Why is Policy Static?
Understanding Policy Non-Change Through the Lense
of Kingdon’s Multiple Streams Model
Programme: Public Administration – Public Management Course: Master Thesis
Supervisor: Dr. Sarah Giest
Student: James V. Johnson, Jr. Student ID: s2309459
Email: johnsojv@lemoyne.edu Word Count: 13,790
Table of Contents
Table of Figures ... 1 Chapter 1: Introduction ... 1 1.1: Problem Statement ... 1 1.2: Research Question ... 2 1.4: Thesis Overview ... 2 1.4.1: Literature Review ... 2 1.4.2: Expectations ... 2 1.4.3: Research Methodology ... 3 1.4.4: Case Description ... 3 1.4.5: Research Analysis ... 3 1.4.6: Conclusion ... 3Chapter 2: Literature Review ... 4
2.1: Performance Measurement ... 4
2.2: Public Policy Reform - The Multiple Streams Model ... 6
2.2.1: The Multiple Streams Model ... 7
2.2.2: Limitations of the Multiple Streams Model ... 10
2.2.3: The Multiple Streams Model in Practice ... 11
2.3: Literature in Context with the Study ... 12
2.3.1: Research Sub-Questions ... 12 Chapter 3: Expectations ... 14 3.1: Expectation 1 ... 14 3.2: Expectation 2 ... 14 3.3: Expectation 3 ... 14 3.4: Expectation 4 ... 14
Chapter 4: Research Methodology ... 15
4.1: Research Design ... 15
4.2: Method of Data Collection ... 17
4.3: Method of Analysis ... 17
4.3.1: Case Selection ... 17
Chapter 5: Case Description ... 19
5.1: Case Background ... 19
5.2: The Cases ... 21
Chapter 6: Research Analysis ... 23
6.1: An Identified Problem ... 23
6.1.1: New York State’s Identified Problem ... 23
6.1.2: The United States Federal Government’s Identified Problem ... 25
6.2: The Proposed Solution ... 26
6.2.1: New York State’s Proposed Solution ... 26
6.2.2: The United States Federal Government’s Proposed Solution ... 27
6.3: The Political Motivation ... 28
6.3.1: New York State’s Political Motivation ... 28
6.3.2: The United States Federal Government’s Political Motivation ... 29
6.4: Policy Entrepreneurs ... 30
6.4.1: New York State’s Policy Entrepreneurs ... 30
6.4.2: The United States Federal Government’s Policy Entrepreneurs ... 31
6.5: Case Comparison ... 32
Chapter 7: Conclusion ... 35
7.1: Main Research Question Reflection ... 35
7.1.1: Sub-Questions Reflection ... 35
7.2: Validity of the Research ... 36
7.3: Suggestions for Future Research ... 37
7.4: Expectations Reflection ... 37 7.4.1: Expectation 1 ... 37 7.4.2: Expectation 2 ... 38 7.4.3: Expectation 3 ... 38 7.4.4: Expectation 4 ... 38 7.5: Recommendations ... 38
7.5.1: Recommendation 1 – Policy Entrepreneur ... 38
7.5.2: Recommendation 2 – Stakeholder Feedback ... 39
7.5.3: Recommendation 3 – Performance Pyramid ... 39
7.6: Closing Remarks ... 39
Table of Figures
Figure 1: Lynch and Cross’ Performance Pyramid ... 6
Figure 3: John Wells Kingdon’s Multiple Streams Model ... 11
Figure 4: NYS Multiple Streams Model - Completed Model ... 31
Figure 5: US Multiple Streams Model - Completed Model ... 32
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Chapter 1: Introduction
1.1: Problem Statement
In 2016, the New York Times brought the problematic healthcare performance measurement system in the United States (US) to light, highlighting the influential backers who are now jumping ship; “Last fall, the Joint Commission, the major accreditor of American hospitals, announced that it was suspending its annual rating of hospitals… Last week, Andy Slavitt, Medicare’s acting administrator, announced the end of a program that tied Medicare payments to a long list of measures related to the use of electronic health records” (Wachter, 2016). Further, the article emphasizes the use of mortality rates to measure performance in the medical field, "The only way to understand whether a high mortality rate, or dropout rate, represents poor performance is to adequately appreciate all of the factors that contribute to these outcomes — physical and mental, social and environmental — and adjust for them” (Wachter, 2016). This is no new finding however, before the implementation of mortality rate measurements as performance indicators, authors and scholars touched upon its ineffectiveness as a performance measure. Park et al., in their 1990 study, found that observed hospital mortality rates have the likelihood of 56-82 percent of random measurement error (Park, et al., 1990). Similarly, Hofer and Hayward, in their 1996 study, found that using RAMR (Risk-Adjusted Mortality Rates) as a performance indicator fails to identify 88 percent of medical centers that deliver subaverage to poor quality care, while 60 percent of identified 'poor-quality providers' are also falsely marked (Hofer & Hayward, 1996).
Further adding to this puzzle, New York State (NYS) recently announced that they are revoking mortality rates as a form of measurement for hospital performance, as they aim to implement an entirely new system (Medicaid Redesign Team, 2015). With this, the problem statement arises; New York State is willing and able to reform their policy regarding mortality rate
indicators for performance, while the United States Federal Government is unable and/or willing to do so.
In exploring this problem statement, I also attempt to fill a gap in the literature regarding policy change. Current literature that seeks to explain policy change seems to be lacking in an understanding of how/why certain policy change varies between federal and state governments. A better understanding can be provided regarding the variation in the indicators and actors, between a state case and a federal case, required to drive successful policy reform.
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1.2: Research Question
How can Kingdon’s Multiple Streams Model help explain the US federal vs. state policy variation regarding the measurements for medical center performance?
The main research question seeks to use Kingdon's Multiple Streams Model as a framework for comparing the cases of New York State and the United States. I used the model's identified variables that drive policy change and attempt to identify them for each case. In doing this, my goal was to provide a better understanding as to why there is a lack of policy change in the case of the US. Using the visualized models for both cases, I could compare each variable side by side per case and thus identify the variables that should be focused upon in the US to drive the policy change in the future.
1.4: Thesis Overview
The following is a brief overview of each of the chapters to come in this thesis.
