Competing Ideals and the Public Agenda in Medicare Reform
| Published date | 01 March 2005 |
| Date | 01 March 2005 |
| DOI | 10.1177/0095399704272593 |
| Author | Kalu N. Kalu |
| Subject Matter | Articles |
Kalu / The “Garbage Can” Model
10.1177/0095399704272593
COMPETING IDEALS AND THE
PUBLIC AGENDA IN MEDICARE REFORM
The “Garbage Can” Model Revisited
KALU N. KALU
Emporia State University
This article analyzes the political and strategic reasons for the policy stalemate in Medicare
reform in the United States. By using the specific case of the National Bipartisan Commission
on the Future of Medicare, which was formed in 1997, this article attempts to explain the
stalemate in the policy process by framing the activities of the various participants within the
context of the “garbage can” model of decision making. It is equally argued that the utility of
the model lies more in its ability to explain the dynamics of the policy process, and that the ex-
istence or nonexistence of a policy window provides the least logical explanationof how vari-
ous policy episodes unfold. The cumulative effects of congressional behavior and whether
members are engaged in the active-passive paradigm of policy making can provide more
powerful indicators for policy events and outcome.
Keywords: Medicare reform; garbage can model; active-passive policy making;
Kingdon’s streams metaphor; National Bipartisan Commission on the Future
of Medicare; Breaux-Thomas proposal; Medicare Act of 2003
The issue of Medicare reform has been an ongoing phenomenon in the
contemporary history of legislative politics in the United States. However,
the very idea of policy reform has its own utility apart from whatever
objective value may be sought in any policy-making process. Hence, the
motivation for engaging in the policy process is equally as useful as the
prime objective being sought, and members of Congress as well as most
AUTHOR’S NOTE: An original version of this article was presented at the 63rd National
Conference of the American Society for Public Administration (ASPA), Phoenix, Arizona,
March 23-26, 2002. I am very grateful to Theodore Marmor and Elizabeth Bradley (both of
Yale University), and Charles Cochran of Texas Tech University for their very insightful com-
ments, suggestions, and critiques that have tremendously enriched this project.
ADMINISTRATION & SOCIETY, Vol. 37 No. 1, March 2005 23-56
DOI: 10.1177/0095399704272593
© 2005 Sage Publications
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ADMINISTRATION & SOCIETY / March 2005
major participants in the policy process understand this language. With
regard to the average congressperson, policy making is driven by such
political considerations as position taking, credit claiming, issue advo-
cacy, constituency service, coalition building, or simple political expedi-
ency. Members of Congress may engage in the policy process simply for
the value of being seen to be doing something as opposed to any credible
argument that something useful can come out of the process. It is essen-
tially a matter of practical politics.
A BRIEF LOOK AT MEDICARE’S JOURNEY
The historical origins of Medicare as a compulsory health insurance
program for the elderly was as contentious as latter efforts at its reform.
The “conflict was settled only by the decisive results of the 1964 elections,
which generated broad liberal Democratic majorities in both the House of
Representatives and the Senate” (Oberlander, 2003a, p. 4). On July 30,
1965, President Lyndon Johnson signed the Medicare bill into Public Law
89-97 (at the ceremony in Independence, Missouri), thus ending one
chapter in the tensed history of Medicare’s journey following years of leg-
islative stalemate. Marmor (2000) explained this as a period of the “Poli-
tics of Legislative Certainty” (p. 45), made possible by the Democratic
victory in the 1964 congressional elections, and of course, the victory of
Lyndon Johnson over the conservative Republican Barry Goldwater. This
gave Democrats control of the all-powerful House Ways and Means Com-
mittee and also programmatic majorities in both chambers. Whereas ad-
vocates in 1965 assumed that
hospitalization coverage was but the first step in Medicare’s benefits and
that more would follow under the same pattern of payroll financing as
Social Security; they also took for granted that eligibility would be gradu-
ally expanded to take in most, if not all, of the population, extending first to
children and pregnant women. Proponents wanted Medicare to emphasize
expansion of access, not the regulation and reform of American medical
care practices. (Marmor, 2000, pp. 95-96)
The initial ambiguity in what Medicare should stand for created a situa-
tion that, on one hand, helped to assuage much of the opposition to the leg-
islation, but on the other, opened up the Medicare bill for attacks as a pre-
cursor to socialized medicine. “The enactment of Medicare was premised
on the popular appeal of the aged, hence, having failed to enact national
Kalu / The “Garbage Can” Model
25
health insurance for all citizens, reformers turned to health insurance for
the elderly” (Marmor, 2000, p. 96).
