feasibility
of the reform, the legislation was supposed to start out budget-neutral, with no dif-
ference between what was spent under the new system compared with projected
spending under the former system of reimbursing usual, customary, and reason-
able charges. At the same time, to ease resistance further, legislators decided to
rapidly increase payments for previously undervalued services and slowly reduce
payments for overvalued services. This would mean that net payments under the
new system would actually need to be higher than under current law. Officials at
the Health Care Financing Administration (HCFA) found they could not reconcile
the contradictory instructions and, months after they had published an interim rule
showing physicians the fees expected under the new system, they reduced all pay-
ments in the final fee schedule in order to make it budget-neutral. The result was
an outrage among individual physicians and organized medicine that generated
over 600,000 letters to HCFA, and many members of Congress blamed agency
technocrats for the surprise cuts and ensuing political fiasco (77, 132).
Dependence on Private Actors and Other Public Agencies

A public agency may be nominally in charge of a new program, but it cannot suc-
ceed without the resources and commitment of individuals and organizations in the
private sector. One of the common games in policy implementation is negotiating
for reliable and timely contributions from independent contractors, grantees, or
other governmental agencies (8, 79, 155). The joint action required to start a new
program and maintain it frequently results in delays, renegotiation of resources
and responsibilities, and confusion among the intended beneficiaries.
During the ill-fated effort to immunize all Americans against the swine flu in
1976, federal officials were frustrated by the lack of cooperation by vaccine man-
ufacturers, who insisted on stronger protection from legal liability for unintended
side effects of a massive immunization program. The issue of liability produced de-
lays and much anxiety since President Ford had so publicly promoted the program
in the middle of the election campaign. Once the vaccine did become available,
further frustrations arose when many state health departments refused to proceed
with mass immunizations given concerns about improper doses for children and
222 OLIVER
emerging reports of Guillain-Barré syndrome in a few adults who received the

vaccine (127).
As implementation of Project Bioshield and the smallpox vaccine program
proceeded, many of the well-known problems in the swine flu affair resurfaced, as
governmental officials and pharmaceutical companies once again were deadlocked
on the issue of legal liability and forced to plan follow-up legislation to address
many unresolved disagreements (6, 190). In addition, hospitals and first responders
across the nation refused to participate in the smallpox vaccine program, given the
exclusion of public health experts from the decision-making process, the lack of
open discussion from the Bush administration about the risks of exposure, and
the small but known risk of dying or becoming disabled by the vaccine. That
resistance brought the highly touted initiative for homeland security to a standstill
(6). Moreover, states still lacked the resources necessary to address deficiencies
in laboratory facilities, epidemiological tracking and reporting, and capacity to

distribute and administer vaccines (69).
Agency Resources
A fundamental problem is that administrative resources may not be commensurate
with the activities required for effective policy implementation. Resources of im-
plementing agencies include the number of personnel, the mix of competencies,
information systems, and experience in handling similar issues.
The development of HMOs in the 1970s was delegated to administrators in
the Public Health Service who were used to running categorical grant programs,
not establishing viable businesses in a competitive marketplace. Their lack of
experience in private health care management was compounded by the rules for
becoming a federally qualified HMO; none of the existing prepaid health plans had
open enrollment or as comprehensive a set of benefits as called for under the 1973
law. The very organizations needed for the fledgling program to get off the ground
were reluctant to participate until Congress amended the law in 1976 and 1978 and
created a separate federal office whose only mission was HMO development (22).
In the 1990s, HCFA (now the Centers for Medicare and Medicaid Services, or
CMS) was assigned responsibility for implementing a host of state waivers for
Medicaid managed care, private insurance regulations and privacy protections un-
der HIPAA, the State Children’s Health Insurance Program, the Medicare+Choice
program for Medicare managed care, new payment systems for home health, nurs-
ing homes, and hospital outpatient services, and new efforts to prevent and pros-
ecute provider fraud and abuse. Yet the agency had actually reduced the number
of full-time employees over time. It also lacked sophisticated information systems
and did not have sufficient flexibility in hiring rules and salaries to attract new
employees with clinical, legal, and information technology expertise (121). There
was sufficient bipartisan agreement on the inadequacy of resources that Congress
included authority for hundreds of new staff at CMS to help the agency implement
its new and complex responsibilities under the Medicare Modernization Act.
Hostile Political Environment

