Because policies are made in the executive, legislative, and judicial branches of government, the list of potential suppliers of health policies—the policymakers —is lengthy. Members of each branch of government play a role as supplier of policies in the political market, although each branch plays its role in different ways.
Legislators as One group of public policy suppliers is elected legislators, whether members Suppliers of the U.S. Congress, state legislatures, or city councils. Few aspects of the political marketplace are as interesting, or as widely observed and studied, as the question of motives for the policymaking decisions and actions of elected legislators. To a large extent, this intense interest in the motivations of policy suppliers reflects the desire by policy demanders for some effective means to pursue their desired policies by exerting influence over the suppliers.
Although neither extreme fully reflects the motivations of legislators, the end points on a continuum of behaviors that policymakers might exhibit can be represented by those who seek to maximize the public interest on one end and by those who seek to maximize self-interest on the other end. A legislator at the public interest extreme would always seek policies that maximize the public interest, although the true public interest might not always be easy to identify. A legislator whose motivations lie at the self-interest extreme would always behave in a manner that maximizes self-interest, whether that interest is reelection, money, prestige, power, or whatever appeals to the self-serving person.
In the political marketplace, legislators can be found all along the continuum between extreme public-interest and extreme self-interest motivations. Although some people incorrectly ascribe dominant self-interest motives to all legislators, the actions and decisions of most legislators, most of the time, are more likely to reflect a complex mixture of the two motivations, with exclusively self-interested or public-interested motives only rarely dominating decisions.
Motives aside, legislators at all levels of government are key suppliers of policies, especially of policies in the form of laws. In political markets, legislators constantly calculate the benefits and costs oftheir policymaking decisions and consider who will reap these benefits and bear these costs. Factoring in the interests they choose to serve, they make their decisions accordingly. Their calculations are complicated by the fact that the costs and benefits of a particular decision often affect many different people in different ways.
In effect, policies typically create winners and losers. The gains enjoyed by some people come at the financial expense of others, or at least at the expense of having someone's problems ignored or someone's preferred solutions postponed. Without overgeneralization, it is fair to say that most of the time most legislators seek to maximize their own net political gains through their policy-related decisions because reelection is an abiding objective.
In view of the reality of winners and losers being created by most policies, legislators may find that their best strategy is to permit the winners their victory, but not by a huge margin, and in so doing cushion the impact on the losers. For example, suppose a legislator is considering a policy that would increase health services for an underserved population but at the expense of higher taxes on others. Options include various policies with the following outcomes: (1) few services at relatively low cost, (2) more services at higher cost, and (3) many services at very high cost. Facing such a decision, and applying the concept of net political gain, policymakers might opt for the provision of a meaningful level of services, but one far below what could have been provided and at a cost below what would have been required for a higher level of services. The "winners" receive more services, but the expense for the "losers," who have to pay for the new services, is not as great as it might have been. Through such "political calculus," legislators routinely seek to maximize their net political gains.
At all levels of government, members of the executive branch play an impor- Executives and tant role as suppliers ofpolicies, although their role differs from that oflegisla- Bureaucrats tors. Presidents, governors, mayors, and other senior public-sector executives as Suppliers offer policies in the form of legislative proposals and seek to have legislators enact their preferred policies. Chief executives, as well as those in charge of government departments and agencies, also make policies directly in the form of rules or regulations used to guide the implementation of laws and in the operational protocols and procedures they use to operationalize the policies they are responsible for implementing. Career bureaucrats who also participate in these activities and thus become suppliers of policies in the political marketplace join elected and appointed executives and managers in their rulemaking and operational duties.
Elected and politically appointed officials of the executive branch often are affected by the same self-interest/public-interest dichotomy that affects legislators; reelection concerns in particular often directly influence their decisions. Like legislators, elected and politically appointed members of executive branches are apt to calculate the net political gains available through their policy-related decisions and actions. As a result, their motivations and behaviors are often quite similar to those of legislators as they participate in the political marketplace. However, there are some important differences between the motivations and behaviors of elected and appointed members of the executive branch of a government and the elected members of its legislative branch.
The most fundamental difference derives from the fact that the executive branch generally bears greater responsibility than does the legislative branch for the state of the economy and is widely perceived to bear even more responsibility than it actually does. Presidents, governors, and mayors, along with their top appointees, are held accountable much more explicitly for economic conditions than Congress, state legislatures, or city councils. Although legislators do not escape this responsibility altogether, the public typically lays most of the responsibility for the economy at the feet of the executive branch. Even when people do blame the legislative branch, they tend, at least in part, to hold the entire Congress or the state or city legislature collectively responsible rather than to blame individual legislators.
