If you look at many of the current Democratic Party candidates for the 2020 election, you will find that most of them have at least one thing in common: they have some sort of plan which is proposing a significant overhaul and restructuring of one system of another. These grand plans are likely no coincidence. As human beings, and voters, we often desire that other people or politicians ought to do something in the most thoughtful and thorough, and in the case of societal change—perhaps boldest— manner possible. We imagine a scenario where the system problem is fully understood by the decision makers, as they have examined all of the data, and also that a clear solution can be found and political consensus achieved—we imagine the Rational-Comprehensive Decision Making model of policymaking (Birkland, 2020). This seductive idealized projection of how others should or could approach big, complex decisions, however, has many profound limitations, such that a true overhaul of a government system using a rational-comprehensive model seems, disappointingly, unlikely, and concept of incrementalism the realistic alternative (Birkland, 2020). The purpose of this paper then, is to argue that despite the allures of the Rational-Comprehensive model, incrementalism is the most realistic lens with which to understanding how policy problems are approached—with the American healthcare system given as an example.
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While the Rational-Comprehensive Decision-Making model presumes that human beings can obtain and hold nearly impossible levels of knowledge as well as execute an exhaustive analysis based on this knowledge, the Incrementalism model takes a more practical approach in acknowledging our shortcomings in decision making as human beings (Birkland, 2020). The model of Incrementalism reminds us that we are not perfect information processors or immune to the influences of vacillating levels of attention and motivation— that we have “bounded rationalism” (Jones, 2003). To explain further: although humans or politicians may set ambitious goals, they are often unable to achieve them due to the impact that emotion mediators, information processing limitations, and resource constraints otherwise have on the execution of their goals (Jones, 2003). Another fundamental presumption of the Rational Decision Making model that makes it often impractical in the policymaking realm is the idea that you could achieve “goal consensus” in order to settle on the most optimal solution (Birkland, 2020). Values of one government party or another, would inevitably come into play, in deciding which solutions make it to the viability table, or on the floor for Congressional debate (Birkland, 2020). According to Charles Lindblom in “The Science of Muddling Through”, an article which discusses both the models of Rational-Comprehensive Decision making as well as Incrementalism, there is a place for Rational Decision-Making—its place is just not in solving complex problems (Lindblom, 1950). Instead, Lindblom asserts, it is only truly suitable for the most straight-forward problems. (Lindblom, 1950).
To illustrate the approach of incrementalism in a public policy problem, one can consider the complex policy problem that is the American Healthcare System. Due to the size of the system, and the complexities of how care is paid for and provided, attempting to improve it by any measure is one of the biggest undertakings a government can pursue. According to Lindblom, this is the exact kind of complex problem which will often lead to an incremental or a “successive limited comparisons” method of decision making (Lindblom, 1950). As most would see it, the American Healthcare system has at least these seemingly obvious problems: not enough people are covered and it is too expensive. However, the solutions to these problems are nowhere near as obvious, especially with inevitable limitations in resources, including as Lindblom would say, “time and money”, as well as a lack of consensus of goals (Birkland, 2020). With unlimited money, you could presumably either provide a government system for all with everyone having the option of private insurance as well, or pay for the private insurance premiums in some way. With unlimited time and political consensus, you may even be able to push through something like Medicare for All while still balancing the budget. In reality, though, Lindblom asserts, time and money are always limited (Lindblom, 1950), and we must operate in the realities of human capacity constraints and budgets to solve societal problems. As such, what we have seen over the past 10 years or so in healthcare reform, despite many having the desire to achieve a significant structural change of the system itself, has been policy by way of incrementalism. There has not been a complete overhaul of the healthcare system—which would likely entail a total reform of the concept of private health insurance. Instead, mostly, by way of the Affordable Care Act (ACA), there have been smaller, adjustments such as government funded subsidies, an online exchange to provide more accessible enrollment to private plans, a regulation requiring the coverage of pre-existing conditions for ACA plans, and the expansion of Medicaid in some states. All of that said, broad, fundamental, structural change was not executed; it was incremental change. Although this outcome may not be ideal in terms of providing a bold, comprehensive solution to a complex problem, it is the realistic product, or solution, of a system with ever persistent limitations in resources, be they on the individual decision maker level or in constraints on building consensus in a democracy. In conclusion, although we as citizens and people may desire that ourselves and others approach big, complex decisions in a highly rational and comprehensive way, what we actually often do when approached with these problems is mostly just what we can—step by step incrementalism.
References
Birkland, T. A. (2020). An introduction to the policy process: theories, concepts, and models of public policy making. New York, NY: Routledge.
Jones, B. (2003). Bounded Rationality and Political Science: Lessons from Public
Administration and Public Policy. Journal of Public Administration Research and Theory, 13 (4), 395-412.
Lindblom, C. E. (1950). The Science of Muddling Through. Public Administration Review, 19, 79–88.
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