Health Policy Making in the United States

Answer

Health Policy Making in the United States

Marijuana is the most commonly used illicit substance in the United States. The federal drug laws and the state laws on medical marijuana use have been in conflict from the onset of states' legalization of medical marijuana use (Cerdá, Wall, Keyes, Galea, Hasin, 2012). Notably, the supreme court of the United States has demonstrated the authority of the federal laws of those of the states in its judgments on medical marijuana cases. The role played by the macro-level factors such as community norms and government laws in relation to substance use is significant in determining marijuana use, abuse and dependence (Choo, Benz, Zaller, Warren, Rising, McConnell, 2014). There is a strong connection between state-level legalization of medical marijuana and the use and abuse of marijuana as well as its dependence. This association between the federal legalization of medical marijuana and marijuana use and abuse is augmented by some underlying common causes that include community norms that support the legalization of medical marijuana and those that support marijuana use (Pacula, Boustead, Hunt, 2014). In my view, legalization of medical marijuana would significantly increase rates of marijuana use, abuse and dependence. Thus, the federal Controlled Substance Act should be enforced to ensure federal prosecution of medical marijuana patients and their providers to discourage the substance use and abuse.

Cerdá, M., Wall, M., Keyes, K. M., Galea, S., & Hasin, D. (2012). Medical marijuana laws in 50 states: investigating the relationship between state legalization of medical marijuana and marijuana use, abuse and dependence. Drug and alcohol dependence, 120(1), 22-27.

This article relates the prevalence of marijuana use and abuse to the state-level legalization of medical marijuana and posits that the legalization of the use of the substance detrimental to public health as it would encourage the public use of the substance.

Choo, E. K., Benz, M., Zaller, N., Warren, O., Rising, K. L., & McConnell, K. J. (2014). The impact of state medical marijuana legislation on adolescent marijuana use. Journal of Adolescent Health, 55(2), 160-166.

This article emphasizes on the contribution of the state-level legalization of medical marijuana increased in increasing the accessibility and appeal of marijuana to youth. This study assesses the impact of medical marijuana legalization in the United States through comparison of trends in marijuana use between states that have legalized the medical use of the drug and those that have not legalized the medical marijuana use.

Pacula, R. L., Boustead, A. E., & Hunt, P. (2014). Words Can Be Deceiving: A Review of Variation Among Legally Effective Medical Marijuana Laws in the United States. Journal of drug policy analysis, 7(1), 1-19.

This article posits that the impact of the state-level legalization of medical marijuana use on the public health depends on the legal provisions that vary from state to state. Therefore, it clarifies the characteristics of various state marijuana laws and how they affect the prevalence of marijuana use.

My position

            The use of marijuana should be discouraged in all forms. The federal legalization of medical marijuana use will not only constitute a blanket permission to the abuse of the substance but will also render the United States a hub of marijuana peddling thus increases the accessibility of the drug by the public resulting into marijuana abuse and dependence.

The context of the legislation 

The context of this legislation is constructed around policy markets in which demanders for and suppliers of policies interact through the following conceptual frameworks and theories of policy making; Stages Heuristic- a framework that views policy making as a four-staged process and Multiple-Streams and Punctuated-Equilibrium Theories (Beaufort 2015). The multiple-stream theory is agenda focused and posits that politics, problems, and possible solutions flow in separate streams in the society. When these streams merge, the confluence provides an opportunity for the government to engage in policy making. The punctuated-equilibrium theory, on the other hand, postulates that policymaking proceeds in small incremental steps that are prone to disruptions and bursts of rapid transformation (Beaufort 2015).

The policy making process occurred at the federal level government through three interrelated and cyclic phases namely; formulation, implementation, and modification (Beaufort 2015).

Formulation

This phase has two distinct and consequential parts namely; agenda setting and development of the legislation.

• Agenda setting

The agenda setting was initiated by the interaction between diverse health-related problems and their possible solutions while considering the dynamic political circumstances that relate these problems to their potential solutions. Therefore, agenda setting is a critical step in policymaking process since it describes the options through which particular combination of problems, potential solutions, and political circumstances can emerge and proceed to the next stage.