The concentration of responsibility for the condition of the economy in the executive branch heavily influences the decision making that takes place there. Because of the close connection between government's budget and the state of the economy, the budget implications of policy decisions will be very carefully weighed in the executive branch. Not infrequently, positions on health policies will differ between the legislative and executive branches because members in the two branches attach different degrees of importance to the budget implications of the policies they are considering.
Career bureaucrats, or civil servants, in the executive branch, whose participation in rulemaking and operations makes them suppliers of policies, also participate in policymaking in the legislative branch. When they collect, analyze, and transmit information about policy options and initiate policy proposals in their areas of expertise, they are important participants in policymaking within the legislative branch. However, the motivations and behaviors of career bureaucrats tend to differ from both those of legislators and those of elected or appointed members of executive branches.
The behaviors and motivations of career bureaucrats in the public sector are often analogous to those of employees in the private sector. Workers in both settings typically seek to satisfy certain of their personal needs and desires through their work. This can obviously be categorized as serving their self-interests in both cases. But government employees are no more likely to be totally motivated by self-interests than are private sector workers. Most workers in both sectors are motivated by similar blends of self-interest and interest in what is good for the larger society.
However, it is also fair to point out that most career bureaucrats watch a constantly changing mix of elected and senior government officials—with an equally dynamic set of policy preferences—parade past them, while they remain as the most permanent human feature of government. It should surprise no one that career bureaucrats develop a strong sense of identification with their home department or agency or that they develop attitudes of pro-tectiveness toward it. This protectiveness is most visible in the relationships between government agencies or departments and those with legislative oversight over them, including authorization, appropriation, and performance review responsibilities. Many career bureaucrats equate the well-being of their agencies, in terms oftheir size, budgets, and prestige, with the public interest. This obviously is not always the case.
The judicial branch of government also is a supplier of policies. For example, The Judiciary whenever a court interprets an ambiguous law, establishes judicial procedure, as Supplier or interprets the U.S. Constitution, it makes policies. These activities are not conceptually different from those involved when legislators enact public laws or when members of the executive branch establish rules and regulations to guide implementation of laws or make operational decisions regarding their implementation. All of these activities represent policymaking because they lead to authoritative decisions made within government for the purpose of influencing or directing the actions, behaviors, and decisions of others.
Policymaking in the judicial branch, however, does differ in certain ways from that in the legislative and executive branches, not only in focus but in operation as well. The responsibilities of courts require them to focus narrowly on the issues involved in specific cases or situations. This stands in stark contrast to the wide-open, if not chaotic, political arena in which most other public policymaking occurs.
The courts are involved in numerous and diverse aspects of health policy, reflecting the entire range of determinants of health (i.e., physical environment, behavior and genetics, social factors, and health services). For example, in a 1980 opinion in what is called the benzene case, the U.S. Supreme Court invalidated an Occupational Safety and Health Administration (OSHA) (www.osha.gov) rule limiting benzene to no more than one part per million parts in the air in workplaces. In the court's view, OSHA had not found a significant risk to the health of workers before issuing the rule. In the past decade, the courts have been especially active in health policy regarding the organization and delivery of health services in the following four specific areas (Anderson 1992; Potter and Longest 1994):
1. the coverage decisions made by insurers in both the private and public sectors;
2. the Medicaid program's payment rates to hospitals and nursing homes;
3. the antitrust issues involved in hospital mergers; and
4. issues related to the charitable mission and tax-exempt status of not-for-profit hospitals.
The heart of the judiciary's ability to supply policies lies in its role in interpreting the law. This power includes the power to declare federal and state laws unconstitutional—that is, to declare laws enacted by the legislative branch to be null and void. This role ofthe courts is clearly illustrated in The Real World of Health Policy: Arizona Abortion Regulation Invades Privacy, Appeals Court Says. The judiciary also interprets the meaning of laws, an important role because many public laws contain vague language. A particularly important element in its role as suppliers of policies rests on the fact that the courts can exercise the powers ofnullification, interpretation, and application to the rules and regulations established by the executive branch in carrying out its implementation responsibilities.
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