Not only are most public policies in all domains, including health, modifications of previously established policies but also most of the modifications reflect only modest changes (Hinckley 1983). The combination of a process that is characterized by continual modification of previous decisions with the fact that these changes tend to be modest has led to the apt characterization of the public policymaking process in the United States as a process of incrementalism (Lindblom 1969, 1992).
The affinity for modest, incremental change in public policy is not in any way restricted to health policy. The operation of the nation's overall political, social, and economic systems reflect preferences for modest rather than fundamental change. As was noted in the discussion of the subject in Chapter 3, members of the power elite in the United States have a strong preference for incremental changes in public policies. They see incremental-ism in policymaking—building on existing policies by modification in small, incremental steps—as allowing time for the economic and social systems to adjust without these systems being unduly threatened by change. Incremental policymaking permits a minimum of economic dislocation or disruption and causes minimal alteration in the social system's status quo.
In policymaking that is characterized by incrementalism, significant departures from the existing patterns of policies occur only rarely; instead, most of the time, the impacts and consequences of policies play out relatively slowly and with some degree of predictability. This accounts for the fact that the major participants in the policymaking process—policymakers in all three branches of government, leaders in health-related organizations and interest groups, and many individuals who benefit from such policies as the Medicare and Medicaid programs—typically have a strong preference for incremental-ism in health policymaking.
The preference rests simply and firmly on the fact that the results and consequences of incrementally made decisions are more predictable and stable than is the case with decisions not made incrementally. Unless a person— whether a policymaker or one affected by policies—is very unhappy with a situation and wishes an immediate and drastic change, the preference for incrementalism will almost always prevail.
Incrementalism in policymaking also provides a mechanism for increasing the likelihood ofreaching compromises among the diverse interests within the political marketplace where policymaking occurs. The potential for compromise is an important feature of a smoothly working policymaking process. Words like "incrementalism" and "compromise" used in the context of public policymaking may bring to mind compromised principles, inappropriate influence peddling, and corrupt deals made behind closed doors. However, "In a democracy compromise is not merely unavoidable; it is a source of creative invention, sometimes generating solutions that unexpectedly combine seemingly opposed ideas" (Starr and Zelman 1993, 8).
The health policy domain is replete with examples ofpatterns ofincre-mentally developed policies. For instance, the history of the evolution of the National Institutes of Health (NIH) (www.nih.gov) vividly reflects incremental policymaking over a span of more than 100 years. Ranging from 1887, when the federal government's expenditures on biomedical research totalled about $300, and extending into the 1930s, when a small federal laboratory conducting biomedical research was initiated, NIH has experienced extensive elaboration (the addition of new institutes as biomedical science evolved); growth (its annual budget is more than $28.5 billion in 2006); and shifts in the emphases of its research agenda (cancer, AIDS, women's health, health disparities, schizophrenia, and pediatric diseases). Every step in NIH's continuing and incremental evolution has been guided by specific changes in policies, each an incremental modification intended to have NIH make carefully measured adjustments in its actions, decisions, and behaviors.
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