• Development of legislation

This step involved proposal of Federal Controlled Substance Act as the specific legislation by the policy makers. The proposals are regarded as hypothetical solutions to the health-related problems they are intended to address. The proposal was then taken through carefully prescribed steps that led to a policy formation. The path through this process pass through federal, state and local levels as follows;

The legislative process at the federal level

A drafted Federal Controlled Substance Act was introduced by the member(s) of the Congress and taken through the following steps (Beaufort 2015);

Step 1: Referral to Committee

The legislation was referred to the standing committee of the house in accordance with carefully delineated rules of procedure.

Step 2: Committee Action

The bill was examined carefully by the committee and found worthy of consideration and was passed to the next stage.

Step 3: sub-committee review

The bill was referred to this stage for study and hearings. The hearings allowed the views of opponents and proponents, the experts, the executive branch, and other public officials to be put on records.

Step 4: Mark UP

 This involved making changes and amendments by the sub-committee to the bill before recommending the bill to the full committee.

Step 5: Committee Action to Report the Bill 

The full committee conducted further study and hearings on the bill and finally voted on its recommendations to the house.

Step 6: Publication of a Written Report

After the voting to report the bill by the committee, a written report on the bill was prepared by the staff at the instructions of the chairman of the committee. The report detailed the intent and scope of the legislation and showed the impact on existing laws and programs. The report also described the dissenting views of the committee members and the position of the executive branch.

Step 7: Scheduling Floor Action

The bill was then placed in chronological order in the calendar of the House.

Step 8: The Debate

The bill on the floor of the house was debated in accordance with the rules and procedures governing the debate on legislation. The rules dictate the conditions and amount of time for every debate.

Step 9: Voting

 After debating and approval of the bill, it was passed through voting by members.

Step 10: Referral to Other Chamber

Once the bill was passed by the House, it was referred to other chamber where it followed the same route through committee and floor action and was approved as it was.

Step 11: Conference Committee Action

The conference reached an agreement and prepared a report for approval of the bill.

Step 12: Final Action

The bill was sent to the president after the approval by the house and the senate. The president approved the legislation, and it became law.

Implementation Phase

The newly formulated law, the Federal Controlled Substance Act, was then subjected to the enactment process that marked the beginning of implementation phase (Beaufort 2015). This phase involved discussions on the responsibility of implementation. The implementing organizations are agencies in the federal and state governments established to carry out the intent of the law as enacted. Therefore, for the federal Controlled Substance Act to affect the determinants of health, its effective implementation by both governments’ agencies is critical. The implementation of the federal Controlled Substance Act took place in series of interrelated steps namely; designing, rulemaking, operating and evaluating (Beaufort 2015).

• Designing

This involved the determination of the working agenda of the implementing organization, planning how to accomplish the task and identifying the agency to perform the task. This is a straightforward management process that involves interrelated social and technical activities within a formal organization setting.

• Rulemaking

This step of implementation of the federal Controlled Substance Act involved the development of regulations by the implementing organization in the executive branch. These rules were specific on the applicability of the federal Controlled Substance Act in the United States.

• Operating

This step involved activities meant to effect the objective of the federal Controlled Substance Act in protecting the public health by eradicating substance abuse. The activities involved assessing the danger of the substance in the environment and imposing sanctions on its use.

• Evaluating

            This stage involves analyzing the effectiveness, benefits and whether its objectives are being met. The federal Controlled Substance Act is currently in conflict with some state medical marijuana laws as some states have legalized the use of marijuana for medical purposes yet, the substance is listed under the federal Controlled Substance Act as harmful to public health and as such outlawed.

• Modification phase

This involves making necessary adjustments on the policy to accommodate the changing circumstances. The individuals, organizations or interest groups that are positively affected by the policy may seek modification of the policy to maintain or increase the benefits they derive from the policy. Likewise, those that are negatively affected may also seek modifications to reduce the negative consequences of the policy.

The expected demanders and suppliers of the policy

The policy markets operate like a typical economic market with demanders for the policy and suppliers of the policy (Beaufort 2015). Demanders of the policy are those who seek public policies that satisfy their preferences while policy suppliers are the policymakers who are in a position to make available public policies (Beaufort 2015).

