Modification of policies in the formulation phase—the reformulation of existing policies—occurs in both agenda setting and legislation development. Recall from the discussion in Chapters 5 and 6 that policy formulation—making the decisions that result in public laws—entails these two distinct and sequentially related sets of activities in which policymakers, and those who would influence their decisions and actions, engage. The result of the formulation phase of policymaking for initial versions of policies is new public laws; for subsequent revisions, the result is amendments to existing laws.
Both initial public laws and the subsequent amendments to them that pertain to health stem from the interactions of (1) diverse arrays of health-related problems, (2) possible solutions to the problems, and (3) dynamic political circumstances that relate to both the problems and their potential solutions. The amendment of previously enacted public laws occurs through the process of legislation development, just as does the creation of an entirely new legislative proposal. The only significant difference is that the possibility of amendment implies the existence of a particular prior public law that can now be changed through amendments. This previously enacted legislation already has a developmental history and an implementation experience, both of which can influence its amendment.
Modification Remember that agenda setting involves the confluence of problems, possi-at Agenda ble solutions, and political circumstances. Policy modification routinely beSetting gins in this stage of activity as problems already receiving attention become more sharply defined and better understood within the context of the ongoing implementation of existing policies. Possible solutions to problems can be assessed and clarified within the same context, especially when operational experience and the results ofdemonstrations and evaluations provide concrete evidence ofthe performance ofparticular potential solutions under consideration. In addition, the interactions among the branches of government and the health-related organizations and interest groups involved with and affected by ongoing policies become important components ofthe political circumstances surrounding their reformulation, as well as of the initial formulation of future new policies. People learn from their experiences with policies, and those in a position to do so may act on what they learn.
Leaders in health-related organizations and interest groups, by virtue of their keen interest in certain health policies—interest driven by the fact that they, and their organizations and groups, directly experience the consequences of these policies—may be well positioned to serve as sentinels regarding whether particular policies are having the effects envisioned by those who formulated and implemented them. Because of their position, they may be among the first to observe the need to modify a policy, and they can use their experience to help policymakers better define or document problems that led to the original policy. These leaders can gather, catalog, and correlate facts that more accurately depict the actual state of a problem and can then share this information with policymakers.
Similarly, these leaders are well positioned to observe the impact and actual consequences of a hoped-for solution to a problem—a solution in the form of a policy. Leaders can devise and assess possible new solutions or alterations in existing ones through the operational experience of the organizations and groups they lead. Finally, their experiences with ongoing policies may become a basis for their attempts to change the political circumstances involved in a particular situation. When the confluence of problems, possible solutions, and political circumstances that led to an original policy is altered, a new window of opportunity may open, this time permitting the amendment of previously enacted legislation.
Health policies in the form ofpublic laws are routinely amended, some ofthem Modification repeatedly and over a span of many years. Such amendments reflect, among at Legislation other occurrences, the emergence of new medical technologies, changing fed- Development eral budgetary conditions, and evolving beneficiary demands. These and other stimuli for change often gain the attention ofpolicymakers through routine activities and reporting mechanisms that occur in the implementation ofpolicies. Pressure to modify policy through changes in existing public laws may also emanate from the leaders of health-related organizations and interest groups— including those that represent individual memberships—who feel the policy consequences. When modifications do occur at the legislation development point in the process, they follow the same set of procedures as the original legislative proposals or bills (steps that were discussed fully in Chapter 6).
In some instances, the impetus to modify an existing law arises from changes in another law. For example, policies intended to reduce the federal budget deficit have typically impinged on other policies, often causing their modification. Implementation of the Deficit Reduction Act of 1984 (P.L. 98369) required a temporary freeze on physicians' fees paid under the Medicare program, and implementation of the Emergency Deficit Reduction and Balanced Budget Act of 1985 (P.L. 99-177), also known as the Gramm-Rudman-Hollins Act, required budget cuts in defense and in certain domestic programs, including a number of health programs.
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