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The dilemmas of incrementalism: Logical and political constraints in the design of health insurance reforms

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  • Thomas R. Oliver

    (School of Hygiene and Public Health at Johns Hopkins University.)

Abstract

Health care reform became a premier issue on the U.S. policy agenda in the 1990s. While the comprehensive proposal put forth by President Clinton failed, states and the federal government successfully pursued a variety of lesser initiatives. This article focuses on a set of reforms intended to make private health insurance more accessible and affordable to individuals and workers in small firms. It outlines the key arguments made by experts to justify stronger regulation of health insurance and the options and difficult tradeoffs that must be considered in policy design. It then examines the scope and strength of legislation adopted by 45 states and the federal government from 1990 to 1996. The substantial variation in state policies demonstrates that even though insurance market reform was the one issue that commanded nearly universal support in the health care debate, few design features were universally accepted by those who crafted the reforms. The article concludes by assessing the pattern of state and federal action. The reforms represent some progress on nominal access to insurance but little progress on the affordability of insurance for individuals and small groups. Few of the reforms present a serious challenge to existing practices and interests of the insurance industry. This pattern of policy design reflects the logical and political constraints of incrementalism. In a system where insurance coverage is voluntary, changes to increase access for one group tend to increase costs and thereby decrease access for another segment of the population. In addition, because incremental reforms will not attract sustained attention and support from the general public, it is politically difficult to impose substantial new regulation on a powerful industry. © 1999 by the Association for Public Policy Analysis and Management.

Suggested Citation

  • Thomas R. Oliver, 1999. "The dilemmas of incrementalism: Logical and political constraints in the design of health insurance reforms," Journal of Policy Analysis and Management, John Wiley & Sons, Ltd., vol. 18(4), pages 652-683.
  • Handle: RePEc:wly:jpamgt:v:18:y:1999:i:4:p:652-683
    DOI: 10.1002/(SICI)1520-6688(199923)18:4<652::AID-PAM6>3.0.CO;2-X
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    References listed on IDEAS

    as
    1. Schneider, Anne & Ingram, Helen, 1993. "Social Construction of Target Populations: Implications for Politics and Policy," American Political Science Review, Cambridge University Press, vol. 87(2), pages 334-347, June.
    2. Henry J. Aaron & Barry P. Bosworth, 1994. "Economic Issues in Reform of Health Care Financing," Brookings Papers on Economic Activity, Economic Studies Program, The Brookings Institution, vol. 25(1994 Micr), pages 249-299.
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    Cited by:

    1. Kevin T. Stroupe & Eleanor D. Kinney & Thomas J.J. Kniesner, 2001. "Chronic Illness and Health Insurance-Related Job Lock," Journal of Policy Analysis and Management, John Wiley & Sons, Ltd., vol. 20(3), pages 525-544.
    2. Jennifer M. Mellor, 2005. "Illustrating Adverse Selection in Health Insurance Markets with a Classroom Game," Southern Economic Journal, John Wiley & Sons, vol. 72(2), pages 502-515, October.
    3. Naomi Zewde, 2021. "Did Marketplace coverage really offer financial protection? Financial gains from the Affordable Care Act's private insurance policies among the previously uninsured," Journal of Risk & Insurance, The American Risk and Insurance Association, vol. 88(2), pages 413-427, June.

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