• The expected demanders of the policy

These include;

• Individuals who view the policy as beneficial in their pursuit of good health
• Individuals who consider the policy as a way through which they can achieve the desired end e.g. a means to achieve economic advantage.
• Organizations with an interest in health affairs such as health plans and technology suppliers and large health systems.
• Well-organized interest groups constituted by a group of individuals or a group of organizations with similar policy ambitions that enter the policy-making market to achieve their objectives.

Notably, the interest groups are the most effective demanders while individuals are the least effective demanders in the policy market. This is due to the ability of the interest groups to combine and concentrate resources of the members thus have a greater impact on the policy market than individuals or organization. However, organizations may have a greater impact than individuals given the fact that organizations have more resources than individuals.

Suppliers of the policy

This category comprises members of the executive, judicial and legislative branches of government who participate in the policy making process (Beaufort 2015). These include;

• Legislators as Suppliers

These are elected members of the United States Congress, state legislatures or city councils. The interest of these suppliers is motivated by the interest of the policy demanders who propelled them to the political office. Consequently, the legislators exhibit a continuum of behaviors that represented by those seeking to maximize self-interest and those seeking to maximize public interest (Beaufort 2015). A legislator on the public interest extreme will make policies that maximize the public interest while legislators on the self-interest extreme will formulate policies to maximize self-interest e.g. re-election, prestige, power, money or any other thing that is self-serving to the individual.

Legislators at all levels of government are significant suppliers of policies in the form of laws. In policy markets, the legislators evaluate the benefits and the cost of their policymaking decisions and make their decisions based on the interest they choose to serve (Beaufort 2015).

• Executives and Bureaucrats as Suppliers

This category of suppliers include members of the executive branch of all levels of government and constitute significant policy suppliers. For instance, all public sector executives including presidents, governors and mayors offer policies as legislative proposals and seek to have legislators enact policies of their preference (Beaufort 2015). Chief executives and government departmental heads and agencies directly supply policies in the form of regulations or rules that guide the implementation of laws, procedures and operational protocols for the policies they implement. However, the behaviors and motives of this category of suppliers are similar to those of the legislators (Beaufort 2015).  The career bureaucrats are the civil servants in the executive branch that contribute to the supply of policies by collecting, analyzing and transmitting information about policy proposals in their area of expertise (Beaufort 2015). The behaviors and motives of the career bureaucrats differ from those of legislators and the executive branch members.

• The Judiciary as a Supplier

The judiciary branch of government is an important supplier of health policies. Through court interpretation of an ambiguous law and establishment of judicial procedures, the judiciary makes policies through the courts. The activities of the judicial branch of government, just like the activities of the legislators and the executive branch of government, are policymaking activities due to their authoritative nature in decision-making that influences or directs the behavior, actions or decisions of others (Beaufort 2015). However, the policy making in the judicial branch of government is different from the other two policy marking entities in both focus and operation. The judicial branch of government as a policy supplier has a narrow focus on the issue involved in the specific case in contrast to the wide political arena in which other policy suppliers operate (Beaufort 2015). Notably, the core of the judiciary’s ability to supply policies is on its interpretive role. For instance, the courts have the power to interpret a federal or state law and declare the law unconstitutional thus the law becomes null and void.

The Expected Interest groups

The interest groups are also called lobby groups, pressure groups or advocacy groups. Their existence is prompted by the need for collective action to achieve particular outcomes in the policy market through influencing the policymaking process. There are two distinct expected interest groups in the health policymaking market; the pluralists and the elites (Beaufort 2015).

• The pluralists and their argument

This group of expected interest groups constitute those who believe that interest groups are essential in public policy making as they play a critical positive role in the policymaking process. They hold the pluralist perspective on the role of interest groups in the process of policymaking (Beaufort 2015). They argue that different interest groups compete with each other and counterbalance each other in the policy marketplace. They contend that power is widely dispersed among competing groups as groups seek their preferred outcomes and in the process a group may win sometimes and lose some other times (Beaufort 2015). The pluralist employs the pluralist theory about the policy making process whose central tenets include the argument that;

• Interest groups present crucial links that connect people and their government.
• Interest groups always compete among themselves for outcomes during which the interests of some interest groups are counterbalanced by the interests of others.
• In the completion, no single group is likely to become too dominant because other existing groups intensify their efforts as groups get more powerful. The ability of the groups to rely on various sources of power is an important mechanism through which the groups can maintain the balance among them. For instance, the concentrated economic interest groups may have power, while, the consumer groups, on the other hand, may have more members.
• There is a fair competition among interest groups. Though with some exceptions, groups normally play by the rules of the game.