The targets of regulatory policies can make policy implementation extremely diffi-
cult. Individuals, organizations, and interest groups facing concentrated costs will
likely continue to resist or seek opportunities to renegotiate the original policy (56,
149, 208). The already difficult job of implementation can become even tougher
if there is an unfavorable shift in the broader political environment. Under the
direction of Labor Secretary Elizabeth Dole, the Occupational Health and Safety
Administration (OSHA) began work on ergonomics standards to protect office
workers in 1990, during the administration of George H.W. Bush. The rulemaking
process, based on scientific and economic studies and negotiations with labor and
business interest groups, continued for ten years and became final just a few weeks
before President Clinton left office in 2001. The new administration under George
W. Bush, trying to establish its pro-business credentials, advocated a repeal of

the OSHA ergonomics standards, and Republican allies in Congress complied,
bringing the lengthy and cautious regulatory effort to a complete halt.
The federal Agency for Health Care Policy and Research (AHCPR), now the
Agency for Healthcare Research and Quality, was nearly terminated in the mid-
1990s after it released its evidence-based practice guidelines that recommended
that individuals suffering low-back pain first try extended bed rest before agreeing
to proceed with back surgery. The problem in applying even the best research
evidence to policy in these circumstances is that it involves entrepreneurial politics:
The cost savings are spread broadly and future beneficiaries of higher-quality
services are unaware of their good fortune, while the providers and patients for
whom services are no longer recommended or paid for are well aware of the
immediate threat to their welfare. When Republicans gained majority control of
both houses of Congress in 1995, back surgeons lobbied sympathetic members
to eliminate the entire AHCPR budget. The other problem for AHCPR was that
Republicans believed the agency had been an advocate, not merely a facilitator, of
President Clinton’s massive health care reform proposal. House leaders saw this
as an opportunity to fulfill their pledge in the Contract with America to eliminate
federal agencies or dramatically cut their size and scope of regulation. It was only
support from a bipartisan group of Senators, plus cultivation of allies in business
and health insurance, that allowed the agency to survive and over time reinvent itself
as a partner with private sector and professional organizations to foster voluntary
approaches to quality improvement (52, 60).
Interagency Coordination
A final challenge in policy implementation lies in coordinating the different tasks,
organizational cultures, and varying degrees of resources when multiple agencies
have responsibility for a given public health issue. The Centers for Disease Control,
National Institutes of Health, Bureau of HIV/AIDS in the Health Resources and
Services Administration, and the FDA have all had major roles since the AIDS
epidemic first emerged in the 1980s (101). Despite the impact of HIV/AIDS and
224 OLIVER
the political mobilization of different constituencies, the job of coordinating public

policy has never been easy or popular. The Bush administration had plans to close
the Office of National AIDS Policy in 2001 before it became interested in the
international impact of the disease.
Many states established children’s health insurance programs separate from
their existing Medicaid programs, as allowed under the federal SCHIP law. Prob-
lems arose because eligibility and enrollment procedures were different and often
managed by different agencies responsible for health or social services. In ad-
dition, the differences in federal matching funds gave states more incentive to
locate children eligible for SCHIP than to locate children eligible for Medicaid.
In California, advocacy groups and health foundations convinced state and local
officials to mount aggressive outreach efforts for both programs, and found that the
most effective method was to get low-income children signed up for health insur-
ance at the same time as they applied for subsidized school lunches. To implement
“Express Lane Eligibility,” it was necessary to develop computer-assisted technol-
ogy to avoid administrative hassles for potential beneficiaries and to get county
schools and public health agencies working together in local enrollment (136).
CONCLUSION
This article has sought to articulate the role of political analysis in the study of
public health policy. To the diverse participants involved in health policy research,
formulation and administration, the value of political analysis lies in (a) seeing
conflict and power as intrinsic elements of policy making and as determinants of
governmental action and inaction, (b) understanding the origins and goals of poli-
cies and programs, (c) anticipating and diagnosing problems in policy implemen-
tation and performance, and (d ) considering how programs should be evaluated
and refined over time.
The politics of agenda setting, policy formulation, and implementation are
complex and, in many respects, uncertain in both their causes and consequences.
Institutional fragmentation, multiple veto points, and inadequate resources make it
difficult for governmental officials to respond to even the most obvious and serious
public health problems. When they do respond, the resulting policies and organi-
zational capacity are often short term and piecemeal. The development of more
substantial capacity to prevent or treat injury and disease depends, therefore, on
whether initial interventions create positive momentum or unintended, negative
repercussions that dissipate public support and political commitment. Opportu-
nities for larger-scale policy innovation do occur periodically, but skilled policy
entrepreneurs and investors must be poised to take advantage by matching their
proposals with the perceived problem and political forces of the moment. The gen-
eral direction of policy is out of their hands and depends on much broader trends
in the economy, social norms, and political attitudes.
It is instructive to remember that government takes on only the problems that

