So, I said I was going to blog, for my audience of one, and instead I find that we have been talking. Apparently, I go on and on about the politics of health policy and the policy at the core of the Washington’s current peculiar politics. It occurs to me that if I write some of this down, I won’t have to go into thinkgs in such excruciating detail. So hear goes:
This whole thing has been so much more than I imagined, I have found it hard to write about. I really am learning how to look differently at the problem of translating the knowledge that we acquire through science into the language and thought processes of policy, while acknowledging and using the tools of politics. I’ve learned some of this through my community work; but this is doing it on a much larger scale than I would have thought possible. A few “bon mots”:
1 Our government is designed to make action difficult in most cases unless most people agree that something is necessary. We do this in many ways: through a bicameral legislature with different constituencies and different operations; through a series of restrictions on what government cannot ever do; through a strong tradition of states that often guard their rights and through a public that has as its default position the notion that government is the last resort of a free economy. WHEN THINGS HAPPEN, IT IS THROUGH THE ALIGNMENT OF THE IRON TRIANGLE
Executive
Stateholders
Legislative
The executive is kind of obvious- but not. Used to be that there was the President, and the Cabinet. Now there there is an “executive office of the president” that houses things like the National Security Council and the Office of Domestic Policy, and those folks are the President’s connection to the various Cabinet posts. So, you have to think- who is actually in charge. Also shows how important health reform was to Obama- he but both the Cabinet Post and the EOP post in the hands of Tom Daschle, only to have his plan thwarted by a limo ride. Well, a few limo rides. Crazy. Anyway, the Federal Health Bureaucracy is vast and confusing and spread out across a number of places. It is functional and dysfunctional at the same time, and has good people stuck in the middle of many a bad system.
The legislative is the House and Senate, they of vastly different cultures. The House is America, warts and all, a Walt Whitman of a legislative body. The Senate is more classical, like Longfellow or Robert Frost. It does not sing the body electric- it sings of our rural roots. Health is divvied up into a morass of non-corresponding committees- for the House, Ways and Means for Medicare A/B, Energy and Commerce for Medicaid and Medicare C/D and other miscellany, Education and Labor for a small bit left over. For the Senate, Finance for Medicare and Medicaid, HELP for everything else. Makes it complitcated to follow a bill.
Then there are the stakeholders, able to drive a stake through anything that they don’t like. We’ve met lobbyists, advocates, pundits, think tankers – all the people talking policy from all around D.C. These folks can give you facts, stories, spin,. Legislative language- you name it, they will supply it for you. This is also the major place in which data and analysis enters into the process; but it is filtered and sorted in ways that don’t always make sense.
Our government is based on the alignment of interests. If you have an iron triangle, then, in order to get anything done, you need to get the Executive, the Legislative and the Stakeholders all on the same page. This, it turns out, is not easy to do. But we keep trying.
I’ll think about more things later. But we are being placed now.