1.4.1: Literature Review
In the literature review chapter, I first explore the existing literature regarding performance measurement, looking specifically at the works of O'Toole and Meier, Robbins and Coulter, Andrews, Boyne and Walker, and Lynch and Cross. In establishing the current state of the literature, I am then capable of highlighting why the current measurement system needs reform, but also how it could be reformed effectively. From here, I move to the works of Thomas Dye, who Dawson and Robinson, contribute to the foundations of the public policy formation/reformation works of literature. With this, I finally land on Kingdon and explore his model, while looking at refuters, model innovators and the model in practice. In the final section of the literature review, I bring each chapter together and demonstrate how they connect to form a conceptual framework that explains policy change/non-change in the field of medical performance measurement. Within this final section, I also provide several sub-questions to compliment my main research question. These are placed here to establish the context of their importance to the study.
1.4.2: Expectations
In the expectations chapter, I provide four expectations based on the independent variables (problem, solution, political and policy entrepreneurship)1 provided in Kingdon’s model.
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Each expectation is directly linked to a unique independent variable, while all target the same dependent variable (policy change/non-change).
1.4.3: Research Methodology
In the research methodology chapter, I highlight the benefits of choosing to use a small-N, most similar comparative research design. I also go into extensive detail about the dependent variable of policy change and the independent variables of problem, solution, political, and policy entrepreneur. With this, the research methodology chapter explains the importance of the comparative research model selected and how it will accurately and effectively answer the research question.
1.4.4: Case Description
Here, I explain the relevance of choosing to explore the variation in medical care performance measures in the US vs NYS. I explain the emergence and relevance of the pay-for-performance and value-based purchasing initiatives in the US, as well as the policy connected to them. From this, an understanding as to the relevance of case choice is provided. I go into detail about both the US as well as NYS and provide relevance for each in the context of this study.
1.4.5: Research Analysis
In the research analysis chapter, I discuss my findings after using the techniques discussed in the research methodology section to help answer the main question. Comparing each case using the four independent variables (the problem stream, the solution stream, the political stream, and policy entrepreneurship), in attempts to identify any variables absent, yet required for policy change in each case.
1.4.6: Conclusion
In this final chapter, I reassess my research question, after conducting my research. I also reflect upon my previously provided expectations and sub-questions. Finally, in concluding the thesis, I provide recommendations as to how US policymakers can drive policy reformation in the future, based on my research findings.
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Chapter 2: Literature Review
In this section, I explore the existing literature relevant to the research question; How can
Kingdon’s Multiple Streams Model help explain the US federal vs. state policy variation regarding the measurements for medical center performance? By exploring the existing models and findings
regarding, performance measurement, public policy reform, and Kingdon's Multiple Streams Model, I will be better equipped to analysis each case's elements and provide a thorough understanding as to why the cases differ in their policy. After this exploration, the chapter is concluded with three sub-questions based on the main research question.
2.1: Performance Measurement
O’Toole and Meier describe public organization performance as, “the achievements of public programs and organizations in terms of the outputs and outcomes they produce” (O'Toole & Meier, 2011). In formulating this understanding of the term, they offer several dimensions of effective performance; efficiency, effectiveness, equity, and public satisfaction. Similarly to this, Robbins and Coulter also put a heavy emphasis on the importance of the organization’s efficiency and effectiveness at reaching their stated objectives as a crucial aspect to performance (Robbins & Coulter, 2002). Authors Andrews, Boyne and Walker further stress the importance of performance dimensions, listing outputs, efficiency, effectiveness, responsiveness and democratic outcomes as the indicators they find most relevant (Andrews, Boyne, & Walker, 2010). Most simply put however, performance is how well an organization accomplishes their stated objectives (Venkatraman & Ramanujam, 1986). Campos et al. also introduce their understanding of the importance of the usage of big data to assess performance, stating, “Increased data inputs from customers and employees through techniques of crowd-sourcing have improved the efficiency of the measurement systems [of performance]” (Campos, Sharma, Jantunen, Baglee, & Fumagalli, 2017).
Modern performance measures are based almost exclusively on the accounting framework introduced in the middle ages, which access organizational performance solely on a financial basis (Bruns, 1998). Researchers have emphasized the importance of effective performance measurements, finding that implementing effective performance measurement systems help ensure that organization actions are aligned with their goals, strategies and objectives (Lynch & Cross, 1991). With this understanding, Lynch and Cross introduce their “performance pyramid,” which is aimed to help organizations better measure their static performance using nine, day-to-day operational performance measures [Figure 1] (Lynch &
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Cross, 1991). With this, it is important to note the importance of ‘living’ performance measurement models, as they often require constant evolution with the changing environment the organization operates in. Kennerly and Neely find, “given the dynamic and rapidly changing environment in which most organizations compete, it is important that organizations effectively manage their measurement system so that it remains appropriate and provides information that is relevant to the issues that are of current importance” (Kennerley & Neely, 2003). They further introduce, based on their findings in their study that, “the existence of capabilities broadly grouped under the categories of process, people, systems, and culture, enables organizations to cope with the changing environment and modify their performance measurement system accordingly” (Kennerley & Neely, 2003). Ultimately introducing these four key concepts that must constantly be kept under check and understood by the organization, to effectively adapt performance measurement for the organization to the changing environment. Andrews, Boyne and Walker, in response to their five levels of performance, offer three levels at which an organization can measure its performance; objective, subjective and perspective (Andrews, Boyne, & Walker, 2010).
In clarifying these measures, objective performance measurement can be understood as a precise assessment of performance, with high reliability, but often proving difficult to capture. Subjective measures of performance, on the other hand, are evaluations of organization performance, typically from first-hand clients, offering the organization a perceptual view of their performance. Finally, perspective performance measurement, as described by Andrews, Boyne, and Walker, is how well the organization is performing according to, not only its clients, but also its staff, stakeholders, and often even the citizens in the community the organization operates. With this, they emphasize that using a combination of the three is the most effective and representative way to understand organization performance, providing different pieces of the "performance jigsaw" (Andrews, Boyne, & Walker, 2010).
With the effective establishment of the current state of the literature regarding performance measurements, there is a foundation provided to the conceptual framework as to 'why' certain performance policy needs changing, but next we must also explore 'how' policy changes.
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Figure 1: Lynch and Cross’ Performance Pyramid
2.2: Public Policy Reform - The Multiple Streams Model
Public Policy authors tend to put a heavy emphasis on the use of metaphoric models when attempting to explain the complexities of public policy creation and reform (Pump, 2011). Lasswell first introduced the concept of using a model of ‘stages’, in his seven-stage model of decision making, to help create a narrative of the decision process (Lasswell, 1956). Later, Dawson and Robinson, in their works for Northwestern University, present a model that displays the process of the effects of the external conditions, the current state of the political system, and the current state of the political process, on public policy outcomes and reforms (Dawson & Robinson, 1963). With this, they argue that public policy reform is heavily influenced by external factors in the environment (Heclo, 1974) (Kiser & Ostrom, 1982) (Kingdon, 1984) (Dawson & Robinson, 1963). In attempting to identify these ‘external factors,’ Heclo introduces the social element, the economic element, and the political instability element as three main external factors that push policy reform (Heclo, 1974). In response to these claims, Kiser and Ostrom push their idea that the variables of social, legal, and resources available are three main external factors that prohibit and/or drive policy change (Kiser & Ostrom, 1982). With this, John Wells Kingdon, in his work
Agendas, Alternatives, and Public Policies, introduces his ‘multiple streams model’ [Figure 3],
which highlights his interpretation of the three most important independent variables for driving policy reformation; the problem stream, the solution stream, and the political stream (Kingdon, 1984).
