The formulation of federal health care policy

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Federal health-care policy is formulated by multistage coalition building: among the bureaucracy, Office of Management and Budget, and policy advisors in the executive; among the parties, committees, and regions in Congress; among providers, state and local officials, and HEW; and among many local interests at the point of implementation. This approach produces strange results, but it speaks to the first limitation of 'rational actor' approaches to policy: uncertainty and disagreement which characterize them. Different institutions in the 'dance of legislation' represent different interests, values, and opinions; lacking a better way to make policy, it is not strange that our system follows its structural instincts and leaves great latitude for their expression and interaction. This approach to policy formulation also speaks to the second major limitation of a rational actor approach: inability to prescribe optimal trade-offs among quality, access, and economy. The general disposition of the government is to expand benefits, sometimes dramatically, sometimes incrementally, and to accompany them by smaller increments of planning, regulation, and control. The latter may not really work; from a central planning standpoint the entire approach is widely perverse. But the approach may conform to the general drift of popular expectations.

Original languageEnglish
Pages (from-to)45-58
Number of pages14
JournalJournal of Urban Health
Issue number1
StatePublished - 1978
Externally publishedYes


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