Beyond the standard Medicare provision (coverage of the aged, lim-
ited hospitalization, nursing home insurance benefits, and social security
financing), it was an incremental approach aimed at containing the oppo-
sition as well as leaving some room for “increments of change set for the
future” (Marmor, 2000, p. 46). To avoid the social stigma generally asso-
ciated with public assistance, proponents made efforts to emphasize it as
an “earned social insurance benefit, rather than charitable dispensations”
(Marmor, 2000, p. 96). Although Medicare now had a constituency in the
elderly population, it was still unable to escape from the growing prob-
lems of American medicine that include health care inflation (Marmor,
2000, p. 96), the predominance of fiscal concerns, growth in supplemental
insurance (Medigap policies), and the inability of the program to match
increasing demands for benefits (Oberlander, 1995, p. 82). Whereas
policy makers in Congress were concerned that funding for the program
might become an uncontrollable burden on the national budget, elderly
beneficiaries wanted to make sure that the benefits they already had would
not be cut.
At one time or the other and for much of its evolutionary process,
Medicare has been mired in either form of crisis politics, regulatory poli-
tics, or budgetary politics. Although it was created in the program-
matic image of Social Security, a defining feature of Medicare politics
has been the fact that it did not “imitate the expansionary and stable poli-
tics of Social security pensions during the three decades from 1935-1965”
(Oberlander, 1995, p. 6). Because passage of the Medicare bill was
achieved through what Paul Starr (1982) referred to as the politics of
accommodation, glaring loopholes in the program’s implementation
made it difficult for benefactors (such as hospitals) to easily acquiesce to a
radical reform of the program. Although the
decision to provide capital reimbursement to hospitals under Medicare in-
volved millions of dollars annually in federal expenditures, the program
enormously strengthened the financial position of the hospital industry,
enabling hospitals to accumulate and borrow capital on their own more
easily. Ironically, this greater financial independence undermined simul-
taneous efforts to improve voluntary planning and coordination of medical
facilities (Starr, 1982, p. 376)
as well as the regulatory power of the government to bring Medicare ex-
penditures within fiscal and budgetary constraints.
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ADMINISTRATION & SOCIETY / March 2005
By making health care (in this case, Medicare) lucrative for providers,
public financing made it exceedingly attractive to investors and set in
motion the formation of large-scale corporate enterprises, which, invari-
ably, led to changes in the organization and behavior of nonprofit hospi-
tals and a general movement throughout the health care industry toward
higher levels of integrated control—that is, horizontal and vertical inte-
gration, diversification, industry concentration, change in type of owner-
ship and control (Starr, 1982, pp. 428-429). The structural changes gave
the hospital industry more capacity and leverage to shape the dynamics of
the market system as well as crucial health care policy initiatives in the
legislature. Hence, there is some merit in casting consequent efforts at
Medicare reform within the legislative drama that informed its origins.
THE IMPETUS FOR MEDICARE REFORM
As Oberlander (2003a, p. 5) argued, the liberal consensus (1966 to
1994) that sustained Medicare policy on an essentially bipartisan frame-
work was shattered in 1995 following a radically altered political environ-
ment and a changing health system that eventually redefined the dynamics
of a new politics of Medicare.
The perceived successes of private sector innovations in the organization,
delivery, and financing of medical services, as well as concerns over Medi-
care’s financial viability, led a broad spectrum of health-policy makers and
analysts to conclude that there is an imperative to restructure Medicare
through the adoption of market-driven reforms. (Oberlander, 1997, p. 596)
The Republicans won majorities in both chambers of Congress (following
the 1994 congressional elections) and a new conservative domestic policy
spearheaded by the new House Speaker Gingrich (R-GA) emerged, with
the market as a model for Medicare reform. “Bipartisanship gave way to
sharp partisan differences, quiescence was replaced by...
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