cannot be resolved through private, voluntary action. Thus, it should not be surpris-
ing that most policies and programs fail to live up to the rhetoric of their advocates.
Depending on factors outlined above, the appropriate standard for research and
evaluation might be whether statutory goals were met. A more modest standard
would be whether the implementing agencies followed the appropriate rules and
procedures. The most pragmatic standard would be whether a new policy rep-
resents an improvement over the previous policy, or other policies implemented
by the same agency or system (79). Policy evaluation, if it accounts for political
conditions and behavior, can be both more valid and valuable to policy makers in
pursuit of better public health.
The Annual Review of Public Health is online at

http://publhealth.annualreviews.org
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P1: JRX
February 11, 2006 21:44 Annual Reviews AR269-FM
Annual Review of Public Health

Volume 27, 2006
CONTENTS
EPIDEMIOLOGY AND BIOSTATISTICS
Effective Recruitment and Retention of Minority Research Participants,

Antronette K. Yancey, Alexander N. Ortega, and Shiriki K. Kumanyika 1
Measuring Population Health: A Review of Indicators, Vera Etches,

John Frank, Erica Di Ruggiero, and Doug Manuel 29
On Time Series Analysis of Public Health and Biomedical Data,
Scott L. Zeger, Rafael Irizarry, and Roger D. Peng 57
The Promise and Pitfalls of Systematic Reviews, Patricia Dolan Mullen
and Gilbert Ramı́rez 81
Hypertension: Trends in Prevalence, Incidence, and Control, Ihab Hajjar,
Jane Morley Kotchen, and Theodore A. Kotchen 465
ENVIRONMENTAL AND OCCUPATIONAL HEALTH
Environmental Justice: Human Health and Environmental Inequalities,
Robert J. Brulle and David N. Pellow 103
Speed, Road Injury, and Public Health, Elihu D. Richter, Tamar Berman,
Lee Friedman, and Gerald Ben-David 125
The Big Bang? An Eventful Year in Workers’ Compensation,
Tee L. Guidotti 153
Shaping the Context of Health: A Review of Environmental and Policy
Approaches in the Prevention of Chronic Diseases, Ross C. Brownson,
Debra Haire-Joshu, and Douglas A. Luke 341
PUBLIC HEALTH PRACTICE
Health Disparities and Health Equity: Concepts and Measurement,
Paula Braveman 167
The Politics of Public Health Policy, Thomas R. Oliver 195
Vaccine Shortages: History, Impact, and Prospects for the Future,
Alan R. Hinman, Walter A. Orenstein, Jeanne M. Santoli,
Lance E. Rodewald, and Stephen L. Cochi 235
What Works, and What Remains to Be Done, in HIV Prevention in the
United States, David R. Holtgrave and James W. Curran 261
vii
P1: JRX
February 11, 2006 21:44 Annual Reviews AR269-FM
viii CONTENTS
SOCIAL ENVIRONMENT AND BEHAVIOR

A Public Health Success: Understanding Policy Changes Related to Teen
Sexual Activity and Pregnancy, Claire D. Brindis 277
An Ecological Approach to Creating Active Living Communities,
James F. Sallis, Robert B. Cervero, William Ascher, Karla A. Henderson,
M. Katherine Kraft, and Jacqueline Kerr 297
Process Evaluation for Community Participation, Frances Dunn Butterfoss 323
Shaping the Context of Health: A Review of Environmental and Policy
Approaches in the Prevention of Chronic Diseases, Ross C. Brownson,
Debra Haire-Joshu, and Douglas A. Luke 341

Stress, Fatigue, Health, and Risk of Road Traffic Accidents Among
Professional Drivers: The Contribution of Physical Inactivity,