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2.2.1: The Multiple Streams Model
Deriving from Cohen et al.’s ‘garbage can model,’ which identifies several key variables in any given decision-making process, Kingdon’s model raises the questions; “how does an idea’s time come?”, and “how do policy issues become political problems?” (Cohen, March, & Olsen, 1972) (Kingdon, 1984). More specifically, the multiple streams model extends the garbage can model to the state level and attempts to explain not only how, but also why certain policy issues move onto government’s agendas, while others fail to (Sabatier, 1988). The model attempts to provide an understanding of the “dynamic, irrational, and unpredictable” act of policymaking (Nutley, Walter, & Davies, 2007). The model's reliability is rooted in data from 247 interviews with transportation and health policymakers in the US federal government and its evident importance in comparative policy research cannot go unnoticed, with more than three dozen citations in articles in the Journal of Comparative Policy Analysis (Beland & Howlett, 2016) (Cohen-Vogel & McLendon, 2009) (Kingdon, 1984). In its essence, the multiple streams model says policy change occurs when a specific policy entrepreneur applies an idea from a given policy stream to an issue in a problem stream at a certain point in time where it is crucial in the political stream (Birkland, 1998). With this, the most important factor regarding Kingdon’s model, is timing, due to the ever-changing agendas in politics (Zahariadis, 2007). Kingdon, in his model, offers four independent variables: the problem stream, the solution stream, the political stream, and policy entrepreneurship.
The Problem Stream
When referring to the problem stream, Kingdon is arguing that to achieve successful policy reform, there must be an agreed-upon problem in the eyes of the public and/or politicians. It is important here, to distinguish the difference between a 'condition' and a 'problem'. Kingdon clarifies that a condition is a societal situation that doesn't warrant action from the government, while a problem is a condition that policymakers believe they should address (Kingdon, 1984). Furthermore, Kingdon stresses the importance of the presence of an indicator that depicts some change in the current system. This indicator can be anything from unintended policy consequences, changing foreign political affairs, or even increased costs and/or decreased budgets for the government department (Kingdon, 1984). The more severe a problem is, the more evident the indicator becomes. With this, To gain the attention of policymakers, the indicator must be well defined and framed in such a way that it shows policymakers how crucial the underlying problem is and thus encourage them to act upon it (Liu, Yamaguchi, & Yoshikawa, 2017). Kingdon identifies this act of framing as a ‘force’, which drives a given indicator to policymaker attention.
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He further urges that these 'forces' are driven by focusing events, feedback, and criticisms (Kingdon, 1984) (Brewer, 2013).
Focusing events are some sort of catastrophe regarding current policy. For example, a major car accident due to high speed limits on the roads could 'force' a speed limit reduction debate onto the table for policymakers. Feedback and criticisms go hand in hand and quite obviously refer to any recommendations, comments or critiques regarding current policy from the public. With this, these three variables are most effective when attempting to identify a problem stream in a case (Kingdon, 1984). This doesn't go without debate however, as several authors argue that the problem identification stream is paradoxical, as the identified 'problem' is often reframed or even abandoned in the long term. Colebach argues that identifying such a clear-cut 'problem', is nothing short of an idealized picture of policymaking (Colebach, 2006).
The Solution Stream
The solution stream also referred to as the policy stream, is the formulation of a clear replacement policy that solves an underlying problem. This can be linked directly to the problem stream, where the solution streams goal is simply to provide a solution to the problems stream. Jones and Baumgartner present their attention theory of policy choice, which states that the connection between the identified problem and a found solution lies primarily with how information flows in the organization, as well as how specific problems are processed and presented in the political process (Jones & Baumgartner, 2005). Kingdon highlights that ideas flow in a 'primeval soup'; where some survive and are taken seriously, while others are not taken seriously and fade out of the minds of policymakers (Kingdon, 1984). What Kingdon means by this in the context of the solution stream, is that for a presented solution to turn into policy, its' presentation is crucial. Moreover, the policy must be presented in such a way that it solves a problem, otherwise, it will fade off the table and leave the minds of policymakers. This is also true for problems that are brought onto the political table. Kingdon emphasizes the importance of a presented solution, where if there is no solution presented, or even there is a solution that does not address a problem, it is very unlikely for there to be a political backing (Kingdon, 1984).
Multiple streams model refuters argue that, given the importance of both a problem and a solution's presence, where if one is absent, the other serves no purpose in furthering political reformation, Kingdon cannot truly claim each to be independent (Robinson & Eller, 2010). Despite this, Kingdon stands true to his model of independence.
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The Political Stream
Unlike that of the solution stream, the political stream focuses on the underlying concepts of power, influence, and pressure that politicians face when making decisions. Furthermore, the concept, according to Kingdon, emphasizes the motivations of politicians to act upon a given problem. Idit Shalev defines motivation most simply as, “the process that moves individuals to action” (Shalev, 2015). Furthering this definition in the policy sector, Post el al. describe political motivation as, “the extent of committed support among key decision-makers for a particular policy solution to a particular problem” (Post, Raile, & Raile, 2010). Kingdon further clarifies the political stream, as factors that influence the political body. With this, he operationalizes political motivation using national mood, government body turnover, and interest group advocacy campaigns as three of the most significant political motivating factors (Kingdon, 1984).
Essentially, the political stream seeks to understand the foreign and internal pressures that a politician is presented with, that ultimately shift his/her interest in each issue. Reyna and Farley demonstrate that the importance of this stream lies within the risk-reward nature of politics, where ideas that have high public support attract politician’s attention simply because it will give them public support if they act upon it (Reyna & Farley, 2006). One can look at the opposite scenario too, where if a policy is very controversial a politician is very unlikely to address it, because it is too risky for his/her public image. With this understanding, Kingdon's political stream attempts to measure the public opinion, risk, and potential benefit to policymakers who would potentially traverse into the subject.