The Elites and their argument

This group constitutes those who believe that most organized interest groups are powerless and ineffectual. Their argument on the role of interest groups is grounded on the power elite model of American society (Beaufort 2015). Their argument is grounded on the idea that the concentration of real political power is in the hands of a few individuals in the population that controls the United States’ key institutions and organizations and much of the nation’s wealth. The Elites’ perspective posits that the public policymaking process is disproportionately influenced and controlled by these few individuals who control power and wealth for themselves in part. This perspective is posited by the majority of Americans who believe in a few members of the society having more influence than the vast majority. The argument further clarifies that a power elite referred to as “the establishment,” is the gatekeeper to public policymaking process (Beaufort 2015). Consequently, no issue get due attention in the policymaking domain unless the power elites find the issue of significance. Besides, the public policies made in response to an issue in the policymaking agenda reflect the ideologies, values, and preferences of the governing power elite.

The superior position of power elites in the society make them dominate policymaking process. Thus, they have a powerful role in the nation’s social and economic systems thereby shaping the formulation of policies and control how these policies are implemented (Beaufort 2015). The argument of the Elites is founded on the power elite theory whose central tenet argues that;

• Real political power resides in a small proportion of the population and that the great power differentials among a large number of interest groups render the interest groups practically meaningless. However, some groups may win minor policy victories, but the significant policies are prevailed upon by the power elites.
• The sharing of consensus by the power elites on the basic values guides the public policymaking: the preeminence of markets, private property rights and private enterprise as the best way to organize the economy, and the importance of individualism and individual liberty.
• Members of the power elite are driven towards incremental changes in public policies. Incrementalism permits time for adjustments for social and economic systems to the changes during policymaking process. This allows minimal economic disruptions and minimal alteration in the status quo of the social system.
• Though power elites protect their power bases, some limited allowance of movement of non-elites into the elite domain is permitted to enhance social stability. This non-elite movement into elite position is only permitted after the non-elites clearly accept the elites’ consensus values.

Interplay Among Demanders and Suppliers in Policy Markets

Demanders and suppliers of various policies pursue the furtherance of their objectives within the policy marketplace (Beaufort 2015). These objectives can be in the best interest of self, or they can be in the best interest of the public. These objectives may also be in the best interest of some subset of society with special needs such as the elderly, poor, or medically underserved. Whatever the case may be, the outcome depends on the relative abilities of the policy market participants to influence the decisions, actions and behaviors of other participants (Beaufort 2015).

The Analysis of public policy environment

The power to shape or determine a policy lies in the influence in policy markets. Such power can be derived from a number of sources (Beaufort 2015). For instance, interpersonal power can be sourced from legitimate, coercive, reward, expert, and referent. These sources of interpersonal power apply to organizations, interest groups and individuals in policy markets (Beaufort 2015).

• Legitimate

Legitimate power is derived from individual’s relative position in a social system, interest group or organization resulting to a form of power referred to as formal power or authority. This authority exists because individuals need to be assigned or to subscribe to certain powers to enable them to fulfill their duties and perform their tasks effectively. All the participants in the policy markets such as elected leaders, health professionals, corporation executives, appointed executives, judges and union leaders possess some legitimate power that goes with their organizational or social positions. As such, policy demanders and suppliers possess legitimate power. Consequently, such entities have influence in the public policy environment because their legitimacy in the policymaking process is recognized.  