Adrian H. Taylor and Lisa Dorn 371
The Role of Media Violence in Violent Behavior, L. Rowell Huesmann and
Laramie D. Taylor 393
HEALTH SERVICES
Aid to People with Disabilities: Medicaid’s Growing Role,
Alicia L. Carbaugh, Risa Elias, and Diane Rowland 417
For-Profit Conversion of Blue Cross Plans: Public Benefit or Public Harm?
Mark A. Hall and Christopher J. Conover 443
Hypertension: Trends in Prevalence, Incidence, and Control, Ihab Hajjar,
Jane Morley Kotchen, and Theodore A. Kotchen 465
Preventive Care for Children in the United States: Quality and Barriers,
Paul J. Chung, Tim C. Lee, Janina L. Morrison, and Mark A. Schuster 491
Public Reporting of Provider Performance: Can Its Impact Be Made
Greater? David L. Robinowitz and R. Adams Dudley 517
Health Disparities and Health Equity: Concepts and Measurement,
Paula Braveman 167
INDEXES
Subject Index 537
Cumulative Index of Contributing Authors, Volumes 18–27 565
Cumulative Index of Chapter Titles, Volumes 18–27 570
ERRATA
An online log of corrections to Annual Review of Public Health
chapters may be found at http://publhealth.annualreviews.org/

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Annu. Rev. Public Health 2006. 27:195–233

THE POLITICS OF PUBLIC HEALTH POLICY

Key Words agenda setting, incrementalism, health reform, policy entrepreneur,

WHY HEALTH IS A POLITICAL ISSUE

Public health commonly involves governmental action to produce outcomes—

or unable to produce by themselves. Gostin argues, “A political community stresses

POLITICS OF PUBLIC HEALTH POLICY 197

Fourth, a healthy population and workforce is vital to economic growth and

THE TRANSLATION OF HEALTH ISSUES INTO

The primary influence of health services research on public policy may be

system when spending for a specific category of services—hospital, physician,

Children’s Health Insurance Program (SCHIP) led officials to compare progress

POLITICS OF PUBLIC HEALTH POLICY 199

The responsiveness of government to a problem depends not only on the perceived

images of access to health care as a societal right, a community responsibility, a

to expediting drug approval were inadvertently causing more postmarketing drug

Social Construction of Target Populations

POLITICS OF PUBLIC HEALTH POLICY 201

Figure 1 Social construction of target populations [from Reference (165)].

As the risks of contracting HIV/AIDS spread to broader segments of the

POLITICS OF PUBLIC HEALTH POLICY 203

SOURCES OF INCREMENTALISM IN HEALTH

uncertainty and potential instability inherent in larger-scale innovation. Another

POLITICS OF PUBLIC HEALTH POLICY 205

Members of each branch of government represent and are accountable to dif-

initiatives are compounded by frequent periods of divided government, during

Accompanying the constitutional checks and balances at each level of govern-

POLITICS OF PUBLIC HEALTH POLICY 207

Massachusetts, Oregon, Washington, and California all followed the example of

POLITICS OF PUBLIC HEALTH POLICY 209

POLITICS OF PUBLIC HEALTH POLICY 211

tracing, quarantine, or mandatory blood testing because of the perceived imbalance

(112). Entrepreneurial politics in pursuit of budget containment produced a series

POLITICS OF PUBLIC HEALTH POLICY 213

Human Services Otis Bowen, proposed a modest expansion of Medicare to protect

Nonetheless, Reagan agreed to support the legislation as long as it added nothing

SOURCES OF HEALTH POLICY INNOVATION

Critical Junctures in Policy Development

POLITICS OF PUBLIC HEALTH POLICY 215

Political Opportunities and Leadership

Second, there is a convergence of three relatively independent “streams” in the

POLITICS OF PUBLIC HEALTH POLICY 217

expansion of governmental authority and bureaucracy. Most important, however,

Policy Entrepreneurs and Investors

POLITICS OF PUBLIC HEALTH POLICY 219

suaded members of the Congressional Women’s Caucus and women in leading

Linkage of Multiple Venues in Health Reform

POLITICS OF POLICY IMPLEMENTATION

Ambiguity in Policy Design

POLITICS OF PUBLIC HEALTH POLICY 221

even contradictory provisions because the legislation is intended to serve multiple

Dependence on Private Actors and Other Public Agencies

emerging reports of Guillain-Barré syndrome in a few adults who received the

in laboratory facilities, epidemiological tracking and reporting, and capacity to

POLITICS OF PUBLIC HEALTH POLICY 223

Hostile Political Environment

W. Bush, trying to establish its pro-business credentials, advocated a repeal of