Policy Entrepreneurship
In introducing the ideology and importance of policy entrepreneurship in the policy process, Kingdon emphasizing that policy entrepreneurs are responsible for identifying key problems in current policy, attract the attention of key decision-makers in the policy's area and finally, use their networks to present the ideas and gain support for policy change (Kingdon, 1984). Furthering this newfound ideology, Eyestone highlights the importance of these individuals and their invested energy and attention to combat the overwhelming forces prohibiting policy innovation (Eyestone, 1978). King and Roberts describe policy entrepreneurs as persons who, “serve as catalysts in the policy innovation process” and “are characterized by their willingness to invest resources -such as time, energy, reputation, and sometimes even money – in the hope of influencing public policy” (King & Roberts, 1987). Most simply put, however, Mintrom defines policy entrepreneurs as individuals who, "seek to initiate dynamic policy change” and argues that, “they do this through attempting to win support for ideas for policy innovation” (Mintrom, 1997).
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King and Roberts, with their research findings on policy entrepreneurs, pose three functions that these entrepreneurs perform; the generation of policy ideas (intellectual function), the devising of a strategy to transform their ideas into laws (strategic function), and the leading of political assaults on decision-makers to help build coalition around the devised problem (activist function) (King & Roberts, 1987). Mintrom touches upon these functions very similarly, and lists four key variables of which policy entrepreneurs must use to win support for policy change; identifying the problem and formulating a replacement, building a network in the problem area, shaping the terms of political debate, and building coalitions (Mintrom, 1997).
2.2.2: Limitations of the Multiple Streams Model
Since its publishing, there have been many comments and critiques regarding the effectiveness of the multiple streams model to truly highlight what causes/hinders policy change. Responding ever so quickly to its release Roger Cobb, former professor of political science at Brown University, argues that the, then newly developed, model is a glorified garbage can model, that lacks content, and relies solely on random decision-making variables that do not have any true correlation to one another (Roger, 1985). More recently, Stout and Stevens argue that using the multiple streams model in today's political spectrum fails to accurately account for the use of social media (Stout & Stevens, 2000). Elder and Cobb further this argument by highlighting the importance of social media in escalating issues on the policy agenda, thus increasing their political stream (Elder & Cobb, 1983). Another common critique regarding the model is that its usage is in the federal government of the United States, how can that be compared to a state government, or a different national government with different variables at play (Howlett & Ramesh, 1995). Sabatier argues that the model will prove ineffective in Eastern countries where culture, history, and political agendas differ greatly from the US (Sabatier, 1999).
Kingdon argues that each of these streams operates individually until all three cross together and a "Policy Window", an ideal situation for policy reform, opens. This idea of stream independence has been refuted by authors such as Robinson and Eller, who feel it is impossible to have true independence of these variables in any given political system (Robinson & Eller, 2010). Stout and Stevens bring compromise to this complaint and argue that each stream flows largely independently, unless a policy entrepreneur attaches problems to solutions (Guldbrandsson & Fossum, 2009) (Stout & Stevens, 2000). Furthermore, Stout and Stevens say that flexibility of interdependence between the streams is, in fact, necessary for the effectiveness of the model and should not be used to critique it (Stout & Stevens, 2000).
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2.2.3: The Multiple Streams Model in Practice
Since its establishment by Kingdon, the multiple streams model has been used, and innovated upon, by many authors (Sharp, 1994). Zahariadis and Allen contribute to the innovation of the model with their work from 1995, where which they test the validity of the model in countries outside of the United States, specifically, Germany and the United Kingdom (Zahariadis & Allen, 1995). With this, the work contradicts naysayers who previously argued that the model was incapable of replication in countries outside of the US. It also demonstrates the flexibility of the model and its importance in shrinking future political gaps in evolution between countries; “The comparative study of public policy represents one way to potentially narrow this gap” (Zahariadis & Allen, 1995). Like this, Powell and Exworthy innovate on Kingdon’s notion of streams and offer a model that incorporates policy stream, process stream, and resource stream to explain decision making (Powell & Exworthy, 2001). Jones extends the model as well, including a formulation section and an implementation section. His main argument in doing so is that policy formation involves catering to both policy and political streams, while policy implementation involves catering to the policy and problem streams (Jones, 1998). Most recently, Howlett et al. created an alternate version of Kingdon’s model, where which they present the model in stages rather than streams. In doing so, the model becomes linear and addresses the complaints that the variables cannot truly be independent (Howlett, Mcconnell, & Perl, 2014).
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2.3: Literature in Context with the Study
The literature on performance and policy come together for this study to create a framework that helps explain policy change/non-change. Effective measures of performance, such as Lynch and Cross' 'performance pyramid,' provide policymakers with the tools necessary to create working incentive policy. This concept of incentive policy, originated in private business management to help incentivize employees and discourage freeriding (Karakaya, Korpeoglu, & Uluso, 2008). With this, in public policy, incentives are implemented to increase the performance of government-funded operations. By linking the pieces of literature on effective performance measurements and public policy, we are presented with the opportunity to create an understanding of whether the correct measurements are being used in policy and how to implement effective measurements in public policy. Furthermore, in using the performance pyramid, policy researchers are better capable of understanding why incentive policy changes and/or does not change. Incentive policy is a relatively new concept in governments. Using Kingdon's multiple streams model, an understanding can be derived as to why/how such policy is changing and/or not changing.
2.3.1: Research Sub-Questions
After exploring the relevant works of literature for the case, several sub-questions can be identified:
1. What is ‘performance’ when referring to medical facilities
This question can be primarily answered through literary research. With this, however, it is important to note that a question like this can be interpreted in many ways, and it is unlikely to find a solidified definition of medical facility performance. What I can do, however, is use the provided understandings from the current literature regarding the subject and attempt to draw connections to our specific case from them. It is important to understand this current field of research because, to effectively interpret the actions of the government body with regards to performance measurement policy, we must first assure that a thorough understanding of performance is provided.
2. Why are the current measurement indicators for medical center performance in the US
and NYS in need of reform?
To answer this question, we can address both the current literary works, but also the public hospital data sets that are currently available. In doing this, the aim is to provide an understanding
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as to why the system in question needs reform. This is an important complement to our primary research question, in that Kingdon's model expresses the importance of a need for reform to effectively begin the policy reform process.
3. Who are the key political figures in the reformation processes
To answer this question, secondary data collection is required. It is important to have an answer to this question, however, because we can then access their actions and compare them to the 'required' actions of political reform leaders described by Kingdon and various other authors, to give us a better understanding of the underlying problems in the case.
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Chapter 3: Expectations
3.1: Expectation 1
The first independent variable, an identified problem stream, will be present in cases of policy change, whereas in cases of policy non-change, it will be absent.