• Reward power

Reward power is anchored on the ability of an individual, organization, or interest group to recompense others for their decisions and actions. Reward power partly stems from legitimate power. This power originates from many sources and may assume different forms. In organizations, the reward power may include control over pay increases, work, and vacation schedules, promotions, recognition of accomplishments, club memberships and office size and location. In the policy markets environment, reward power expresses itself in the form of favors that can be exchanged or provided, specific influence with particular groups or individuals, and also include any influence that can be stored for later use.

• Coercive power

Coercive power, unlike the Reward power, is based on the capacity of an individual, organization, or interest group to withhold or to prevent another from obtaining desired rewards.

• Expert power

Expert power is vested in individuals but can also be exercised by an interest group or organization. This power emanates from possessing the expertise valued in policy markets that may include expertise in performing crucial tasks or solving problems. Individuals with expert power are normally the occupants of formal positions of authority and can transfer some of the expert power to the interest group or organization. Within the policymaking environment, individuals can exercise their expert power and become associates of other participants in public policy markets.

• Referent power

Referent power is derived from the resulting influence that comes with the ability of some individuals, interest groups and organizations to engender admiration, emulation, and loyalty from others. In the public policy environment, when this form of power pertains to individuals it amounts to charismatic power. Charismatic power is normally associated with individuals with strong convictions about the correctness of their preferences, have self- confidence in their own abilities, and are perceived as legitimate agents of change in the society (Beaufort 2015). Although charisma is highly valued in the public policy environments, an individual, organization, or interest group cannot gain enough power to influence the policymaking process heavily through referent or charismatic power. However, these forms of power are significant boosting other sources of power in a policy market. The power bases in policy markets are interdependent and always complement or conflict with each other. For instance, organizations, individuals or interest groups that are able to use reward power wisely can strengthen their referent power (Beaufort 2015). However, organizations, individuals or interest groups that abuse their coercive power are most likely to weaken or lose their referent power. Notably, effective participants in the marketplace for policies tend to be informed of their sources of power and strive to act accordingly. For example, for organizations, individuals, and interest groups to succeed in influencing policymaking process, they must be careful to recognize the sources of their power and act accordingly.

The organizations, individuals or interest groups do understand intuitively the benefits and costs of using each kind of power in a particular way and can apply these powers appropriately in different situations and accordingly on various individuals they wish to influence.

My strategic policy

My strategic policy that would diffuse results of public policy environment is grounded on the Iron Triangles model that posits the relationships that exist among participating individuals, organizations, and interest groups in policy markets. Notably, any policy environment attracts a set of participating individuals, organizations, and interest groups, each of which has some stake in policies affecting the domain. Thus, each participant seeks to influence the policymaking process (Beaufort 2015). In this interaction, some of the participants in the domain demand policies while others supply the policies demanded. Consequently, these participants collectively form a policy community. This policy community is formed around a particular policy domain and constitutes legislators with focused interest in a domain, usually with jurisdiction in the domain within the legislative committees, the private-sector interest groups in the domain, and the executive branch agencies that is responsible for the implementation of the public laws in the domain (Beaufort 2015). The legislators and the executive branch agencies act as policy suppliers within the domain while private-sector interest groups are the policy demanders in the domain. This three components of policymaking environment constitute a triad of organized interests, with all the three existing in accord that results in the stability of the policymaking environment that can withstand attempts to make undesired changes. Consequently, I present a strategic policy called the Iron Triangles by advocating for the maintenance of the triad that would act as checks and balances in the events playing out in the policy markets. This will significantly diffuse the results of public policy environments that has always been in the favor of the most influential members of the society.

Conclusion

Health policies are made in the context of policy markets, in which policy demanders and policy suppliers interact. The federal government, state government, and, to some extent, the local governments have important health policy roles.

The policy demanders include those who need the public policies to meet their health-related objectives or such objectives as an economic advantage.  Notably, individuals alone cannot effectively demand the public policies. However, the most effective demand emanates from the interest groups although organizations are more effective demanders than individuals. The suppliers of health policy include elected legislators and appointed executive members of all the three branches of government as well as the civil servants who staff the government. The policy markets are influenced by these stakeholders or participants, each of which has an interest to be served by the policy. Consequently, the iron triangles provide the best strategic policy that can help defuse the result of these influence on the policymaking process by preventing attempts to make undesired changes in the policies.