3.2: Expectation 2
The second independent variable, an identified solution stream, will be present in cases of policy change, whereas in cases of policy non-change, it will be absent.
3.3: Expectation 3
The third independent variable, an identified political stream, will be present in cases of policy change, whereas in cases of policy non-change, it will be absent.
3.4: Expectation 4
The fourth independent variable, an identified policy entrepreneur, will be present in cases of policy change, whereas in cases of policy non-change, he/she will be absent.
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Chapter 4: Research Methodology
In this section, I aim to establish the research design and methods, of which we will use to help further the knowledge of the research question at hand. Using a small-N Comparative analysis, the research design aims to answer the question; How can Kingdon’s Multiple Streams
Model help explain the US federal vs. state policy variation regarding the measurements for medical center performance? The goal of the research is to look at the cases of NYS and US in
attempts to further our knowledge about policy change and/or non-change in the US government.
4.1: Research Design
The design for this research is a small-N, most similar comparative research design. With this design, it was important that I chose two cases, with different outcomes in the dependent variable. The goal of using this design is to highlight the small differences between the two cases that could be influencing a difference in the dependent variable. In choosing two cases with opposite outcomes for the dependent variable of policy reformation, the US Federal Government and the New York State Government, I attempted to explore the underlying mechanisms that could be linked to this variation. Furthermore, in implementing both cases into the multiple streams model, I can better understand the concepts that encourage policy reformation in New York State, while having a lack thereof in the Federal Government. With this, the dependent variable of interest is value-based purchasing policy reform or most simply put, policy change. Based on the multiple streams model, four independent variables are identified:
1. An identified problem with the current policy
The multiple streams model highlights the importance of the problem stream in the policy reformation process. Most simply put, the problem stream is an agreed-upon problem in the eyes of the public and/or politicians (Kingdon, 1984). This variable is important for driving policy change, because it frames a political situation in such a way, that encourages politicians to act upon it, thus driving policy change. To effectively operationalize this variable, I used Kingdon’s identification of the presence of stakeholder feedback opportunities, as well as clear public criticisms of current policy.
2. A proposed solution to replace to current policy
The multiple streams model highlights the importance of the solution stream for effective policy formation/reformation. The solution stream refers to the formulation of
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a clear replacement policy that solves an underlying problem. Kingdon claims that this variable is important, because if there is no solution presented, or even there is a solution that does not address a problem, it is very unlikely for there to be a political backing (Kingdon, 1984). To operationalize present solutions for each case, I investigated the NYS Department of Health's website, as well as the US' Department for Medicare and Medicaid website, researched press releases, and identified key documents in both cases (where available), all in search of formal solution statements by the departments. I also used Lynch and Cross' performance pyramid as a reference to measure the effectiveness of the proposed replacement measures in each case.
3. Political motivation to act on the issue
The multiple streams model highlights the importance of the political stream for effective policy formation. The political stream attempts to understand the foreign and internal pressures that a politician is presented with. This is an important variable, because it ultimately leads to the shifting of policy maker's interest in acting upon a policy issue. To effectively operationalize political motivations, I used Kingdon's operationalizing variables of national mood, government body turnover, and interest group advocacy campaigns in attempts to best identify political motivation in each case.
4. Policy Entrepreneurship
Kingdon emphasizes the importance of an actor, a policy entrepreneur, to drive each of the other independent variables forward. A policy entrepreneur is an individual who is responsible for identifying key problems in current policy, attract the attention of key decision-makers in the policy's area and finally, use their networks to present the ideas and gain support for policy change (Kingdon, 1984). This is an important variable for the research, because Kingdon argues that without a policy entrepreneur, none of the other variables in the multiple streams model hold any weight, as the policy entrepreneur is credited with driving the other variables forward. To best operationalize the identification of a policy entrepreneur for each case, I used King and Roberts’ three stated qualities that policy entrepreneurs must possess. They highlight that he/she must generate new policy ideas (intellectual function), devise a strategy to transform those ideas into law (strategic function), and lead political advocacy campaigns to stress the importance of the policy (activist function) (King & Roberts, 1987).
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With these independent variables, the dependent variable, policy change, is operationalized simply by the policy change/non-change in each case.
4.2: Method of Data Collection
To better understand the relationship between these two cases and the difference in their policy outcomes, the research data were collected using a qualitative approach. The primary method of data collection was the use of secondary data. For the case of NYS, I used document analysis, exploring the 2015 state-level document, "A Path Toward Value-Based Payment: New York State Roadmap for Medicaid Payment Reform," from NYS' Department of Health. This document highlights the current problems in the eyes of NYS politicians as well as their proposed solution to this problem. Along with document analysis, I investigated the NYS Department of Health promotional video for VBP reform, which takes the VBP reform document I analyzed and turns it into a common language video for the public to understand. For the case of the US, I first analyzed current US Medicare and Medicaid Administrator, Seems Verma's speech regarding VBP in the US moving forward. With this, I also explored a combination of speeches throughout Donald Trump's career as a candidate for the presidency as well as during his presidential term. To get the most accurate representation of comparison, since each case had such different available resources for data collection, I extensively explored both the NYS Department of Health, as well as the US Medicare and Medicaid websites, looking for indicators for each of the four independent variables previously identified.
4.3: Method of Analysis
The method of case analysis for this research is a small-N comparative study, focusing on cross-case inference between the cases of NYS and the US. Furthermore, using a deductive analysis, the research aims to use Kingdon’s multiple streams model theory as a tool to compare the cases. With this, a further clarification as to why I chose each case is needed.
4.3.1: Case Selection
For this study, I focused on two cases. The first case being, the United States Federal Government's current value-based purchasing model, which places a heavy emphasis on mortality rates. I chose to look at the US for this study for several reasons. The primary reason being that the US is one of the only countries that has a value-based purchasing system in place, where the medical facility is run privately, but publicly subsidized based on set performance indicators. Due to the competitive nature of the private market, the US healthcare system is a unique place to research medical trends. This is beneficial to the study, because it provides me
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with the transparency of data between different facilities to help better understand the actual effects of mortality rates on subsidization.
The second case I chose is New York State's newly developed "Value-Based Payment Reform," which aims to provide a much more accurate understanding of hospital performance and therefore, more accurate financial allocations to the deserving facilities. I chose New York State primarily because of this undergoing change. The fact that the change is happening right now is a perfect opportunity to truly look at how the independent variables play out and apply them to the model in comparison to the US federal government. Similarly, I chose New York State as the comparison, opposed to a different country to compare to the US, because the politics that comprise US State government and US Federal government are very similar, thus aiming the research more towards the research question, rather than differing political systems. With also lines with my targeted research gap, in that no study has aimed to use Kingdon's model to better understand the variation between state and federal policy.
After justifying why each case is individually relevant for this study, it is also important to point out why their comparison is of interest. The case selection was based on the diverse case model, where the two cases for analysis cover the entire variation of cases regarding the independent variable of policy change. With this, VBP policy is undergoing reform currently in the case of NYS, while in the case of the US, it has yet to do so. Furthermore, this comparison provided the opportunity to test Kingdon’s model in each of these situations to better understand the importance of the independent variables in driving policy change. After the research was conducted, it was clear based on the comparison, the level of importance of each stated variable to drive policy change. This representation was only possible, because of the comparison between a case with change and a similar case without change, both of which are affected by the same problem in policy and the same policy change is required.
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Chapter 5: Case Description
In 2010, the United States government introduced its Value-Based Purchasing System under President Barack Obama. At the time, it was agreed upon with little hesitation, that the use of mortality rates to measure the performance of these medical facilities was the most accurate and effective tool available. This has changed tremendously, however, yet US policy has stayed stagnant on the issue. The second case of interest, New York State, has just recently announced in 2015 that they will be breaking away from the US VBP and forming their own policy, with different measurement indicators. Since its announcement in 2015, the policy has reached its final stages and is being prepared to replace the current system in the coming years.
The case description chapter seeks to provide a more in-depth understanding of the history of VBP in the US, as well as a better understanding of mortality rates as a form of measurement. Furthermore, this chapter provides an understanding as to why this is a puzzle of interest and how each case comes into play.
5.1: Case Background
Privatized healthcare is often argued to be more efficient, accountable, and sustainable than its public counterpart. This has been refuted in recent studies, however, where private-sector medicine was found lacking in timeliness, as well as patient hospitality without a public backing; as their primary focus was finance (Basu, Andrews, Kishore, Panjabi, & Stuckler, 2012). Keeping this finding in mind, it is estimated that roughly 79% of the United States healthcare system is operated in the private sector (American Hospital Association, 2019). Despite this privatized majority, 64% of healthcare spending in the US is paid for by the government via programs such as Medicare and Medicaid (Himmelstein & Woolhandler, 2015). It is evident that, although most of the US healthcare system is “privatized,” the US government still has a very large role in the financing of medical services, thus a large influence over the privatized medical industry. They accomplish this using financial allocation initiatives, where the US government provides grants and funding to private medical facilities based on pre-determined criteria. To both provide funding, while also promoting the overall increase in medical care performance, the pay-for-performance (P4P) rooted concept of value-based purchasing (VBP) was introduced with the affordable care act of 2010. Before an understanding of the VBP initiative can be provided however, it is important to provide a brief understanding of P4P as well.
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5.2.1: Pay-for-Performance (P4P) and Value-Based Purchasing (VBP)
Defined in terms of healthcare by Mathes et al., P4P is, “a payment model that rewards healthcare providers for meeting pre-defined targets for quality indicators of efficiency parameters to increase the quality or efficiency of care” (Mathes, et al., 2019). To simplify this definition, current P4P models have created quality standards for medical facilities and use these standards to reward medical facilities with monetary incentives; the higher they perform based on forecasting, the more state and federal funding they are rewarded. The US' Value-Based Purchasing program is formulated from this P4P model, to improve the overall performance of medicine in the US. The program focuses on providing deserving medical facilities with monetary incentives based on their quality of care and performance (Damberg, et al., 2014). The obvious question that arises from this is, how can one provide a systematic definition of medical facility performance with so many variables at play?
The method implemented and still currently being used for medical performance measurement in the US is the risk-adjusted mortality rate (RAMR) (Thomas & Hofer, 1999) (Racz & Sedransk, 2012). This method of performance measurement estimates the patient probability of death, using indicators such as age, sex, preexisting conditions, etc. Using this estimate, the RAMR is used to compare medical center observed mortality rates vs. its expected based on its mortality estimates. Rubenstein et al. conducted a study to test the actual relationship between mortality rates in a medical facility and quality of care provided, finding that patients who receive poor quality of care were twice as likely to die than patients who received quality care (Rubenstein, Quinn, & Harper, 1997). What is important to note from this, are the specific performance indicators that are being used in this model, that being mortality. From this, we can derive that, according to the RAMR, medical facility performance is based purely on facility mortality rates compared to the industry average. But if this is the case, what are the underlying variables that determine mortality?
This ideology is touched upon in the literature by many. Park et al. found, in their 1990 study, that observed hospital mortality rates have the likelihood of 56-82 percent of random measurement error (Park, et al., 1990). Furthermore, Hofer and Hayward, in their 1996 study, found that using RAMR as a performance indicator fails to identify 88 percent of medical centers that deliver subaverage to poor quality care, while 60 percent of identified ‘poor-quality care providers’ are also falsely marked (Hofer & Hayward, 1996). The evident ineffectiveness of measurement based on mortality rates, that existed well before the introduction of VBP in the US,
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warrants reform. With the available data in today's ever-growing 'big-data' trend, why is the US using such an outdated measurement driver for such an important performance indication?
5.2: The Cases
The United States introduced its value-based purchasing initiative in 2010 under the Obama Administration. The initiative was part of a much bigger reformation of US healthcare, labeled "Obama-Care," which aimed to reduce costs of healthcare for Americans collectively. "Using an RMR, the new system created a public rankings list of US hospitals, while also rewarding higher performing facilities with increased government subsidization and consequently penalizing lower-ranking facilities with reduced government funds (Marjoua & Bozic, 2012). Quoting from the policy document directly, the main goal of the VBP initiative was to provide, “value-based incentive payments to hospitals that meet the performance standards” (Office of the Legislative Counsel, 2010). With this, evidence has piled up regarding the ineffectiveness of such a measure as RMR to access medical facility performance.
After Obama’s term came to an end, and Donald Trump took office, he vowed to repeal and replace Obamacare, stating in his 2015 campaign speech in Dallas TX, “ We’re going to repeal it, we’re going to replace it, and get something great” (Trump, 2015). With this, however, little to no mention of anything relating to VBP occurred, but the primary focus was on medical provider pay and access to adequate healthcare. With only one recorded mention from Trump's Medicare and Medicaid administrator, Seems Verma, throughout her three years in her role, the US has shown little interest in amending the VBP indicators.
The second case, New York State, has begun their movement toward an amended VBP initiative. After being included in the federal government’s VBP system for five years, NYS lawmakers decided it was time to separate themselves and form their own initiative. In 2015, the NYS government issued their proposal to reform their VPB system, in attempts to more accurately reward deserving medical facilities. Quoting directly from the policy document, the reform aims to, “…move away from a situation where increasing the value of the care delivered (preventing avoidable admissions, reducing administrative waste) harms the financial sustainability of providers, towards a situation where the delivery of high-value care can result in higher margins” (Medicaid Redesign Team, 2015). In its essence, what the reform aims to do is change how facilities are scored and evaluated, transitioning from the current system where scoring doesn't accurately represent performance, to a system where it does. With this, it is evident that, in the case of NYS, the policy is in reformation.
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Comparing each of these cases offers an opportunity to use the policy change variables in Kingdon’s Multiple Streams Model to help better understand policy change. In doing this, I aim to identify the variables that are present in the case of NYS to the indicators present/absent in the case of The US Federal government.
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Chapter 6: Research Analysis
In this section, I discuss my findings after using the techniques discussed in the research methodology section to help answer the main question; How can Kingdon’s Multiple Streams
Model help explain the US federal vs. state policy variation regarding the measurements for medical center performance? Comparing each case using the four independent variables (the
problem stream, the solution stream, the political stream, and the policy entrepreneur) I aim to identify any missing variables that Kingdon argues are mandatory for policy change in each case.
6.1: An Identified Problem
Kingdon’s multiple streams model puts its first emphasis on the importance of an identified problem that a given policy reform is attempting to address. The model argues that an identified problem is a variable that must be present in any given case that seeks to successfully reform policy (Kingdon, 1984). Kingdon further lists his idea of three operationalizing variables: focusing events, public feedback, and stakeholder criticisms. Using this understanding, the identified problem was the first variable that I explored in the research. Looking at actions of both the NYS government and the US Federal Government, this portion of the research was conducted to identify:
1. Where and when both cases provided a clear, systematic understanding of what the problem with the current VBP system is.
2. Any given focusing event in each case.
3. Feedback and criticisms from the public and other stakeholders in each case (stakeholder organizations and citizens) that identify the current VBP system as problematic (if any).
6.1.1: New York State’s Identified Problem
Looking first at the case of New York State, it is evident that a problem was identified and stated by the government entity. First appearing in a 2015 document, "A Path Toward Value-Based Payment: New York State Roadmap for Medicaid Payment Reform," NYS briefly touches upon the problems with the current system. The document says that the current system is a "fragmented system, overly focused on inpatient care" and going on further to call it predominately a "re-active system of medicine," rather than a system of pro-active preventative medicine (New York State Department of Health, 2015). This, however, cannot be classified as a clear identification of the problem, as it lacks depth and does not provide the citizen with enough information to drive support for the reformation. With being just lightly touched upon in this
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proposal document, as the movement pushed forward, so did the interpretation and identification of the clear problem the reformation is seeking to solve.
In the efforts to gain momentum for the proposed reform of the NYS value-based purchasing system, The NYS Department of Health created a promotional video to gain backing for their change, where which they extensively describe the problem with the current system in place; “The Primary aim of the New York State Medicaid program, and those who work within it, is to improve the health and lives of the people and communities it serves. The current fee-for-service system creates barriers for providers to achieve this goal. [The current system] rewards volume – including patient admissions and readmissions, more than it does value and delivery of quality healthcare. The sicker a patient gets, the more reliant they are on the services that providers offer. Too many provider systems are having to sustain themselves financially through volume. As a result, hospitals and emergency rooms fill with sick patients whose illnesses and complications could have been prevented with good primary care. We have a moral obligation to change that” (New York State Department of Health, 2016). With this statement, as well as the accompanying video, NYS puts a definition to the problem that they are seeking to address with their policy reformation. Although this statement does not specifically address the problem of mortality rates for performance measurement, it does detail that the current system rewards volume rather than actual care, which is attributed to the measures of performance, specifically that of mortality rate.
Attempting next to identify a focusing event, which helped drive the policy reform onto the political table, I was unable to do so. I could not find a catastrophic event regarding current hospital performance measurement policy that could be directly attributed to this policy reformation. I was, however, capable of identifying very strong indicators of feedback and criticisms in the case of NYS.
In 2015, in the adolescence of the reform initiative, the NYS Department of Health opened a forum for public comments on the subject, In doing so, the organization was seeking feedback from the public in attempts to identify whether the problem they saw in their eyes was a problem in the eyes of the public as well. Biotechnology Industry Organization (BIO), the world's largest biomedical trade association was one of the first to comment, saying that there needs to be a new program in place that ensures patients have access to new medications, has stronger patient protections, has a detailed benchmark methodology to promote evidence-based VBP as well as establishing meaningful and specific quality measures. With this, Bio argues, “it is not the case that existing quality measures are always appropriate for every provider. For example, a quality measure may be benchmarked to a different population (e.g., one that is inherently healthier) than
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the patient population being treated by a specific provider, especially if that provider is a medical specialist” (Public Comments on Value-Based Payment Roadmap, 2015). In saying this, as well as going into detail regarding the other point previously mentioned, BIO demonstrates that they too feel there are inert problems with the current system. BIO is not alone, however, as other major actors such as the Primary Care Development Corporation, The New York State Nurses Association, The New York State Association of Health Care Providers also commented in the forum, all expressing their similar views regarding the problematic system currently in place (Public Comments on Value-Based Payment Roadmap, 2015).
6.1.2: The United States Federal Government’s Identified Problem
The United States has some overlap with that of NYS, simply because NYS is a part of the US. With this, it is important to note that the identified problems by the stakeholders in NYS also applies to the case of the US. Despite this, however, it was very difficult to find evidence of a problem statement within the US Federal Government, regarding current VBP. When extensively researching the topic through the US centers for Medicare and Medicaid, ample VBP initiatives are listed, but none of which have any sort of reform stated. All of these initiatives also include mortality rates as a primary measure of performance, with no comment on the ineffectiveness of the measure (Centers for Medicare & Medicaid Services, 2019). Despite this lack of problem identification by the organization of interest, other political figures in the federal government have spoken out about the negative implementations of the current system.
When the Trump administration came into power, they immediately expressed their dissatisfaction with the VBP system put in place by the Obama administration. In exploring the actual benefits of the current VBP system, the administration conducted a study on its effectiveness and found that most hospitals in the program receive little to no financial benefit for their participation, making it a flawed incentive program (Government Accountability Office, 2017). Trump's Centers for Medicare and Medicaid Services administrator, Seems Verma, stated, “We need to make sure we’re not forcing, not mandating individuals to participate in an experiment, a trial that there’s not consent around” (Dietsche, 2018). With this, there have been many reforms regarding the healthcare policy put in place by the Obama administration, including the Tax Cuts and Jobs Act, which lighted the tax on citizens without health insurance, The American Patients First Plan, which lowered prescription drug prices, as well as several other non-formal acts that further reformed the current policy in place. Despite this, however, no systematic statements arose about the problems regarding the current VBP system. It seems that the Federal
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government failed to identify a concrete problem regarding mortality rates and the current VBP system, despite the push from organizations such as the ones listed for NYS.
Like the case of NYS, finding a focusing event proved very difficult. I was unable to identify one for the case of the US.
Looking finally at a form of feedback from the public, the US government failed to provide a stream such as that of NYS. Although the Department of Health's website offered the opportunity to submit comments, there was no specific outlet for comments regarding VBP. The problem stream is being voiced by major stakeholders such as the ones listed in the NYS case, yet there is no stream provided to address these concerns with government officials.
6.2: The Proposed Solution
The next variable of interest, when referring to Kingdon’s Multiple Streams Model, is that of a proposed solution to the identified problem. The solution must be directly reflective of the problem and be clearly defined to gain support and momentum for the policy reform. Quite literally, a proposed solution needs to be a policy ready to replace the flawed one and fix the problems identified previously. In the context of this study, the proposed solution must replace current performance measures with ones that more accurately represent the performance of medical facilities. Using Lynch and Cross' performance pyramid as a template to follow regarding the representativeness of the proposed solution for each case can be provided, I searched for evidence of replacement measurement which represents each of the categories provided in the pyramid model. With this, in looking at the policy documents of both The NYS Government and The US Federal Government, I also attempt to identify where and when a proposed solution was provided to the problem of current VBP, from each case.
6.2.1: New York State’s Proposed Solution
In the case of New York State, it was very evident that a well-planned and thorough solution was proposed in correlation with the identification of the problem. Like that of the problem variable, the solution to the problem was brought to light first in the 2015 document, "A Path Toward Value-Based Payment: New York State Roadmap for Medicaid Payment Reform", where the NYS Department of Health not only goes into detail about the current state of the VBP system in the US, but also highlights extensively how they plan to fix these problems. More specifically, the document highlights the goals and systematic implications of the proposed payment reform, stating, "in essence, the State's Medicaid payment reform goals attempt to move away from a situation where increasing the value of the care delivered harms the financial sustainability of
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providers towards a situation where the delivery of high-value care can result in higher margins" (New York State Department of Health, 2015). It goes further to systemize how the reformation will achieve this goal; providing an eight-factor list which includes, financial transparency and fairness, scalability and fixability, availability of multi-year phasing, aligning payment policy with quality goals, reward improved performance and continued high performance, strong and accurate evaluation components, strategic planning, and lastly, financially rewarding performance instead of penalizing underperformance. With this, the document clearly identifies how the proposed reform will fix the established problems with the current VBP system.
With this initial document, NYS has continued to update their solution statements, in attempts to make them easier to understand when addressing the public. In their promotional video discussed in the previous section, it is stated that the new value-based purchasing reform will, “encourage providers to focus on the delivery of quality preventive and primary care, and to coordinate that care with other providers throughout the patient’s journey” and further goes on to say that the reform is designed to, “improve patient health and reduce avoidable costs by creating saving that can be reused within the system” (New York State Department of Health, 2016).
In context with this study, however, what is most important to look at is the proposed solution to omitting the usage of mortality rates. This is briefly touched upon in the eight-point list mentioned above, where they point out the importance of strong and accurate evaluation component, but do not point directly to the exclusion of mortality rates. In 2019 however, the initiative shared with the public their proposed replacement measurements for mortality rates, where they go into extensive detail about the quality measures they plan to use (Proposed 2020 TCGP VBP Quality Measures, 2019). In this proposed replacement, NYS has ample new measurement categories with the goal of more accurately representing the true performance of each medical facility. Comparing these new measurements to Lynch and Cross' performance pyramid however, the new measurements seem to only be representative of level 4 of the pyramid, regarding the quality of care offered. There are no measurement indicators which highlight customer satisfaction, productivity, flexibility or vision, which Lynch and Cross also argue are mandatory for effective performance measurement. With this, although the new measurement solutions could use some improvement to accurately represent all aspects of performance, it was clear that they are a huge improvement from their mortality rate counterpart.
6.2.2: The United States Federal Government’s Proposed Solution
It proved very difficult to find any solution statements presented by the US Federal Government, simply because it seems as if they haven't identified and/or addressed the problem
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of the VBP system in place. Political figures of power have, however, alluded to changes to the system that are in the works, but have not made any objective claims. Administrator Verma comments that planning has begun to make altercations to the flawed system in place that are, “intended to encourage health system change while minimizing provider burden and maintaining access to care” (Dietsche, 2018). With this claim, however, there are no systematic solution statements made, so one cannot derive a proposed solution from this. Furthermore, since no solution statement was provided in this case, no new variables were presented formally could be assessed with Lynch and Cross' pyramid model.
6.3: The Political Motivation
The next variable of interest with regards to Kingdon's Multiple Streams Model is that of the political motivations. This not only refers quite literally to the motivations of policymakers who have the power to move an issue of interest forward to drive policy change, but also refers to the politics surrounding the initiative. Kingdon highlights three key factors that he finds to be most influential when establishing political motivation; the national mood, government body turnover, and interest group advocacy campaigns (Kingdon, 1984). Using these three variables, I will attempt to uncover where the motivations of the politicians of interest lay, in context with the policy problem and solution.
6.3.1: New York State’s Political Motivation
In the case of NYS, looking first at the variable of national (statewide) mood, it is clear why politicians were motivated to initiate change. As mentioned previously, most of the influential actors in the medical feed responded to the NYS open forum, all expressing their agreeance that the current VBP is flawed. Furthermore, however, as recently as November 2019, demonstrators in NYS formed a picket group at the New York Health Plan Association (NYHPA), in attempts to bring attention to the "deadly denials and racist algorithms" of the current VBP system in place (Robbins K., 2019). This is no new news, however, as pickets like this have been happening at the annual meeting for several years now in Albany, NY. With this, The New York Times also emphasizes the public's mood regarding the current system. In the articles addressed once before in chapter one, the Times highlights the important actors who are backing out of NYS’ VBP system, due to their stakeholder feedback and predictions of failure (Wachter, 2016). With this, the mood from the public regarding the current VBP system in NYS is clearly seeking reform. These examples not only demonstrate the presence of a statewide mood seeking reform, but also provide a clear example of active interest group advocacy activity regarding the subject.
